aga2006 hall 3

Depression Presenting as Gastrointestinal Symptoms in the Older PatientKaren E. Hall, M.D., Ph.D.Clinical Assistant Professor Division of Geriatric MedicineUniversity of Michigan, Ann Arbor VAMC: 

Depression Presenting as Gastrointestinal Symptoms in the Older Patient Karen E. Hall, M.D., Ph.D. Clinical Assistant Professor Division of Geriatric Medicine University of Michigan, Ann Arbor VAMC

Objectives: 

Objectives Recognize abdominal pain as a significant symptom of depression in older adults Make a diagnosis of depression when appropriate Consider treatment for depression in the management of chronic unexplained abdominal pain

Aging of the Population: 

Aging of the Population By 2010: 18-20% of population will be aged 65 years or older “All” gastroenterologists will see geriatric patients in their practice with the following complaints: Abdominal pain Weight loss Early satiety or bloating

What is the cause of the pain?: 

What is the cause of the pain? “Structural pathophysiology” Ulcer Mass/neoplasm Biliary Diverticulitis Ischemia “Functional” IBS Dyspepsia …………………………….. Depression?

Depression: 

Depression Prevalence increases with age

Prevalence of IBS: 

Prevalence of IBS Prevalence of IBS symptoms defined by 2 or 3 Manning criteria (Manning 2 or Manning 3) or the Rome I and II criteria in 5000 randomly selected adults Hillia and Farkkila Alimentary Pharmacol and Therapeut 20:339-45, 2004

IBS and Depression : 

IBS and Depression Abdominal pain : 27-30% Manning 2 or 3 IBS patients 44% of Rome I and II Depression: 30.6% in Manning 39.3% in Rome I and II Rome I and II criteria define a subset of IBS patients with more severe abdominal pain and greater likelihood of depression

Rome III : 

Rome III Rome III: subdivide Functional Dyspepsia into new categories: Abdominal Bloating and Satiety Epigastric Pain Syndrome (EPS) “Continuous” pain No relation to bowel movements, menses, eating 3 months, with onset 6 months prior Clouse et al. Gastroenterology 130:1492-97, 2006

Rome III EPS Patients: 

Rome III EPS Patients Pain rated as severe “out of proportion” to objective assessments “Catastrophizing” is common Psychosocial distress Management geared to psychosocial coping strategies and non-narcotic medications Most literature is based on studies of patients < 65 years

Rome III Functional abdominal pain syndrome (FAPS): 

Rome III Functional abdominal pain syndrome (FAPS) May be primarily a disorder of CNS amplification of normal regulatory visceral signals, rather than a functional abnormality in the GI tract CNS acting agents may be more efficacious Drossman DA. Gastroenterology 130: 1377-90, 2006

Why should gastroenterologists diagnose depression?: 

Why should gastroenterologists diagnose depression? Important for gastroenterologists to recognize depression as a factor that may cause or intensify abdominal pain Important to make a “positive diagnosis” Similar to IBS – issues of abandonment if diagnosis is a “last resort” Drossman DA Gastroenterology 130:1377-90, 2006 Especially important if you are the second, third, fourth opinion!

Presentation of depression in the geriatric patient: 

Presentation of depression in the geriatric patient Young Old dysphoric mood (sad) anhedonia crying withdrawal anxiety somatization suicide attempts suicide completion

Interview: 

Interview Ask about depression: Ask about anhedonia and social withdrawal Sleep disturbance and poor food intake also common Helpful to use an assessment tool: Geriatric Depression Screen 15 item questionaire without “aches and pains” Positive score is > 5/15 Sensitivity 95%, specificity 90% Can be administered by non-MD Yesavage JA et al. J Psychiatric Res 17: 37-49, 1983

Interview: 

Interview Two item depression screen “Have you often during the past month felt down, sad or depressed?” “Have you often during the past month felt like giving up your usual social activities?” Sensitivity 80%, specificity 97% to “rule out” depression Useful for rapid “rule out” in situations where depression is assumed to NOT be likely

Interview: 

Interview Watch for non-verbal cues Flat affect “Uninterested” in the visit – doesn’t engage No smiles or jokes May become angry if questioned about depression Avoids answering questions or negotiates a “no” answer: “Isn’t it normal to be depressed when old?” If patient is equivocating or negotiating – interpret as a positive indicator

Anxious Depression: 

Anxious Depression Watch for anxiety Anxious depression (8-20% of depressed patients > 65 years) May endorse anxiety as the primary symptom, or family may describe patient as anxious Anxiety may manifest as somatization Primary Anxiety Disorder is rare in older patients Watch for “free floating anxiety” – patient shifts symptoms from one system to another as problems are discussed If patient is shifting symptoms or has “panic” symptoms – suspect anxiety disorder

