Alzheimers Disease Coordinated Care for San Diego Seniors

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Alzheimers Disease Coordinated Care for San
Diego Seniors
Recognizing and Managing Depression in Dementia
Joshua Chodosh, MD UCLA Department of Medicine
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ACCESS PROGRAM PARTNERS
Kaiser Permanente San Diego Scripps Clinic UCSD
Healthcare Meals-on-Wheels Greater San Diego San
Diego Alzheimers Association Southern Caregiver
Resource Center
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Overview

• Learning goals
• Background
• Guide to an efficient and targeted evaluation
• Pharmacological therapies
• Summary

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Learning goals

• Increase appreciation for the challenges of
  depression in demented patients
• Develop differential diagnosis
• Conduct an efficient appropriate evaluation
• Increase knowledge of appropriate medical
  therapy

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Clinical Case

• 79 year old male patient of yours with 3-year
  history of Alzheimers disease and recent
  functional decline, referred in to you by ACCESS
  care manager for depression eval
• no longer dressing without assistance
• more apathetic appearing
• sleeping at only 2-hour intervals
• 3-pound weight loss over the past 3 weeks
• Cornell Depression Scale score 17
• Meds Aricept 10mg QD Tylenol 1000mg TID for OA
  Atenolol 50 mg QD for hypertension

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Background

• Depression present in at least 20 of patients
  with Alzheimers disease.
• Exacerbates cognitive deficits of pre-existing
  dementia.
• Affects up to 50 of Alzheimer caregivers.
• Most people never receive treatment.
• Depressive symptoms may reflect an underlying
  delirium and vice versa.

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Background

• Depression in dementia is treatable
• Major depression may be more common in earlier
  AD, less common later and expressed similar to
  depressed non-demented
• Consider depressive reaction to diagnosis
• Mixed anxiety and depression common anxiety
  complicates behavior 50 60 in early AD
• Depressive symptoms common 20 40
• Added burden on patients and caregivers
• Affect function, compliance, and adherence to Rx

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Recognizing Depression

• May manifest in atypical ways
• New onset of agitation
• Wandering
• Apathy
• Crying out
• Insomnia
• Change in functional status
• Beware suicidal ideation (if present with
  psychosis, need psychiatric consultation)

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Cornell Scale for Depression

• Assessment of 19 possible symptoms over prior
  week, given as part of initial ACCESS screening
  by care managers and repeated at 6-month
  intervals
• Based upon interview with family caregiver
• Range 0 - 38
• Score of gt 7 (For a diagnosis of major
  depression in dementia)
• Sensitivity of 0.90
• Specificity of 0.75

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Possible Depression

• Cornell Scale for Depression in Dementia Score
  gt 7
• Or answers yes to any of following questions
• Frequent crying
• Weight loss gt 2lbs / month
• Recent behavior change
• New onset withdrawal, agitation, or irritability
• Recent change in sleep pattern
• Self-deprecating or hopeless statements

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Inquire About.

• Any recent changes in care-giving
• Any recent changes in usual routines
• New sensory impairments
• Lost glasses
• Broken hearing aides
• Recent illness
• Recent personal losses (death of friend, family
  member)
• Painful medical conditions such as OA

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ACCESS Algorithm for Evaluation and Treatment of
Depression
Probably not depressed, reassess in 6 months
Cornell Scale gt 7 or Acknowledges Yes to
Questions (previous slide)
No
Yes
Medications that may cause or exacerbate
depression?
Stop or change meds
No
Yes
Any alcohol use?
Yes
Counsel to stop, Monitor for withdrawal
No
Cornell gt 7 OR still suspicious of depression?
Yes
Probably not depressed - Reevaluate in 6 months
Probably depressed and should receive 1. Trial
of antidepressants 2. Information about depression
No
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Guidelines for Antidepressant Medications

• Issues reflect tolerance, dosage, and titration
• Dosing is typically 1/2 of usual dose given to
  non-elderly population, maximal dose further
  reduced with cognitive impairment. (Start low
  and go slow.)
• SSRIs generally better tolerated than TCAs
  (tricyclics) in elderly populations.
• Limited evidence supporting use of SSRIs in
  dementia-associated depression, however there is
  considerable clinical experience.
• Usually wait 4-6 weeks for clinical response
  before any increase in dose.

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SSRI Adverse Effects Profile

• Common
• Insomnia
• Agitation
• Tremor
• Headache
• GI distress
• Sexual dysfunction

• Less Common
• Hyponatremia
• Neutropenia
• Thrombocytopenia
• Sinus bradycardia
• EPS/Parkinsonism
• Delirium

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SSRI Comparison Table
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SSRI Comparisons Cont.
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Case Follow- up

• Delirium work-up revealed no metabolic
  abnormalities or evidence for infection.
• Started Paroxetine 10 mg QD.
• Sleep duration increased to 5 hours but otherwise
  no change over the first few weeks.
• By 5 weeks, however, apathy improved and pt.
  resumed dressing with minimal assistance
  appetite increased.
• Dose was maintained at 10 mg with plans for
  reassessment in 2 -3 months.

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Summary

• Depression is quite common in patients with
  dementia and even more prevalent amongst
  caregivers (who may also present to you, if you
  are a PCP for ACCESS caregivers).
• SSRIs tend to be better tolerated than other
  antidepressants but start at no more than 1/2
  usual starting dose.
• Can take 6 weeks or longer to achieve therapeutic
  effect.
• Consider geriatric psychiatric consultation if
  SSRI is ineffective.