LateLife Depression

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Late-Life Depression

• Seki Balogun, MD
• Assistant Professor of Internal Medicine
• Div. of General Medicine, Geriatrics, Palliative
  Care

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Introduction

• Serious health concern
• Significant impact on
• morbidity and mortality
• health care costs and utilization
• In older adults, depressive illness is
• Under diagnosed
• Under treated
• Over 80 of mental health treatment for depressed
  elderly is delivered by physicians other than
  psychiatrists

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Introduction

• Not a normal consequence of aging!
• Different from grief and bereavement
• Normal responses to life events
• Loss of a loved one
• Loss of physical, cognitive or social function
  from illness

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Grief and Bereavement

• Usually in response to death of a loved one
• Causes both somatic and emotional distress
• Normal grief
• Distress gradually diminishes over months
• The bereaved develops a sense of acceptance
• Considerable range in the duration and intensity
  of process

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Complicated Grief

• Persistence of disruptive emotional reactions and
  four of eight symptoms, for at least six months
• Difficulty moving on
• Numbness/detachment
• Bitterness
• Feelings that life is empty without the deceased
• Trouble accepting the death
• Sense that the future holds no meaning without
  deceased
• Agitation, being on edge
• Difficulty trusting others since loss
• Others social withdrawal, difficulty in
  returning to productive living

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Bereavement related depression

• Those with complicated grief, who meet the
  diagnostic criteria for major depression and/or
  generalized anxiety disorder
• Difficult to differentiate
• Persistence of severe symptoms of early grief
• Medical sequelae
• Higher mortality and morbidity (especially in
  men)
• Substance abuse (alcohol, sedatives, tobacco)
• Disease exacerbation (CHF, COPD)
• Treated for depression if symptoms persist for at
  least 2 8 weeks after a major loss

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Epidemiology

• Prevalence varies with medical co-morbidities and
  functional status

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Prevalence

• Nursing Homes
• Cognitive impairment increases incidence of
  depression and makes diagnosis difficult
• In cognitively intact 10 20 percent
• In cognitively impaired 50 -70 percent

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Risk Factors

• Depression in early life
• Usually have a familial history
• Female sex
• Social isolation
• Marital status
• Widowed, divorced, separated
• Lower socioeconomic status
• Medical comorbidities
• Uncontrolled pain
• Insomnia
• Functional and Cognitive Impairment

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Impact

• Increased health utilization and costs
• Increased office and ER visits
• Increased drug use
• Higher risk of substance abuse
• Increased length of hospital stay
• Medical comorbidity
• Fourfold increase in death post- MI
• 3.4 times more likely to die over 10 years after
  a stroke
• Increased one year mortality after admission to a
  nursing home

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Impact

• Psychiatric comorbidity
• Anxiety
• Somatization
• Suicide risk
• Less suicide attempt than younger pts, but more
  likely to succeed
• Highest suicide rate in white men age 85 yrs and
  older 55 per 100,000
• Most were in 1st depression episode
• Had seen a physician within last month of life

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Pathogenesis Late-Life Depression

• Theories
• Hormonal mechanism (serotonin, norepinephrine,
  dopamine)
• Damage to frontal sub cortical pathways
  implicated in some subtypes
• Neurodegeneration
• Cerebrovascular disease

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Classification

• Major Depression
• Dysthmia
• Subsyndromal depression
• Psychotic depression
• Vascular depression
• Dementia related Depression

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Major Depression

• DSM IV criteria
• 5 or more of the following, present for at least
  two weeks
• Depressed mod
• Loss of interest or pleasure in activities
• Changes in appetite or weight
• Insomnia or hypersomnia
• Psychomotor retardation or agitation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Difficulty thinking, concentrating or making
  decisions
• Recurrent thoughts of death or suicidal ideation
  or attempts
• In late life more likely to be chronic
• Recovery more transient, frequent relapses
• More so with extensive comorbidity

