Week 1

In this Module…

We shall take an interactive approach
You are expected to

- Read the case of Mr O

- Think / Suggest what you would do

(You can have multiple attempts. You can move on only when the most appropriate choice is made)

We shall

- Provide knowledge on the topic

- Provide further information on Mr O as the case goes on

- Ask you further questions on what next

What you expect to understand…

Mood issue is a continuum from normal emotional response to clinical disorder
Common mood issues in old and how the same condition differs between older adults and the younger counterpart
The multi-dimensional aspects on emotion and mood
Preventive measures
Common assessment / screening tools
What you can do if you suspect the elder has mood issue

Are you ready?

Let’s start
Three, Two, One … Go

Case Study - Story of Mr. O (1)

Story of Mr. O (1)

People	Information
	Name: Mr. O Age: 75 Background: - Known hypertension, on regular drugs - Lives with wife who has dementia and has progressive worsening of self care over past six years
	Name: Mrs. O Age: 71 Background: Dementia and progressive worsening of self care over past six years
	Name: Jack Mr and Mrs.O's son Background: Noted his father has been more tired and social withdraw, have generalized aches and pain, eating less and poor sleep in past 3 months
	Name: You Background: - Healthcare worker - You are Jack’s friend - Jack is worried about Mr.O’s condition and is seeking your advice

The continuum of mental health

WHO defines mental health as a state of well being in which the individual

- Realizes his /her own abilities

- Can cope with the normal stress of life

- Can work productively and fruitfully

- and is able to make contribution to his/ her community

State of mental health is a continuum: a good reference is the Mental Health Continuum model

Mental health continuum: strive to thrive

Common symptoms of mood issue

	Somatic complaints:headaches, digestive issues, pain, memory complaints
	Low energy state - Loss of energy level, or appetite - Emotionally flat or loss of pleasure (apathy)
	High energy state - Difficulty concentrating, feeling restless, or on edge - Increased worry or feeling stressed - Anger, irritability or aggressiveness
	Change in sleep - Difficulty sleeping or sleeping too much
	Thoughts or behaviors that interfere with work, family, or social life: self-neglect, excessive reassurance seeking
	Warning thoughts - Sadness or hopelessness, suicidal thoughts

Local Data showed

(Lam LCW et al. Soc Psychiatry Psychiatr Epidemiol 2015; 50: 1379-1388)

Among community older adults (age 65-75) and in preceding one week

Depression and Anxiety are two most common mood disorders in older adults

However, remember from the “Mental Health Continuum Model”

- Continuum from healthy to illness

- Depressive episode: 4.7%

- Using depressed mood as example,

NOT all “depressed mood” = "depression”

Depression is considered to exist on a continuum from normal sadness (mood symptom) to pathological severe depression (disorder)

Why are elderly so prone to have mood problem ?

Factors affecting psychological health

Chronic disease
Physical impairment with functional limitations
Pain (both physical limitation or the feeling of not so able)
Psycho-social elements: Grief, loneliness or major life events including relocation (going to old age home), loss of dignity and respect
Side effects of medications
Personality, Coping skills and Social Support

Older adults may have…

Distress and sense of helplessness from functional impairment / communication challenges
Adjustment difficulty after retirement: lack of life goal / financial independence
Social isolation and feelings of out of touch
Loss of confidence and self-worth
Sense of loneliness

Going back to Question 1:
Do you think Mr O has depression?

Depression (for adults)

It is a broad and heterogeneous diagnosis
Distinction should be made between “depressive mood” (symptom) versus “depressive disorder”

The WHO International Classification of Diagnosis version 10 (ICD-10) or Diagnostic Statistical version V (DSM-V) give reference guidelines to the diagnosis on mood disorders

Diagnostic reference to Depression
(not diagnostic criteria)

Depressive Disorder (ICD-10)

- At least 2 out of 3 (low mood, loss of interests / pleasure, loss of energy) symptoms plus

- Others (reduced concentration, reduced self-esteem, guilt feeling, pessimistic, idea or act of self harm, disturbed sleep, reduced appetite)

- Present for at least 2 weeks

- Severity (mild, moderate, severe) depends on clinical assessment on severity of each and total number of symptoms

Diagnostic reference to Depression

DSM-V for Major Depressive Disorder (at least 5/9 for at least 2 weeks)

- Core Symptoms:

Depressed mood AND / OR
Reduced interest / pleasure

- Somatic Symptoms:

Change in appetite
Change in sleep pattern
Reduce energy level
Psychomotor agitation / retardation

- Cognitive Symptoms

Poor concentration
Inappropriate guilt
Tight death, suicide

Depressive mood versus
Depressive disorder

Subthreshold depressive symptom

- One symptom of depression but with insufficient others symptoms / functional impairment to meet criteria for full diagnosis (of disorder)

Among community living elders in HK

- Subsyndromal / Subthreshold depressive symptoms: 12.5 – 37.8%

- Major depression: 1.54%

The above description is for adults.

