GERIATRIC DEPRESSION

1. GERIATRIC DEPRESSION November 13, 2001 Eric Troyer, M.D. Swedish Family Medicine

2. Case 1 • Eva is an 80 y.o. female • Complaints: Poor sleep, mild weight loss due to poor appetite, slowing down recently. • History of incontinence, cardiovascular disease, and diabetes. • How might you approach this patient’s problems?

3. 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, appetite change or weight loss, feelings of worthlessness/guilt, psychomotor changes, loss of concentration and focus, recurrent thoughts of death

4. SIG E CAPS • Sleep • Interest • Guilt (“Are you a burden to others?”) • Energy • Concentration • Appetite • Psychomotor changes • Suicidality (“Do you wish you could die?”)

5. Vegetative Symptoms • Sleep • Interest • Guilt (“Are you a burden to others?”) • Energy • Concentration • Appetite • Psychomotor changes • Suicidality (“Do you wish you could die?”)

6. Vegetative Symptoms • These can often occur in other medical illnesses • Not discriminating or sensitive

7. Psychological Symptoms • Sleep • Interest • Guilt (“Are you a burden to others?”) • Energy • Concentration • Appetite • Psychomotor changes • Suicidality (“Do you wish you could die?”)

8. Psychological Symptoms • More reliable and are independent of age • But, elderly patients less willing to talk about psychological problems • Pay attention to: • anxiety • physical discomfort • adaptation to a new lifestyle

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

10. Case 1 • SIG E CAPS & DM for Eva: • Positives: Sleep, Appetite, Psychomotor retardation • Negatives: Interests, Guilt, Energy, Concentration, Suicidality, Depressed mood

11. Case 1 • Poor sleep due to nocturia. • Appetite changes due to decreased taste and smell. • Slowing down due to new claudication.

12. Case 2 • George is a 74 y.o. male • Complaints: Sore muscles, dizziness, constipation. Repeated visits to doctor with vague symptoms. • Daughter reports patient impossibly uncooperative and has angry outbursts. • Wife died 2 years ago; he moved in with daughter 3 months ago after a fall.

13. INCIDENCE IN ELDERLY • MAJOR DEPRESSION • 3% community dwelling • 14% two years after spouse dies • 15% medically ill • 25% long-term-care settings • DEPRESSIVE SX’S • 17-37% in primary care settings • 42% in long-term-care settings

14. How is Depression Different in the Elderly? • Less verbalization of emotions or guilt • Minimize or deny depressed mood (“masked depression”) • Preoccupied with somatic symptoms • 65% have hypochondriacal symptoms • Cognitive impairment can be marked • Hopelessness appears to be persistent

15. How is Depression Different in the Elderly? • Depressive ideation, anxiety, psychomotor retardation, and weight loss have high assoc. with disability • More anxiety, agitation and psychosis • esp. delusions with themes of guilt, nihilism, persecution, jealousy • Medical Conditions can mask or cause depression

16. How is Depression Different in the Elderly? • Subsyndromal depression is more common and presents as: • new medical complaints • exacerbation of GI sx’s or arthritic pain • cardiovascular sx’s • preoccupation with health • diminished interest, fatigue, poor concentration

17. Case 3 • Francine is a 67 y.o. female • Complaints: Sad, decreased interests, shaky, “falling apart.” • Your nurse mentions that she took a while to bring back, esp. out in the lobby. • Your exam shows tremor and cogwheel rigidity.

18. Autoimmune Cerebrovascular Chronic pain Degenerative Disease Endocrine Metabolic Neoplasms Infections DRUGS Propranolol Cimetidine Clonidine Benzodiazepines Steroids Tamoxifen Many more... Medical Conditions Mask or Cause Depression

19. Parkinson’s Disease • About 50% of patients develop depression • Useful treatment includes TCA’s • ECT helps depression and PD sx’s: • tremors, rigidity, & bradykinesia improved with 3-4 sessions • depression improved after 7-9 sessions

20. Early Alzheimer’s Dz • Presents with: • insomnia • fatigue • agitation • psychomotor retardation • decreased interest & energy • concentration problems • 50% of AD pt’s have depressive sx’s (15-20% with major depression)

21. Vascular Depression • Cerebrovascular disease can precipitate or perpetuate depression • Caused by ischemia (“silent strokes”) in prefrontal cortex and basal ganglia; motor & sensory deficits usu. not found. • Apathy, psychomotor retardation, cognitive decline • May explain incr. depression s/p CABG

22. Pseudodementia • aka “dementia of depression” • cognitive decline that clears if depression is treated • however, dementia rate in these patients is still 20%/year even after full recovery of intellectual function

23. Workup • It might include: • H & P • CBC, TSH, testosterone • ESR, renal/liver function • U/A • EKG • brain imaging if tumor or vascular disease suspected

24. Case 4 • Eugene is a 70 y.o. male • Dx’d with bladder cancer, had cystectomy and now with Indiana pouch. Needs to cath through umbilicus q4hr. His wife recently dx’d with breast cancer. • Pt. has single episode of major depression 25 years ago following tough work situation and increased EtOH use.

25. Case 4 (cont’d) • Symptoms: Withdrawn, no interest in activities (not even Mariners games), sleeping excessively, lost 10#, constant worry about cath procedure, belief he is burden to family. • Statements like, “I wish I was dead,” and, “my problem will affect this entire hospital.”

26. Case 4 • SIG E CAPS & DM for Eugene: • Positives: Sleep, Interests, Guilt/Burden, Energy, Concentration, Appetite, Psychomotor retardation, Suicidal (passive), Depressed mood • Additional findings: Nihilistic, Delusional

27. SUICIDE IS A REAL RISK • 25% of all completed suicides are > 65 • Suicide rate for depressed men over 65 is 5 times higher than for younger men • 20% of older people who committed suicide saw a physician that day • Increased risk: financial problems, physical illness, recent loss, EtOH, abuse, isolation

28. INTERVENTIONS • Seek out medical illness • Recognize medical side effects • Rehab services to maximize remaining function and retrain impaired iADL’s • Involve family and caretakers • Counsel re: role transitions, grief, dependency • Medications / ECT

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

30. 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

31. fewer side effects good safety record more expensive least expensive activation, tremor anxiolytic, somatic sleep, appetite PREFERRED ANTIDEPRESSANTS • SSRI’s • Celexa, Paxil • Zoloft, Prozac • TCA • Nortriptyline • Others • Wellbutrin • Serzone • Remeron

32. TCA Desipramine HCA Trazodone SNRI Effexor Sedation, hypotension cognitive slowing Dizzy, anorexia, nausea, BP increase ACCEPTABLE ANTIDEPRESSANTS

33. ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY • Too many side effects: • Older TCA’s: • amitriptyline, clomipramine, doxepin, imipramine, protriptyline, trimipramine • MAOI’s: • phenelzine, tranylcypromine

34. Other Drugs • Newer atypical anti-psychotics: • for “jump start” or behavior issues • Risperdal (risperidone), Seroquel (quetiapine), Zyprexa (olanzapine) • Psychostimulants • for “jump start” or for severe apathy

35. Electroconvulsive Therapy (ECT) • Works well for psychotic depression, high suicide risk, Parkinson’s-related depression, failed drug treatment • Very effective short term, but with high relapse rates over next 6-12 months. • Drug therapy can reduce relapse