Which of the following is associated with poor anti-depressant response in geriatric depression?
B. Multiple factors have been examined in an attempt to predict the treatment response in elderly depressed patients. A prospective study examining neurological and neuropsychological factors showed that a combination of extrapyramidal signs, pyramidal tract signs, and impairment of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant monotherapy, with 89% sensitivity and 95% specificity. Microstructural white matter abnormalities may also perpetuate depressive symptoms in older adults by disrupting connectivity with cortico-striato-limbic networks, which form the basis of mood regulation. Lower fractional anisotropy in this network predicted poorer treatment response in geriatric depression. Although enlarged cerebral ventricles have been reported in some studies, this is not examined as a predictor of treatment response. Earlier age of onset and somatic symptoms suggest better response to initial antidepressant treatment.
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Which of the following present at the time of onset of depression predict greater risk of depressive relapse after treatment discontinuation in elderly patients with depression?
C. Executive dysfunction predicts a poor or delayed response to antidepressant therapy and also a greater risk of relapse after discontinuing treatment. None of the other core symptoms of depression has been shown to be strong predictors of later relapse.
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Secondary depression may be caused by physical illnesses in elderly people.
Which of the following is correct with regard to depression and physical illness?
D. Late-life depression often occurs in the context of medical health issues; it is two to three times more common in the medically ill elderly patient. The diagnosis ‘depression due to a general medical condition’ (more commonly, secondary depression) is used when depressed mood or anhedonia occur in patients already diagnosed with an illness that is clearly linked to depression as a physiological consequence. For example, nearly 25% of patients with myocardial infarction have a major depressive episode. Primary depression can exist alongside a general medical condition with no direct physiological relationship. In fact, such co-existing depression and a general medical condition is more common than depression secondary to medical problems. Depression may also exacerbate the outcome of medical illnesses. Although hypothyroidism is considered to cause depression traditionally, recent studies show that a TSH value of 10 μU/L or greater was found in only 0.7% of elderly patients with clinical depression. Thus the rate of subclinical hypothyroidism in an elderly depressed group may be similar to that of the elderly population in general.
Psychosis in elderly people may be due to dementia, Parkinson’s disease, or schizophrenia.
Which of the following is correct with respect to the clinical features of late-onset psychotic syndromes?
E. The term late-onset schizophrenia is applied to patients whose first symptom of schizophrenia-like psychosis begins after the age of 40. For patients whose symptoms begin after the age of 60, the term very-late-onset schizophrenia-like psychosis (VLOSLP) is used. Paranoid delusions are the most common symptoms in late-onset schizophrenia, followed by auditory hallucinations. Partition delusions are often noted in late/very late-onset schizophrenia where the patient typically believes that people, objects, or radiation can pass through what would normally constitute a barrier to such passage. Negative symptoms are conspicuously absent in most cases. In psychosis associated with Alzheimer’s dementia, simple paranoid delusions are more common than hallucinations. In psychosis associated with Parkinson’s disease, visual hallucinations are more common than delusions.
Which of the following forms of grief therapy treats unresolved grief as a form of phobic avoidance?
A. Some individuals with abnormal grief reaction may be avoiding reminders of their grief, leading to unresolved emotions. Addressing these issues by encouragement may not be sufficient and a behavioural approach may be needed in some cases. The approach commonly used is known as guided mourning. This treats unresolved grief in a way similar to other forms of phobic avoidance by exposure to the avoided situation. Thus guided mourning involves intense reliving of avoided painful memories and feelings associated with bereavement. During treatment, patients are exposed to avoided painful memories or situations related to the loss of their loved one – both in imagination and in real life.
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