Does older adult differ?

Special features of depression in older adults

Lesser

- Subjective feelings of low mood / sadness (“depression without sadness”)

- Loss of pleasure

More

- Loss of energy

- Psychological symptoms (eg. guilt, suicide ideation, anxiety symptoms)

- Executive dysfunction

- Somatization / Hypochondriasis

- Social withdrawal

Discussion

That sounds sophisticated and require expertise in a diagnosis!
I am not a medical doctor. Can I (as healthcare worker) help? Do we have something simple?
Yes, you can, and you have!

You may ask…

1. Is it likely to be depression?

Two steps approach
Preliminary Screening → Detail assessment

2. Is there anything more serious than depression that needs immediate attention?

Assess Red-Flag

Is it likely to be depression?

Preliminary Screening → Detail assessment

Preliminary Screening
- Single question: “ Over the past 2 weeks, how often have you felt down, depressed, or hopeless?” (PHQ-2)
Patient Health Questionnaire (PHQ-2)
OR
- Geriatric Depression Scale - 4 question version (GDS-4)
Geriatric Depression Scale (GDS-4)

A PHQ-2 score of 3 or more has sensitivity of 84% in detecting depression
A GDS-4 score of 2 or more has 60-76% sensitivity in detecting depression

Reference source from : Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings - Module on Common Mental Health Problems in Older Adults 2019

Is it likely to be depression?

Detailed assessment with PHQ-9 or GDS-15 is recommended if PHQ-2≥3 or GDS-4≥2

Interpretation of PHQ-9
Patient Health Questionnaire (PHQ-9)

- 0-4: Normal

- 5-9: Mild

- 10-14: Moderate

- 15-19: Moderately severe

- ≥20: Severe

Interpretation of GDS-15
Geriatric Depression Scale (GDS-15)

- ≥8: Suggestive of depression

Reference source from : Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings - Module on Common Mental Health Problems in Older Adults 2019

Anything more serious?

Assess Red Flag

- Self Harm: any thought or planned act

- Psychosis / Mania: hallucination / false belief

Summary of Chapter 1

Mood issue is a continuum from normal emotional response to clinical disorder

- Depressed mood ≠ Depressive disorder

Two questions to ask

- Is it likely depressive mood or depressive disorder?

- Is there any suggestion that the person may endanger oneself or others?

Depressive mood versus
Depressive disorder

Two steps approach

- Preliminary Screening → Detail assessment

Preliminary Screening

- Single question: “ Over the past 2 weeks, how often have you felt down, depressed, or hopeless?” (PHQ-2) OR

- Geriatric Depression Scale - 4 question version (GDS-4)

Detailed assessment

- PHQ-9 or GDS-15 is recommended if PHQ-2 ≥ 3 or GDS-4 ≥ 2

Refer if PHQ-9 ≥ 10, or GDS-15 ≥ 8

Suggestions of danger

Red Flag feature

- Self Harm: any thought or planned act

- Psychosis / Mania: hallucination / false be

Refer if yes

- End of Chapter 1-

Week 2

MOOC 7
Chapter 2

Let's recall...

What you expect to understand…

Mood issue is a continuum from normal emotional response to clinical disorder
Common mood issues in old and how the same condition differs between older adults and the younger counterpart
The multi-dimensional aspects on emotion and mood
Preventive measures
Common assessment / screening tools
What you can do if you suspect the elder has mood issue

Case study Story of Mr O (2)

The story continue...

Wait...

Mr O has a number of somatic complaints, and anxiety is more common than depressive episode (see Chapter 1), can he have anxiety or other medical diseases?

