WEEK 10 DISCUSSION

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Family Medicine 03: 65-year-old woman with insomnia

User: Lisa Abbott

Email: [email protected]

Date: October 18, 2018 13:03 GMT/UTC

Learning Objectives

The student should be able to:

Describe the common causes of insomnia in the elderly.

Describe the common therapeutic options for major depressive disorder and their side effects.

Perform history, physical, and tests to rule out medical causes of depressive symptoms.

Describe the diagnostic criteria for major depressive disorder.

Recognize the importance of inquiring about the use of complementary and alternative therapies.

Describe the risk factors for elder abuse.

Appreciate the effects of depression on the patient's family.

Knowledge

Common Causes of Insomnia in the Elderly

Issues that may lead to an environment that is not conducive to sleep .

Specific examples include: noise or uncomfortable bedding.

You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night's sleep.

Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.

Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.

Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may

report loud snoring or cessation of breathing during sleep.

In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.

In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during

sleep respectively.

As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these

movements.

Disturbances in the sleep-wake cycle include jet lag and shift work.

Patients with depression and anxiety commonly present with insomnia.

Any patient presenting with insomnia should be screened for these disorders.

Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.

Pain or pruritus may keep patients awake at night.

Those with GERD may report heartburn, throat pain, or breathing problems.

These patients may also have trouble identifying what awakens them.

Detailed questioning may be needed to elicit the symptoms of this disorder.

Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies

may be required to detect this problem.

Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS) , this has

progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours,

waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be

difficult to distiguish from insomnia.

Good Sleep Hygiene

Your Personal Habits

Fix a bedtime and an awakening time. The body "gets used to" falling asleep at a certain time, but only if this is relatively fixed. Even if

you are retired or not working, this is an essential component of good sleeping habits.

Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late

afternoon for most people is a "sleepy time." Many people will take a nap at that time. This is generally not a bad thing to do, provided you

limit the nap to 30 to 45 minutes and can sleep well at night.

Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate

sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.

Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as

chocolate, so be careful.

Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.

Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise

within the two hours before bedtime, however, can decrease your ability to fall asleep.

Your Sleeping Environment

Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem,

and make appropriate changes.

Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can

keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.

Block out all distracting noise, and eliminate as much light as possible.

Reserve the bed for sleep and sex. Don't use the bed as an office, workroom or recreation room. Let your body "know" that the bed is

associated with sleeping.

Getting Ready For Bed

Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety

and reduce muscle tension.

Don't take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it

useful to assign a "worry period" during the evening or late afternoon to deal with these issues.

Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.

Get into your favorite sleeping position. If you don't fall asleep within 15 to 30 minutes, get up, go into another room, and read until

sleepy.

Getting Up in the Middle of the Night

Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to

sleep within 15 to 20 minutes, then do not remain in the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read, have a light snack,

do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or

engaging activity such as office work, housework, etc. Do not watch television.

A Word About Television

Many people fall asleep with the television on in their room. This is often a bad idea. Television is a very engaging medium that tends to keep

people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the

patient should go to bed. This also applies to computers, tablets and smart phones. Some people find that the radio helps them go to sleep.

Since radio is a less engaging medium than TV, this is probably a good idea.

Risk Factors for Completed Suicide

Sex: The person most likely to succeed in a suicidal attempt is a white male. While females are more likely to attempt suicide; males are more likely

to complete one.

Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age.

Elderly persons attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status to be poor, experience

poor sleep quality, lack a confidante, and experience stressful life events.

Importantly, approximately 75% of elderly persons who commit suicide had visited a primary care physician within the preceding month, but

their symptoms were not recognized or treated, underscoring that physicians must be tuned in to the signs and symptoms of depression and

risks for suicide. Drug overdose is the most common means of suicide on the elderly, making the safety of medications chosen to treat the

condition important.

Previous attempts: Having previously attempted suicide is a risk factor for completed suicide.

Military Service: The suicide rate of military veterans in the United States is higher than that of the general population.

Poverty by itself is not a risk factor.

Major Depression Diagnostic Criteria

For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.

A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

Depressed Mood

(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):

Sleep: Insomnia or hypersomnia nearly every day.

Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.

Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt

about being sick).

Energy (decreased): Fatigue or loss of energy nearly every day.

Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or

as observed by others).

Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a

month).

Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness

or being slowed down).

Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a

specific plan for committing suicide.

Major Depressive Disorder vs. Bereavement

The presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major

Depressive Episode. The table below adapted from the DSM V discusses some potential differences:

Major Depressive Episode Bereavement (Grief)

Persistent depressed mood and inability to anticipate

happiness or pleasure Feelings of emptiness and loss

Depression persistent, not tied to specific thoughts or

preoccupations

Depressed feelings often decrease in intensity over days to weeks and occurs in

waves, associated with thoughts of the deceased

Pervasive unhappiness and misery Grief may be accompanied by positive emotions and humor

Self-critical or pessimistic ruminations Preoccupation with thoughts and memories of the deceased

Feelings of worthlessness and self-loathing Self-esteem is generally preserved. May be self-deprecating—feeling they should

have done more or told the deceased how much he or she was loved

Suicidal ideation because of feeling worthless, undeserving of

life, or unable to cope with the pain of depression

Individual thinks about death and dying, generally focused on the deceased and

possibly about joining the deceased

Risk factors for Late-life depression

Risk factors for late-life depression include:

Female sex

Social isolation

Widowed, divorced, or separated marital status

Lower socioeconomic status

Comorbid general medical conditions, e.g. stroke, heart disease and cancer

Uncontrolled pain

Insomnia

Functional impairment

Cognitive impairment

Depression in the Elderly

Depression is a very serious disease in the elderly:

Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.

Alcohol and drug abuse are very common comorbidities complicating depression.

Completed suicide is more common in older depressed patients.

Suicide assessment five-step evaluation and triage (SAFE-T)

1. RISK FACTORS

a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B

personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk

c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations

d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization

e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health

status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual

abuse. Social isolation

f. change in treatment: discharge from psychiatric hospital, provider or treatment change

g. Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk

a. Internal: ability to cope with stress, religious beliefs, frustration tolerance

b. external: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent

a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever

b. Plan: timing, location, lethality, availability, preparatory acts

c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions

d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.

e. Explore ambivalence: reasons to die vs. reasons to live

›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition

›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION

a. Assessment of risk level is based on clinical judgment, after completing steps 1–3

b. Reassess as patient or environmental circumstances change

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with

significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.

Screening for Depression

The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression , but especially patients with chronic diseases

like diabetes, as they are at high risk for depression.

The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:

1. Little interest or pleasure in doing things.

2. Feeling down, depressed, or hopeless.

If positive it should be followed up by a diagnostic instrument such as:

PHQ-9

Geriatric Depression Scale - Short Form (GDS-SF)

Screening for Dementia in Geriatric Patients with Depression

Screening for dementia is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in demented

patients.

Two dementia screening tools are:

The Mini-Cog exam

The Mini-Mental State Exam (MMSE)

The Mini-Cog exam is faster and more sensitive and specific than the MMSE.

Sensitivity Specificity

Mini-Cog 99% 93%

MMSE 91% 92%

Side Effects of SSRI/SNRIs

Common side effects of SSRI/SNRIs include:

Headaches

Sleep disturbances (drowsiness and, less frequently, insomnia)

Gastrointestinal problems such as nausea and diarrhea

Sexual dysfunction

They can also cause:

Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death)

Increased risk of gastrointestinal bleeding

In the elderly you also have to be concerned about an increased risk for falls with these medications, and recent studies show that they might have

adverse effects on bone density.

Older antidepressants such as TCAs can cause arrhythmias. Citalopram and Escitalopram can cause QT interval prolongation at higher doses,

especially in the face of hypokalemia and hypomagnesemia or when combined with other medication that have this same effect. Reports of

symptomatc arrythmia is uncommon.

Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.

Depression in Hispanics

Due to factors such as economics, culture, and differences in presentation, Hispanics have their depression identified less frequently than non-

Hispanic whites. This holds true in some other ethnic groups as well, such as African Americans.

Hispanic patients will more frequently present to a doctor for somatic complaints such as myalgias or fatigue, rather than with stated mood-related

complaints.

U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant Hispanics are up to 50% lower

than U.S.-born Hispanics.

Psychosis is no more common in Hispanics than other groups, but symptoms of perceptual distortion such as hearing noises or seeing shadows

(known as celajes) are more common and must be differentiated from psychotic hallucinations.

