1. Which One of the Following Ranges of Percentages Best Represents the Prevalence

C H A P T E R 1 9 Affective Disorders 165

1. Which one of the following ranges of percentages best represents the prevalence of current major depressive disorder in community-living elderly persons? a. Less than one percent b. 1% to 3% c. 4% to 6% d. 7% to 9% e. 10% to 15%

Rationale: Due, at least in part, to differences in the diagnostic criteria of major depression used, studies have reported varying estimates of the community prevalence of major depression. The prevalence of major depressive disorder in community-living elderly persons has been estimated at between one percent and three percent. Current and lifetime prevalence of depressive disorders was assessed in 4,559 non-demented individuals between ages of 65- 100 years as part of the Cache County Study. The point prevalence of Major Depression was estimated at 4.4% in women and 2.7% in men. These are higher prevalence estimates than those reported previously in North American studies. Many more elderly suffer from clinically significant depressive symptoms that do not meet DSM-IV-TR criteria for a diagnosis of major depressive disorder. The prevalence of depressive symptoms among el derly patients in primary care practices is 9.9% and up to 30% among older adults in nursing home facilities.

The recommended option is b.

Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry.1999;174:307-311. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003; 58(3):249-265.

Blazer DG, Steffens DC, Keoing DH. Mood Disorders. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 275-299____

Koenig HG, Blazer DG. Mood disorders. In: Blazer DG, Steffens DC, Busse EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004: 241-268.Steffens DC, Skoog I, Norton MC, Hart AD, Tschanz JT, e al. Prevalence of depression and its treatment in an elderly population: the Cache County study. Arch Gen Psychiatry. 2000 Jun; 57(6):601-7. 19-2. Which one of the following cognitive domains is disproportionately affected by late-life depression? a. Constructional deficits b. Executive function c. Impaired semantic fluency and nNaming d. Motor slowingVisiospatial function e. SyntaxPoor verbal fluency with preserved naming

Rationale: Studies of depressed elderly have found several domains of cognitive impairment compared to healthy controls, including executive function, informational processing speed, working memory, executive function, as well as impairment of acquisition and recall memory, with impairment, with better preserved recognition memoryretrieval memory difficulty, and memory improvement with cueing/recognition. Frontal lobe function s are dispropotionately affected is commonly impaired in late-onset depression. While cognitive impairment may improve somewhat after successful treatment, typically it does not normalize. Executive dysfunction, in particular, particularly is associated with poorer outcomes in late-onset depression. The etiology of cognitive impairment in late-life depression is heterogeneous and includes cortical and subcortical gray and white matter disease and other subcortical vascular lesions and early Alzheimer’s disease pathology. Cognitively impaired depressed elders are at high risk for developing dementia within two to three years.

Alexopoulos GS, Meyers BS, Young RC, et al. Executive dysfunction and long-term outcomes of geriatric depression. Arch Gen Psychiatry. 2000; 57(3):285-290.

Nebes RD, Buter MA, Mulsant BH, et al. Decreased working memory and processing speed mediate cognitive impairment in geriatric depression. Psychol Med. 2000; 30(3):679-691.

Welsh-Bohmer KA, Attix DK. Neuropsychological assessment of dementia. In: Blazer DG, Steffens DC, Busse EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 34rdth ed. Washington, DC: American Psychiatric Publishing, Inc.; 20049: 213-226

189-206. 19-3. Which one of the following is least likely to contribute to a poor prognosis in late-life depression? a. Alcohol abuse b. Anxiety disorders c. Executive dysfunction d. Onset after age 60 e. Progressing white matter lesions

Rationale: Progressing white matter lesions and executive dysfunction are associated with a lower rate of remission and increased likelihood of progression to dementia. Alcohol abuse and anxiety disorders are associated with poorer response. Compared to adult onset depressive disorders, Oonset in late life, however, does not appear to affect prognosis. Medical co-morbidity is also a risk factor for inferior treatment response and poor antidepressant tolerability.

The recommended option is d.

Koenig HG, Blazer DG. Mood disorders. In: Blazer DG, Steffens DC, Busse, EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004: 241-268. Blazer DG, Steffens DC, Keoing DH. Mood Disorders. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 275-299_

Mitchell AJ, Subramaniam H. Prognosis of depression in old age compared to middle age: a syste matic review of comparative studies. Am J Psychiatry. 2005 Sep; 162(9):1588-601.

Oslin DW, Katz IR, Edell WS, et al. Effects of alcohol consumption on the treatment of depression among elderly patients. Am J Geriatr Psychiatry. 2000; 8(3):215-220.