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Dysthmia

• Chronic, low intensity mood disorder.
• Symptoms must be present for more than two years
  consecutively.
• Characterized by
• anhedonia
• low self-esteem
• low energy
• Greater risk of developing major depression
• Higher prevalence of cardiac disease
• May be treatment resistant

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Subsyndromal depression

• May not meet criteria for major depression or
  dysthmia
• Fewer symptoms
• Shorter duration
• Typically have high disease burden
• Poorer health and social outcomes
• Functional impairment
• Higher health utilization and costs

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Psychotic Depression

• More common in elderly
• Delusions a prominent presentation
• Can be
• Congruent with mood (worthlessness,
  impoverishment, guilt, death)
• Somatic
• Paranoid or persecutory
• Hallucinations (uncommon)
• Tend to be transient

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Vascular Depression

• Develops
• after an acute cerebrovascular event (post
  stroke depression)
• In association with chronic ischemic changes in
  brain (vascular depression)
• Factors in development of PSD
• Location (left hemisphere)
• Time from stroke (greatest risk - 1st 3 6
  months, up to two years)
• Higher risk of vascular dementia

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Dementia related Depression

• Depression
• Can be a prodrome to AD
• Complication of illness
• Common complication in other dementia syndromes
• Parkinsons disease
• Lewy body dementia
• Frontotemporal Dementia
• Huntingtons Dementia

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Depression in Alzheimer-type Dementia

• AAGP diagnostic criteria
• A. 3 or more of the following in 2- week period
• Clinically significant depressed mood
• Decreased positive affect
• Social withdrawal
• Disturbed appetite
• Disturbed sleep
• Psychomotor retardation or agitation
• Irritability
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Recurrent thoughts of death or suicidal ideation,
  or attempt
• B. Meets criteria for Alzheimers type Dementia
• C. Symptoms cause significant distress and
  dysfunction
• D. Symptoms not caused by delirium or another
  condition

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Diagnosis

• Challenging!
• Helpful clues
• Mood or somatic symptoms out of proportion to
  that expected
• Change in mood or interest
• Poor response to medical treatment
• Poor motivation to participate in treatment
• Lack of engagement with care givers

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Screening tools

• Two question screener
• During the past month, have you been bothered by
  feeling down, depressed or hopeless?
• During the past month, have you been bothered by
  little interest or pleasure in doing things?
• Geriatric depression scale (multiple sites)
• PHQ-9 (primary care settings)
• Cornell Scale for Depression in Dementia
• Center for Epidemiologic Studies Depression Scale

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Screening tools
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Treatment

• Crucial components
• Addressing comorbid conditions
• Tailoring treatment interventions to patient
• Monitoring therapy for side effects and
  effectiveness
• Assuring close follow up

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Treatment

• Complete history guides treatment!
• Assess for suicide ideation, plan, attempt
• Urgent psychiatric referral!
• Assess for psychotic symptoms
• Is the patient on medications with depressant
  side effects (benzodiazepines, opiates) or
  abusing alcohol?
• Other medical conditions associated with
  depression (hypothyroidism, diabetes)?
• Hx of prior depressive episodes, prior drug
  therapy?
• Family history

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Treatment

• Psychotherapy
• Pharmacotherapy
• Electroconvulsive therapy
• Can be used in combination or singly
• Better outcomes with combination therapy

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Psychotherapy

• Useful but underutilized
• Limiting factors
• Medicare and other insurances reimburses only 50
  percent of allowable charge
• Availability of adequately trained therapists
• Modalities (Individual, Couples, Family or group
  therapy)
• Effective for older patients and their caregivers

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Pharmacotherapy

• Efficacy comparable across medication classes
• Side effect profile determine medication
  selection
• All medications typically take 4 6 weeks to
  show efficacy , in elderly patients may take
  longer (8 16 weeks)
• Monotherapy preferred when possible
• Start low, go slow!