Hispanics and other ethnic and economic minorities are less likely to receive adequate therapies.

Elder Abuse

Early research indicates the following risk factors for abuse:

1. Dementia.

2. Shared living situation of elder and abuser (except in financial abuse).

3. Caregiver substance abuse or mental illness.

4. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder's dependency and the resulting stress has not been found to

predict abuse.

5. Social isolation of the elder from people other than the abuser.

Clinical Skills

Complementary and Alternative Therapies

When obtaining a medication history, health care providers should ask routinely about herbal and other supplements - as well as over-the-counter

medications and nutritional supplements. Patients frequently will not mention the use of complementary and alternative medical treatment unless

they are asked about them. Be respectful when patients discuss alternative therapies, even if you are unfamiliar or skeptical about a particular

treatment.

Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce side effects, just like

conventional drugs. Even where they were obtained is important, as supplements have repeatedly been found to be contaminated with other herbs,

heavy metals, and even prescription drugs. Only a few herbs have been scientifically studied, so information on their effectiveness is limited. St.

John's Wort has been shown to be effective for short-term treatment of mild to moderate depression.

Management

Treatments for Primary Insomnia in the Elderly

Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and

multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines different behavioral treatments, resulting in

improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:

Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually

been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency

increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is

sustained) until the individual's optimal sleep time is obtained.

Sleep compression therapy: The patient is counseled to decrease the amount of time spent in bed gradually to match total sleep time rather

than making an immediate substantial change.

Pharmacological Therapy

All drugs for the treatment of insomnia can be associated with side effects - particularly prolonged sedation and dizziness - that can result in the risk

of injuries and confusion.

Preferred agents:

Class Agents Comments

Benzodiazepine Receptor Agonists

zolpidem (Ambien)

eszopiclone (Lunesta)

Improved sleep onset latency, total sleep time, and wake after sleep onset

Tricyclic Antidepressants doxepin 3-6 mg Doxepin only suggested agent in this class

Orexin Receptor Antagonist suvorexant (Belsomra) Improved sleep-onset and/or sleep-maintenance insomnia.

Benzodiazepines can be effective but have more complications and the additional risk of addiction.

Antihistamines, antidepressants (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in

older adults.

Combining CBT-I and pharmacological therapy can be helpful in some patients.

The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular

physical activity in the elderly, assuming there are no other contraindications to such activity.

Antidepressant Medications

Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are

four major classes of antidepressants:

Class Mechanism Examples

Selective serotonin reuptake

inhibitors (SSRIs)

Selectively block reuptake of serotonin, potentiating serotonin's effect on

the post-synaptic neuron

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Tricyclic antidepressants (TCAs) Block reuptake of norepinephrine and serotonin, potentiating their effects

on the post-synaptic neuron

Nortriptyline (Pamelor)

Amitriptyline

Clomipramine (Anafranil)

Doxepin (Sinequan)

Monoamine oxidase (MAO)

inhibitors

Block pre-synaptic catabolism of norepinephrine and serotonin (rarely

used today)

Phenelzine (Nardil)

Tranylcypromine (Parnate)

Serotonin and norepinephrine

reuptake inhibitors

Block reuptake of norepinephrine and serotonin, increasing their

concentration/availability

Venlafaxine (Effexor) and

Duloxetine (Cymbalta)

Others Norepinephrine and dopamine reuptake inhibitors Bupropion (Wellbutrin)

Serotonin antagonist and reuptake inhibitors Nefazodone (Serzone) and

Trazodone (Desyrel)

Norepinephrine and serotonin antagonist, antihistaminic effects Mirtazapine (Remeron)

Serotonin partial agonist and reuptake inhibitor Vilazodone (Viibryd)

Management of Depression

When treating patients with major depression disorder, a biopsychosocial approach should be considered. "Bio" refers to pharmacotherapy; "psycho"

refers to psychotherapy; and "social" refers to the identification of life stressors.

While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most

beneficial and comprehensive therapy, and is associated with the highest rates of remission.

Medication:

In a first episode of depression, it's usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a

high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and - in the elderly, who

experience increased rates of recurrence - continuous therapy should be considered.

SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects

compared to the older tricyclics and, unlike the tricyclics, have little risk in overdose. A tricyclic such as amitriptyline would not be a first-line

approach.

Psychotherapy:

Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can

be especially useful for patients who want to avoid medication.

Exercise:

Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression

and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination simultaneously with other

modalities.

Avoidance of other substances:

Additionally, avoidance of recreational drug and excessive alcohol use is a necessary part of any treatment regimen.

ECT:

While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients

with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy.

Antidepressant Profiles

Effectiveness:

The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all about equally effective in both

adult and geriatric patients. While matching the patient's symptoms with the drug's profile, keep in mind that each patient's reaction to a medication

is different and the final selection needs to be individualized.

Cost:

Cost is another strong consideration. There are now generic preparations of many antidepressants, making them more affordable.

Drug-drug interactions:

Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.

Side effects

While antidepressants are relatively safe, there are potential side effects which vary in frequency and intensity between medications and the

individual patient.

Safety during pregnancy:

Most SSRIs are categorized by the U.S. Food and Drug Administration as Pregnancy Category C, but trimester-specific or population-

specific risks exist. Paxil is Pregnancy Category D.

Profiles

Drug Comments

Fluoxetine

(Prozac)

Unusually long half life (two to four days), so effects can last for weeks after discontinuation.

Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and

insomnia.

Sertraline

(Zoloft)

In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-

compulsive, panic, and posttraumatic stress disorders.

More gastrointestinal side effects than the other SSRIs.

Paroxetine

(Paxil)

Side effects can include significant weight gain, impotence, sedation, and constipation.

Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

Paxil is Pregnancy Category D

Fluvoxamine

(Luvox)

Particularly useful in obsessive-compulsive disorder.

Greater frequency of emesis compared to other SSRIs.

Citalopram

(Celexa)

Most common side effects include nausea, dry mouth, and somnolence.

Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.

Escitalopram

(Lexapro)

Approved specifically for Generalized Anxiety Disorder.

Overall, fewer side effects than citalopram.

Adherence to Antidepressant Medication in the Elderly

Providers note adherence to depression treatment in older adults occurs only about half the time. The reasons are understandable and include:

Inability to afford the medication

Concerns about side effects

Worry about the stigma of the diagnosis

Not understanding how to take the medication properly

The important thing is to not blame the patient, but to educate her/him about the recommendations, allowing the patient to ask questions and fully

express any concerns.

Studies

Evaluation of Fatigue or Depression

A complete metabolic panel (A) screens for electrolyte, renal, and hepatic problems

A TSH (D) can detect hypothyroidism

A CBC (F) will show anemia and vitamin deficiencies

Clinical Reasoning

Medical Conditions Associated with Depression

A number of diseases either cause depressive symptoms or have depression as a comorbidity at higher rates than would be normally expected.

In looking for the causes and associations of depression, first consider the common conditions. Then think about the very serious diseases that you

don't want to miss. Beyond that, there's a very wide range of diagnoses that can look like depression:

Hypothyroidism:

About 5% of the U.S. population has hypothyroidism. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis.

Hypothyroidism can be treated with thyroid-replacement medications such as triiodothyronine (T3) and/or levothyroxine (T4). Once TSH levels are

returned to the normal range, the symptoms of depression often subside.

Parkinson disease:

Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between

depressive symptoms and Parkinson disease, it is unclear whether one causes the other or if both may arise from some common mechanism. A

recent study has indicated that depressive symptoms are an early feature of Parkinson disease, preceding the characteristic movement problems

seen in Parkinson such as tremor and rigid muscles. Therefore, people with signs of depression who start to develop movement problems should be

promptly evaluated to rule out a diagnosis of Parkinson disease.

Dementia:

Dementia and depression may be difficult to differentiate, as people with either disorder are frequently passive or unresponsive, and they may appear

slow, confused, or forgetful. The Mini-Mental State Examination (MMSE) is useful to assess cognitive skills in people with suspected dementia. (The

MMSE examines orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, write a sentence

spontaneously, and copy a complex shape.) Early and accurate diagnosis of dementia is important for patients and their families because it allows

early treatment of symptoms. For people with other progressive dementia, early diagnosis may allow them to plan for the future while they can still

help to make decisions. These people also may benefit from drug treatment.

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