# 002 Assessing Post-Stroke Depression in Elderly

Fast Facts and Concepts #002 PDF

Authors: Catherine Tsufis, Steven Denson MD, John McGuire MD, Mark Wright MD, Judith Kosasih MD, Bambi Wessel

Objectives: Recognize and assess post-stroke depression in elderly patients. 

Context: Geriatric Stroke Patient Follow-Up Visit

Action: Assessment of post-stroke depression (PSD) is a complex task that does not lend itself to a single evaluation tool. Research has shown that a self-administered mood scale or interview-administered questionnaires can identify depressive symptoms.

ACGME Competencies: Patient care, Medical knowledge

Underlying Science: The physiological and biochemical causes of post stroke depression are unclear, and are thought to be multifactorial.  It is theoretically tied to either direct ischemic or collateral damage to the left frontal lobe.  Other theoretical causes of depression and PSD include availability and receptor sensitivity to serotonergic and noradrenergic neurotransmitter systems within the brain.

Incidence/Prevalence: The incidence of depressive symptoms within 6 months to 2 years post-stroke is estimated at over 33%¹. Patients who have suffered transient ischemic attacks (TIAs) may also be at an increased risk for depression². Abnormal mood may impede functional recovery by impairing physical and cognitive function³. Post-stroke depression (PSD) may also be associated with an increased risk of death, including death by suicide. Elderly post-stroke patients must be evaluated frequently at each scheduled visit as a preventative measure and to determine underlying etiology if changes. Risk Factors for PSD include a prior history of stroke or psychiatric illness, female gender, living alone, premorbid reduced socialization, intellectual/language/ functional impairment, lesion laterality, duration from time of stroke (<6 month, high risk), and generalized cortical atrophy⁴.

Depression Assessment:

1. Clinical Assessment Tools

• Self-Administered Mood Scale: These assessments include the Beck Depression Inventory and PH-9 questionnaire. Patients answer a short series of questions assessing common depression symptomatology.
  • Beck Depression Inventory http://www.fpnotebook.com/psych/exam/bckdprsninvntry.htm
  • PHQ-9 http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/

Interviewer-Administered Questionnaires: These assessments include the Hamilton Depression Rating scale and Clinical Global Impression scale. The questionnaires are administered by a primary health care provider or psychiatrist at scheduled visits.

• Hamilton Depression Rating Scale http://healthnet.umassmed.edu/mhealth/HAMD.pdf
• Clinical Global Impression-

http://miksa.ils.unc.edu/unc-hit/media/CGI.pdf

• Other: The DSM-IV criteria has demonstrated acceptable sensitivity and specificity in diagnosing PSD⁵
  • DSM-IV criteria

http://www.mental-health-today.com/dep/dsm.htm

2. Common Symptoms of PSD

1. Depressed mood: feeling apathetic, sad, helpless, hopeless
2. Feelings of guilt: a common symptom of major depressive episodes that may not be present in PSD patients
3. Suicide: thoughts or attempts, homicide
4. Insomnia hypersomnia: difficulty falling sleep (early), difficulty staying sleep (middle), or waking early in the morning (late)
5. Work & activities: loss of interest in daily activities, loss in ability to work, loss of enjoyment in activities (anhedonia)
6. Psychomotor retardation: slowness of thought and speech, impaired ability to concentrate, decreased motor activity
7. Agitation & Irritability: fidgeting, hand-wringing, nail-biting
8. Anxiety: psychological (fears, worrying) and somatic (sweating, indigestion, stomach cramps, diarrhea, palpitations, hyperventilation, paresthesia, flushing, tremor, headache)
9. Somatic symptoms: GI (loss of appetite, weight loss) or general (back aches, heaviness in limbs, headache, muscle aches)
10. Sexual symptoms: loss of libido, impaired performance

3. Differential Diagnosis Assessment:

1. It is important to consider apathy in the differential diagnosis of PSD. Apathy is common in PSD patients and may be mistaken for PSD. The apathy inventory (AI) is a valid & reliable assessment in diagnosing apathy⁶

http://www.cmrr-nice.fr/doc/IA_tous_en.pdf

1. Cognitive deficits
2. Fatigue
3. Anosognosia-lack of awareness, denial or underestimate of sensory, cognitive of affective impairment (60% in R-CVA, 24% L-CVA)
4. Poststroke Anxiety Disorder (highly comorbid with PSD, up to 75%⁸)

• Pseudobulbar affect (affective disinhibition syndrome)
• Vascular Depression ( associated with cerebrovascular disease (silent strokes)

Other:

• Mood disorder due to generalized condition
• Substance induced mood disorder
• Dysthymic disorder
• Unrecognized schizoaffective disorder
• Dementia

REFERENCES:

1. Hackett, ML, Anderson, CS. (2005). Predictors of depression after stroke: A systematic review of observational studies Stroke. 36(10), 2296-2301.
2. Luijendijk HJ. Stricker BH. Wieberdink RG. Koudstaal PJ. Hofman A. Breteler MM. Tiemeier H. (2011). Transient ischemic attack and incident depression. Stroke. 42(7), 1857-61.
3. Mikami K. Jorge RE. Adams HP Jr. Davis PH. Leira EC. Jang M. Robinson RG.(2011) Effect of antidepressants on the course of disability following stroke. American Journal of Geriatric Psychiatry. 19(12):1007-15.
4. Andersen G, Vestergaard K Ingemann-Nielsen M, Lauritzen L.(1995). Risk factors for Post-Stroke Depression. Acta Psychiatry. Scand. 92(3), 193-8.
5. Berg, A, Lonnqvist J, Pahomaki H, Kaste M.(2009). Assessment of Depression After Stroke: A Comparison of Different Screening Instruments. Stroke. 40:523-529.
6. Robert PH, Clairet S, Benoit M, Koutaich J, Bertogliati C, Tible O, Caci H, Borg M, Brocker P, Bedoucha P.(2002) The Apathy Inventory: assessment of apathy and awareness in Alzheimer’s disease Parkinson’s disease and Mild cognitive impairment. International Journal of Geriatric Psychiatry, 17: 1099 – 1105.
7. Hackett ML, Anderson, CS, House A, Halteh C. (2008). Interventions for Preventing Depression After Stroke. Cochrane Database Syst. Rev. July 16 (3) CD003689.
8. Åström M. (1996) Generalized Anxiety Disorder in Stroke Patients: A 3-Year Longitudinal Study. Stroke. 27:270-275.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation:  Catherine Tsufis, Steven Denson MD, John McGuire MD, Mark Wright MD, Judith Kosasih MD, Bambi Wessel - Fast Fact #2: Assessing Post-Stroke Depression in Elderly. September 2012, Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

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