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Clinical Correlates of Apathy in Geriatric Depression
2013 AAGP Annual Meeting
AAGP Annual Meeting 2013 Poster Abstracts Early Investigator Posters Poster Number: EI 01
Prevalence of Depression in Chronically Ill Older Adults (NHANES, 2009-10) Margaret A. Ege, MD1; Erick Messias, MD1; Lewis Krain, MD1,2; Puru B. Thapa, MD1,3 1
University of Arkansas for Medical Sciences, Department of Psychiatry, Little Rock, AR United States Department of Veterans Affairs, Department of Psychiatry, North Little Rock, AR 3 Arkansas Mental Health Research and Training Institute, Little Rock, AR 2
Introduction: Depression has long been associated with medical comorbidities such as cardiovascular disease, stroke, and thyroid disease, but more recently its connection to other medical problems, such as osteoporosis and asthma, is receiving more attention. Depression is often overlooked in the medically ill as are medical problems in the depressed. Each of these scenarios may result in inadequate treatment and increased morbidity and mortality from either condition. Recognizing the prevalence of depression in individuals with chronic medical illness is thus paramount. This is particularly relevant in the elderly who typically have more medical comorbidities. If an association between depression and certain medical comorbidities were established, integrated screening tools could be developed to identify such problems with resultant interventions to reduce the burden of these illnesses for both the individual and community. Methods: Data from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) were used to identify individuals sixty years of age and older (n¼2,063). The prevalence of depression (diagnosed using the Patient Health Questionnaire depression scale [PHQ-9]) was estimated in the sample as a whole, and also by the type and number of chronic medical illnesses they were listed as having. Results: The prevalence of major depression in the total sample was 10% (95%C.I. 8.3-12%) and 72.9% (95% CI 70.3-75.3%) had at least one chronic medical comorbidity. The prevalence of depression by medical comorbidity was as follows: osteoporosis 11.4% (7.6-16.8%; p¼0.51), arthritis 12.9% (11-15%; p¼0.002), coronary artery disease 13.3% (7-23.7%; p¼0.23), gout 13.5% (7.7-22.5%; p¼0.19), diabetes 17% (12.2-23.3%; p¼0.0004), stroke 17.1% (10.3-27%; p¼0.03), asthma 19% (12.8-27.2%; p¼0.005), chronic obstructive pulmonary disease 20.1% (12.7-30.3%; p¼0.006), and congestive heart failure 25.9% (14.4-42%; p¼0.001). The prevalence of depression in subjects with zero and in those with at least one chronic medical condition was 5% (2.9-8.5%) and 11.6% (9.5-14%; p¼0.001), respectively. If a subject met criteria for depression, the likelihood that they also had at least once chronic medical condition was 86.2% (78.8-91.3%). Of those with at least one chronic medical condition, the adjusted odds ratio was 2.5 (95% C.I. 1.49-4.36). Conclusions: These results support the association between chronic medical comorbidities and depression among those 60 years of age and older. Although the cross-sectional nature of the present study limits our ability to determine causality, the results do suggest that presence of a chronic medical illness may significantly increase the risk of depression and that the presence of depression in this population is associated with increased likelihood of a medical comorbidity. This has important implications for those treating the aging ill. Poster Number: EI 02
Clinical Correlates of Apathy in Geriatric Depression Taya Varteresian, DO; Prabha Siddarth, PhD; Helen Lavretsky, MD UCLA Semel Institute for Neuroscience and Human Behavior and the Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA Introduction: Apathy is a disorder of motivation commonly present in geriatric depression, but different from depressed mood with respect to neuroimaging correlates and treatment approaches. Apathy is likely to influence treatment response and outcomes of geriatric depression. The purpose of this study is to identify the clinical correlates of apathy in late-life depression. Methods: One hundred forty older adults with major depression participated in this clinical study. All participants had at least moderate depression with Hamilton Depression rating scale (HAM-D) scores of 17, and Mini Mental Status Examination (MMSE) scores of >26. Apathy was evaluated with the Apathy Evaluation Scale (AES) with higher scores representing less apathy. All subjects were assessed for the presence quality of life (health related and self-reported), medical burden, vascular risk Am J Geriatr Psychiatry 21:3, Supplement 1
