SP Lecture 5: Psychosocial, Sexual Health & Stress

What is the onset of depression vs delirium vs dementia?

Depression: gradual · Delirium: acute (hours to days) · Dementia: gradual (months to years)

How is attention affected in depression?

Usually intact

How is attention affected in delirium?

Impaired, fluctuating

How is attention affected in dementia?

Intact early, impaired later

What is the cognition pattern in delirium?

Severe, fluctuating confusion

What is the cognition pattern in depression?

Mild memory/concentration issues

What is the mood pattern in delirium?

Anxiety, agitation

What is the mood pattern in dementia?

Often indifferent, possible mood swings

What is the reversibility of depression, delirium, and dementia?

Depression: treatable · Delirium: usually reversible · Dementia: generally irreversible

What is 'pseudo-dementia'?

Depression-related cognitive impairment — improves with antidepressant therapy

Delirium is considered what kind of situation?

An acute medical emergency

What commonly causes delirium? (select all that apply)

1. Infections (UTI/pneumonia) 2. Polypharmacy 3. Electrolytes

What is the #1 risk factor for developing delirium?

Pre-existing dementia

What percentage of dementia is Alzheimer's disease?

60-80%

What is the presentation of Alzheimer's disease?

Insidious onset; early episodic short-term memory loss (retrograde preserved); progressive anomia, agnosia, apraxia, executive dysfunction

What is the pathology of Alzheimer's disease? (select all that apply)

1. Amyloid-β neuritic plaques 2. Neurofibrillary tau tangles

What percentage of dementia is vascular dementia?

10-20%

What is the cognitive decline pattern of vascular dementia?

Stepwise decline (or subcortical insidious loss)

What are the presenting features of vascular dementia? (select all that apply)

1. Stepwise cognitive decline 2. Early executive dysfunction 3. Processing delay 4. Pseudobulbar affect 5. Gait instability

What is the etiology of vascular dementia? (select all that apply)

1. Multi-infarct strokes 2. Subcortical ischemic white matter disease

What is the clinical triad of Lewy body dementia? (select all that apply)

1. Detailed visual hallucinations 2. Pronounced cognitive fluctuations 3. Spontaneous parkinsonism

Which sleep disorder is common in Lewy body dementia?

REM sleep disorder

What is the key medication warning in Lewy body dementia?

Severe neuroleptic sensitivity to typical antipsychotics

What is the age of onset of frontotemporal dementia?

Younger — 50s-60s

What are the presenting features of frontotemporal dementia? (select all that apply)

1. Prominent personality changes 2. Disinhibition 3. Hyperorality 4. Apathy 5. Progressive primary aphasia

What is preserved early in frontotemporal dementia?

Visuospatial and motor skills

What imaging is done in a dementia workup, and why?

Non-contrast CT or MRI brain — rule out subdural, tumor, NPH

Which labs are ordered in a dementia workup? (select all that apply)

1. TSH 2. B12 3. CBC 4. CMP

Which cholinesterase inhibitors are used for dementia? (select all that apply)

1. Donepezil 2. Rivastigmine 3. Galantamine

Cholinesterase inhibitors are used for which dementias/stages?

Mild-moderate AD and DLB

What is memantine used for?

Moderate-severe AD

What is first-line management for dementia?

Environmental safety & caregiver support

What is subjective cognitive decline (SCD)?

Self-reported memory loss with normal objective cognitive screening

What is mild cognitive impairment (MCI)?

Objective deficit in ≥1 domain with ADLs and IADLs functionally preserved

What defines dementia (major NCD)?

Deficits severe enough to interfere with independence (needs help with IADLs or ADLs)

What is the annual conversion rate of MCI to Alzheimer's dementia?

~10-15% per year (vs 1-2% in healthy controls)

What are the features of the Mini-Cog? (select all that apply)

1. 3-word recall + clock drawing test 2. Rapid (3 min) 3. High sensitivity 4. Minimal educational or cultural bias

What is the MoCA cutoff?

What does the MoCA test that makes it superior for MCI? (select all that apply)

1. Executive function 2. Visuospatial 3. Abstraction

What does the IADL mnemonic SHAFT stand for?

Shopping, Housekeeping, Accounting/finances, Food prep, Telephone/transit

Why must dementia history be corroborated with an informant?

Patients with executive/memory deficits often lack insight (anosognosia)

Which medical conditions are commonly linked to depression in older adults? (select all that apply)

1. Cardiovascular disease (HF, MI) 2. Neurologic disorders (stroke, Parkinson's, Alzheimer's) 3. Chronic pain (OA, chronic back pain) 4. Endocrine (hypothyroidism, diabetes) 5. Malnutrition/vitamin deficiency (B12, folate, vitamin D)

What is the vascular depression hypothesis?

Microvascular white matter ischemic lesions (MRI hyperintensities) disrupt frontostriatal pathways

How does vascular depression present? (select all that apply)

1. Psychomotor slowing 2. Apathy 3. Executive dysfunction

How can corticosteroids affect mood?

Mood lability, depression, mania, or steroid psychosis

How do benzodiazepines/sedatives cause depression?

Chronic use blunts affect and causes psychomotor depression

Which centrally acting antihypertensives can cause depression? (select all that apply)

1. Clonidine 2. Methyldopa 3. Reserpine

How do centrally acting antihypertensives cause depression?

Reduce central monoamines

Why can propranolol mimic depression?

Lipophilic — crosses the BBB; fatigue and lethargy mimic depression

How do anticholinergics and first-gen antihistamines mimic depression?

Lethargy, cognitive slowing, apathy

Which chemotherapy/biologic agents can cause depression? (select all that apply)

1. Interferon-α 2. Anti-androgens/GnRH agonists 3. Vinca alkaloids

What should a medication reconciliation for depression include?

