DEPRESSION IN THE ELDERLY

1
DEPRESSIONIN THE ELDERLY

• Module developed by
• James T. Birch, Jr., MD, MSPH
• Assistant Clinical Professor
• Dept. of Family Medicine, Division of Geriatric
  Medicine
• Landon Center on Aging
• University of Kansas Medical Center

2
Objectives

• Review the diagnostic criteria for depression
• Increase awareness of the prevalence and
  consequences of untreated depression in the older
  adult
• Discuss screening, treatment, and follow-up for
  those who have depression

3
Content

• 1. Define depression
• 2. Review the epidemiology of depression in the
  elderly.
• 3. Risk Factors
• 4. Recognition of signs and symptoms
• 5. Differential Diagnosis
• 6. Screening Tools
• 7. Treatment
• 8. Review the consequences/complications of
  inadequately treated depression.
• 9. ACOVE 3 Indicators

4
Introduction

• Depression is under-recognized and undertreated
  in the older adult
• Many older adults who die by suicide (up to 75)
  suffer with depression and most visited a
  physician within a month before death
• Untreated depression can delay recovery or worsen
  the outcome of other medical illnesses via
  increased morbidity or mortality
• Depression is NOT a part of normal aging

5
What is Depression?

• DSM-IV-TR Definition
• Five or more of the following must have been
  present during the same 2-week interval and
  represent a change from baseline functioning
• One(1) of the symptoms must be depressed mood or
  loss of interest or pleasure
• Geriatric Nursing (26)32005

6
What is Depression?

• DSM-IV-TR (a.k.a. core symptoms occur most of
  the day nearly every day)
• Depressed mood
• Loss of interest in all or almost all
  activities or pleasure (anhedonia)
• Appetite change or weight loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation

7
What is Depression?

• DSM-IV-TR (cont.)
• Loss of energy or fatigue
• Feelings of worthlessness or excessive guilt
• Difficulty with thinking, concentration, or
  decision making
• Recurrent thoughts of death or suicide
• Preoccupation with somatic symptoms, health
  status, or physical limitations

8
What is Depression?

• For Major Depression, these symptoms
• Produce social impairment
• Are not related to substance abuse
• Are not related to bereavement

9
What is Depression?

• Types of Depressive Disorders (DSM-IV)
• Mild episode of major depression
• Moderate episode of major depression
• Severe episode of major depression
• Severe episode of major depression with psychotic
  features
• AMDA Clinical Practice Guideline

10
What is Depression?

• Minor depression is common
• 15 of older persons
• Causes ? use of health services, excess
  disability, poor health outcomes, including ?
  mortality
• Major depression is not common
• 12 of physically healthy community dwellers
• Elders less likely to recognize or endorse
  depressed mood

11
What is Depression

• Late-life depression (a geriatric syndrome)
• is a recurrence of depressive symptoms that
  initially occurred during early adulthood.
• there is no known or identifiable precipitating
  factor.
• patients usually have no family history of
  depression. Depressed mood is not required to
  meet criteria for major depressive disorder.

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Epidemiology (of major depression)

• Community-Dwelling 1 - 9

• Primary Care Settings 10 12

• Nursing Home
• 10-26
• Permanent Placement Up to 43

• Hospitalized
• 11 45

13
Risk Factors

• Alcohol or substance abuse
• Current use of a medication associated with a
  high risk of depression
• Hearing or vision impairment severe enough to
  affect function
• History of attempted suicide
• History of psychiatric hospitalization

14
Risk factors

• Medical diagnosis or diagnoses associated with a
  high risk of depression
• New admission or change of environment
• New stressful losses (loss of autonomy, privacy,
  functional status, body part, family member or
  friend)
• Personal or family history of depression or mood
  disorder

15

• What medications do YOU prescribe for older
  adults that might place them at risk for
• DEPRESSION ?

