E12 - Don't Forget About the Neurocognitively Impaired Populations

Explore the intersection of depression and neurocognitive disorders in elderly patients. The discussion highlights the challenges in differentiating between depression and apathy, the importance of accurate diagnosis, and the appropriate pharmacological considerations for treatment. Join us as we delve into the complexities of mental health in the aging population.

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Transcript

Thanh: 0:01

Welcome to the Y in Psychiatry!

Dr. Amayo: 0:03

Hi, this is Dr. Amayo C/L fellow.

Thanh: 0:06

Where we delve into the intricate nuances of psychiatric topics.

Dr. Handratta: 0:09

My name is Dr. Handratta attending psychiatrist. I did my residency from University of Connecticut and then I did my fellowship from Georgetown University in consultation and liaison.

Thanh: 0:19

Each episode features interview style discussions that explore the intersection of the mind medicine and the human experience. Together we'll uncover the hidden why and the groundbreaking discovery shaping the psychiatric landscape. So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche. Only on The Y in Psychiatry.

Dr. Amayo: 0:47

Welcome back to the Y in psychiatry. Today we'll be talking about depression and neurocognitive disorders. So when I'm seeing a patient with Parkinson's disease or a patient with some form of dementia, I've noticed that it is hard to tell if they have depression or their mental status exam is just a continuation of their disease process. So I guess my question today to is how depression or disease how can you tell the difference in this population?

Dr. Handratta: 1:07

So that's a very good question. A lot of people get confused between depression and dementia, and patients with dementia can also have depression. And you talked about two separate population, Alzheimer's, dementia, and Parkinson's disease. In Parkinson's disease, it's very difficult actually to say whether the patient's lack of facial emotion, the mask face. Is because the disease or the patient actually has depression. So one thing that I tell people and I like usually tell my residents, medical student and my fellows is that the type of skills that you're going to use will make a difference. So in our population who doesn't have dementia, and in the younger population we use PHQ9. PHQ nine actually has a lot of questions on the neuro, which data symptoms. If you use PHQ nine in an elderly population that has dementia, then it becomes confusing because you can get false positive. Because as we age, we will actually accumulate a lot of those neurovegetative symptoms, right? Decreased energy, problem with sleep, problem with appetite slowing up our psychomotor activity. So we use something called as a geriatric depression scale. Because geriatric depression scale focuses more on the affective symptoms rather than the neurovegetative symptoms. So it's usually scored out of 15, anything, five and above is considered to be positive. And when you're scoring the geriatric depression scale, you have to look at the instruction because some of them are scored in the reverse way. So this is just a yes and no question. So it's very important actually, what kind of scales you're using. Now when you see a patient with dementia who also complain of depression. So you have to treat the underlying depression because if you don't treat the underlying depression, it's going to lead to a poor prognosis. It can lead to a rapid decline in the cognitive functioning, plus it can decrease the quality of life for the patient as well as for the caregiver. Plus it also increases the risk of institutionalization, so it's extremely important actually to diagnose depression in patients with dementia and treat it accordingly to improve the quality of life. Okay. Did I answer the question?

Dr. Amayo: 3:19

So to help differentiate depression from neurocognitive disorder, you're saying we should use the geriatric depression scale which is a scale that's got out of 15 five and above is positive, and it's also important to treat depression in this population cause not using depression, at least to worse outcomes? Poor cognitive function, harder for the caregivers and just overall poor prognosis. And then my next question is, I know apathy is a significant problem in this population and sometimes it's hard for me to differentiate between apathy and depression. Why? Why is that?

Dr. Handratta: 3:49

So apathy is actually a lack of motivation. It's a lack of motivation for goal-directed behavior. For example, goal-directed behavior is the inability of the patient to start a conversation. Doing basic task in life. So they will have a decreased motivation for this goal-directed behavior. They'll have decreased motivation for goal-directed cognitive activities like lack of ideas, curiosity, when they're in a social setup. And there's also a decrease in the emotion. They don't respond to positive as well as negative events. So a lot of times family members actually look at the patient and say that, Hey, they're not showing any emotions at all. Most likely this is depression. ANd they actually come to the provider because the main complaint is that the patient is not engaging in day-to-day activities. So naturally it means that the patient is depressed. And a lot of times physicians get confused and they basically treat the patient like they have depression.

Dr. Amayo: 4:43

But, but it is not quite depression, but it's like depression?

