services administration (hrsa) of the u.s. department of 1 ... · this project is supported by the...
TRANSCRIPT
![Page 1: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/1.jpg)
![Page 2: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/2.jpg)
This project is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) under 1 U1QHP28724-
01-00, Cultivating a Culture of Caring for Older Adults, for
$2.5 million. This information or content and conclusions
are those of the author and should not be construed as the
official position or policy of, nor should any endorsements
be inferred by HRSA, HHS or the U.S. Government.
2
![Page 3: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/3.jpg)
Faculty Disclosure Information
In the past 12 months, I have no relevant financial
relationships with the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial services
discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use
of a commercial product/device in my presentation.
3
![Page 4: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/4.jpg)
RACIELA B. AUSTIN, MSN, AGNP-C
ASSISTANT CLINICAL PROFESSOR
DIVISION OF GERIATRIC MEDICINE AND GERONTOLOGY
Depression Among Older Adults
I have no actual or potential conflict of interest to disclose
![Page 5: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/5.jpg)
Objectives
KNOW and UNDERSTAND
• Epidemiology
• Risk Factors
• Clinical Manifestations
• Assessment
• Depression Screening Instruments
• Diagnosis
• Non-Pharmacological Interventions
5
![Page 6: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/6.jpg)
Depression (Unipolar)- late life
• Onset of symptoms at a younger age
(genetic + psychosocial factors)
• Onset at of symptoms later in life for the
first time (brain circuitry)
6
Introduction
![Page 7: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/7.jpg)
Depression is a normal consequence of
aging.
a) True
b) False
7
Question # 1
![Page 8: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/8.jpg)
Epidemiology
8
• Life expectancy: 79 years old (2014)-increased from 47
years in 1900s
• By 2030: 70 million older adults in the US – 65 years and
older (20% of total US population)
• By 2050: 2 billion older adults worldwide – 60 years and
older (20% of total population)
![Page 9: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/9.jpg)
• Prevalence of Depression
Minor depression (“other specified depressive disorder” in
DSM-5): presence of persistent depressed mood with 2 or
3 additional symptoms of major depressive disorder 15% of older people (range 8% to >40%)
Associated with use of health services, excess disability, poor health outcomes, including mortality
Negative impact: physical and social functioning and QOL
Increased risk for subsequent Major Depression
9
Epidemiology (continued)
![Page 10: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/10.jpg)
• The rate of Major Depression among
community dwelling older adults range
from:
• A) 6-10%
• B) 12-20%
• C) 11-45%
10
Question # 2
![Page 11: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/11.jpg)
• Prevalence of Depression
• Major depressive disorder
6%–10% of older adults in primary care clinics
12%–20% of nursing home residents
11%–45% of hospitalized older adults
11
Epidemiology (continued)
![Page 12: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/12.jpg)
• Female (2:1 ratio)
• Social Isolation/Living Alone
• Widowed, divorced or separated
• Loss of a loved one; Bereavement
• Insomnia **
• Functional and Cognitive Impairment
• Lower socio-economic status
• Co-morbid medical conditions (uncontrolled pain)
12
Risk Factors
![Page 13: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/13.jpg)
• Caregiving
• Family History of Depression
• Previous History of Depression
• Medications
• Alcohol/Substance Abuse
• Admission to Long Term Care
13
Risk Factors (continued)
![Page 14: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/14.jpg)
• Depression is more common among older
adult females.
• A) True
• B) False
14
Question # 3
![Page 15: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/15.jpg)
• 1) Somatic Complaints- (GI complaints)
• 2) Memory Problems/Difficulty Concentrating
• 3) Agitation/Anxiety
• 4) Weight Loss/Lack of Appetite
• 5) Social Withdrawal
• 6) Chronic Pain
15
Clinical Manifestations
![Page 16: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/16.jpg)
• 7) Decreased energy and motivation
• 8) Increased dependency (difficulty
completing ADLs)
• 9) Increased pre-occupation with death
16
Clinical Manifestations
![Page 17: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/17.jpg)
• Ms X is 82-year-old female
• CC: worsening right hip, increased fatigue, lack of appetite – loss a total of 12 pounds in one year (first 6 pounds intentional wt. loss)
• Recent hospitalization: Severe Sepsis, Pyelonephritis, Transaminitis
• PMH: History of Depression (tapered off Lexapro back in May 2017)
17
Case Study
![Page 18: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/18.jpg)
• SH: Lives alone, goes out with friends on
occasion; husband died 2 years ago
• Medical History: Hyperlipidemia,
Hypothyroidism
• Current Medications: Simvastatin,
Levothyroxine
18
Case Study (continued)
![Page 19: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/19.jpg)
Physical Examination: Normal Vital Signs Gen. Appearance: NAD CV: WNL Resp: WNL Musculoskeletal: + TTP on SI joint (R) Most recent labs from most recent hospitalization: Elevated White Count, Elevated BUN 19
Case Study (continued)
![Page 20: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/20.jpg)
• What should we do next?
