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7 Components of Depression Evaluation

7 Components of Depression Evaluation


  • The clinical challenge of treating geriatric depression with cognitive impairment is determining the extent to which cognitive changes are caused by depression versus underlying brain pathology. This slideshow provides a list of elements that are important to a comprehensive evaluation of geriatric depression.

  • With the growing aging population in the United States and many other countries, it is important for mental health professionals to develop skills to diagnose and treat cognitive impairment in older patients with depression. the co-occurrence of depression and cognitive impairment doubles every 5 years after the age of 70 years. The first step of an extended evaluation is to perform the psychiatric interview focusing on current symptoms, stressor (bereavement, illness, interpersonal conflicts), history of previous episodes, and previous response to treatment.


  • Ask specific questions about suicidal ideation, suicidal intent, and history of suicide attempts. Clinical screening questionnaires should not be used to formally diagnose depression or suicidality, but they do provide important information to help identify at-risk individuals. The Beck Depression Inventory (BDI-II) is a widely used scale for these purposes. Although it was not meant specifically for older adults, it can be useful to survey suicidal ideation and has item content consistent with DSM-IV diagnostic criteria for depression. A score of 15 is often considered to be the lower range of mild but clinically significant depression. The 15-question Geriatric Depression Scale: Short Form (GDS-S) was developed as a basic screening measure for depression in older adults. A score of higher than 5 indicates that a more thorough clinical investigation is needed. It is a generally valid measure of mild-to-moderate depression in Alzheimer patients with mild-to-moderate dementia.


  • With or without cognitive impairment, the occurrence of depression in later life is a clinical concern. Obtain a family history of depression, other psychiatric illnesses, and dementia including age at onset, as well as current perceptions of family support. Given the possibility of impairments in reporting cognitive and functional behaviors, clinicians should try to obtain collateral information from family members, particularly with suspected dementia, where family is often the first to notice subtle cognitive changes.


  • Cognitive impairment and depression are common among older adults, and the combination of these 2 conditions may lead to persistent difficulties with both cognition and mood, as well as everyday living. Survey the patient and family members about performance of daily activities, focusing on changes in performance or involvement, as well as current level and recent changes in community involvement. It is important to carefully assess functional activities to determine whether deficits are caused more by loss of knowledge or ability (Alzheimer disease) or whether they are caused by loss of interest or motivation (depression and some dementia).


  • One important but perhaps overlooked aspect of diagnosing either depression or cognitive impairment is a thorough review of risk factors and medical conditions that can be a primary cause or exacerbating element in both these conditions. This is particularly important in geriatric mental health. Document comorbid or contributing medical conditions (eg, hypothyroidism, chronic pain), with a special emphasis on a comprehensive history of vascular risk factors, as well as a careful review of currently prescribed and over-the-counter medications.


  • It is essential to rule out medical conditions that may present as depression or a decline in cognition. Laboratory tests—such as a complete blood cell count, thyroid-stimulating hormone level, HIV/STD, vitamin B12/folate levels—will help to determine medical contributors.


  • Common neuropsychological deficits in late-life depression and clinical correlates include information processing speed, attention and concentration, executive functions, and memory. Neuroimaging may be indicated (brain MRI is preferred over CT) in the context of cognitive impairment, focal neurological findings, and/or significant vascular risk factors.


  • For more on this topic, see Depression and Cognitive Impairment in Older Adults, by Guy G. Potter, PhD and David C. Steffens, MD, on which this slideshow is based.

Comments

Useful presentation
Mainly adequate family support and care givers affection will be a main treatment along with antidepressants.

Dr.Vishalakshi @

Suicide risk is definitely important to assess . If not for safety , for the communication, connection and interaction and for expression of emotion. Physical health and medication ( herbs and over the counter. vitamins are drugs and do affect health ) may be taking can contribute to depression. Loss and grief and social isolation are factors. Elimination, hydration and sleep . This is a huge area and nothing replaces a therapeutic relationship to be to be able to assess and treat appropriately. I don't know how many times I have heard physicians say " "You are getting old". This is not helpful. Elderly people are human beings

Brenda E @

Suicide risk is definitely important to assess . If not for safety , for the communication, connection and interaction and for expression of emotion. Physical health and medication ( herbs and over the counter. vitamins are drugs and do affect health ) may be taking can contribute to depression. Loss and grief and social isolation are factors. Elimination, hydration and sleep . This is a huge area and nothing replaces a therapeutic relationship to be to be able to assess and treat appropriately. I don't know how many times I have heard physicians say " "You are getting old". This is not helpful. Elderly people are human beings

Brenda E @

Suicide risk is definitely important to assess . If not for safety , for the communication, connection and interaction and for expression of emotion. Physical health and medication ( herbs and over the counter. vitamins are drugs and do affect health ) may be taking can contribute to depression. Loss and grief and social isolation are factors. Elimination, hydration and sleep . This is a huge area and nothing replaces a therapeutic relationship to be to be able to assess and treat appropriately. I don't know how many times I have heard physicians say " "You are getting old". This is not helpful. Elderly people are human beings

Brenda E @

I also think it is very important to obtain collateral information from family, caregivers and friends to obtain a clear picture of the client. Family and friends are most often the first to notice changes of concern.