S63
2013 AAGP Annual Meeting factors and resilience. Psychomotor retardation was measured by the Unified Parkinson’s Disease Rating Scale (UPDRS). Pearson’s correlations and partial correlations were used to evaluate the relationship between apathy and depression, anxiety, resilience quality of life and psychomotor retardation. Results: 140 older adults (73 (52%) women) with a mean age of 70.3 7.8 years and education of 15.62.8 years were recruited. The mean age at depression onset was 44.423.9 years. None of the participants had dementia (mean MMSE scores 28.71.3). The depression severity was moderate (HAM-D mean score 18.93.2) with mild-moderate comorbid anxiety (HAM-A mean score 9.272.8). Apathy (AES) was not associated with age, sex, BMI, medical illness burden or MMSE score. Greater severity of apathy correlated with greater severity of depression (HAM-D: r¼ -.33, p<.0001), but not with anxiety (HAM-A: r¼ -.02, p ¼ .8). Controlling for severity of depression, greater apathy was associated with reduced resilience to stress (CD-RISC: r¼ .30, p<.0004), worse self-rated quality of life (QLESQ: r¼.33, p<.0001) and higher degree of psychomotor retardation (UPDRS: r¼-.32, p<.0001). Similarly, controlling for depression, apathy was related to worse health-related quality of life in terms of greater role limitations due to emotional problems (r¼.19, p<.02), worse energy (r¼.37, p<.0001), worse emotional wellbeing (r¼.22, p<.01) and worse social functioning (r¼.24, p<.005). Conclusions: Our findings suggest that apathy is associated with greater severity of depression and worse functional impairment, reducing subjects’ resilience, self-rated and health-related quality of life, psychomotor retardation, and disability that requires separate clinical assessment and additional treatment considerations.
Poster Number: EI 03
Apathy in Late-life Depression: Prevalence, Persistence and Associated Disability Genevieve Yuen, MD, PhD; Saumya Bhutani, BA; Faith M. Gunning, PhD; Joanna Seirup, BS; Eric Woods, BS; George Alexopoulos, MD Weill Cornell Medical College, New York, NY Introduction: The syndrome of apathy, whether in the context of neurodegenerative disease, vascular insults, traumatic brain injury, or psychiatric disorders, is increasingly recognized as a common source of significant disability. Further, when present in geriatric depression, degree of apathy predicts poor depression outcome. We previously reported a modest effect of escitalopram treatment on apathy in geriatric depression. This study examined the prevalence of apathy in geriatric depression, the relationship between apathy and disability, and the clinical significance of change in apathy following escitalopram treatment in terms of the effect on disability measures. Methods: Participants were 68 non-demented elderly individuals with non-psychotic major depression. After a 2-week singleblind placebo period, subjects who still had a Hamilton Depression Rating Scale (HDRS) 18 received escitalopram 10mg daily for 12 weeks. Apathy was assessed with the Apathy Evaluation Scale (AES). Disability was evaluated with the Sheehan Disability Scale (SDS) and the World Health Organization Disability Assessment Scale (WHODAS-II). These measures, including HDRS, were administered at baseline and again following 12 weeks of escitalopram treatment. Results: At baseline, 39% of depressed patients met criteria for significant apathy (AES 36.5). Severity of apathy at baseline was significantly correlated with degree of disability. Multivariate regression analysis revealed a stronger relationship between baseline disability and apathy than between disability and the rest of the depressive syndrome. Improvement in apathy, following escitalopram treatment significantly correlated with improvement in disability measures, whereas improvement in the rest of the depressive syndrome did not appear to have a significant correlation with change in disability measures. The overall change in apathy (AES 35.1, SD 9.6 versus 28.3, SD 8.0, p<.01) and disability measures (WHODAS-II 36.0, SD 10.2 versus 30.0, SD 8.6, p<.01) following escitalopram treatment, however, were small. Conclusions: Apathy is a prevalent and important aspect of late-life depression that has significant implications on disability. The strong relationship between apathy and disability suggests that the presence of apathy should be routinely screened for and that there is a need for the development of more effective apathy-targeted treatments of depression.
