Depression in Older Adults

1. Depression in Older Adults Mary McDonald, MD Associate Professor Department of Family Medicine, Division of Geriatrics

2. Learning Objectives (1 of 2) The learner should be able to�. Describe the prevalence of depression in older adults List risk factors for suicide in older adults Summarize the characteristic features of the atypical presentation of depression in older adults

3. Learning Objectives (2 of 2) List a differential diagnosis for depression Outline treatment strategies for depression in older adults Compare the different therapeutic agents used for pharmaceutical treatment of depression List relative contraindications for electroconvulsive therapy Summaries the response to treatment for depression

5. Overview Epidemiology Diagnosis Clinical Course Suicide Treatment: Psychotherapy, Drugs, ECT Managing Non-response

6. Epidemiology of Depression in Older Adults 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 1%�2% of physically healthy community dwellers Elders less likely to recognize or endorse depressed mood

7. DSM-IV Criteria: Major Depression Gateway symptoms (must have 1) Depressed mood Loss of interest or pleasure (anhedonia) Other symptoms Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feelings of worthlessness or guilt Difficulty concentrating, making decisions Recurrent thoughts of suicide or death

8. Atypical Presentation of Depression in Older Adults More often report somatic symptoms Less often report depressed mood, guilt May present with �masked� depression cloaked in preoccupation with physical concerns and complicated by overlap of physical and emotional symptoms

10. Diagnostic Challenge Symptoms of depressive and physical disorders often overlap, e.g., Fatigue Disturbed sleep Diminished appetite Seriously ill or disabled persons may focus on thoughts of death or worthlessness, but not suicide Side effects of drugs for other illnesses may be confused with depressive symptoms

11. Hallmarks of Psychotic Depression Patients have sustained paranoid, guilty, or somatic delusions (plausible but inexplicably irrational beliefs) Among older patients, most commonly seen in those needing inpatient psychiatric care In primary care, may be seen when patients exhibit unwarranted suspicions, somatic symptoms, or physical preoccupations

12. Differential Diagnosis (1 of 2) Medical illness can mimic depression Thyroid disease Conditions that promote apathy Dementia has overlapping symptoms Impaired concentration Lack of motivation, loss of interest, apathy Psychomotor retardation Sleep disturbance

13. Differential Diagnosis (2 of 2) Bereavement is different because: Most disturbing symptoms resolve in 2 months Not associated with marked functional impairment

14. Clinical Course in Major Depression Recurrence, partial recovery, and chronicity . . . ? disability ? use of health care resources ? morbidity and mortality

15. Suicide in Older Adults Older age associated with increasing risk of suicide One fourth of all suicides occur in persons ? 65 Risk factors: depression, physical illness, living alone, male gender, alcoholism Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing

16. Steps in Treating Depression Acute�reverse current episode Continuation�prevent a relapse Continue for 6 months Prophylaxis or maintenance�prevent future recurrence Continue for 3 years or longer

17. Treatment Options Psychotherapy Pharmacotherapy Electroconvulsive therapy (ECT)

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

19. Pharmacotherapy Individualize choice of drug on basis of: Patient�s comorbidities Drug�s side-effect profile Patient�s sensitivity to these effects Drug�s potential for interacting with other medications

20. Antidepressants Selective serotonin-reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCAs) Others: bupropion, venlafaxine, duloxetine, nefazodone, mirtazapine, MAOIs, methylphenidate

21. SSRIs Citalopram, escitalopram, fluoxetine, paroxetine, sertraline For mild to moderately severe depression Side effects: Anxiety, agitation, nausea & diarrhea, sexual effects, pseudoparkinsonism, ? warfarin effect, other drug interactions, hyponatremia/SIADH Falls and fractures in nursing-home patients

22. TCAs Anticholinergic side effects limit appropriateness in older adults Secondary amine TCAs most appropriate for older patients are nortriptyline and desipramine-less anticholinergic For severe depression with melancholic features Avoid in the presence of conduction disturbance, heart disease, intolerance to anticholinergic side effects

23. Bupropion Generally safe & well tolerated. Appropriate for add-on therapy with an SSRI ? activity of dopamine & norepinephrine Side effects: Insomnia, anxiety, tremor, myoclonus Associated with 0.4% risk of seizures

24. Venlafaxine Acts as SSRI at low doses; at higher doses SNRI (selective norepinephrine reuptake inhibitor) Effective for major depression & generalized anxiety Side effects: Nausea Hypertension Sexual dysfunction