OTC supplements and sleeping aids

How does depression atypically present in older adults? (select all that apply)

1. Apathy, fatigue, social withdrawal 2. Irritability or agitation 3. Somatic complaints (headaches, GI symptoms, pain) 4. Early morning awakening 5. Memory/concentration complaints 6. Functional decline

What sleep disturbance is typical of geriatric depression?

Early morning awakening (terminal insomnia)

When screening older adults for depression, what should you ask about rather than mood alone?

Functional changes

Why do older adults often deny sadness?

They interpret questions about sadness as personal weakness or mental illness stigma

What GDS-15 score suggests depression?

>5 points — warrants full clinical evaluation

What are the DSM-5-TR criteria for a major depressive episode?

≥5 of 9 symptoms for ≥2 consecutive weeks, including depressed mood or anhedonia

What are the 9 MDE symptoms (SIG E CAPS + mood)? (select all that apply)

1. Depressed mood 2. Sleep disturbance 3. Interest loss (anhedonia) 4. Guilt/worthlessness 5. Energy decrease 6. Concentration decline 7. Appetite change 8. Psychomotor agitation/retardation 9. Suicidal thoughts

What defines persistent depressive disorder (dysthymia)?

Chronic depressed mood >2 years without symptom-free periods >2 months

What defines adjustment disorder with depressed mood?

Symptoms within 3 months of an identifiable stressor; does not meet full MDE

Which conditions are examples of depression due to another medical condition? (select all that apply)

1. Stroke 2. Hypothyroidism 3. Pancreatic cancer

What causes substance/medication-induced depression?

Alcohol misuse or medication initiation/withdrawal

What happened to the bereavement exclusion in DSM-5?

Removed — if a grieving older adult meets full MDE criteria, diagnose and treat major depression

Which SSRIs are first-line for geriatric depression? (select all that apply)

1. Sertraline 2. Escitalopram

Why are sertraline and escitalopram first-line in older adults?

Favorable drug interactions

Which SSRI should be avoided in older adults, and why?

Paroxetine — potent anticholinergic (Beers)

Which antidepressant suits comorbid depression and neuropathic/joint pain?

Duloxetine

Which antidepressant provides appetite stimulation and insomnia relief?

Mirtazapine

What is the dosing rule for antidepressants in older adults, and how long should a trial last?

'Start low, go slow, aim therapeutic' — allow 8-12 weeks

What lab should be monitored on SSRIs/SNRIs in older adults, and why?

Sodium (baseline and follow-up) — high risk of SIADH and severe hyponatremia

What does CBT target in depression?

Restructuring negative cognitive distortion and catastrophizing

Which psychotherapy is proven effective for depression with executive dysfunction?

Problem-Solving Therapy (PST)

What is behavioral activation?

Structured scheduling of pleasant events

How does psychotherapy efficacy compare to pharmacotherapy in mild/moderate late-life depression?

Equal efficacy

How does aerobic & resistance exercise help depression?

Stimulates BDNF and hippocampal neurogenesis

What are examples of social prescribing? (select all that apply)

1. Senior centers 2. Volunteerism 3. Group walks

Which lifestyle therapy addresses seasonal patterns of depression?

Sleep hygiene & bright light therapy

What are the indications for ECT in geriatric depression? (select all that apply)

1. Severe treatment resistance 2. Psychotic depression 3. Acute suicidality 4. Life-threatening food refusal

Is ECT safe in medically fragile older adults?

Yes — gold standard efficacy and safe under modern anesthesia

Which demographic has the highest completed suicide rate in the US?

Older Caucasian males >75

What is the suicide attempt-to-completion ratio in the elderly vs adolescents?

4:1 in the elderly vs 200:1 in adolescents

What does the low attempt-to-completion ratio in older adults reflect?

Low ambivalence, high lethality

What are the geriatric suicide risk factors? (select all that apply)

1. Living alone/social isolation 2. Physical illness/chronic pain 3. Functional disability 4. Recent bereavement

What are the geriatric suicide warning signs? (select all that apply)

1. Stockpiling pills 2. Giving away possessions 3. Suddenly updating wills 4. Sudden calmness after depression

What percentage of older suicide completers saw their PCP within the prior 30 days?

70%

What question should be asked of every depressed older adult?

Do you own or have access to a firearm?

What intervention saves lives in suicide prevention?

Restricting lethal means

What does lethal means safety counseling include? (select all that apply)

1. Remove firearms 2. Blister-pack pills with family assistance

What collaborative care model is used for geriatric depression?

IMPACT model (care manager + psychiatric consultation)

When should follow-up be scheduled after starting/titrating an antidepressant?

Within 1-2 weeks

What is the response to acute suicidality with intent or plan?

Prompt psychiatric consultation or ED referral

What is the 988 Suicide & Crisis Lifeline?

Free 24/7 call and text support nationwide

How do veterans reach the Veterans Crisis Line?

Dial 988, then press 1

What is The Friendship Line (Institute on Aging)?

Dedicated 24/7 geriatric crisis line and warmline

What does the Eldercare Locator connect patients to?

Area Agencies on Aging local resources

Why do older patients rarely volunteer sexual concerns? (select all that apply)

1. Embarrassment 2. Stigma 3. Internalized ageism 4. Perceived provider discomfort

How should clinicians open sexual health conversations?

Routinely initiate with normalizing, open-ended questions

What language should be used in a sexual history?

Gender-neutral, inclusive language (e.g., 'partners')

Sexual dysfunction is often the first sentinel sign of which conditions? (select all that apply)

1. Systemic atherosclerosis 2. Diabetes 3. Depression