Poster Number: EI 04
Neuropathologic Correlates of Cognitive Impairment in Late Life Depression
Megan E. Gillum, BA1; Meryl Butters, PhD2; Robert A. Sweet, MD2; Ronald L. Hamilton, MD3; Michelle D. Zmuda, BA2; Charles F. Reynolds, III, MD2 1
University of Pittsburgh School of Medicine, Pittsburgh, PA University of Pittsburgh School of Medicine, Department of Psychiatry, Pittsburgh, PA 3 University of Pittsburgh School of Medicine, Department of Pathology, Pittsburgh, PA 2
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Am J Geriatr Psychiatry 21:3, Supplement 1
AAGP Annual Meeting 2013 Poster Abstracts Early Investigator Posters Poster Number: EI 01
Prevalence of Depression in Chronically Ill Older Adults (NHANES, 2009-10) Margaret A. Ege, MD1; Erick Messias, MD1; Lewis Krain, MD1,2; Puru B. Thapa, MD1,3 1
University of Arkansas for Medical Sciences, Department of Psychiatry, Little Rock, AR United States Department of Veterans Affairs, Department of Psychiatry, North Little Rock, AR 3 Arkansas Mental Health Research and Training Institute, Little Rock, AR 2
Introduction: Depression has long been associated with medical comorbidities such as cardiovascular disease, stroke, and thyroid disease, but more recently its connection to other medical problems, such as osteoporosis and asthma, is receiving more attention. Depression is often overlooked in the medically ill as are medical problems in the depressed. Each of these scenarios may result in inadequate treatment and increased morbidity and mortality from either condition. Recognizing the prevalence of depression in individuals with chronic medical illness is thus paramount. This is particularly relevant in the elderly who typically have more medical comorbidities. If an association between depression and certain medical comorbidities were established, integrated screening tools could be developed to identify such problems with resultant interventions to reduce the burden of these illnesses for both the individual and community. Methods: Data from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) were used to identify individuals sixty years of age and older (n¼2,063). The prevalence of depression (diagnosed using the Patient Health Questionnaire depression scale [PHQ-9]) was estimated in the sample as a whole, and also by the type and number of chronic medical illnesses they were listed as having. Results: The prevalence of major depression in the total sample was 10% (95%C.I. 8.3-12%) and 72.9% (95% CI 70.3-75.3%) had at least one chronic medical comorbidity. The prevalence of depression by medical comorbidity was as follows: osteoporosis 11.4% (7.6-16.8%; p¼0.51), arthritis 12.9% (11-15%; p¼0.002), coronary artery disease 13.3% (7-23.7%; p¼0.23), gout 13.5% (7.7-22.5%; p¼0.19), diabetes 17% (12.2-23.3%; p¼0.0004), stroke 17.1% (10.3-27%; p¼0.03), asthma 19% (12.8-27.2%; p¼0.005), chronic obstructive pulmonary disease 20.1% (12.7-30.3%; p¼0.006), and congestive heart failure 25.9% (14.4-42%; p¼0.001). The prevalence of depression in subjects with zero and in those with at least one chronic medical condition was 5% (2.9-8.5%) and 11.6% (9.5-14%; p¼0.001), respectively. If a subject met criteria for depression, the likelihood that they also had at least once chronic medical condition was 86.2% (78.8-91.3%). Of those with at least one chronic medical condition, the adjusted odds ratio was 2.5 (95% C.I. 1.49-4.36). Conclusions: These results support the association between chronic medical comorbidities and depression among those 60 years of age and older. Although the cross-sectional nature of the present study limits our ability to determine causality, the results do suggest that presence of a chronic medical illness may significantly increase the risk of depression and that the presence of depression in this population is associated with increased likelihood of a medical comorbidity. This has important implications for those treating the aging ill. Poster Number: EI 02
Clinical Correlates of Apathy in Geriatric Depression Taya Varteresian, DO; Prabha Siddarth, PhD; Helen Lavretsky, MD UCLA Semel Institute for Neuroscience and Human Behavior and the Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA Introduction: Apathy is a disorder of motivation commonly present in geriatric depression, but different from depressed mood with respect to neuroimaging correlates and treatment approaches. Apathy is likely to influence treatment response and outcomes of geriatric depression. The purpose of this study is to identify the clinical correlates of apathy in late-life depression. Methods: One hundred forty older adults with major depression participated in this clinical study. All participants had at least moderate depression with Hamilton Depression rating scale (HAM-D) scores of 17, and Mini Mental Status Examination (MMSE) scores of >26. Apathy was evaluated with the Apathy Evaluation Scale (AES) with higher scores representing less apathy. All subjects were assessed for the presence quality of life (health related and self-reported), medical burden, vascular risk Am J Geriatr Psychiatry 21:3, Supplement 1