Dr. Handratta: 4:46

Yes. Because the geriatric depression score will be negative in these patients because they're not depressed. They just have a decrease in the motivation to do everything. Lack that motivation. Theyll lack that umph, basically. And we'll talk actually about the areas of the brain that can get involved.

Dr. Amayo: 5:02

Yeah. I guess in, and this is specific to this population, so if I get a 20 year old with apathy-like symptoms would it matter as much if I give them an SSRI, if I just treat them as depression? Or does, or do I need to still worry about is this depression or is this apathy in that population?

Dr. Handratta: 5:17

That's a great question. So younger population, when you use an SSRI or SNRI especially SSRI, as you increase the dose of SSRI. Serotonin and dopamine work against each other. So when you increase the serotonin too much, there's a neural mechanism that is involved: the ventral tegmental area, which is actually a dopaminergic center in the midbrain. Yeah. That usually sends dopaminergic signals into your nucleus accumbens. That's a mesolimbic pathway. And to your cerebral cortex, that is a mesocortical pathway. So the meso limbic pathway, the dopaminergic system will be affected if there's too much serotonin in the system. So you can actually induce apathy in a younger population if you use a very high dose of s rri, or they have a polymorphism in one of their serotonin receptors in the ventral tegmental area.

Dr. Amayo: 6:04

So that is why SSRI caused that mutant effect, that's a side effect of SSRI when they feel like everything is dull and nothing is as exciting. Okay? So that's why that happens. And so in let's, so how can we differentiate apathy from depression in our older population?

Dr. Handratta: 6:19

So the best way actually to treat a patient in psychiatry is using scales. And also the scales help you to know how you are how the patient is responding to the treatment, right? So we know that for the depression, we use geriatric depression score scale. Yep. For apathy, there's something called an apathy evaluation scale, right? So when a family member complains of, like a lack of motivation. The patient doesn't do anything, so I, what I do is that I also introduce the a apathy evaluations scale. It's out of 72, so the score is between 18 to 72. Higher the score more is the apathy. Then now apathy and depression. They can also coexist. Or they can be two separate entities.

Dr. Amayo: 7:02

Of course, right? Make my job harder.

Dr. Handratta: 7:05

Now, it's very important to differentiate between the two because they look very similar, but the treatment is very different. The neural circuitry that is involved in depression and the neuro circuitry involved in apathy are very different. So one of the problem is that if you treat depression, and you ignore apathy. Now, suppose that the patient had apathy, but you misdiagnosed depression and use an SSRI or SNRI. seRotonergic Drugs can make apathy worse. so when they have apathy, you basically use a dopaminergic agent or you use a cholinesterase inhibitor. So research data shows that when you use cholinesterase inhibitor, it increases the activity in your ventral striatum. There's a nucleus accumbens, the reward center of the brain. So a lot of times when the patient has Alzheimer's dementia and you're using a cholinesterase inhibitor, it can help with apathy. Please don't use cholinesterase inhibitors in frontal temporal dementia because apathy is also seen in front of temporal dementia because they have no cholinergic deficit, so you cannot use a cholinesterase inhibitor, frontal temporal dementia. That is one thing I want people to actually take home, you can use choline inhibitor in other condition, but not to treat apathy in patients with frontotemporal dementia. Ok. So patients will have dementia, especially like in patients with Alzheimer's dementia. The approximate prevalence rate of apathy in Alzheimer's dementia is about 80%. Very high right. Apathy can also be seen in patients who have subcortical dementia, like Parkinson's disease, dementia, right? Or patients with subcortical stroke can also actually have apathy.

Dr. Amayo: 8:36

Is there a medication for those patients?

Dr. Handratta: 8:38

The best thing to use is go for a dopaminergic agent like you can use bupropion or you can use a stimulant. If there's no cardiac contraindication or the patient doesn't have seizures, then you definitely can use a stimulant in elderly population. Methylphenidate is a preparation that has been studied for the treatment of depression as an augmentation strategy in elderly patients. But again, there is no clinical trial. There's no FDA approved medication to treat apathy.

Dr. Amayo: 9:06

That makes sense. Yeah. Okay. Lemme see if I get it straight. Especially in our elderly population, it's significant. It's important for us to differentiate between apathy and depression because sometimes our common antidepressants don't work if they have apathy, I, we give them an SSRI or an SNRI can worsen the apathy And one way to help differentiate apathy is using the apathy evaluation scale. And then especially in this population cholinesterase inhibitors for patients with, say, Alzheimer's or a neurocognitive disorder. Cholinesterase inhibitors helps with apathy as well as dopamine agents like buproprion, and in some cases stimulants however, for the cholinesterase inhibitors to be careful with patients with patient with FTD frontotemporal dementia do not have a as it they acetylcholine dysfunction in their pathology. Is that correct?