16
Medications that may cause symptoms of Depression

• Anabolic steroids
• Anti-arrhythmic medications (amiodarone,
  mexilitine)
• Anticonvulsant medications
• Barbiturates
• Benzodiazepines
• Carbidopa or levodopa
• Certain beta-adrenergic antagonists (i.e.
  propranol)

17
Medications that may cause symptoms of Depression

• Clonidine
• Cytokines (specifically IL-2)
• Digitalis preparations
• Glucocorticoids (prednisone)
• H2 blockers
• Metoclopramide
• Opioids

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Laboratory Tests for Evaluation

• CMP (lytes, BUN, creat, Ca, glucose)
• CBC
• Serum levels of anticonvulsant drugs, TCAs,
  digoxin, theophylline
• Thyroid function (T3, T4, TSH)
• EKG
• Folate level
• UA
• Vitamin B12

19
Differential Diagnosis

• Thyroid disorders (hypo- and hyper-thyroidism)
• Dementia (or mild cognitive impairment)
• Bereavement
• Anxiety Disorder
• Substance Abuse Disorder
• Personality Disorder
• Diabetes mellitus
• Underlying malignancy
• Anemia
• Medication side effects

20
Differential Diagnosis

• DEPRESSION
• Subacute onset
• Family recognition early
• Rapid progression
• Impairment inconsistent over time
• Pt admits deficits
• Appears depressed
• Anhedonia
• Abstract thought usually normal
• I dont know response to questions
• Pt often unconcerned

• DEMENTIA
• Insidious onset
• Delayed family recognition
• Slow progression
• Impairment consistent slow, gradual decline
• Pt denies/unaware of deficits
• Not depressed
• Can experience pleasure
• Abstract thought impaired
• Near miss answers
• Pt tries to cover up

21

• What is the most commonly used and validated
  screening tool for diagnosis of Depression in the
  elderly patient?
• The Geriatric Depression Scale

22
Screening Tools

• Geriatric Depression Scale (GDS validated) 15
  item scale ( gt 5 points or positive responses is
  diagnostic)
• Cornell Scale for Depression in Dementia (scoring
  system gt12 means probable depression)
• Center for Epidemiologic Studies of Depression
  Scale (CES-D)
• Patient Health Questionnaire 9 (9 item
  self-rating scale)
• AMDA Clinical Practice Guideline

23
Screening Tools

• Two item scale (PHQ-2)
• During the previous 2 weeks..
• 1. Have you often been bothered by feeling
  down, depressed or hopeless?
• 2. Have you often been bothered by having
  little interest or pleasure in doing things?
• (Yes answer to either is considered positive)
• Sensitivity 100 Specificity77 PPV 14
• NEJM 35722 11/29/07

24
Treatment

• The consequences of depression in the elderly
  require serious attention because of the
  disproportionately high risk of suicide
• For the year 2000, 13 of the U.S. population was
  65 and older, and the suicide rate accounted for
  18 of all suicides
• Geriatric Nursing (26)3 2005
• http//www.cdc.gov/ncipc/wisqars/default.htm

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Treatment

• Goals of therapy improve mood, function, and
  quality of life
• Goals of treatment of an acute depressive episode
  are to achieve recovery and prevent future
  episodes of depression
• The intended outcome should be complete
  resolution of symptoms, not simply a reduction in
  depressive symptoms.
• Three phases of treatment are generally required
  to achieve these goals.

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Treatment

• Acute Phase (reverse current episode)
• Duration about 3 months Goal is complete
  recovery from signs and sx of acute episode
• Continuation Phase (prevent a relapse)
• Duration 4-6 months Goal is to prevent relapse
  as sx continue to decline and functionality
  improves
• Maintenance Phase (prevent future recurrence)
• Duration 3 months or longer Goal is to prevent
  recurrence of a new depressive episode

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Treatment

• Pharmacotherapy
• Psychotherapy
• Electroconvulsive therapy (ECT)

28
Treatment

• Patients should be monitored for response to
  treatment by
• Observation for resolution of signs and symptoms
  of depression
• Documenting improvement in scores on screening
  tools
• Improvement in attendance at and participation in
  usual activities
• Improvement in sleep pattern
• Also monitor patients carefully for side effects
  and interactions with other medications