Anxious Depression: 

Anxious Depression Compared to patients with pure depression, patients with anxious depression may: Be less likely to respond to single agent antidepressant Be likely to require more psychosocial intervention (frequent visits) Be harder to convince they are depressed Anxiety Disorder Suggest get a gero-psychiatrist involved

Plan: 

Plan Acknowledge fears or concerns (“cancer”) Review existing records/tests Explain why tests should or should not be repeated (especially endoscopy) If depression seems likely, include it in the differential on first visit “validation” of the diagnosis early will improve likelihood of successful treatment

Case: Abdominal Pain in 86 yr man: 

Case: Abdominal Pain in 86 yr man 86 year old man referred to Turner Geriatric GI clinic for additional opinion concerning his chronic abdominal pain Weight loss of 20 lbs over 6 months, persistent abdominal pain (epigastric) Not associated with meals, bowel movements, position Also complains of early satiety and has decreased his oral intake substantially Stomach always “feels full” Occasional nausea, no vomiting

Case : 

Case PH: HTN, hypothyroid x 10 years, atrial fibrillation, BPH Medications: Synthroid 100 micrograms Lisinopril 10 mg Digoxin 125 micrograms Protonix 40 mg x 6 months ASA 81 mg Coumadin Multivitamin

Case : 

Case Lives in Traverse City (4 hours from Ann Arbor where he was seen) Married 52 years, retired engineer, 3 children Independent in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) Has felt “tired” – has been avoiding social functions because it is “too much effort” Disturbed sleep

Case : 

Case Px: Vitals BP 145/68 pulse 76, afebrile No cardiopulmonary findings, pulses full No tremor or slow reflexes No abdominal mass or aneurysm No edema Rectal: soft stool, negative for OB Geriatric Depression Scale positive (11/15) with multiple indicators of social withdrawal and hopelessness

Case : 

Case Has been seen by GP multiple times 2 gastroenterologists 2 EGDs with biopsies of stomach and small bowel – negative Colonoscopy with negative biopsies – diverticuli CT with contrast – no masses MRI – no masses Air contrast barium enema - normal Labs – normal lipase, renal, LFTs

Case : 

Case Reviewed available records Discussed differential with patient and wife: 1. Ischemia – possible (MRA) 2. Occult pancreatic or retroperitoneal mass – possible but pain had been present for 6 months and recent MRI negative 3. Medication – Digoxin (level, K+, EKG) doesn’t explain pain 4. Neuropathic (paraneoplastic or degenerative) – CXR, PSA, CBC

Case : 

Case 5. Depression – positive GDS, high index of suspicion that depression is augmenting pain symptoms Physicians and patient endorsed depression as a contributing factor to pain – recommended treatment “Treating depression does not mean abandoning patient or dismissing other possible causes”

Slide26: 

It may take 4-6 weeks for treatment of depression with medication to be fully effective So – starting early is beneficial

Antidepressants for abdominal pain: 

Antidepressants for abdominal pain Paucity of data in geriatric patients with Rome III B1a: “Postprandial distress syndrome” or B1b: “Epigastric pain syndrome” Studies of neuropathic pain or IBS in younger patients TCA: amitriptyline (Elavil), desiprimine SSRI or SNRI: duloxetine (Cymbalta) fluoxetine (Prozac), paroxetine (Paxil) Drossman DA. Gastroenterology 130: 1377-90, 2006 Drossman DA et al. Gastroenterology 125:19-31, 2003 Creed F et al. Gastroenterology 124:303-317, 2003

Antidepressants for geriatric patients: 

Antidepressants for geriatric patients TCA: extremely anticholinergic amitriptyline (Elavil) is the worst nortriptyline (Pamelor) is the least (but still associated with significant symptoms) Very effective in severe depression Several trials in chronic pain syndromes and IBS BPH limited our use of TCA in this patient

Antidepressants for geriatric patients: 

Antidepressants for geriatric patients SSRIs: better tolerated than TCA in geriatric patients Fluoxetine (Prozac) is “activating” and may increase anxiety in anxious depression Paroxetine (Paxil) and mirtazepine (Remeron) are sedating, Remeron is prophagic but not tested for use in pain syndromes Venlafaxine (Effexor) and sertraline (Zoloft) are moderately activating, Zoloft associated with diarrhea and anorexia Citalopram (Celexa) has few interactions with other meds, known complication: hyponatremia

Citalopram (Celexa) for abdominal pain: 