• A) Check CBC and CMP
• B) Order UA & C/S
• C) Order Hip x-ray
• D) Check CBC, CMP and order Hip X-ray
20
Case Study: QUESTION # 1
![Page 21: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/21.jpg)
• Findings:
• CMP and CBC -WNL
• Right Hip X-ray- moderate degenerative
changes
21
Case Study (continued)
![Page 22: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/22.jpg)
Plan:
• Continue to push fluids
• Small frequent meals
• Tylenol 500 mg every 4-5 hours as needed
• Diclofenac Gel
• RTC in 2 weeks
22
Case Study (continued)
![Page 23: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/23.jpg)
• Comprehensive and systematic
• Investigate somatic complaints
• Psychiatric and Medical History
• Laboratory Tests and Medication Review
• Functional and Cognitive Assessment
• Use Screening Tools
23
Assessment
![Page 24: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/24.jpg)
• 2-Item Patient Health Questionnaire
• Yes or No Response
• Score of 3 or more – indicates possible clinically significant depression
• "During the past month, have you been bothered by feeling down, depressed or hopeless?"
• •"During the past month, have you been bothered by little interest or pleasure in doing things?"
24
Depression Screening Instruments
![Page 25: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/25.jpg)
9-Item Patient Health Questionnaire (PHQ-9)
• 9 items cover diagnostic criteria for major depressive disorder
• Those who acknowledge thinking they would be “better off dead” or “hurting yourself” should be asked about presence of firearm in the home
• Initial 2 questions (PHQ-2) can be used for screening
• Serial administrations can be used to reliably assess response to treatment
25
Depression Screening Instrument
![Page 26: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/26.jpg)
Ms. X returns to clinic
• CC: “foggy,” worseningincreased fatigue x
3 weeks, worries about her grandchildren,
denies insomnia, lack of appetite
• PMH: Hypothyroidism, Hyperlipidemia
26
Case Study
![Page 27: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/27.jpg)
What should we do next?
a) Check TSH
b) Check B12
c) Administer PHQ-2 or PHQ-9
d) All of the Above
27
Question
![Page 28: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/28.jpg)
• TSH and B12 – WNL
• PHQ-2 Screen – 6 points!
• Denies SI/HI
28
Case Study
![Page 29: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/29.jpg)
Is Ms. X clinically depressed?
A) Yes
B) No
29
Case Study
![Page 30: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/30.jpg)
• Ms X is 82-year-old female
• CC: worsening right hip, increased fatigue, lack of appetite – loss a total of 12 pounds in one year (first 6 pounds intentional wt. loss)
• Recent hospitalization: Severe Sepsis, Pyelonephritis, Transaminitis
• PMH: History of Depression (tapered off Lexapro back in May 2017)
30
Case Study
![Page 31: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/31.jpg)
Ms. X returns to clinic
• CC: “foggy,” worsening increased fatigue x
3 weeks, worries about her grandchildren,
denies insomnia, lack of appetite
• PMH: Hypothyroidism, Hyperlipidemia
31
Case Study
![Page 32: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/32.jpg)
What should we do next?
a) Do nothing, she will get over it!
b) Initiate antidepressant
c) Offer counselling
d) B and C
32
Case Study
![Page 33: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/33.jpg)
• Offered Counselling –patient deferred
• Started on low dose Lexapro
• Contracts for Safety
• RTC in 4-6 weeks
33
Case Study
![Page 34: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/34.jpg)
• Major Depression- insert DSM 5
34
Diagnosis
![Page 35: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/35.jpg)
• 1) Decrease symptoms- if untreated it
increases likelihood of death
• 2) Reduce relapse and recurrence
• 3) Improve QOL
• 4) Decrease mortality rates
35
Goals of Treatment
![Page 36: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/36.jpg)
• Psychotherapy –first line of treatment
• Most effective – pharmacological +
psychotherapy/counselling
• Family and Social Support
• Grief Management
• Reminiscence
36
Non-Pharmacological Treatments
![Page 37: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/37.jpg)
• Recognize non specific symptoms
• Rule out organic causes
• Use Screening Tools
37
Conclusion
![Page 38: Services Administration (HRSA) of the U.S. Department of 1 ... · This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health](https://reader033.vdocuments.net/reader033/viewer/2022042213/5eb6b70e077dd037015f1ab7/html5/thumbnails/38.jpg)
38
Questions?