Transcript Geriatric Depression

Kimothi Cain, MD, MPH
Psychiatry Psychosomatic Fellow
Persons 65 years or older
39.6 million in 2009 (the latest year for which data is
available) or 12.9% of the U.S. population
72.1 million or 19% of the population estimated in
2030
Department of Health and Human Services, 2012
Of 39.6 million US seniors:
3 million have a depressive disorder
5 million have subsyndromal depression
Less than 10% are treated
19% of all suicides are by patients over 65
The second highest U.S. suicide rates are white men
over age 65
More somatic complaints: Persistent, vague,
unexplained physical complaints such as pain,
GI disturbances, weakness, insomnia, anergy
Less likely to present with depressed mood
Agitation, anxiety
Memory problems, difficulty concentrating
Social withdrawal
In primary care, depressed geriatric patients
frequently present with somatic complaints
Chief complaints of 1043 geriatric patients in a primary care setting
who were subsequently diagnosed with Major Depressive Disorder
Simon GE, et al. N Engl J Med. 2012;341(18):1329-1335
Hypothyroidism
Calcium
B12 deficiency
Vitamin D deficiency
Heart disease
Neurological illnesses
Cancer
COPD
Autoimmune diseases
CVA
Trauma
Alzheimer disease
Other neurodegenerative diseases
etc. etc.
Evidence for Drug-Induced Depression associated with drug groups
DRUG CLASS/DRUG
Calcium channel blockers
LEVEL OF EVIDENCE
+/-
AVAILABLE LITERATURE
COMMENTS
Prescription symmetry analysis,
Results are conflicting—newer have
cohort study examining suicide
fewer reports.
rates
ACE inhibitors
+/-
Prescription symmetry analysis
No comment
ARBs
+/-
Case reports
No comment
Alpha interferons
++
Uncontrolled and controlled
No comment
studies
Beta interferons
+/-
Corticosteroids
+
4 RCTs and 1 naturalistic study
No comment
Case control study, cross-sectional
Results of trials are suggestive of DID,
analysis
especially over >65
**Reflects authors’ global assessment of evidence; --- little or no convincing evidence; +/- limited evidence; + moderately strong
evidence; ++ strong evidence; +++ very strong/unequivocal evidence
Rogers et al, Psychiatry, 2008; 5(12): 28–41
Geriatric Depression Scale
DSM-V criteria for MDD
At least 5 of 9 symptoms, present nearly every day for 2 or more
weeks:
1. Depressed mood or irritable most of the day**
2. Decreased interest or pleasure in most activities (anhedonia)**
3. Significant weight change (5%) or change in appetite
4. Change in sleep: Insomnia or hypersomnia
5. Change in activity: Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Guilt/worthlessness
8. Concentration: diminished ability to think, concentrate, or indecisiveness
9. Suicidality: Thoughts of death or suicide, or has suicide plan
** Depressed/irritable or anhedonia required for diagnosis
Geriatric depression can be challenging to
diagnose and treat
Consider psychotherapy, group therapy
Healthy lifestyle
Behavior activation
Consider an antidressant antidepressant
Increases use of primary care medical resources
Depressive symptoms significantly reduce
survival of medical illness
Increases risk of suicide
Decrease in lean body mass and total body water
Increase in body fat, prolongs half life
Hepatic metabolism decreases, as well as
production of albumin
Decrease in renal function
Antidepressant Target sx
Starting
dose
Incremental
increase
Target dose
(Not the same for
seniors)
Sertraline
Depression
25mg qday
Anxiety
Cardioprotective
25mg q3-6 weeks
Usually requires
less than 200mg.
Max 200mg
Escitalopram
Depression
Anxiety
5mg qday
5mg q3-6 weeks
Max 20mg
Mirtazapine
Insomnia
Poor appetite
Depression
Anxiety
7.5mg qhs
7.5mg q3-6 weeks Max 45mg
1. Fluoxetine
-Long half-life metabolites
-Drug-drug interactions
2. Paroxetine
-Anticholinergic
-Short-half life with marked withdrawal sx