Citalopram (Celexa) for abdominal pain Used to treat pediatric recurrent abdominal pain 12 week open label trial in 25 patients (7-18 years) 84% decreased Clinical Global Impression Scale-Improvement to < 2 (1=very much improved; 5=very much worse) Campo JV et al. J Amer Acad Child Adolescent Psych 43:1234-42, 2004

Case : 

Case Sleep an issue: Started paroxetine (Paxil) 10 mg qhs x 1 week then 20 mg ghs Warned family to monitor suicidality Removed guns from the house Digoxin level toxic (2x upper limit of normal) Held dig and restarted at lower dose Mild nausea resolved in 3 days, but pain still present for 3 weeks then slowly decreased

Case : 

Case On return visit 6 weeks later pain was “almost gone” Review of additional tests were reassuringly negative Patient referred back to PCP for follow-up of endogenous depression Anticipate a minimum of 6-12 months treatment (likely longer)

Final Word: “But I’m not a psychiatrist” : 

Final Word: “But I’m not a psychiatrist” If you are not comfortable initiating treatment for depression: Extremely helpful to document signs of depression, and make a positive diagnosis for the primary physician Save patient unnecessary tests and risk You may save a life by identifying depression and preventing a suicide – geriatric patients have the highest successful suicide completion rate

Slide34: 

Talk will be on my website after DDW: http://sitemaker.umich.edu/khallinfo Contact info: kehall@umich.edu

Case 2: Anxious depression: 

Case 2: Anxious depression 77 woman brought in by daughter because “everything hurts, especially her stomach” Pain in abdomen moves around, no association with bowel movements Patient very concerned it might be cancer (husband died of colon cancer) On ROS also has chest pain, SOB, headache, joint pains, chronic low back pain, itching skin, concerning skin lesions House officer felt “trapped” in room – “just one more thing”

Case 2: Anxious depression: 

Case 2: Anxious depression Daughter: “Mother is a worrier” PH: HTN, OA, OP, basal cell ca, hysterectomy, possible diverticular disease (treated with antibiotics for LLQ pain) Medications: HCTZ, amilodipine, fosamax, calcium + vitamin D, ASA, ibuprofen, acetaminophen + codiene 4-6 per day, alprazolam (Xanax) 0.5 mg “for sleep” qhs

Case 2: Anxious depression: 

Case 2: Anxious depression SH: husband died 3 years ago of metastatic colon cancer Lives alone, doing her ADLs, needs help with some IADLs: laundry, cleaning, transport (doesn’t drive) Calls daughter daily with concerns Daughter is worried patient not remembering that she called, patient losing ability to do gardening and laundry – “forgets things”

Case 2: Anxious depression: 

Case 2: Anxious depression During interview patient forgets answers to questions and repeats questions Appears anxious Difficult to elicit details about other issues: patient perseverates on pain and other somatic symptoms Difficulty sleeping Denies “depression” or decreased appetite

Case 2: Anxious depression: 

Case 2: Anxious depression Px: no significant findings, no masses, firm stool in rectum negative for OB, no tremor Mini Mental Status Exam: 23/30 0/3 on short term recall 6/10 orientation Could do “serial 7s” Not typical pattern of dementia – appeared to have impaired concentration GDS: difficult as patient continually negotiated negative answers

Case 2: Anxious depression: 

Case 2: Anxious depression Suspected anxious depression Also signs of memory impairment – suspect Xanax contributing to forgetfulness Recommendations: Taper Xanax (over 2 weeks) Hold fosamax (unlikely to be causing pain but can cause esophagitis) TSH, usual labs, screening colonoscopy Endorsed anxiety as a symptom of depression Paxil10 mg (avoid activating SSRIs like fluoxetine)

Case 2: Anxious depression: 

Case 2: Anxious depression Follow-up visits: q2 weeks x 3 Negative colonoscopy Memory improved (MMSE 28/30 – still missing 2/3 STR ?early dementia?) Still very anxious – “Can’ sleep” Started trazodone (Desyrel) 50 mg qhs (anxiolytic antidepressant) Refered to geropsychiatrist (took several visits to convince her to go)

Final Word: “But I’m not a psychiatrist” : 

Final Word: “But I’m not a psychiatrist” If you are not comfortable initiating treatment for depression: Extremely helpful to document signs of depression, and make a positive diagnosis for the primary physician Save patient unnecessary tests and risk You may save a life by identifying depression and preventing a suicide – geriatric patients have the highest successful suicide completion rate

Slide43: 

Talk will be on my website after DDW: http://sitemaker.umich.edu/khallinfo Contact info: kehall@umich.edu