Dr. Handratta: 9:50

That's right.

Dr. Amayo: 9:51

So now has me thinking. It seems like a minefield, pharmacological minefield. So what pharmacological pitfall should I be concerned about or aware of when I'm seeing this patient? I'm actually seeing one tomorrow. So what's steps or what things should I make sure eye I am watchful for?

Dr. Handratta: 10:10

Got it. So when you're treating patients with dementia and they have depression, How do they have apathy? Whatever you are actually treating and whatever you are diagnosed the patient with. Now the treatment of depression. Now apathy separate. Now we are not talking about apathy. The patient suppose that doesn't have apathy, they just have depression. You can use any antidepressant like the antidepressant you use in younger patient population, right? Only thing I want you guys to remember is that start low and go slow in an elderly patient. Okay, because the entire metabolism changes. It slows down in elderly patients, plus elderly patients are also on polypharmacy, so you have to look at a lot of drug interactions. Plus elderly patients will also have other medical comorbidities, right? Like they can be hypothyroid, they can have liver disease, they can have kidney problems, they can have cardiovascular problems, and they can also have hyponatremia. So you have to look at medical comorbidities before you decide which particular antidepressant you are going to use.

Dr. Amayo: 11:14

And so if they have apathy or if they have depression and apathy, still the same method, use a common antidepressant, start low. Go slow.

Dr. Handratta: 11:21

Yeah. So when they have apathy with depression, then. Again, there's no placebo control clinical trials, right? So when there is apathy with depression, I usually go with something that is more dopaminergic in nature and doesn't have the serotonergic effect to it. For example, bupropion is not a bad choice in this particular patient population if they have apathy along with depression, or you can actually use a cholinesterase inhibitor if it's a patient with Alzheimer's dementia. And see if the apathy actually improves. And once the apathy is improved, you can actually then do a geriatric depression scale and see the patient now has depression. Okay? And then treat the depression accordingly. But I'll be very careful with the serotonergic agent if the patient actually has apathy. Apathy, okay? But at the same time, we also very careful with Bupropion and dopaminergic agent. If the patient has a psychotic symptoms, please do not use a dopaminergic agent. Okay?

Dr. Amayo: 12:18

That's why, I guess that's why I like this formulation. You're considering with that, with those mixtures. So it seems like overall you wanna verify if they have depression or apathy or if they have both. Cause that would direct our treatment. So with apathy, lean motor, cholinesterase inhibitors, and the pulmonary agent. But be careful if this, if they have FTD, Stay away from the cholinesterase inhibitors if they have psychotic symptoms, stay away from the dopaminergic agents as well.

Dr. Handratta: 12:43

I'll make one more small comment before

Dr. Amayo: 12:45

oh, yeah.

Dr. Handratta: 12:45

So be careful with the antidepressant. You can use any antidepressant. All right. It's, there's no contraindication for antidepressants, but be very careful when you're using antidepressant that has lot of cytochrome interaction, like fluoxetine. Ok. Paroxetine. Fluvoxamine because these are the three antidepressants, will interact with a lot of cytochrome P450 inhibiting it. So if you don't want to actually have the headaches of looking at the cytochrome P450 interaction, some of the antidepressants, which you don't have to worry about cytochrome interaction are venlafaxine, desvenlafaxine, escitalopram,mirtazapine so these are some of the antidepressants that you can use in elderly patient if you don't want to think about drug interaction, right? But always please make sure that when you're diagnosing a patient with depression, rule out bipolar disorder. That is one thing you always do when you're evaluating a patient with depression. Whether the patient is young or elderly, you have to make sure they don't have bipolar disorder.

Dr. Amayo: 13:43

So yeah, those two things. Bipolar disorder and signify if it's just apathy or apathy and depression and stay away from those medications. That has a lot of cytochrome interactions with other medications. Thank you. And that's all we have for the Y in Psychiatry.

Dr. Handratta: 13:57

Thank you guys

Katrina: 14:01

Thank you for joining us on today's episode. Feel free to tap that our tireless team is already hard at work, cobbling together another potpourri of fascinating discussion for next week, so be sure to tune in, visit our website and our podcast feed and let us know your thoughts on the episode. Subscribe so you don't miss our releases every Wednesday. Until next time, keep smiling, keep shining, and stay curious.