Taylor WD, Steffens DC, MacFall JR, et al. White matter hyperintensity progression and late-life depression outcomes. Arch Gen Psychiatry. 2003; 60(11):1090-1096. 19-4. Vascular depression is associated with which one of the following symptoms? a. a. Apathy b. Preserved insightAwareness of deficits c. Lack of cognitive impairment d. Severe agitation e. Preserved Vverbal fluency and naming preserved Rationale: Vascular depression refers to the concept that some late-life and late-onset de - pression is associated with subcortical cerebrovascular disease. Depressed elderly with subcortical vascular disease are more likely to be apathetic and to have executive dysfunction as well as more, cognitive impairments, and greater disability than those depressed elderly with nonvascular depression. Fluency and naming are most impaired in vascular depression. Patients with vascular depression have more apathy and psychomotor retardation and less agitation, guilt, and insight.

The recommended option is a.

Alexopoulous GS. Late-life mood disorders. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 609- 654.

Blazer DG, Steffens DC, Keoing DH. Mood Disorders. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 275-299

Steffens DC, Taylor WD, Krishnan KR, et al. Progression of subcortical ischemic disease from vascular depression to vascular dementia. Am J Psychiatry. 2003; 160(10):1751-1756. 19-5. Late-onset mania, with onset after age 50, is associated with which one of the following? a. Cerebrovascular disease b. Decreased mortality c. High prevalence of family history of bipolar disorder d. Rarely secondary to drug-induced side effects e. Shorter episodes of manic symptoms

Rationale: Little is known about bipolar disorder in elderly persons. Most patients with manic syndromes have bipolar mood disorder. Onset in late life accounts for approximately 10% of bipolar disorder among older adults. It is associated with cognitive impairment, which correlates highly with cerebrovascular disease and other central nervous system disorders. Compared to early-onset bipolar disorder, late onset is less likely to be associated with a family history of mood disorders. There appears to be an association between late onset and longer episodes of illness, with shorter intervals of mood stability between episodes. Late-life mania frequently is secondary to medications, drug-drug interactions, and medical illnesses. The morbidity and mortality associated with late-life mania often is high. Compared with geriatric unipolar depression, less is known about treatment effects and neurobiology of late life bipolar disorder, yet individuals with early onset bipolar disorder continue to experience relapsing syndromes of mania and depression into later life with significant functional consequences. Onset in later-life accounts for approximately 10% of bipolar disorder among older adults. It is associated with cognitive impairment, which correlates highly with cerebrovascular disease and other central nervous system disorders. Compared to early-onset bipolar disorder, late onset is less likely to be associated with a family history of mood disorders. There appears to be an association between late onset and longer episodes of illness, with shorter intervals of mood stability between episodes. Manic episodes are more frequently due to medications, drug-drug interactions, and medical illnesses in late-onset bipolar disorders. The morbidity and mortality associated with late-life mania is also high.

Alexopoulos GS. Late-life mood disorders. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 609- 654.

Forester BP, Antognini F, Kim, S: Geriatric Bipolar Disorder. In: Agronin ME, Maletta GJ, eds. Principles and Practice of Geriatric Psychiatry. 2 nd Edition. Lippincott Williams & Wilkins; 2011 423-449.

Young RC, Klerman GL. Mania in late life: focus on age at onset. Am J Psychiatry. 1992; 149(7):867-876. 19-6. Which one of the following is true about the relationship between late-life depression and disability? a. Depressed elderly persons have a poorer prognosis following a disabling illness b. Disability is associated with poor outcome of treatment of depression c. Functional disability is impacted more by most major medical conditions than by depressive symptoms d. Medical rehabilitation is ineffective for disabled, depressed elderly persons e. Executive dysfunction has little impact on treatment outcomes

Rationale: Depression is common in disabled elderly persons and causes excess disability in conditions such as stroke and arthritis. Depression amplifies physical symptoms and disability. Recovery from conditions such as hip fracture, stroke, and cardiac disease is less successful in depressed elderly, but medical rehabilitation is effective and also may improve depression. Similarly, treatment of depression in disabled persons is effective and may improve disability. The mediators of the relationship between depression and disability include executive dysfunction.

Blank K, Kennedy GJ, Lantz MS, et al. Impact of late-life depression. In: Blank K, Kennedy GJ, Lantz MS, Watson LC, eds. Late-Life Depression: Progress and Hope. Lessons Learned From Geriatric Psychiatry. Bethesda, MD: American Association for Geriatric Psychiatry; 2004: 8-11.