Charlene Mulder RN

charlene @

Rule out tertiary syphilis as a cause for dementia.

R @

Helpful presentation. I am dismayed to see that questions about the use of alcohol, marijuana, or other drugs was not included.
Also, getting a TSH is not sufficient to rule out thyroid disease. MUST get a free T3 and free T4. Also we need to consider other hormone deficiencies such as low estrogen, progesterone, and testosterone, as they can also cause mood and memory changes.

Susan @

Agree with Susan @ Sat, 2017-07-15 10:01. The evaluation must be way more comprehensive. This presentation may suit the insurance purposes well but is unlikely ta help a patient.

Andrius @

Excellent points.

Amin @

An important topic to address for sure. However, several additional topics need to be included:
1. Drug-drug interactions or DDIs. An average medicare recipient is on about 8 drugs with numerous side effects that, if left unattended, will contribute to depression. The fastest way to address this is to get pharmacogenetic (PGx) testing done and weed out ineffective, toxic and pain causing medications. This is particularly pertinent to SLC101 poor metabolizer who developed painful myopathies in response to statins, CYP 2C9 and 2C8 poor metabolizer who are intolerant of NSAIDS, and CYP 2D6 ultrafast metabolizers who develop toxicity symptoms when treated with opiate prodrugs. Many docs feel uncomfortable with PGx data interpretation since this powerful technology is relatively new. Please check my webpage www.medpicker.com for useful tools and contact me if there are questions.
2. Genotype your patient for MTHFR mutations that are common among those of European ancestry and that could result in deterioration of cardiovascular system, elevated BP, cognitive impairment (known as VCI-vascular cognitive impairment) and vascular depression. Pathogenic variant carrier supplementation with L-Methylfolate usually improves mood in about 3 mos. To learn more on vascular depression follow this link https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0720-5
3. As a colleague correctly pointed out in Comments, consider bFTD and order brain MRI and neurocognitive test battery. Please see our case example on the topic here: https://www.ncbi.nlm.nih.gov/pubmed/28452647

Andrius @

Could I receive a printed copy of this?
Thank you,
Tammi Hackley

Tammi @

This a very good and useful presentation

Daniel @

This looks very useful

Paul @

As we wait for the extended evaluation of geriatric depression, Empirical Prescriptive interventions may be considered.
This may focus on enhancement of serotonin and norepinephrine neurotransmitters functions for the emotional and somatic symptoms of depression, respectively, and for reduction in rate of cognitive decline.
Examples may include:
1. Fluoxetine plus Memantine (to maintains sufficient blood levels of serotonin,& to retard decline in cognition)
2. Sertraline, fluoxetine or duloxetine plus Donepezil and/or Memantine.
3. Mirtazapine plus donepezil and/or Memantine
Wild Card: Given that happiness is ultimate goal of all goals (quality of life, is paramount), increasing happy neurotransmitter neuronal activities in geriatric patients, depressed or/and demented should not always be viewed negatively.

Wilfred @

With risk of inducing akathisia, toxic psychosis and iatrogenic loss of memory?

roger @

Given that memory loss and depression – for any given reason, (bereavement, loss of independence, contributing chronic medical conditions, prescription medications, over pruning of dendritic nerves endings, over expression of COX-2 enzyme activities, and so on), are inevitable parts and parcel of growing old, rigorous diagnostic tools, though very important by their own right, may not be as important in this population as in taking preventive measures to ameliorate the apparent and inevitable debilitating condition of old age, comorbid environmental and psychosocial stressors. Such preventive measures may include:
Physical exercise, Tai Chi, Mindfulness exercise, and
Nutritional supplements (Omega 3 fatty acids, Vitamin B-complex- methylfolate Vitamin D w/Vit-K2, Calcium with Zinc).
These supplements may have POTENTIALS to
Reduce dangers from oxidative generated free radicals,
Maintain mitochondrial functional integrity, membrane permeability and blood circulation.
Preserve or improve neurogenesis, and are
Easily accessible, and may impose little or no health danger – patient/care giver is in control.
http://www.sciencedirect.com/science/article/pii/S0166223606000683

Wilfred @

Sleep quality, daylight quality, outdoor exercises as well as social and joyful activities, improved diet, adequate hydration, breathing, reviewed medications that might have become obsolete, detrimental or conducive of depression and cognitive impairment, ought to be part of the assessment and treatment plan.

Martine @

In a small community memory loss screening with Mini-mental status exam in middle aged and older adults pseudodementia was more common than dementia. In the serial subtractions test: take 7 from 100 and keep taking 7 from your answer, those with pseudodementia said they couldn't possibly do it and then with support did it fine and those with true dementias said they could do it fine but did it very poorly. In the former it was associated with major depressive disorder symptoms. I don't know if this has been replicated.

