1.05.12 Depression in Elderly Outline

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Depression & Suicide Across Lifespan-Medicine Across the Li es an Week 2

Wednesday, January 04, 2012

Bhattacharya

Simple 2 Diagnostic Questions

o Over the last 2 weeks, have you Lost interest or pleasure in doing things you

enjoyed doing before?

Been feeling down, depressed or hopeless?o Identifies most medically ill people w/ major depressio

If positive, can do 15 item Geriatric Depression Screen toassess extent of depression.

Hallmarks of Psychotic Depression

o Patients have sustained paranoid, guilty, or somaticdelusions (plausible but inexplicably irrational beliefs)

o Among older patients, most commonly seen in thoseneeding inpatient psychiatric care

o In primary careunwarranted suspicions, somaticsymptoms, or physical preoccupations

Differential Diagnosis

o Medical illness can mimic depression Thyroid disease Conditions that promote apathy

o Dementia has overlapping symptoms Impaired concentration Lack of motivation, loss of interest, apathy Psychomotor retardation Sleep disturbance

o Bereavement is different because: Most disturbing symptoms resolve in 2 months Not associated with marked functional impairment

Consequences of Major Depression

o disability use of health care resources

morbidity and mortalitySuicide in Older Adultso Older age associated with increasing risk of suicideo One fourth of all suicides occur in persons 65o Risk factors: depression, physical illness, living alone, male

gender, alcoholism

o Violent suicides (e.g. firearms, hanging) are more common thnon-violent methods among older adults, despite the potenti

for drug overdosing

(White males over age 65)

Epidemiology of Depression in Older Aduls

o Minor depression is common 15% of older persons Causes use of health services, excess

disability, poor health outcomes, including

mortality

oMajor depression is not common 6%10% of physically healthy community

dwellers

Elders less likely to recognize or endorsedepressed mood

o Whats the difference?DSM-IV Criteria: Major Depression

o Gateway symptoms (must have 1) Depressed mood Loss of interest or pleasure (anhedonia)

o Other symptoms Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feelings of worthlessness or guilt Difficulty concentrating, making decisions Recurrent thoughts of suicide or death

Total of 5 symptoms for at least 2 weeks for major

depression.

Minor Depression (dysthymia)-MORE COMMONo Dont meet DSM IV criteriao Symptoms of depression, but not enough to meet all

criteriao At least 2 weeks duration (minimum)o 2-5 symptomso Increased use of health services, higher disability &

higher mortality than non-depressed

Atypical Presentation of Depression in Older

Adultso More often reportsomatic symptomso Less often report depressed mood, guilto May present with masked depression cloaked in

preoccupation with physical concerns & complicated

by overlap of physical & emotional symptoms

Diagnostic Challengeo Overlapping Depressive & Physical Symptoms:

Fatigue Disturbed sleep Diminished appetite

o Seriously ill or disabled persons may focus onthoughts of death or worthlessness, but not suicide

o Side effects ofdrugsfor other illnesses may beconfused with depressive symptoms


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Steps in Treating Depressiono Acute episodereverse current episodeo Continuation of recent episodeprevent a relapse

Continue for 6 monthso Prophylaxis or maintenance from more distant

episodeprevent future recurrence

Continue for 3 years or longer3Treatment Options

1-Psychotherapy2-Pharmacotherapy

3-Electroconvulsive therapy (ECT)

1)Psychotherapy Talk therapyo Individualize standard approaches

1. Cognitive-behavioral therapy Focus on maladaptive patterns of thinking Retrain mind to not think they are worthless

2. Interpersonal psychotherapy Identify areas in need of skill building

(relationships at work, family, etc)

Focus on communicating FEELINGS3. Problem-solving therapy Family very involved

o Combine with an antidepressant (has been shown toextend remission after recovery)

o Watch for depressive syndromes in caregivers, whomight benefit from therapy themselves

2) Pharmacotherapy

o Individualize choice of drug on basis of: Patients comorbidities Drugs side-effect profile Patients sensitivity to these effects Drugs potential for interacting w/ other meds

Antidepressantso Selective serotonin-reuptake inhibitors (SSRIs)o Tricyclic antidepressants (TCAs)o Others: bupropion, venlafaxine, duloxetine,

nefazodone, mirtazapine, MAOIs,

methylphenidate

SSRIso Citalopram= Celexa or Lexapro, escitalopram,

fluoxetine, paroxetine, sertralineo For mild to moderately severe depressiono Side effects: Start on dose for 1 wk.

