aga annual meeting may 2006 depression presenting as gastrointestinal symptoms in the older patient...

AGA Annual MeetingMay 2006

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


Aging of the PopulationAging of the Population

By 2010: 18-20% of population will be aged 65 By 2010: 18-20% of population will be aged 65 years or olderyears or older

““All” gastroenterologists will see geriatric patients All” gastroenterologists will see geriatric patients in their practice with the following complaints:in their practice with the following complaints: Abdominal painAbdominal pain Weight loss Weight loss Early satiety or bloatingEarly satiety or bloating


DepressionDepression

Prevalence increases with agePrevalence increases with age

0

5

10

15

20

25

30

%

GeneralPopulation

Age > 65

Age > 65 inNursing Home


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

02468

101214161820

%

IBS

Manning 2

Manning 3

Rome I

Rome II


Rome III Functional abdominal pain Rome III Functional abdominal pain syndrome (FAPS)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?

Important for gastroenterologists to recognize Important for gastroenterologists to recognize depression as a factor that may cause or intensify depression as a factor that may cause or intensify abdominal painabdominal pain

Important to make a “positive diagnosis”Important to make a “positive diagnosis”Similar to IBS – issues of abandonment if Similar to IBS – issues of abandonment if

diagnosis is a “last resort”diagnosis is a “last resort”Drossman DA Gastroenterology 130:1377-90, 2006Drossman DA Gastroenterology 130:1377-90, 2006

Especially important if you are the second, third, Especially important if you are the second, third, fourth opinion!fourth opinion!


Presentation of depression in the Presentation of depression in the geriatric patientgeriatric patient

Young Old

dysphoric mood (sad) anhedoniacrying withdrawal

anxietysomatization

suicide attempts suicide completion


InterviewInterviewAsk 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-MDYesavage JA et al. J Psychiatric Res 17: 37-49, 1983


InterviewInterview

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


InterviewInterview

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 DepressionAnxious DepressionWatch 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 patientsWatch 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 DepressionAnxious 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 DisorderSuggest get a gero-psychiatrist involved


PlanPlan

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 manCase: Abdominal Pain in 86 yr man

86 year old man referred to Turner Geriatric GI clinic for additional opinion concerning his chronic abdominal painWeight 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”


It may take 4-6 weeks for treatment of depression with medication to be fully effective

So – starting early is beneficial


Antidepressants for abdominal painAntidepressants 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 patientsAntidepressants 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 patientsAntidepressants 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 painCitalopram (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


Talk will be on my website after DDW:

http://sitemaker.umich.edu/khallinfo

Contact info:

[email protected]


Case 2: Anxious depressionCase 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”



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



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”



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



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



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)



Follow-up visits: q2 weeks x 3Negative 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


Talk will be on my website after DDW:

http://sitemaker.umich.edu/khallinfo

Contact info:

[email protected]

aga annual meeting may 2006 depression presenting as gastrointestinal symptoms in the older patient...

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