Augustus F. Kinzel, M.D

Augustus @

Insomnia

poyin @

Attemptting to assess suicide risk is a waste of time and is likely to mislead with false positives leading to inappropriate interventions see : http://bjpo.rcpsych.org/content/2/1/e1

Declan @

The CASE method that Dr. Shea is teaching has been a huge improvement over the techniques I learned 15 years ago and I think make these thoughts more of a thing of the past when used correctly.

Russell @

Can you please share what is CASE being taught by Dr. Shea.

Angelina @

Surprisingly, the cognitive tests are missing from the list. Not only the screening tests like Mini‐Mental State Examination (MMSE), which can be part of the psychiatric interview, but also the neuropsychological tests for cognitive deficit to rule out frontotemporal dementia, that might clinically present as a mood disorder. The major deficit in FTD is the executive function. The instruments used to assess it include the Word Fluency Task, Stroop Test, Wisconsin Card Sorting Test, Trailmaking Test and Porteus Mazes. It would be wise to obtain a baseline around the time of the first depression episode and retest later on.

Michael @

Where is the time to do these tests?

Kiran @

Excellent suggestion to do blood tests, as Depression may be related to imbalances in certain chemicals in the body

There is good evidence that deficiencies of both Vitamin D and the Omega-3 Fatty Acids play a major part in Depression, and that correcting them before starting "talking therapies" is worth while.

Here are links to evidence:
http://www.vitamindwiki.com/Depression
https://www.vitamindcouncil.org/health-conditions/depression/
https://www.greenvits.eu/blogs/news/88500611-what-to-do-about-depression
https://www.greenvits.eu/pages/omega-3
http://www.expertomega3.com/omega-3-studies

Here are blood tests that show the levels of Fatty Acids, based on the foods that the person has eaten for the past 60-90 days:
USA: http://omegaquant.com/omega-3-index/#test ( suggest test Omega-3 Index Plus )
Europe: https://www.sanomega.net/shop/fatty-acid-analysis/

It would be interesting to hear from others who have achieved successes in making these measurements and helping the patient to make changes in diet and lifestyle
.

Rufus @

To the best of my knowledge, the association between Vit D deficiency and depression is rather weak. And improvement of the symptoms from the Vit D supplements is not impressive at all.
http://www.psychiatrictimes.com/depression/what-role-vitamin-d-depression

The effect of omega 3 is also weak, if at all
https://www.ncbi.nlm.nih.gov/pubmed/26936905
https://www.ncbi.nlm.nih.gov/pubmed/26537796

BTW the article you quoted came from the sponsors and producers of the vitamins and supplements. vitamincouncil.org being the worst offender, and greenvits.eu actually SELL the supplements. I wouldn't trust them.

Michael @

The impact of omega 3 in children is not weak. It is also likely that there are groups of people for whom Omega 3 is without help and people for whom it is helpful. Hopefully in the foreseeable future we will be able to assess who will respond to which antidepressant, which nutrient.

roy @

I agree that effect of Vitamin D and Omega 3 is overblown!

Kiran @

Screening for ADHD, which could be mistaken for dementia, can be done in a simple 2 minute rating scale. Lots of older people were never diagnosed. Neuroimaging will not determine ADHD.

cheryl @

Cheryl, please tell us how can someone confuse ADHD with dementia and how can a 2 min rating scale help. There are sx's of impulsiveness in FTD, but these do not make ADHD, the way we diagnose it. TIA

Michael @

What about Gifted Adults that have never, through life circumstances, have realised that they are gifted. The line between ADHD and Giftedness is a fine one. The needs of a gifted adult are vastly different to an adult with ADHD. The problem goes even further - how many children are simply labelled as ADD and fed Ritalin or something simply based on the reports of a junior school teacher and so called school psychologist? I would welcome some input on any research being done regarding the proper diagnoses of both children and adults on the subject of ADHD and Giftedness? The two are never spoken about in the same breath and by comparison to ADHD Giftedness is hardly heard of.

beefy @

There may be a broadly researched, scientifically accepted and useful definition for the condition of being "gifted, " but I suspect not. More likely, there is a collection of human abilities that, although individually testable, are not always competently tested by using a widely accepted scientific protocol. Like you say, we usually have to make do with diagnoses by overworked teachers and school psychologists.

Researchers like Dr. Russell Barkley have scientifically-based ways to measure executive functions,.which are at the core of a variety of human cognitive capabilities. Presumably persons extremely capable in even just one of these functions could qualify as "gifted," and those very impaired regarding an executive function could demonstrate a "disorder" which might fit under the general heading "attention deficit disorder." However, science is now capable of separately measuring these executive functions, and giving us more useful information than is captured by the term "gifted."

I suggest you check out Dr. Barkley's books and back issues of "The ADD Report" published by Russell A. Barkley & Associates to see if the term "gifted" is useful in a scientific sense. I suspect it's too imprecise to be medically useful, and that "giftedness" is in the eye of the beholder. Also, books and articles by Thomas E. Brown, and the book "Bright Kids Who Can't Keep Up" by Ellen Braaten and Brian Willoughby---the latter book describes the condition of "slow processing speed," with ADD as just one possible disorder that would handicap a "gifted" person.

Jeff at headhunter1942@gmail.com

Jon @

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