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GERIATRIC DEPRESSION

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

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GERIATRIC DEPRESSION

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  1. GERIATRIC DEPRESSION July 11, 2000 Pat Borman, M.D. Swedish Family Medicine

  2. 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

  3. 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

  4. CASE 3 • AR is an 85 y.o. black female • Large CVA last year, required nursing home placement • Withdrawn, makes no friends, no interest in activities • Poor sleep, loosing weight • Anxious, fretful, afraid her son will not come to visit

  5. 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

  6. 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

  7. 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

  8. Metabolic Endocrine Autoimmune Disorders Infections Neoplasms Cerebrovascular Disease Degenerative Neurological Disease DRUGS Propranolol Cimetidine Clonidine Benzodiazepines Steroids MANY,MANY MORE Medical Conditions Mask or Cause Depression

  9. SYMPTOMS MOOD COGNITIVE VEGETATIVE VOLITIONAL SIGNS APPEARANCE BEHAVIORS PSYCHOMOTOR RETARDATION PHYSCHOMOTOR AGITATION SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION

  10. 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

  11. 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 • Men:60% complete guns or hanging • Women:70% attempt with drugs • Increased risk: financial problems, physical illness, recent loss, ETOH, abuse, isolation

  12. GERIATRIC PRESCRIBING PRINCIPLES • C Caution, Compliance • A Adjust dose for Age • R Review, Remove, Reduce • E Educate START LOW & GO SLOW

  13. 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

  14. Least side effects good safety record cost can be a problem Least expensive activation, tremor anxiolytic PREFERRED ANTIDEPRESSANTS • SSRIs • Celexa, Paxil • Zoloft, Prozac • TCA • Nortriptyline • HCA • Wellbutrin • Serzone

  15. TCA Despiramine HCA Trazodone Remeron SNRI Effexor Sedation, hypotension cognitive slowing appetite, wt gain constipation Dizzy, anorexia, nausea, BP increase ACCEPTABLE ANTIDEPRESSANTS

  16. ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY • Too many side effects: • TCA • Amitriptyline, doxipine, protriptyline, Amozapine, trimipramine • MAOI • Phenalizine, trancypromine

  17. 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

  18. 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

  19. 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.

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