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Louis A. Cancellaro, PHD, MD Professor Emeritus Interim Chair January 11, 2012 Depression in the...

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  • Louis A. Cancellaro, PHD, MDProfessor EmeritusInterim ChairJanuary 11, 2012Depression in the Presence of Dementia:A Diagnostic Challenge

  • EpidemiologyInexact diagnosis compromises researchMajor depressive disorder (MDD) either precedes or co-exists with Alzheimers Disease (AD) occurs more frequently than can be explained by chance alonePrevalence rates:-MDD in non-demented patients>60yo =0.6-8%-MDD in AD (age/sex matched)=15-30%

  • Epidemiology 60% of non-demented elderly patients with severe depression are later diagnosed with AD (@ 3 yr. follow-up)

    Elderly patients with MDD + mild cognitive decline are twice as likely to develop AD than those without mild cognitive decline, who had no greater incidence of AD (@12 yr. follow-up)

  • Etiology of Depression in ADPsychologicalGrief over loss of cognitive functionBiologicalAnalogous to stroke, especially dominant hemisphere, where MDD is prevalent and is responsive to anti-depressantsAD has associated deterioration of locus ceruleus, which is purportedly disrupted in MDD, as well

  • DiagnosisDiagnosing depression in elderlyInexactPart of a continuumSadness MDD Psychotic DepressionFrequently presents with somatic symptoms as opposed to classical DSM IV criteria

  • DiagnosisDiagnosing depression in elderlyUse family + patient for historyReport >2 weeks history of (one or more): Loss of energy, loss of interests Increase in somatic symptoms w/o adequate physical explanation Behavioral and/or personality change Suicidal tendencies Delusions

  • DiagnosisDiagnosing depression in elderlyNo precise diagnostic testsBiochemicalRadiologicalPsychologicalHamilton Depression Rating ScaleDSM-IVExperienced clinicians are the most help

  • DiagnosisDiagnosing AD in elderly with MDDHistory of cognitive decline beyond just loss of concentrating abilityPatient may, or may not, complain of memory loss

    Cognitive psychological testsMini-mental statusFull battery

  • DiagnosisDiagnosing depression and AD in elderlyEven more inexact, especially if signs of AD not previously recognizedMDD in elderly frequently presents with personality change and/or somatic symptomsBehavioral changeLoss of concentrating ability; poor judgmentVague physical symptomsLoss of energyNerves

  • DiagnosisDepression + AD in elderlyDifficult to make a dual diagnosisSerious risks associated with a missed diagnosisThus, the clinician must consider the coexistence of both conditions if one is present, until proven otherwise

  • EpidemiologySuicide risk:For all patients 65 years of age vs
  • Diagnosis

  • Dementia and Depression: Distinguishing Features

    FeatureDementiaDepressionOnsetUnclear, insidiousClear, recent, often a major psychotic eventProgressionRelatively steady declineUneven, often no progressionPatient insightOften unaware of deficits, not distressedNearly always aware of deficits and quite distressedAffectBland, some labilityMarked disturbanceTest PerformanceGood cooperation and effort, stable achievement, little test anxiety, near miss responsesPoor cooperation and effort, variable achievement, considerable anxiety, dont know responsesShort-term memoryOften impairedSometimes impairedLong-term memoryUnimpaired early in diseaseOften inexplicably impaired

  • Differential DiagnosisEndocrineThyroid diseaseDiabetes MellitusCushingsAddisonsHyperparathyroidismCardiovascular and pulmonary diseaseMICongestive heart failureCOPD

  • Differential DiagnosisEndocrineCardiovascular and pulmonary diseaseAnemiaB12Kidney and liver diseaseHepatitis CInfectionsAIDS, TB, hepatitis, chronic fatigue syndrome, other chronic infections

  • Differential DiagnosisEndocrineCardiovascular and pulmonary diseaseAnemiaKidney and liver diseaseInfectionsNeurological diseaseCVA, low pressure hydrocephalus, Parkinsons, subdural hematoma, sleep apnea, brain tumor, seizure disorder

  • Differential DiagnosisMedication side effects and interactionsPsychotropicsBenzodiazepinesAnti-psychoticsAnti-convulsantsAnti-depressantsSleeping agentsPulmonary and cardiac drugsSteroids

  • Differential DiagnosisMedication side effects and interactionsOccult malignancyLymphomas, leukemias, multiple myelomaRetro-peritoneal tumorsCollagen vascular diseaseSLE, polymyalgia rheumatica, rheumatoid arthritis, scleroderma, fibromyalgia Medications used in treatmentAlcoholismOther psychiatric disordersAnxiety disordersMania

  • Evaluation and ManagementSuspecting MDD either preceding or coexisting with ADHistory (from patient and family)Chief ComplaintDepressed (less common)NervesMemory loss Somatic symptoms (energy, GI symptoms, weakness)

  • Evaluation and ManagementHistoryChief ComplaintCourse of illness (one or more):2 weeksinterest in daily activitiescognitive abilityPersonality change with impulsivenessSuicidal tendencies

  • Evaluation and ManagementHistoryAssessmentLack of medical condition sufficient to explain signs and symptomsPatient more detached than usualMeets most of DSM-IV criteria for MDDPerformance on cognitive testsIf AD present, caregivers report frustration, hopelessness in themselvesSuicide risk factors reviewed with patient and family Domestic violence risk factors reviewedReview differential diagnosis, especially medication side effects and interactions

  • Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with ADMedicationsAnti-depressants 85% improvement in mood if MDD presentPlus occasional improvement in cognitionNo improvement in mood or cognition if MDD is not present

  • Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with AD Medications:Anti-depressants: low doses, increase slowlySSRIs (1/4-1/2 normal starting dose)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)SSRIs + donepezil (Aricept ) = safeSSRIs + other meds may alter metabolismTCAs not well tolerated

  • Evaluation and Management

  • Evaluation and Management

  • Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with ADMedications Psychotherapy (slow, repetitive process)SupportiveBehavior (statistically significant improvement)Family (especially with caregivers)

  • Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with ADMedicationsPsychotherapyManagement of suicidal behaviorFrequent assessmentECT may be required

  • SummaryMDD frequently precedes or co-exists with AD

    Diagnosis of MDD in elderly is inexact

    If MDD + AD is suspected, effective treatment of the MDD can not only improve the mood and behavior of the patient, but also improve condition

  • I, Louis A. Cancellaro M.D.

    DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

    Disclosure Statement of Financial Interest

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