Anxiety Disorder in older adults

Anxiety, depressive episode and the combinations are the commonest

- Generalized anxiety disorder (GAD) and mixed anxiety and depressive disorder are the two commonest form

- Any common mental disorder: 11.2%

- Depressive episode: 4.7%

- Generalized anxiety disorder: 5.5%

- Mixed anxiety and depressive disorder: 3.6%

- Other anxiety disorder: 1.24%

There are large overlap on manifestations between depressive mood and anxiety as they share common risk factors

- cross reference slide:

Chapter 1: Low Mood - Factors affecting psychological health

The overlap between depression and anxiety

Diagnostic reference to GAD in adult (ICD-10)

Generalized Anxiety Disorder (GAD) is characterized by generalized and persistent anxiety (most days for at least several weeks) in any environmental circumstances
Common symptoms

- Apprehension (worries)

- Motor tension (eg. Restlessness, tremor)

- Autonomic overactivity (eg. lightheadness, palpitation, epigastric discomfort)

- Somatic symptoms from chest (eg. fear of choking, chest discomfort) and abdomen (eg. churning in stomach)

How older person differ?

Older adults commonly have the following symptoms

- More somatic symptoms

- Excessive uncontrollable worry / anxiety

- Edginess, nervousness or restlessness

- Chronic fatigue or tiring out easily

- More irritable or agitated

- Poor quality of sleep or difficulty falling / stay asleep

- Tense muscle

How to screen for GAD in older adults?

The GAD-7 Scale can be used a rough guide for screening
Scores of 5, 10, 15 are used as cutoff for mild, moderate and severe GAD

Reference source from : Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings - Module on Common Mental Health Problems in Older Adults

Case study - Story of Mr.O

Let’s also recall Mr O had

- Low energy state (more tired, social withdraw, loss of appetite)

- Somatic complaints (generalized aches and pain)

- Poor sleep

- On and off in past few months but not persistent

PHQ-9 scored 5/30 and GDS-15 at 5/15
There is no red flag feature

A GAD-7 was also performed on Mr.O
of which he scored 4/21

Yes .. You need to explore concerns from Mr O.
How to do so?

You need to

- Built rapport: you are concerned about him

- Ask if he has any concern / worry about himself

- Ask about psycho-social stress:

Recent stress and coping strategy
Daily functioning
Role changes (care-giver strain)

Ask about his physical functioning

Case study - Story of Mr O (3)

Discussion

Mr O is likely to have subthreshold depressive symptom. The main stressor likely from coping with wife who has dementia (care-giver strain)
A rough guide on management strategy is provided by PHQ-9

Summary of Chapter 2

About 10% of local older persons have anxiety related issues
Sleep problem, appetite change, excessive worry, fatigue, physical pain are common symptoms for both anxiety or depressive issue
The GAD-7 is a useful tool for assessment
To address anxiety and depressive issue, it is essential to explore and identify the stressors for psychosocial support

-End of Chapter 2-

Week3

MOOC 7
Chapter 3

Let's recall...

Recall on Mr O

Mrs O had dementia and was getting worse
Mr O was main caregiver to Mrs O

- Felt tired in coping

- Worried on her worsening and he could not cope

- Felt alone by himself

Mr O was likely to have depressive episode from caregiver strain

Understanding Caregiver Strain

Many older persons who suffer chronic illnesses require constant care from their family members
Caregivers stretch themselves too far in the care-giving roles and ignore their own needs
A mental status called “Burnout” would emerge if caregivers could not manage their stress properly

Symptoms of “Burnout”

Physical: Feeling fatigue & sick, and ignoring time for taking rest and meals
Cognitive: Frustrated, negative, passive & feeling hopeless
Emotional: Depressed & agitated
Interpersonal: Socially isolated, being hostile & resentful

Sources of caregiver stress

Fear of death and aging process
Feeling sad and blaming oneself for not providing adequate care to the patient
Inadequate knowledge & skills
Over-dependence on the caregiver
Family members may not be willing to share the care-giving tasks & responsibilities
Heavy financial burden due to long term medical expense
Lack of social support & resources

Principal of management

Refer to Mr.O case

Main management direction will be:

- Psychosocial management of Mr O

- Empowerment / respite relief of care-giver strain (see module on dementia care)

Rule out medical causes (inform Mr O’s practitioner at next visit)
Ruling out Red Flag symptoms (see above article)
Avoid using drugs unless necessary (issue on poly-pharmacy, medication cascades and drug-drug interactions)

