TREATMENT OF DEPRESSION IN THE ELDERLY

1. TREATMENT OF DEPRESSION IN THE ELDERLY Jackie L. Neel, D.O. OSU Center for Health Sciences College of Osteopathic Medicine (Revised 9/2002)

2. “It is not enough for a great nation merely to have added new years to life--our objective must also be to add new life to those years.” ---John F. Kennedy Depression of the Elderly - - Jackie L. Neel, D.O.

3. Our population is Aging! • 2/3 of all the people in the history of the world who have reached age 65 are alive today! • 1/2 the women who are 65 today will survive to age 85. • 1980-1990 population over 85 increased by 40%; centenarians doubled. • Avg. lifespan in 1900=47, today=75 Depression of the Elderly - - Jackie L. Neel, D.O.

4. Healthy functioning older adults are at no greater risk for depression than younger adults Depression of the Elderly - - Jackie L. Neel, D.O.

5. Risk Factors • Depression increases in the elderly due to: • Multiple losses • Medical illness • Cognitive dysfunction • The greatest risk factor for depression in the elderly is history of previous depression Depression of the Elderly - - Jackie L. Neel, D.O.

6. Jobs Money Homes Friends Abilities Health Hopes Bereavement Compounding of Adverse Life Events in Aging Depression of the Elderly - - Jackie L. Neel, D.O.

7. Prevalence of Depression in Medical Illness Stroke 26-61% Cancer 18-39% Myocardial infarct 15-19% Rheumatoid Arthritis 13% Parkinson’s Disease 10-37% Diabetes 5-11% Depression of the Elderly - - Jackie L. Neel, D.O.

8. Categories of Medical Problems in elderly inpatients with Major Depression Circulatory 69% Digestive 61% Endocrine, metabolic 45% Other 25% Genitourinary 24% Mean # of medical problems = 5 Depression of the Elderly - - Jackie L. Neel, D.O.

9. Alzheimer’s Vascular and other dementia Common infections (i.e. pneumonia or UTI) Substance abuse Endocrine disorders Electrolyte imbalance Tumor Endocrine Prescription meds Common Secondary Causes of Depression in the Elderly Depression of the Elderly - - Jackie L. Neel, D.O.

10. Dementia and Depression • Alzheimer’s - 20-40% • Similar rates with other dementia's • Vascular • Parkinson’s • Huntington’s • Brain injury • B12,folate • Depression may precede other symptoms Depression of the Elderly - - Jackie L. Neel, D.O.

11. Having a mental disorder in late life increases mortality by 1.6 - 2.5 times Depression of the Elderly - - Jackie L. Neel, D.O.

12. Rates of MI are 4.5 times greater in patients with history of major depression Depression of the Elderly - - Jackie L. Neel, D.O.

13. Suicide • 15% of severely depressed persons commit suicide • Elderly white males are at greatest risk • 80% consult physician in the month before death • Elderly are less likely to have had previous attempts or to complain of suicidal thoughts--more likely to complete it. Depression of the Elderly - - Jackie L. Neel, D.O.

14. Suicide, cont. • 10 years after stroke • Mortality for non-depressed is 40% • Mortality for depressed is 70% Depression of the Elderly - - Jackie L. Neel, D.O.

15. DSM-IV criteria may not be met Deny most mood symptoms, but may appear fearful or sad Loss of interest in usual activities Irritable, brooding Somatic Diagnosing Depression in the Elderly Depression of the Elderly - - Jackie L. Neel, D.O.

16. DSM-IV criteria may not be met Sleep and appetite changes Fatigue Less suicidal complaints, but highest rate in elderly males Social withdrawal Diagnosing Depression in the Elderly, cont. Depression of the Elderly - - Jackie L. Neel, D.O.

17. The Diagnosis of Depression in the Elderly is Often Missed • Sx of medical illness may be the same as depression • low energy • loss of interest • anorexia • fatigue Depression of the Elderly - - Jackie L. Neel, D.O.

18. The Diagnosis of Depression in the Elderly is Often Missed, cont. • Study at Duke University • Assessment given to elderly medical admits • Of those meeting criteria for depression, only 40.5% received an anti-depressant Depression of the Elderly - - Jackie L. Neel, D.O.

