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| processes); brain injury and neurologic disorders—injury to medial frontal area may cause apathetic syndromes; strokes that affect frontal area often associated with depression; other patterns of behavior (eg, disinhibition, mania) associated with other injuries and disorders; early life experiences—traumatic experiences at young age may lead to neural changes and increased susceptibility to psychiatric disorders; interaction—relationships among internal and external factors and mood are complex; categorizing depression as “reactive” or “endogenous” too simplistic |
| Active listening: “listen with two ears”; diagnostic—recognize signs and symptoms that indicate treatable syndrome (eg, major depressive disorder); use diagnosis to guide management; empathetic—piece together narrative of life events and responses; identify underlying vulnerabilities and contributory circumstances; seek to understand patient as individual and reasons for current crisis |
| Diagnosis: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) lists signs and symptoms of depression (eg, sleep disturbance, loss of interest in activities, inappropriate guilt, loss of energy, mood changes, reduced concentration, changes in appetite, depressed psychomotor response, suicidality); depressive episode defined as ≥5 symptoms for ≥2 wk |
| Distinctive symptoms of major depression: melancholy—intractable and debilitating; diminished vital sense—decreased mental and physical potency; reduced zest for life and capacity for pleasure; diminished self-regard—decreased confidence and self-efficacy; increased “blameworthiness” and sensitivity to and preoccupation with errors; diurnal pattern of distress—symptoms worse in morning and improve throughout day; note, diurnal pattern of physical symptoms (eg, nausea and stomachache) also may indicate depression |
| Alcohol abuse or intoxication: always ask about alcohol use; patients may not volunteer information; simulates depression—contributes to mood instability; causes interval insomnia and disturbed continuity of sleep; affects appetite and mood; complicates depression—lowers threshold for self harm (intoxication increases likelihood of acting on suicidal thoughts); age of onset—alcohol abuse may begin late in life, often in association with stress specific to life phase (eg, ailing spouse) |
| Wish to hasten death: studies looking at terminally ill patients have found that patients wishing to hasten death also have symptoms of major depression; psychologic distress often more important factor than physical pain among people who ask for physician-assisted suicide (data from Oregon); anecdotal evidence suggests that terminally ill patients with concomitant major depression no longer wish to hasten death once depression treated |
| Assessment of suicide risk: among older individuals, depression most common reason for suicide; expressed intentions—important to ask about suicidal ideation or plans, but many suicidal patients deny intentions; mental status— high-risk findings include psychic pain, self-loathing, and hopelessness (“lethal triad”); other red flags include perturbation, delusions of guilt, hallucinations advising suicide, and passive wishes for death; history—patients with past attempts at suicide at highest risk; other red flags include history of acute demoralizing crisis and concurrent substance abuse |
| Expectant trust: conceptualized by Jerome Frank; patient perception that clinician cares, is competent and optimistic about outcome, and will not abandon patient; attitude inspires hope (important for treatment of depression and prevention of suicide) |
| Formulation of narrative: assess vulnerabilities (eg, personality traits, psychosocial circumstances, substance abuse), current stressors and life circumstances (eg, conjugal bereavement), and how these interact to create current crisis (eg, loneliness, suicidality); approach to treatment—leverage strengths to compensate for vulnerabilities and resolve crisis |
| Response to medical therapy: depression generally does not remit with first intervention; Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial looked at response to pharmacotherapy among ≈4000 outpatients (few exclusions; population representative of most practice settings); level 1—depression remitted in ≈30% of patients after first intervention (substantial trial with citalopram); level 2—for remaining patients, augmenting treatment with bupropion (eg, Wellbutrin) or buspirone (Buspar) resulted in remission in ≈30% of patients in each group; switching to sertraline (Zoloft), venlafaxine (Effexor), or bupropion resulted in remission in 18%, 25%, and 21%, respectively; level 3— augmenting treatment with lithium or triiodothyronine resulted in remission in 16% and 25% of patients in each group; switching to mirtazapine (Remeron) or nortriptyline resulted in remission in 12% and 20%, respectively; level 4— switching to monoamine oxidase inhibitor (MAOI) or combination of venlafaxine plus mirtazapine resulted in remission in 7% and 14%, respectively; overall results—remission achieved in 70% of patients; numerous extended trials often necessary |