25. Mirtazapine Norepinephrine, 5-HT2 , and 5-HT3 antagonist Associated with weight gain, increased appetite May be used for nursing-home residents with depression & dementia, nighttime agitation, weight loss May be given as single bedtime dose (sedative side effects); available in sublingual form

27. ECT (Electroconvulsive Therapy) Treatment for severe, endogenous depression Pt sedated An electrode placed over each temple, AC of about 400 mA and 71 to 120 V passed between them for 0.1 to 0.5 s Pt awake within 5 to 10 minutes and up to 30 minutes Mechanism of effect is unknown Treatments usually every other day for 6-14 sessions

28. Contraindications to ECT No absolute contraindications Relative contraindications Conditions with increased intracranial pressure Intracerebral hemorrhage Pheochromocytoma Recent myocardial infarction Space-occupying intracerebral lesions Unstable vascular aneurysms or malformations

29. Reasons to use ECT Effective for treatment of major depression & mania; response rates exceed 70% in older adults First-line treatment for patients at serious risk for suicide, life-threatening poor intake Standard for psychotic depression in older adults; response rates 80%

30. Cognitive Effects of ECT 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

31. Using ECT Continue pharmacotherapy following completion of ECT treatment May use maintenance ECT to prevent relapse

32. Incidence of Response 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

33. Managing Nonresponse 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 Add psychotherapy Consult a geriatric psychiatrist

35. Summary (1 of 2) 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 diagnosis: medical illnesses, dementia, bereavement

36. Summary (2 of 2) Suicide is a serious concern in depressed older patients, particularly older white males Treatment (acute & preventive) should be individualized and may include: Psychotherapy Pharmacotherapy ECT Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions

38. Case Study#1: Mrs. Lewis 86 year old white male presents to clinic for scheduled f/u HTN visit. He was widowed 6 months prior. His blood pressure is quite high and upon questioning, he states that he has not been taking his medications. He cannot explain why. He is not sleeping well. He has lost 8 pounds since his last visit

39. Mr. Lewis When questioned, Mr. Lewis reports that he does �have a few� drinks in the evening to help him sleep. He has been an avid vegetable gardener in the past but decided not to plant this spring

40. Mr. Lewis Risk Factors for Suicide Depression living alone male gender alcoholism

41. Mr. Lewis Interventions Initiate SSRI Grief Counseling Remove firearms from home Involve family, if patient consents

42. Case Study #2: Mrs. Brown 78 year old female to clinic with daughter, who is concerned about her mom�s memory. Forgetting appointments Hygiene diminishing Not eating well/losing weight Refusing to leave house Mistakes in finances

43. Depression VS Dementia Cognitive impairment Sleep disturbance Loss of appetite Weight loss Diminished self-care Flat affect Cognitive impairment Sleep disturbance Loss of appetite Weight loss Diminished self-care Flat affect

44. How to differentiate? Early dementia often associated with some thought/perceptual disturbances, bizarre though processes and/or behaviors Therapeutic trial of antidepressant can help differentiate

45. Mrs. Brown Therapeutic trial of SSRI initiated Cognitive status improved but not to baseline Functional status unchanged Dose of SSRI increased No further improvement noted Dizziness resulted Formal Neuropsychiatric Testing confirmed diagnosis of early dementia

46. Case Study #3 Margaret Margaret is an 86 year old nursing home resident with multiple chronic medical conditions including HTN, Afib, Osteoarthritis and DMII and has been described as demented. She has been losing weight over the last year, is bed-bound and speaks few words. She is underweight at 96 lbs.

47. Margaret No medical explanation for her severely debilitated state. Laboratory studies essentially normal. No sign of infection Rate of decline would be unusual for a dementia illness Discussed with daughter and agreed to therapeutic trial of an SSRI

48. Margaret- 6 years later Weight now 160 pounds Wheelchair bound but self-propels throughout facility Hair done, makeup on, smile on face Never misses bingo, bunko, pokeno

49. References Adapted from GRS6 educational series GRS6 Chapter Author: Gary Kennedy, MD Adams and Victor�s Neurology. Chapter 57, Reactive Depression, Endogenous Depression and Manic-Depressive Disease http://www.accessmedicine.com.proxy.kumc.edu:2048/content.aspx?aID=981299&searchStr=electroconvulsive+therapy#981299 Current Psychiatry. Chapter 21. Mood Disorders. http://www.accessmedicine.com.proxy.kumc.edu:2048/content.aspx?aID=32347&searchStr=electroconvulsive+therapy#32347