Anxiety, agitation, nausea & diarrhea, sexualeffects, pseudoparkinsonism, warfarin effect,other drug interactions, hyponatremia/SIADH

Falls and fractures in nursing-home patients

TCAso Anticholinergic side effects limit appropriateness in

older adults

o Secondary amine TCAs most appropriate for older ptsare nortriptyline & desipramine-less anticholinergic

o For severe depression with melancholic featureso Avoid in presence of conduction disturbance, heart

disease, intolerance to anticholinergic side effects

Other Antidepressants:

Bupropiono Generally safe & well tolerated.o Appropriate for add-on therapy with an SSRIo activity ofdopamine & norepinephrineo Side effects:

Insomnia, anxiety, tremor, myoclonus Associated with 0.4% risk of seizures

Venlafaxine= Effexoro Works on Norepi & Serotonin

Low dose: Acts as SSRI higher doses SNRI(selective norepinephrine reuptake inhibitor)o Effective for major depression & generalized anxietyo Side effects:

Nausea Hypertension Sexual dysfunction

Mirtazapine= Remerono Norepinephrine, 5-HT2 , and 5-HT3 antagonisto Associated with weight gain, increased appetiteo May be used for nursing-home residents with

depression & dementia, nighttime agitation, wt losso May be given as single bedtime dose (sedative side

effects)

available in sublingual formo Given to help w/ depression sleep & gain weight too3) Electroconvulsive Therapy: ECTo Treatment for severe, endogenous depressiono Pt sedatedo An electrode placed over each temple, AC of about

400 mA & 71 to 120 V passed between them for 0.1 to

0.5 s

o Pt awake within 5 to 10 min & up to 30 minuteso Mechanism of effect is unknowno Treatments usually every other day for 6-14

sessions


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Contraindications to ECT

o No absolute contraindicationso Relative contraindications

Conditions with increased intracranialpressure

Intracerebral hemorrhage Pheochromocytoma Recent myocardial infarction

Space-occupying intracerebral lesions Unstable vascular aneurysms ormalformations

Reasons to use ECT

o Effective for treatment ofmajor depression &mania;

response rates exceed 70% in older adultso First-line treatment for patients atserious risk

for suicide, life-threatening poor intake

o Standard for psychotic depression in olderadults;

response rates 80%

Cognitive Effects of ECT

o Anterograde amnesia improves rapidly aftertreatment

o Retrograde amnesia is more persistent; recallof events just before tx may be lost permanently

o Lasting effects not shown in longitudinalstudies

o Right unilateral treatment: fewer side effects butless effective than bilateral

Using ECTo Continue pharmacotherapy following completion

of ECT treatment

o May use maintenance ECT to prevent relapseIncidence of Response to treatment

o 40% of cases of major depression respond toinitial pharmacotherapy within 6 weeks

o Additional 15% to 25% achieve remission withcontinued treatment for 6 weeks (12 wks total)

Managing Nonresponseo Most common prescribing errorfailure to

dose to recommended level w/in 1st 2 wks of tx

o When monotherapy fails: Consider switch to another drug class Add psychotherapy- talk therapy Consult a geriatric psychiatrist

Summary

o In older adults, depression is Common (especially minor depression) Associated with morbidity Difficult to diagnose because of atypical

presentation, more somatic concerns,

overlap with symptoms of other illnesses

o Differential diagnosis: medical illnesses,dementia, bereavement

o Suicide is a serious concern in depressed olderpatients, particularly older white males

o Treatment (acute & preventive) should beindividualized and may include:

Psychotherapy Pharmacotherapy ECT

o Choice of antidepressant should be based oncomorbidities, side-effect profiles, patient

sensitivity, potential drug interactions


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Case Study #2: Mrs. Brown

o 78 yo female to clinic w/ daughter, who isconcerned about her moms memory. Forgetting appointments Hygiene diminishing Not eating well/losing weight Refusing to leave house Mistakes in finances

o How to differentiate? Early dementia often associated with some

thought/perceptual disturbances, bizarre though

processes and/or behaviors

Therapeutic trial of antidepressant can helpdifferentiate

o Therapeutic trial of SSRI initiated Cognitive status improved but not to baseline Functional status unchanged

o Dose of SSRI increased No further improvement noted Dizziness resulted

oFormal Neuropsychiatric Testing confirmeddiagnosis of early dementia

Case Study #3) Margareto Margaret is an 86 year old nursing home resident with

multiple chronic medical conditions including HTN, Afib,

Osteoarthritis and DMII and has been described as

demented. She has been losing weight over the last year,

is bed-bound and speaks few words. She is underweight

at 96 lbs.

o No medical explanation for her severely debilitated state.Laboratory studies essentially normal. No sign of

infectiono Rate of decline would be unusual for a dementia illnesso Discussed with daughter and agreed to therapeutic trial

of an SSRI

6 Years latero Weight now 160 poundso Wheelchair bound but self-propels throughout facilityo Hair done, makeup on, smile on faceo Never misses bingo, bunko, pokeno

Case Study #1: Mr. Lewiso 86 year old white male presents to clinic for

scheduled f/u HTN visit. He was widowed 6

months prior. His blood pressure is quite high

and upon questioning, he states that he has not

been taking his medications. He cannot explain

why. He is not sleeping well. He has lost 8

pounds since his last visit

o When questioned, Mr. Lewis reports that he doeshave a few drinks in evening to help him sleep. Whats a few? What defines 1 serving?

o He has been an avid vegetable gardener in thepast but decided not to plant this spring

o Risk Factors for Suicide Depression living alone male gender alcoholism

o Have you ever thought of hurting yourself?Have you ever tried?

If he says yes, as WHAT ARE YOUR PLANS?o Do you have any fire arms in the house? Are they

loaded?Are the bullets away from the weapon?

o Interventions Initiate SSRI (will take a month) Grief Counseling Remove firearms from home Involve family, if patient consents


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1.05.12 Depression in Elderly Outline

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