Psycho-social Management

Essence of counseling: to establish “therapeutic relationship”
From counseling to guidance
Counseling by non-counselor

- Active listening and non-judgmental

- Allow expression of emotion

- Express empathy

Guidance / psycho-education

- Give information and provide rationale

- Suggestion, guidance and advice

Empowerment/ Respite

Strengthen social support and mobilize community support
Learning on how to interact with subjects with cognitive impairment
Maintain healthy lifestyle (exercise, sleep hygiene)
Promote functioning in daily activities
Stress reduction (relaxation, exercising, mindfulness)

What family /friends can do
with a depressed older adults

Be with them but NOT to disparage their feeling

- Talk and listen with appropriate assurance

- Point out realities and offer hope

Encourage and assist in seeking help
Find out local support group and attend meeting with them whenever possible
Alert on severe depression (and cues on active attempt of suicide)

Is drug treatment good to older adults?

You learnt for previous slides that antidepressant may be used in major depression, yet need to balance between risk and benefit. Overall, older adults are prone to have the following side effects (True / False)

(A) Increase falls?

(B) Increase cardiac arrhythmia?

(D) Upper gastrointestinal bleeding?

Feedback of
"Is drug treatment good to older adults?"

Any False / True:
Though different drug class or different drug within same class may have different side effects profile, older adults are more prone to side effects of individual drug overall.

Besides, older adults tend to be on multiple drugs because of multiple pre-existing diseases. Drug-drug (prescribed or over-the –counter supplements) interactions may occur leading to predictable or unpredictable that side effects.

Pharmacological intervention should always be judged on balance of risk / benefit and among different treatment options.

Common antidepressant
drugs and side effects

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The Story of Mr O (4)

End of the story

His sleep, appetite and energy level recovered over 3 months

Overview on mood and mental problems in older adults

Older adults are prone to have mental / mood problems because of

- Functional limitation: disease limiting mobility, chronic pain, frailty

- Life events: bereavement, decline of socio-economic status with retirement or disability

Common mental problems

Distress and sense of helplessness due to physical deterioration in function

- eg. Blurred vision and hearing difficulty

Adjustment difficulty after retirement

- eg. Loss of financial independence, lack of life goal

Social isolation and out of touch with changing world
Loss of confidence and self-worth
Sense of loneliness as adult children leaving the family
The stress, if maladaptive, manifest with body, mind, behavior and emotion issues

Common manifestations on mental problems

Preventive measures against mood problem

Maintain healthy lifestyle and physical health

- Make time for leisure, hobbies, life-long learning

Develop personal relationship

- Spend time and talk with trusted friends /relatives who can offer support

- Care for family members and contribute

- Share experience and wisdom with younger generations

Be aware of own condition

- Look for stressors

- Avoid setting goals that are too hard to achieve

Advance planning in finance
Seek help in case of need

Approaches to mental health complaints in older adults

Reference source from : Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings - Module on Common Mental Health Problems in Older Adults 2019

Management of mild mental health complaints

Pyscho-social intervention

- Acknowledge symptoms

- Ask for their own explanation of the cause of symptoms and elicit their concerns

- Discuss potential links between the person’s emotions/stress and symptoms

- Promote self-care: reduce stress, strengthen social support, maintain healthy lifestyle and promote functioning in daily activities

Support and give advice to the caregivers
Monitor of progress
Report to family doctor at next scheduled follow up who may

- Review if any investigation is necessary

- Avoid ordering more investigations than is necessary

- Communicate with patient about the normal clinical and test findings and reassure that no serious disease has been identified

- Consider if antidepressant or anxiolytic drugs is needed (usually not necessary)

Summary of Chapter 3

Older adults are prone to have mental / mood problems because of

- Functional limitation: disease limiting mobility, chronic pain, frailty

- Life events: bereavement, decline of socio-economic status with retirement or disability

Preventive measures against mood problem

Maintain healthy lifestyle and physical health

- Make time for leisure, hobbies, life-long learning

Develop personal relationship

- Spend time and talk with trusted friends /relatives who can offer support

- Care for family members and contribute

- Share experience and wisdom with younger generations

Be aware of own condition

- Look for stressors

- Avoid setting goals that are too hard to achieve

Advance planning in finance
Seek help in case of need

Approaches to mental health complaints in older adults

Reference source from : Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings - Module on Common Mental Health Problems in Older Adults 2019