19. Pseudodementia • Cognitive problems related to depression • Higher incidence of development of dementia • Past hx of mood disorder • Depressive sx precede cognitive sx • Acute onset • Increase in dependency Depression of the Elderly - - Jackie L. Neel, D.O.

20. Pseudodementia, cont. • Slow psychomotor response,low motivation and social interaction • Improve with antidepressant • Better to risk over-diagnosis and treat for depression • Use clinical judgement based on patient history and function Depression of the Elderly - - Jackie L. Neel, D.O.

21. Treatment of Depression in the Elderly • Treat co-morbid conditions and etiologies of secondary depression • Choose appropriate level of care • Keep in mind that suicide occurs more in elderly than in any other age group • Choose therapies appropriate to age and cognitive functioning • Psychosocial interventions Depression of the Elderly - - Jackie L. Neel, D.O.

22. Watch for Signs of Elder Abuse and Neglect • Malnutrition and dehydration • Bruises, fractures, burns • Mental abuse • Neglected medical care • Sexually transmitted diseases Depression of the Elderly - - Jackie L. Neel, D.O.

23. Pharmacology START LOW -- GO SLOW Depression of the Elderly - - Jackie L. Neel, D.O.

24. Pharmacologic Complications in the Elderly • Pharmacokinetics • Pharmacodynamics • End-organ physiological change • Medical illness • Cognitive decline • Polypharmacy • Compliance • Life adversity Depression of the Elderly - - Jackie L. Neel, D.O.

25. Pharmacokinetics and the Elderly •  Gastric motility and pH • Causes  absorption •  Fat/lean body ratio • Causes  volume of distribution and  half-life •  Hepatic blood flow • Causes  breakdown Depression of the Elderly - - Jackie L. Neel, D.O.

26. Pharmacokinetics and the Elderly, cont. •  Activity of some catabolic enzymes • Causes  plasma levels and half-life •  GFR • Causes  clearance and  accumulation Depression of the Elderly - - Jackie L. Neel, D.O.

27. Pharmacodynamics and the Elderly • Increased sensitivity to: • Sedation • Cardiovascular effects • Anticholinergic effects Depression of the Elderly - - Jackie L. Neel, D.O.

28. Noncompliance in the Elderly • 40-70% noncompliance • 10% take drugs prescribed for others • 20% take drugs not currently prescribed • 40% stop drugs too soon Depression of the Elderly - - Jackie L. Neel, D.O.

29. Principles of Pharmacologic Treatment • Use medications with minimal Anticholinergic, cardiovascular and orthostatic effects • Begin with low dose • Monitor compliance • Monitor side effects • Increase dose slowly, but use adequate amounts Depression of the Elderly - - Jackie L. Neel, D.O.

30. Use the More Selective Drugs with Less Side Effects First • Selective Serotonin Reuptake Inhibitor (SSRI) Fluoxetine (Prozac) 10-80 mg/d Fluvoxetine (Luvox) 25-250 mg/d Paroxetine (Paxil) 10-60 mg/d Sertraline (Zoloft) 25-200 mg/d Citalopram (Celexa) 25-200 mg/d Escitalopvam (Lexapro) 10-20 mg/d • Safe, effective • Side effects--Activation,GI, headache, sexual, enzyme inhibition (Cyt P450) Depression of the Elderly - - Jackie L. Neel, D.O.

31. Use the More Selective Drugs with Less Side Effects First, cont. • Serotonin Syndrome • Myoclonus, hyperreflexia, tremor • Confusion, agitation, hypomania • Fever, sweating, shivering • Diarrhea • Stop or reduce drug • Propranolol, clonazepam Depression of the Elderly - - Jackie L. Neel, D.O.

32. Use the More Selective Drugs with Less Side Effects First, cont. • Venlafaxine (Effexor) • 12.5mg BID-350 mg/d, XR 37.5,75,150 mg/d • Reuptake inhibition of serotonin and norepinephrine • May be more efficacious in refractory cases and vegetative depression • Side effects--nausea, activation, serotonin syndrome, htn, tremor Depression of the Elderly - - Jackie L. Neel, D.O.