29
Treatment Pharmacotherapy

• Antidepressants
• SSRIs
• Celexa (citalopram) 20-40mg/day
• Lexapro (ecitalopram) 10-20mg/day
• Prozac (fluoxetine) 20-40mg q am
• Paxil (paroxetine) 10-40mg q am or q hs
• Zoloft (sertraline) 50-200mg q am
• Better tolerated than tricyclics
• SIADH at high doses and sexual side effects
• Interact with CYP-450 isoenzymes by inhibition
• Can increase the anticoagulant effect of warfarin
• Do not discontinue abruptly taper the dose

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Treatment Pharmacotherapy

• Antidepressants (SSRIs continued)
• Nausea and diarrhea might occur
• Fluoxetine is not a preferred drug for use in the
  elderly due to a prolonged half life (4-6 days
  metabolite 9.3 days) and potential for many drug
  interactions. It might also induce anxiety, sleep
  disturbance, and/or agitation
• Paroxetine is also not favored due to
  anti-cholinergic properties and other effects
  noted with fluoxetine

31
Treatment Pharmacotherapy

• Antidepressants
• Tricyclics (secondary amines)
• Norpramin (desipramine) 20-150 qd / q hs
• Pamelor, Aventyl (nortriptyline) 20 100 mg q hs
  
• Potential for anticholinergic and sedative
  effects
• Avoid in pts. who are prone to constipation,
  orthostatic hypotension, glaucoma, or who have
  BPH
• May cause ventricular conduction delays and heart
  block
• May be fatal in overdose

32
Treatment Pharmacotherapy

• Antidepressants
• Bicyclics
• Effexor (venlafaxine) 75 mg BID
• Effexor XR 75 100mg qd
• Fewer drug interactions
• Can cause or aggravate hypertension
• Pts. are at risk for withdrawal syndrome

33
Treatment Pharmacotherapy

• Antidepressants
• SNRI and SSRI
• Cymbalta (duloxetine) 30-60 mg/day
• Norepinephrine, 5HT2 and 5HT3 antagonist
• Remeron (mirtazapine) 15-45 mg q hs
• Can cause serotonin syndrome when given with
  other SSRIs

34
Treatment Pharmacotherapy

• Antidepressants
• Norepinephrine-dopamine reuptake inhibitor
• Wellbutrin (bupropion) 100 mg TID
• Wellbutrin SR 150 mg BID
• Serotonin antagonist and reuptake inhibitor
• Serzone (nefazodone) 150mg BID
• Desyrel (trazodone) 50 200mg q hs

35
Treatment Pharmacotherapy

• Antidepressants
• Stimulants
• Ritalin (methylphenidate) 20mg BID
• Provigil (modafinil) 400mg q am
• Dexedrine (dextroamphetamine)
• 2.5-5mg 7am and noon

36
Treatment Pharmacotherapy

• Antidepressants
• Monoamine Oxidase Inhibitors (MAOIs)
• Marplan (isocarboxazid) 30 mg/day
• Nardil (phenelzine) 3045 mg/day
• Parnate (tranylcypromine) 3040 mg/day
• Orthostatic hypotension, falls
• Life-threatening hypertensive crisis if taken
  with tyramine-rich foods, cold remedies (pressor
  amine)
• Fatal serotonin syndrome possible if taken with
  SSRI, meperidine

37
Treatment

• Should the elderly patient experiencing
  bereavement be treated for Depression?
• NO!
• However, if symptoms of MAJOR DEPRESSION persist
  for more than 2 months after the loss, treatment
  for depression should be strongly considered.
• Unutzer, J. NEJM, Nov. 29, 2007

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Treatment Psychotherapy

• Cognitive-behavioral
• Interpersonal
• Short-term psychodynamic
• Life review, reminisce
• Problem solving
• Supportive
• Bereavement therapy
• Behavioral
• Dialectical-behavioral therapy