Lenze EJ, Rogers JC, Martire LM, et al. The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry. 2001; 9(2):113-135. 19-7. Which one of the following statements about the mortality rate for elderly patients with bipolar disorder is true? a. It is higher than for late-life unipolar depression b. It is lower than for late-life unipolar depression c. It is the same as the community base rate for this age group d. It is the same as for late-life unipolar depression e. It has no effect on recovery from myocardial infarction and cardiovascular accidents

Rationale: The mortality rate for elderly patients with bipolar disorder is greater than the community base rate for this age group and exceeds the rate for late-life unipolar depression.

Alexopoulos GS. Late-life mood disorders. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 609- 654.

Dhingra U, Rabins PV. Mania in the elderly: a 5-7 year follow-up. J Am Geriatr Soc. 1991;39(6):581-583.

Forester B, Antognini FC, Stoll A. Geriatric bipolar disorder. In: Agronin ME, Maletta GJ, eds. Principles and Practice of Geriatric Psychiatry. New York: Lippincott Williams & Wilkins; 2006: 369-391. Forester BP, Antognini F, Kim, S: Geriatric Bipolar Disorder, in Principles and Practice of Geriatric Psychiatry. 2nd Edition. Edited by Agronin ME, Maletta GJ, Lippincott Williams & Wilkins, 423-449, 2011. 19-8. Which one of the following statements is true regarding the Geriatric Depression Scale (GDS)? a. Assigns scores of 0 for “not at all” to 3 for “nearly every day” b. Is focused on somatic and vegetative symptoms c. Is not validated in psychiatric settings d. Is a screening instrument for late-life depression e. Is a scale of 15- and 30-item versions for self or caregiver administration

Rationale: The GDS is a self-report scale with both a 30-item and a 15-item version. It is designed in a yes/no format and has been found to be valid when compared with the Hamilton Depression Rating Scale and the Zung Self-Rating Depression Scale. The GDS minimizes questions about somatic and vegetative symptoms and has been validated repeatedly in psychiatric settings. The GDS is a preferred screening instrument for late-life depression.

The recommended option is d.

Blank K, Kennedy GJ, Lantz MS, Watson LC. Diagnosis. In: Blank K, Kennedy GJ, Lantz MS, Watson LC, eds. Late-Life Depression: Progress and Hope. Lessons Learned From Geriatric Psychiatry. Bethesda, MD: American Association for Geriatric Psychiatry; 2004: 12-25.

Watson LC, Pignone MP. Screening accuracy for late-life depression in primary care: a systematic review. J Fam Pract. 2003;52(12):956-964. 19-9. Which one of the following statements is true about depression in elderly persons with Parkinson’s disease (PD)? a. Apathy and social withdrawal in PD patients are diagnostic of depression and are not related to motor symptoms b. Degeneration of subcortical nuclei, including the serotonergic raphe nuclei, is thought to be an etiology of depression in PD c. Electroconvulsive therapy (ECT) has been shown to produce long-lasting relief of both depression and motor symptoms d. The prevalence of depressive symptoms in PD is about 10% e. Treatment with L-dopa is associated with increasing mood stability

Rationale: Depression is common in PD (estimates of clinically significant depressive symptoms are 50% or more) and may be due to degeneration of subcortical nuclei. In addition, treatment with antiparkinsonian agents may cause depression or mood instability. ECT has been shown to produce transient relief of both depressive and motor symptoms in patients with PD, but ongoing pharmacologic therapy typically is required. Making a diagnosis of depression in PD is difficult because symptoms such as fatigue, apathy, and social withdrawal may be related to the motor symptoms of PD irrespective of mood state.

Blazer DG, Steffens DC, Keoing DH. Mood Disorders. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 275-299

McDonald WM, Richard IH, DeLong MR. Prevalence, etiology, and treatment of depression in Parkinson’s disease. Biol Psychiatry. 2003; 54(3):363-375. 19-10. Which one of the following statements is true about psychotic depression in elderly persons? a. Cerebrovascular risk factors are more commonly associated with psychotic than nonpsychotic depression b. Delusions commonly are somatic in nature, such as having cancer or being unable to eat c. Hallucinations occur more than delusions among depressed elderly d. Psychotic depression occurs in 20% to 45% of elderly persons in primary care settings e. Treatment outcome with antidepressants is better than with electroconvulsive therapy (ECT)

Rationale: Major depressive disorder with psychotic features in late life typically is associated with delusions rather than with hallucinations. Individuals with delusional depression tend to be older and respond well to ECT, as opposed to antidepressant medication alone. Older adults with major depression with psychotic features are more likely to require inpatient hospitalization and ongoing psychiatric treatment. Somatic delusions are common, including having an incurable illness or being unable to eat or swallow food. Cerebrovascular risk factors predispose an older adult to syndromes including executive dysfunction, vascular depression, and dementia, but have no significant association with psychotic features. Recently Ccombination therapy with olanzeapine and sertraline was shown to be superior to olanzeapine with placebo in a double blind trial for both older and younger adults with psychotic depression.

Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003; 58(3):249-265.

Blazer DG, Steffens DC, Keoing DH. Mood Disorders. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 275-299___

Meyers BS. Late-life delusional depression: acute and long-term treatment. Int Psychogeriatr. 1995;7 Suppl:113-124. Meyers BS, Flint JA, Rothschild AJ, et al. A Double-blind Randomized Controlled Trial of Olanzapi ne Plus Sertraline vs Olanzapine Plus Placebo for Psychotic Depression. : Arch Gen Psychiat ry. 2009;66(8):838-847 19-11. Which one of the following statements is true when comparing depressed and nondepressed elderly patients? a. Family members report an increased burden of care when a relative suffers from depression b. In the nursing home environment, utilization of services is uniform for both groups c. In the primary care setting, the number of medical appointments is similar d. Rates of medical hospitalizations and length of stay are comparable e. Testing, referrals, and procedures conducted in office settings prove more effective in the treatment of the depressed elderly patient

Rationale: Depression is linked to increased utilization of medical services. Vague complaints and poor compliance with treatment results in increased medical visits, tests, referrals, hospitalizations, and procedures, which typically prove ineffective. Frequency of hospitalization is comparable for both groups while the length of stay per admission was more than twice for depressed patients. In the nursing home environment, depression significantly increased demands on nursing care time. Among family members who care for older depressed relatives, significant expense, time expenditure, stress, and impairment of physical and mental health is experienced by the caregiver.

Beekman AT, Deeg DJ, Braam AW, et al. Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychol Med. 1997;27(6):1397-1409.

Blank K, Kennedy GJ, Lantz MS, Watson LC. Impact of late-life depression. In: Blank K, Kennedy GJ, Lantz MS, Watson LC, eds. Late-Life Depression: Progress and Hope. Lessons Learned From Geriatric Psychiatry. Bethesda, MD: American Association for Geriatric Psychiatry; 2004: 8-11. Additional questions:

19-12. What is the estimated prevalence of bipolar disorder in community dwelling patients 65 years or older?

a. <1%

b. 1-2%

c. 3-4%

d. 5-6%

e. 7-8%

Rationale: Several studies have shown that the prevalence of bipolar disorders may decrease with aging. In community samples, the prevalence of bipolar disorders is estimated to be less than 1 %. These studies have been criticized for not including institutionalized patients, hence, potentially under estimating prevalence. The prevalence of bipolar disorder is much higher among older patients in nursing homes and other institutions.

Beyer JL. Bipolar Disorder in Late Life. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009: 301-315

Depp CA, Jeste DV: Bipolar disorder in older adults: a critical review. Bipol Disor. 2004; 6:343–367

Unutzer J, Simon G, Pabiniak C, et al: The treated prevalence of bipolar disorder in a large staff-model HMO. Psychiatr Serv.1998; 49:1072–1078 19-13. Which of the following is not true about epidemiology of bipolar disorders in older adults?

a. The prevalence is equal among males versus females.

b. Comorbid personality disorders are not common in older bipolar patients.

c. Neurological disorders are common.

d. Late-onset maina accounts for 10% of all bipolar disorders.

Rationale: Medical and neurologic disorders are more commonly seen in older bipolar patients, than age matched controls. It is also estimated that 10% of mania has its onset late in life, although most commonly bipolar disorder first manifests in early adulthood. Although nearly 70% of older bipolar patients are female, this is largely a reflection of the sex ratio in this age group. When corrected for the population sex ratio, prevalence of bipolar disorders is comparable among men and women. Personality disorders, on the other hand, are very common in patients with bipolar disorder, seenidentified as a co-morbid condition in over 60% of patients.

The recommended option is cb.

Beyer JL. Bipolar Disorder in Late Life. In: Blazer DG, Steffens DC eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2009:301-315___

Depp CA, Jeste DV: Bipolar disorder in older adults: a critical review. Bipol Disor. 2004; 6:343–367