Depression in the Elderly: Recognition, Diagnosis, and Treatment

1. Depression in the Elderly: Recognition, Diagnosis, and Treatment LOUIS A. CANCELLARO, PhD, MD, EFAC Psych Professor Emeritus and Interim Chair ETSU Department of Psychiatry & Behavioral Sciences

2. Diagnosis • Diagnosing depression in elderly • Use family + patient for history • Report >2 weeks history of (one or more): • Loss of energy, loss of interests • Increase in somatic symptoms w/o adequate physical explanation • Behavioral and/or personality change • Suicidal tendencies • Delusions

3. MDD • The symptoms cannot be the result of a medical illness, alcohol or drug usage, medications, or other psychiatric disorder.

4. Atypical Presentation of the Geriatric Patient • Older patients are more likely to report somatic complaints and less depressed mood than younger adults. • Older depressed patients may present with a “masked presentation,” i.e., the patient reports physical rather than mood complaints such as back pain or constipation.

5. Predisposing Factors • Prior history of depression • Women with prior history are more likely than men to have recurrent episodes • Prior suicidal attempts/family history of depression/suicide • History of substance or alcohol abuse • Lack of social support • Males living alone/loss of spouse • Medical illness/disability • Cognitive impairment/dementia

6. Barriers to Recognition of MDD • Medical Illness • Most geriatric patients suffer from several chronic illnesses, particularly cardiac disease, Type 2 diabetes, hypertension, arthritis, COPD, malignancies and G I disorders • MDD in older medically ill patients is 10 times more frequent than in community dwelling older individuals • MDD is diagnosed in 25% to 50% of geriatric inpatients referred for psychiatric consultation

7. Barriers to Recognition of MDD Primary Care Clinicians • May not be aware of the MDD diagnostic criteria • May attribute depressive symptoms to: • The aging process • Functional decline • Personal loss

8. Barriers to Recognition of MDD Primary Care Clinicians • May not routinely screen for depression • May believe treatments are marginally effective • May inadequately treat patients with depression

9. Cognitive Decline and Depressive Symptoms • Depressed patients tend to exaggerate the degree of their cognitive dysfunction as well as emphasizing their disabilities; while downplaying their depressive symptoms. Hence the term “pseudo dementia depressive syndrome”. • Following charts will assist the clinician in distinguishing the difference between depression and dementia; and depression and grief.

14. Grief vsDepression

15. Aids to Recognition ofDepression • Ask the patient about depressive feelings – “Do you often feel sad or depressed?” “Lose interest or pleasure?” • Patients with unexplained complaints • Failure to thrive • Making a slower than expected recovery from a medical illness; older patients are less likely to be spontaneous in reporting depressive symptoms • Inquire about recent loss of any kind. Losses equate to increased risk.

16. Aids to Recognition of Depression • Ask directly about suicidal thoughts or morbid preoccupation with death • For all patients 65 years of age <65; rate is 50% higher. Lethality is 1 out of 2 attempts vs 1 out of 8 in younger. • Suicide is highest in elderly white, depressed, drinking males with medical problems who live alone. • Use of firearms are the most common completion method in elderly, both men and women.

17. Aids to Recognition ofDepression • Use screening instruments, simple scales can serve clinicians such as Brief Geriatric Depression Scale

18. Treatment • Use pharmacological and non-pharmacological modalities • Some patients are reluctant to take medication, therefore it is necessary to educate the patient and significant family members as to choice rationale • Become familiar with several antidepressants from different classes

19. Choice of Antidepressant • Previous history of response • Side effect profile • Safety profile • Pharmacokinetic profile • Potential for drug/drug interactions • Cost • Medical condition/age

20. Duration of Treatment • 30% -40% of geriatric MDD are chronic with recurrence rates greater than 30% 3-6 years after resolution of initial depression • Recommend maintenance indefinitely

21. Pharmacotherapy Selective Serotonin Reuptake Inhibitors (SSRIs) • Generally considered first line of choice • Well tolerated in the elderly-no cognitive impairment-1/4 to ½ normal starting dose • Favorable side effect profile • Common GI complaints; nausea and appetite loss may diminish if taken with meals and full glass of water • Low toxicity

22. Pharmacotherapy • Withdrawal symptoms may occur if stopped abruptly-flu-like symptoms, dizziness, and agitation • Shorter acting drugs are preferred; paroxetine and sertraline. • Sexual dysfunction may occur with usage • May inhibit P450-2D6 system, thus requires lower dose or a lower dose of other drugs given in concert. Sertraline is least interactive.

23. Treatment of Comorbid Anxiety and Depression in Elderly Patients • Risk of chronic benzodiazepine use increases with advancing age. Often one sees both an anti-depressant and benzodiazepine used in combination • Benzodiazepine use should be avoided. Use occurs 3-10 times more frequently than antidepressants • Venlafaxine XR and SSRIs are useful for both anxiety and depression

24. Reasons for Treatment Failure • Inadequate trial • Inadequate dosage • Poor compliance

25. Noncompliance • Lack of knowledge about the illness • Lack of knowledge about drug side effects • Cost-can’t afford to purchase • Can’t read the label • Can’t access the drug-safety caps • Polypharmacy-too many drugs taken

26. When do you Refer to aPsychiatrist • Presence of a comorbid psychiatric disorder • Presence of comorbid medical and neurological conditions • Drug resistant depression • Presence of psychosis (hallucinations/delusions) • Need for electroconvulsive therapy • Need for psychotherapy

27. Remember: Clinical Responsibilities • Foster a clinical/patient relationship • Understand patient stressors • Educate patient and care providers • Correct prejudices • Simplify drug regimen • Convey confidence • Know medication cost