39
Treatment Psychotherapy

• Individualize standard approaches
• Cognitive-behavioral therapy
• Interpersonal psychotherapy
• Problem-solving therapy
• Combination with an antidepressant has been shown
  to extend remission after recovery
• Watch for depressive syndromes in caregivers, who
  might benefit from therapy

40
Treatment Psychotherapy

• Individualize choice of drug on basis of
• Patients comorbidities
• Drugs side-effect profile
• Patients sensitivity to these effects
• Drugs potential for interacting with other
  medications

41
Treatment ECT

• For depression with pronounced psychotic features
  and resistance to standard medical therapy
• Effective for treatment of major depression
  mania response rates exceed 70 in older adults

42
Treatment ECT

• First-line treatment for patients at serious risk
  for suicide, life-threatening poor intake
• Standard for psychotic depression in older
  adults response rates 80

43
Treatment ECT

• Side Effects
• Anterograde amnesia improves rapidly after
  treatment
• Retrograde amnesia is more persistent recall of
  events just before treatment may be lost
  permanently
• Lasting effects not shown in longitudinal studies
• Right unilateral treatment fewer side effects
  but less effective than bilateral

44
Treatment ECT

• Contraindications
• Increased intracranial pressure
• Recent MI or CVA and unstable CAD increase risk
  of complications
• Continue pharmacotherapy following completion of
  ECT treatment
• May use maintenance ECT to prevent relapse

45
Treatment Response
Responsive to initial pharmacotherapy 40

• 40 of cases of major depression respond to
  initial pharmacotherapy within 6 weeks
• Additional 15 to 25 achieve remission with
  continued treatment for 6 weeks
• GRS, 2006

Monotherapy fails 35-45
Responsive to continued treatment 15-25
46
Treatment Response

• The most common prescribing error is failure to
  increase the dose to the recommended level within
  the first 2 weeks of treatment
• When monotherapy fails
• Consider switch to another drug class
• Combine lithium carbonate, methylphenidate, or
  triiodothyronine with secondary amine TCA
• Add psychotherapy
• Consult a geriatric psychiatrist

47
Treatment Response

• Reasons for partial response or treatment failure
• Dementia that is confused with or accompanied by
  late life depression
• Concurrent psychosis (interferes with diagnosis
  and treatment of depression)
• Compliance is difficult when patients are
  depressed
• www.medscape.com/viewarticle/41887

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Consequences and Complications of Inadequately
Treated Depression

• Recurrence, partial recovery, and chronicity . .
  .
• ? disability
• ? use of health care resources
• ? morbidity and mortality
• Suicide (one fourth of
• all suicides occur in
• persons ? 65)

49
Consequences and Complications of Inadequately
Treated Depression

• Which demographic in the elderly population has
  the highest risk and incidence of suicide?
• Highest white males age 80 older
• Next highest white males between 65 and 80
• AMDA Guidelines

50
Consequences and Complications of Inadequately
Treated Depression

• Suicide
• Ask the patients about thoughts of hurting
  themselves if YES, ask whether they have a plan
  if YES, ask what it is then ask about stockpiled
  medications or weapons in the home. Patients
  with a plan require emergent psychiatric
  evaluation in ER or local crisis unit.

51
Consequences and Complications of Inadequately
Treated Depression

• Risk factors for suicide
• depression
• older age
• physical illness
• living alone (single, divorced, or separated and
  without children)
• male gender
• drug abuse or alcoholism
• having a personal or family history of suicide
  attempt
• severe anxiety or stress
• specific plan with access to firearms or other
  means.