| Maintenance pharmacotherapy: important, especially for older patients who respond to pharmacotherapy; randomized placebo-controlled study compared maintenance therapy to paroxetine (eg, Paxil) and psychotherapy; depression recurred less frequently (35%-37%) among patients treated with paroxetine (with or without psychotherapy), compared to those treated with psychotherapy or placebo alone (68% and 58%, respectively) |
| Electroconvulsive therapy (ECT): appropriate for patients unresponsive to pharmacotherapy and for those in imminent danger; single most effective treatment for acute episodes of major depression; usually well tolerated, even by very old patients; adverse effects—cardiovascular effects (eg, arrhythmias) relatively uncommon, and usually benign and manageable; cognitive effects (eg, memory loss) highly variable and not dependent on age; risk for adverse cognitive effects increases with number and frequency of treatments and bilateral (vs unilateral) electrostimulation; usually time-limited; effect—ECT interrupts depressive episode, but does not prevent relapse (therefore, additional treatment necessary); maintenance ECT—weekly, biweekly, or monthly sessions may be effective; interval shortened or extended as necessary to prevent recurrence of serious depression |
| Persistence and vigilance: critical; continuity of care and ongoing assessment of, eg, therapeutic response, adverse effects, emergent problems, necessary; important for clinician to remain supportive and optimistic |
| Questions and answers: treatment history—ask about efficacy and tolerability of previously used antidepressants; choice and dosing of antidepressants—speaker begins with low-dose selective serotonin reuptake inhibitor (SSRI; eg, citalopram 5 mg), then increases dose every week, as tolerated; if additional therapy needed once adequate dose reached, speaker adds buspirone (based on results from STAR*D trial) |
| DELIRIUM AND ALZHEIMER’S DISEASE —Joel D. Posner, MD, Professor of Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY |
| Aging population: individuals \>65 yr of age represent ≈17% of population of United States; aging baby boomers (cohort of ≈80 million people) beginning to face age-related health issues |
| Delirium and dementia: often overlooked or minimized; delirium (acute; medical emergency) may occur in patients with baseline dementia, but may go unrecognized and untreated |
| Assessing mental status: baseline assessment required in order to recognize changes in mental status; Mini-Mental State Examination (MMSE) recommended annually (requires <10 min; may be performed by auxiliary staff); change in score indicates change in mental status; components of MMSE—orientation; registration; attention; calculations; recall; language; assessment of orientation normally made by asking about state and country; speaker prefers to ask questions about time, place (ie, setting), and person |
| General: acute change in mental status; potentially life-threatening medical emergency; waxing and waning levels of consciousness distinguishes delirium from dementia (chronic; relatively stable); agitation and visual hallucinations also common |
| Reversible causes: mnemonic spells DEMENTIA |
| Drugs: prescription and over-the-counter (OTC) medications; sleep medications, psychiatric medications, anticholinergic agents (including OTC antihistamines), and others may cause acute confusion |
| Endocrine abnormalities: eg, hyperthyroidism and hypothyroidism associated with atypical signs in older adults |
| Metabolic causes: hypoxia (eg, during sleep, exercise, or normal activities); hypoglycemia; electrolyte imbalance (eg, diuretic use may result in hyponatremia, causing acute confusion and risk for death); impaired function of liver or kidneys |
| Ears, eyes, and emotions: impaired hearing or vision may increase confusion and lead to odd behaviors; depression may present as acute confusional state |
| Nutrition and normal-pressure hydrocephalus: deficiencies of vitamin B12 , folate, or thiamine may accompany alcohol abuse, and may represent medical emergency (parenteral supplementation required); identification of normal-pressure hydrocephalus has treatment implications for patients <75 yr of age |
| Takes up space in brain: eg, tumors, trauma, subdural hematoma |
| Infections: atypical presentations common among older adults |
| Arteries: anything that prevents oxygenated blood from reaching brain (eg, heart failure, cardiac arrhythmias); acute confusional state (without chest pain or shortness of breath) is presenting symptom of myocardial infarction in 25% of adults \>85 yr of age |
| Work-up: history and physical examination; MMSE or other assessment of mental status; laboratory tests—complete blood cell (CBC) count (detects severe anemia and evidence of infection); sedimentation rate (high rate may signal arteritis, especially when accompanied by acute confusion); thyroid function tests; electrolyte levels; renal function tests; blood glucose levels; vitamin B12 and folate levels (methylmalonic acid test for B12 ; homocysteine levels better indicator of folate status than serum level of folic acid; supplement empirically); other tests—electrocardiography; oximetry; chest x- ray; computed tomography (CT; identifies normal-pressure hydrocephalus); magnetic resonance imaging (MRI; visualizes old aneurysms not visible on CT); magnetic resonance arteriography (MRA; visualizes blood vessels) |