S63
2013 AAGP Annual Meeting factors and resilience. Psychomotor retardation was measured by the Unified Parkinson’s Disease Rating Scale (UPDRS). Pearson’s correlations and partial correlations were used to evaluate the relationship between apathy and depression, anxiety, resilience quality of life and psychomotor retardation. Results: 140 older adults (73 (52%) women) with a mean age of 70.3 7.8 years and education of 15.62.8 years were recruited. The mean age at depression onset was 44.423.9 years. None of the participants had dementia (mean MMSE scores 28.71.3). The depression severity was moderate (HAM-D mean score 18.93.2) with mild-moderate comorbid anxiety (HAM-A mean score 9.272.8). Apathy (AES) was not associated with age, sex, BMI, medical illness burden or MMSE score. Greater severity of apathy correlated with greater severity of depression (HAM-D: r¼ -.33, p<.0001), but not with anxiety (HAM-A: r¼ -.02, p ¼ .8). Controlling for severity of depression, greater apathy was associated with reduced resilience to stress (CD-RISC: r¼ .30, p<.0004), worse self-rated quality of life (QLESQ: r¼.33, p<.0001) and higher degree of psychomotor retardation (UPDRS: r¼-.32, p<.0001). Similarly, controlling for depression, apathy was related to worse health-related quality of life in terms of greater role limitations due to emotional problems (r¼.19, p<.02), worse energy (r¼.37, p<.0001), worse emotional wellbeing (r¼.22, p<.01) and worse social functioning (r¼.24, p<.005). Conclusions: Our findings suggest that apathy is associated with greater severity of depression and worse functional impairment, reducing subjects’ resilience, self-rated and health-related quality of life, psychomotor retardation, and disability that requires separate clinical assessment and additional treatment considerations.
Poster Number: EI 03
Apathy in Late-life Depression: Prevalence, Persistence and Associated Disability Genevieve Yuen, MD, PhD; Saumya Bhutani, BA; Faith M. Gunning, PhD; Joanna Seirup, BS; Eric Woods, BS; George Alexopoulos, MD Weill Cornell Medical College, New York, NY Introduction: The syndrome of apathy, whether in the context of neurodegenerative disease, vascular insults, traumatic brain injury, or psychiatric disorders, is increasingly recognized as a common source of significant disability. Further, when present in geriatric depression, degree of apathy predicts poor depression outcome. We previously reported a modest effect of escitalopram treatment on apathy in geriatric depression. This study examined the prevalence of apathy in geriatric depression, the relationship between apathy and disability, and the clinical significance of change in apathy following escitalopram treatment in terms of the effect on disability measures. Methods: Participants were 68 non-demented elderly individuals with non-psychotic major depression. After a 2-week singleblind placebo period, subjects who still had a Hamilton Depression Rating Scale (HDRS) 18 received escitalopram 10mg daily for 12 weeks. Apathy was assessed with the Apathy Evaluation Scale (AES). Disability was evaluated with the Sheehan Disability Scale (SDS) and the World Health Organization Disability Assessment Scale (WHODAS-II). These measures, including HDRS, were administered at baseline and again following 12 weeks of escitalopram treatment. Results: At baseline, 39% of depressed patients met criteria for significant apathy (AES 36.5). Severity of apathy at baseline was significantly correlated with degree of disability. Multivariate regression analysis revealed a stronger relationship between baseline disability and apathy than between disability and the rest of the depressive syndrome. Improvement in apathy, following escitalopram treatment significantly correlated with improvement in disability measures, whereas improvement in the rest of the depressive syndrome did not appear to have a significant correlation with change in disability measures. The overall change in apathy (AES 35.1, SD 9.6 versus 28.3, SD 8.0, p<.01) and disability measures (WHODAS-II 36.0, SD 10.2 versus 30.0, SD 8.6, p<.01) following escitalopram treatment, however, were small. Conclusions: Apathy is a prevalent and important aspect of late-life depression that has significant implications on disability. The strong relationship between apathy and disability suggests that the presence of apathy should be routinely screened for and that there is a need for the development of more effective apathy-targeted treatments of depression.
Poster Number: EI 04
Neuropathologic Correlates of Cognitive Impairment in Late Life Depression
Megan E. Gillum, BA1; Meryl Butters, PhD2; Robert A. Sweet, MD2; Ronald L. Hamilton, MD3; Michelle D. Zmuda, BA2; Charles F. Reynolds, III, MD2 1
University of Pittsburgh School of Medicine, Pittsburgh, PA University of Pittsburgh School of Medicine, Department of Psychiatry, Pittsburgh, PA 3 University of Pittsburgh School of Medicine, Department of Pathology, Pittsburgh, PA 2
S64
Am J Geriatr Psychiatry 21:3, Supplement 1