52
Consequences and Complications of Inadequately
Treated Depression

• Violent suicides (e.g. firearms, hanging) are
  more common than non-violent methods among older
  adults, despite the potential for drug overdosing

53
ACOVE 3 Quality Indicators

• Total of 20 IF-THEN-BECAUSE directives for care
  of Depression they include
• Screening for and Recognizing Depression
• Documenting Depression Symptoms
• Suicidal Ideation
• Evaluate for Comorbid condition
• Initiating Depression Treatment
• Antidepressant Choice

54
ACOVE 3 Quality Indicators

• Psychotic Depression
• Electrocardiogram for Tricyclic Use
• Interactions with MAOIs
• Depression Follow-Up
• The First 12 Weeks of Depression Treatment
• Continuing Depression Therapy

55
ACOVE 3 Quality Indicators

• Indicators 4 thru 7 were selected for review

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ACOVE 3 Quality Indicators

• Indicator 4 IF a VE receives a diagnosis of a
  new depression episode, THEN the medical record
  should document at least three of the nine DSM-IV
  target symptoms for major depression within 2
  weeks of diagnosis, BECAUSE monitoring depression
  treatment requires identification and reevalution
  of the presenting depression symptoms.

57
ACOVE 3 Quality Indicators

• Indicator 5 IF a VE receives a diagnosis of a
  new depression episode, THEN the medical record
  should document on the day of diagnosis the
  presence or absence of suicidal ideation and
  psychosis, BECAUSE suicidal patients may require
  hospitalization, and patients with psychotic
  depression may need antipsychotic medication or
  ECT and referral to a psychiatrist.

58
ACOVE 3 Quality Indicators

• Indicator 6 IF a VE has thoughts of suicide,
  THEN the medical record should document, on the
  same date, that the patient has no immediate plan
  for suicide or was referred for evaluation for
  psychiatric hospitalization AND..

59
ACOVE 3 Quality Indicators

• Indicator 7 IF a VE has thoughts of suicide,
  THEN the medical record should document on the
  same date, that the patient was asked about
  access to firearms, BECAUSE the likelihood of
  suicide increases if the patient has a specific
  plan to commit suicide and access to firearms,
  and it decreases if the patient is hospitalized
  to receive psychiatric care.

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Summary

• All health care workers should maintain a high
  index of suspicion for the presence of depression
  or depressive symptoms in their patients.
• Screen older
• adults for
• depression
• at the initial
• visit

61
Summary

• 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
• Differential diagnoses include other medical
  illnesses, dementia, bereavement

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Summary

• Suicide is a serious concern in depressed older
  patients, particularly older white males
• Treatment (acute preventive) should be
  individualized and may include
• Pharmacotherapy
• Psychotherapy
• ECT
• Choice of antidepressant should be based on
  comorbidities, side-effect profiles, patient
  sensitivity, potential drug interactions

63
Final thought

• On the Threshold of Eternity. In 1890, Vincent
  van Gogh painted this picture seen by some as
  symbolizing the despair and hopelessness felt in
  depression. Van Gogh himself suffered from
  depression and committed suicide later that same
  year.

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References

• Geriatrics Review Syllabus, 6th Edition American
  Geriatrics Society, 2006, Chap. 35, pp. 269-79
• Nakajima, G.A., Wenger, N.S. Quality Indicators
  for the Care of Depression in Vulnerable Elders
  JAGS (55)S2S302-11 Oct. 2007
• Current Geriatric Diagnosis and Treatment
  Landefeld, C.S., et al McGraw-Hill Co., 2004.
  Chap. 14, pp. 100-107
• Depression Clinical Practice Guideline American
  Medical Directors Association
• Buffum, M.D., et al Treating Depression in the
  Elderly An Update on Antidepressants Geriatric
  Nursing 26(3) 138-142
• Kotylar, M. Update on Drug-Induced Depression in
  the Elderly Am J of Geriatric Pharmacotherapy
  3(4)Dec. 2005 288-300
• http//www.medscape.com/viewarticle/41887
• Update on Depression in the Elderly
• Retrieved 02/19/2009
• National Institute of Mental Health Older
  Adults Depression and Suicide Facts
• http//www.nimh.nih.gov/health/publications/older
  -adults-depression-and-suicide-facts-fact-sheet/in
  dex
• Unutzer, J. Late-Life Depression NEJM 357(22)
  Nov. 29, 2007 pp2269-76