GERIATRIC DEPRESSION

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GERIATRIC DEPRESSION

• July 11, 2000
• Pat Borman, M.D.
• Swedish Family Medicine

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Case 1

• JT is an 80 y.o. white male
• Complaints - bad taste in mouth, sore muscles,
  dizziness, constipation. Repeated visit to
  doctor with vague symptoms.
• Daughter reports impossibly uncooperative with
  angry outbursts.
• Widowed 3 years ago, moved in with daughter 3
  months ago

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CASE 2

• MG is a 78 y.o. asian female
• Complains bitterly of a left facial pain or
  fullness to you, her family and her friends
• On her own saw a neurologist, rheumatologist, ENT
  specialist, accupuncturist, massage therapist
• Trails of NSAIDS, narcs, neurontin, capsaicin,
  ice, heat, steroids have failed

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CASE 3

• AR is an 85 y.o. black female
• Large CVA last year, required nursing home
  placement
• Withdrawn, makes no friends, no interest in
  activities
• Poor sleep, loosing weight
• Anxious, fretful, afraid her son will not come to
  visit

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INCIDENCE OF DEPRESSION

• GERIATRIC
• 3 community dwelling
• 14 two years after spouse dies
• 15 medically ill
• 25 chronic care facilities
• 25-35 have depressive symptoms

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DSM-IV DIAGNOSTIC CRITERIA

• 5 or more symptoms lasting 2 wk, change from
  previous functioning
• Depressed mood and/or loss of interest
• Altered sleep, loss of energy, wt loss, feelings
  of worthlessness/guilt, loss of concentration and
  focus, recurrent thoughts of death

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How is Depression Different in the Elderly?

• Less verbalization of emotions or guilt
• Minimize or deny depressed mood
• Preoccupied with somatic symptoms
• Cognitive impairment can be huge
• More anxiety, agitation and psychosis
• Medical Conditions can mask OR cause depression

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Medical Conditions Mask or Cause Depression

• Metabolic
• Endocrine
• Autoimmune
• Disorders
• Infections
• Neoplasms
• Cerebrovascular
• Disease

• Degenerative Neurological Disease
• DRUGS
• Propranolol
• Cimetidine
• Clonidine
• Benzodiazepines
• Steroids
• MANY,MANY MORE

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SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION

• SYMPTOMS
• MOOD
• COGNITIVE
• VEGETATIVE
• VOLITIONAL

• SIGNS
• APPEARANCE
• BEHAVIORS
• PSYCHOMOTOR RETARDATION
• PHYSCHOMOTOR AGITATION

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INTERVENTIONS

• Seek out medical illness
• Recognize medical side effects
• Rehab services to maximize remaining function
• Involve Family/care taker
• Counseling role transitions, grief, family
• Medications
• ECT

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SUICIDE IS THE REAL RISK

• 25 of all completed suicides are 65
• Suicide rate for depressed men over 65 is 5 times
  higher than for younger men
• Men60 complete guns or hanging
• Women70 attempt with drugs
• Increased risk financial problems, physical
  illness, recent loss, ETOH, abuse, isolation

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GERIATRIC PRESCRIBING PRINCIPLES

• C Caution, Compliance
• A Adjust dose for Age
• R Review, Remove, Reduce
• E Educate
• START LOW GO SLOW

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MEDICAL THERAPY IN GERIATRIC DEPRESSION

• Select based on symptoms, prior response,
  concurrent illness, side effect profile
• Reassess after 4-6 weeks
• Increase dose, augment with second agent, add
  psychotherapy
• Consider psychiatric consult/referral

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PREFERRED ANTIDEPRESSANTS

• SSRIs
• Celexa, Paxil
• Zoloft, Prozac
• TCA
• Nortriptyline
• HCA
• Wellbutrin
• Serzone

• Least side effects
• good safety record
• cost can be a problem
• Least expensive
• activation, tremor
• anxiolytic

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ACCEPTABLE ANTIDEPRESSANTS

• TCA
• Despiramine
• HCA
• Trazodone
• Remeron
• SNRI
• Effexor

• Sedation, hypotension
• cognitive slowing
• appetite, wt gain
• constipation
• Dizzy, anorexia, nausea, BP increase

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ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY

• Too many side effects
• TCA
• Amitriptyline, doxipine, protriptyline,
  Amozapine, trimipramine
• MAOI
• Phenalizine, trancypromine

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CASE 1 Treatment Options

• Consider Serzone for anxiolytic properties
• Much too expensive for him
• Start Nortriptyline 10 mg q d
• Family Counseling for role transitions, and grief
  counseling
• Excellent response, household happier

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CASE 2 Treatment Options

• After 14 months of exhausting all the specialists
  and unhappy with the side effects off all the
  drugs
• Start PAXIL 10 mg q d
• Pain and facial pressure completely resolved in
  14 days

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CASE 3 Treatment Options

• Given wt loss, inability to sleep
• Select Remron 15 mg q hs
• In 8 weeks she is up 7 pounds, starting to make
  friends, went on her first nursing home outing,
  such a good response to rehab the family is
  considering taking her home.