33. Use the More Selective Drugs with Less Side Effects First, cont. • Nefazodone (Serzone) • 50-600 mg divided or HS q Day • Safe, anxiolytic, increases sleep, less sexual side effects • Side effects--dizziness,sedation, GI, CytoP450 inhibition Depression of the Elderly - - Jackie L. Neel, D.O.

34. Use the More Selective Drugs with Less Side Effects First, cont. • Bupropion (Wellbutron) • 75-150 mg TID, SR 100-150 mg BID • Safe, effective, no sexual side effects, activation • Side effects--activation, GI, HA, Seizures Depression of the Elderly - - Jackie L. Neel, D.O.

35. Use the More Selective Drugs with Less Side Effects First, cont. • Mirtazapine (Remeron) • 7.5-60 mg (sedating at the lower doses) • Safe, antidepressant, anti-anxiety, 1X/d • Helps sleep and appetite in elderly at low dose • Side effects--constipation, dizziness, dry mouth, somnolence • Agranulocytosis or neutropenia (rare) Depression of the Elderly - - Jackie L. Neel, D.O.

36. Tricyclic Antidepressants • Effective antidepressants BUT avoid due to: • Orthostatic hypotension • Slow cardiac conduction • Increase HR • Decreased heart rate variability • Sedation Depression of the Elderly - - Jackie L. Neel, D.O.

37. Tricyclic Antidepressants, cont. • Effective antidepressants BUT avoid due to: • Sexual • Dry mouth • Constipation • Urinary retention Depression of the Elderly - - Jackie L. Neel, D.O.

38. If other types of antidepressants fail: • Nortriptyline and desiprimine • Starting at low doses • Monitoring blood levels can be used • Trazodone (Desyrel) • Use for sleep in low doses--very high doses may be necessary for antidepressant effect • May lead to orthostasis • Less anticholinergic side effects. Depression of the Elderly - - Jackie L. Neel, D.O.

39. If other types of antidepressants fail, cont. • Psychostimulants • Ritalin--5mg q am-5-10 mg tid • Watch BP and HR • May cause psychosis • May mobilize the vegetatively depressed and medically ill Depression of the Elderly - - Jackie L. Neel, D.O.

40. For depression with psychotic features: • Low doses of higher potency antipsychotics • .5 - 2 mg haloperidol (Haldol) will often suffice • 2.5 - 5 mg olanzepine (Zyprexa) • 25 mg quetiapine (Seroquel) • .25 - .5 mg risperidone (Risperdal) • May go higher if tolerated and no response at lower doses Depression of the Elderly - - Jackie L. Neel, D.O.

41. For depression with psychotic features, cont. • Mood Stabilizers • Lithium • Valproate (Depakote) • Carbemazepine (Tegretol) • Monitor blood levels • Liver enzymes for Depakote and Tegretol • CBC for Tegretol • TSH, Cr for Lithium Depression of the Elderly - - Jackie L. Neel, D.O.

42. For depression with psychotic features, cont. • For agitation: • Lorazepam (Ativan) .5-1 mg TID PO or IM or IV • Increased risk for falls with use Depression of the Elderly - - Jackie L. Neel, D.O.

43. Electroconvulsive Therapy • For depression which is: • Unresponsive to medication • With psychotic features • Putting the patient at risk due to poor oral intake or suicidality • More cardiac risks in the elderly, but can be performed safely Depression of the Elderly - - Jackie L. Neel, D.O.

44. Problem Solving Supportive Cognitive Behavioral Reminiscent Pets Touching Education Family Groups Psychosocial Intervention Psychotherapy Depression of the Elderly - - Jackie L. Neel, D.O.

45. Erikson’s Final Stage of Development • Integrity Versus Despair and Isolation • Feeling life has been worthwhile and accepting your place in the life cycle • “Healthy children will not fear life if their parents have integrity enough not to fear death.” Depression of the Elderly - - Jackie L. Neel, D.O.

46. References • Zisook, S, M.D., and Downs, N. S., M.D., Diagnosis and Treatment of Depression in Late Life, Journal of Psychiatry 1998;59 (suppl 4), pg. 80-91. • Medical Advances -- Health in Mind and Body, Vol. 2, No. 1 Depression of the Elderly - - Jackie L. Neel, D.O.