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Selective serotonin reuptake inhibitors (SSRIs)

• First line
• Better tolerated
• Potential side effects
• Parkinsonism
• Akathisa
• Anorexia
• Sinus bradycardia
• Hyponatriemia
• Serotonin syndrome (AMS, myoclonus, tremors,
  hyperreflexia, fever, autonomic changes)
• May be less efficacious than other drugs or ECT
  in severe forms of melancholic and psychotic
  depression

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Dual action agents

• Venlafaxine and duloxetine
• Serotonin norepinephrine reuptake inhibitors
  (SNRIs)
• 2nd line agents
• Useful in patients with pain
• Well tolerated (less in the frail elderly)
• Potential adverse effects
• Dose-dependent risk for diastolic hypertension
• GI distress (less with Venlafaxine XR)
• Agitation (less with Venlafaxine XR)

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Dual action agents

• Miirtazepine
• Serotonergic and noradrenergic properties
• Useful in insomnia, agitation, weight loss or
  anorexia
• Maybe useful in parkinsonism, essential tremors
  or nausea from chemotherapy
• Side effects
• Sedation (diminish with prolonged use and higher
  doses)
• Appetite increase and weight gain
• Dry mouth
• Constipation
• Serotonin syndrome

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Atypical antidepressants

• Few studies in the elderly
• Bupropion
• Activating maybe useful in lethargy, daytime
  sedation or fatigue
• Contraindicated in seizure disorders, concurrent
  use of benzodiazepines, alcohol detoxification,
  hx of bulimia
• Adverse effect dose-dependent diastolic
  hypertension

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Atypical antidepressants

• Nefazodone
• Available in US in generic preparation only
• Brand Serzone removed from market due to
  hepatotoxicity
• Useful in depressed pts with insomnia, anxiety,
  agitation
• Side effects sedation, restlessness,
  hyponatriemia
• Patent inhibitor of CYP450-3A4 isoenzyme
• Significant drug- drug interactions with
  macrolide antibiotics, antiarrythimcs and other
  psychotropics

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Atypical antidepressants

• Trazodone
• Sedative effect at low doses
• Rarely used as a sole agent
• Antidepressant effect at higher doses
• Orthostatic hypotension
• Excessive daytime sleepiness
• Other side effects hyponatriema, priapism (rare)

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Tricyclic antidepressants

• Significant side effects in the elderly
• Anticholinergic (orthostatic hypotension, urinary
  retention, constipation, increased confusion,
  cardiac conduction effects)
• May be useful in psychotic depression (severe)
• May reduce risk of relapse after ECT
• Secondary amine TCA (nortriptyline, desipramine)
  better tolerated than tertiary amine TCAs
  (amitriptyline, imipramine, doxepin)

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Monoamine oxidase inhibitors

• Rarely used in elderly
• Except
• if previously tolerated or treatment responsive
  
• Resistant to all other antidepressants
• Special dietary and medication restrictions to
  prevent serotonin syndrome and hyperadrenergic
  crisis
• Side effects orthostasis, agitation, insomnia

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Duration of treatment

• Usual course for first episode in most adults 6
  -12 months after full remission
• To prevent relapse (higher in elderly)
• Gradual taper required with most medications
• Long term treatment may be required in
• Frequent relapses or recurrence
• Chronic dysthmia or depression
• Long term safety data in elderly (esp. with
  comorbities) lacking

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Electroconvulsive therapy

• Important and viable treatment option for
  depression in elderly
• Used in medication resistant cases
• More commonly used in older patients
• Poorer tolerance and response to medications
• May develop more severe complications of
  depression
• Therapeutic response in majority of cases
• Adverse effect
• Confusion post ECT (usually transient)

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Brain stimulation therapies

• Being evaluated for treatment of depression
  refractory to ECT
• Used in Parkinsons disease and epilepsy
• Limited data in the elderly

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Summary

• Late life depression is sometimes difficult to
  diagnose
• Has significant impact on quality of life and
  health outcomes
• Not a normal consequence of aging
• Highest suicide rates in the elderly
• Excellent response with different treatment
  modalities