Psycho-social Management

Active listening and in non-judgmental way
Allow expression of emotion and express empathy
Identify areas of concern
Guidance / psycho-education

- Give information and provide rationale

- Suggestion, guidance and advice

Strengthen social support and mobilize community support
Maintain healthy lifestyle (exercise, sleep hygiene)
Promote functioning in daily activities

-End of Chapter 3-

Potential resources

Cadenza training materials

壓力管理, 優質生活樂頤年
http://www.cadenza.hk/training/pdf/ps/CTP001_cur3_ps1.pdf
與抑鬱情緒說再見
http://www.cadenza.hk/training/pdf/ps/CTP002_cur3_ps1.pdf
生命花園：壓力管理與情緒健康
http://www.cadenza.hk/training/pdf/ps/CTP002_cur6_ps4.pdf
護老者與長者攜手同行面對慢性病
http://www.cadenza.hk/training/pdf/ps/CTP003_cur4_ps4.pdf

Elderly Health Service.(2020).

Stress Management - Care-giver Stress.
Retrieved from https://www.elderly.gov.hk/english/carers_corner/caregiverstress.html
長者健康服務網站 .(2020).壓力處理之認識家中護老者的精神壓力.
Retrieved from https://www.elderly.gov.hk/tc_chi/carers_corner/caregiverstress.html

Reference

World Health Organization. (2017). Mental health of older adults. Retrieved from
https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults

Primary Care Office. (2019). Module on common mental health problems in older adults. Retrieved from
https://www.fhb.gov.hk/pho/english/resource/files/
Module_on_Common_Mental_Health_Problems.pdf

Clark, L.A., Cuthbert, B., Lewis-Fernández, R., Narrow, W.E., Reed, G.M. (2017). Three approaches to understanding and classifying mental disorder: ICD-11, DSM-5 and the National Institute of Mental Health's Research Domain Criteria. Psychological Science in the Public Interest, 18(2), 72-145.

Stein, D.J., Szatmari, P., Gaebel, W., Berk, M., Vieta, E., Maj, M., Vries, Y.A.D., Roest, A.M., Jonge, P.D., Maercker, A., Brewin, C.R., Pike, K.M., Grilo, C.M., Fineberg, N.A., Briken, P., Cohen-Kettenis, P.T., Reed, G.M. (2020). Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies. BMC Medicine. 18, 21. Retrieved from
https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1495-2

Pocklington, C. (2017). Depression in older adults. British Journal of Medical Practitioners. 10(1), a1007. Retrieved form
https://www.bjmp.org/files/2017-10-1/bjmp-2017-10-1-a1007.pdf

Lam, L.C.W., Wong, C.S.M., Wang, M.J., Chan, W.C., Chen, E.Y.H., Ng, R.M.N., Hung, S.F., Cheung, E.F.C., Sham, P.C., Chiu, H.F.K., Lam, M., Chang, W.C., Lee, E.H.M., Chiang, T.P., Lau, J.T.F., Os, J.C., Lewis, G., Bebbington, P. (2015). Prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in HK: the HK Mental Morbidity Survey(HKMMS). Social Psychiatry and Psychiatric Epidemiology. 50, 1379-1388.

Wong, M. Institute of Mental Health Castle Peak Hospital. Elderly depression. Retrieved from
https://www3.ha.org.hk/cph/imh/mhi/article_02_02_03.asp

Quiz, feedback and certificate

Handouts

Reference Link

Relevant Cadenza Training Materials

Disclaimer

The videos in this course provide information for educational purposes only. The videos do not provide medical recommendations or diagnoses and are not substitutes for medical advice. It is crucial that you talk with your healthcare providers to discuss any questions you may have and seek them for medical advice, before you make any medical decisions. As the videos are only for educational purposes, we will not be responsible for any decisions you will make or consequences you will have based on the information they provide. In no event shall the Funder have any liability of any kind to any person or entity arising from or related to any actions taken or not taken as a result of any of the contents herein.

The continuum of mental health

Mental health continuum: strive to thrive

MOOC 7Chapter 2

MOOC 7Chapter 3

Psycho-social Management

Any False / True:

MOOC 7
Chapter 2

MOOC 7
Chapter 3