Depression in old age: primary care setting
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Transcript of Depression in old age: primary care setting
DEPRESSION IN OLD AGE(FOR PRIMARY HEALTHCARE ENCOUNTER)
AHMED EID ELAGHOURY, MDEGYPTIAN AND ARAB BOARD-CERTIFIED IN PSYCHIATRY
Taif, SA 2
Old Man in Sorrow (On the Threshold of Eternity)
is an oil painting by Vincent van Gogh, 1890
Feb 2017
3
BACKGROUND
• DEPRESSION IS NOT A NORMAL CONSEQUENCE OF AGING
• DEPRESSION OFTEN GOES UNDIAGNOSED IN PRIMARY CARE
• DEPRESSION AMONG MEDICAL OUTPATIENTS ABOVE AGE 65 YRS: 7% - 36% • FHX OF DEPRESSION: 2X ↑ RISK, LONGER EPISODE, MORE FREQUENT, MORE SUICIDAL • LATE LIFE DEPRESSION MAY BE: A PRODROMAL STAGE OF DEMENTIA OR AN INDEPENDENT
RISK FACTOR FOR DEMENTIA.
• THERAPEUTIC NIHILISM: PATIENT, FAMILY, OR PROVIDER ARE NOT ENCOURAGED TO START RX
UpToDate: Jul, 2016BMJ Best Practice: Dec,2016
Feb 2017Taif, SA
Taif, SA 4
RISK FACTORS FOR LATE-LIFE DEPRESSION
• FEMALE SEX
• SOCIAL ISOLATION
• WIDOWED, DIVORCED, OR SEPARATED MARITAL STATUS
• LOWER SOCIOECONOMIC STATUS
• COMORBID GENERAL MEDICAL CONDITIONS
• UNCONTROLLED PAIN
• INSOMNIA
• FUNCTIONAL IMPAIRMENT
• COGNITIVE IMPAIRMENT
UpToDate: Jul, 2016Feb 2017
Taif, SA 5
MAJOR DEPRESSIVE EPISODE, MDE
• COURSE: SINGLE EPISODE/RECURRENT EPISODE [2-M APART]• REMISSION: IN PARTIAL REMISSION/IN FULL REMISSION• LATE ONSET PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA): CHRONIC
EPISODE FOR AT LEAST 2 YRS
DSM5, 2013Feb 2017
Taif, SA 6
OTHER DIFFERENT PRESENTATIONS1. MDE WITH ANXIOUS DISTRESS: ANXIETY, FEARFULNESS. RISK FOR:
SUICIDE, RX NON-RESPONSE, LONGER EPISODES2. MDE WITH MIXED FEATURES: SUBSYNDROMAL HYPOMANIA; IRRITABLE
DEPRESSION. RISK FOR: BIPOLAR DS, SRI NON-RESPONSE OR SRI WORSENING
3. MDE WITH MELANCHOLIC FEATURES: SOMATIC/BIOLOGIC SYNDROME. RISK FOR: SRI NON-RESPONSE, PSYCHOTIC SX
4. MDE WITH PSYCHOTIC FEATURES: MOOD-CONGRUENT/MOOD-INCONGRUENT. E.G. COTARD SYNDROME
5. MDE WITH CATATONIA: DEPRESSIVE STUPOR
DSM5, 2013
Feb 2017
Taif, SA 7
DEPRESSIVE DS DUE TO ANOTHER MEDICAL CONDITION, AMC
• DUE TO THE DIRECT PATHOPHYSIOLOGICAL CONSEQUENCE OF AMC• THERE IS AN EVIDENCE FROM HX, PE / LAB, IMAGING • W/O DELIRIUM• CAN BE: WITH DEPRESSIVE FEATURES, WITH MDE-LIKE FEATURES / WITH MIXED
FEATURES• COMMON EXAMPLES: HYPOTHYROIDISM,OBESITY, DM, IHD, VIT D ↓, CANCER• POST-STROKE (VASCULAR) DEPRESSION: FIRST 2 YRS AFTER A STROKE, ESP LT
BRAIN (COMMON IN 3-6 MS AFTER), RISK FACTOR FOR VASCULAR DEMENTIA
DSM5, 2013Feb 2017
Taif, SA 8
MEDICATION-INDUCED DEPRESSIVE DS
• AFTER EXPOSURE TO A MEDICATION• DURING/SOON AFTER SUBSTANCE INTOXICATION/WITHDRAWAL• NO EVIDENCE OF AN INDEPENDENT DEPRESSIVE DS: E.G. PRIOR HX,
PROTRACTED SX• COMMON WITH: STEROIDS, INF, PROPRANOLOL
DSM5, 2013UpToDate: Jul, 2016
Feb 2017
Taif, SA 9
SCREENING THROUGH PHQ-2: TWO QS
• Q1: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT DOWN, DEPRESSED, HOPELESS?' [DEPRESSED MOOD]
• Q2: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT LITTLE INTEREST OR PLEASURE IN DOING THINGS?' [ANHEDONIA]
• A POSITIVE RESPONSE TO EITHER QUESTION (SN= 97%, SP= 67%): ASSESS FOR A DEPRESSIVE DS
• ALSO: GERIATRIC DEPRESSION SCALE, GDS (>5 SUGGESTS DEPRESSION) AVAILABLE AS A FREE APP
PHQ: patient health questionaireBMJ Best Practice: Dec,2016
Feb 2017
Taif, SA 11
MANAGEMENT
• CONSIDER: COMORBID CONDITIONS AND DRUG INTERACTIONS• ANTICHOLINERGIC LOAD: BEERS CRITERIA (POTENTIALLY INAPPROPRIATE PRESCRIBING)• COMBINED: PSYCHOTHERAPY + SOMATIC THERAPY ---- PHYSICAL EXERCISE• SOMATIC THERAPY: DRUGS + BRAIN STIMULATION• DRUGS: CITALOPRAM, S-CITALOPRAM, SERTRALINE, MIRTAZAPINE, TRAZODONE ---- LONGER DURATIONS• ALSO: ANALGESICS, FOLIC ACID, VIT D, VIT B12, L-THYROXIN, ARIPIPRAZOLE, METHYLPHENIDATE,
LITHIUM• AVOID: TCA, PAROXETINE, BZD• BRAINS STIMULATION: ECT, TMS
Feb 2017