Transcript DEPRESSION AND OTHER MOOD DISORDERS

DEPRESSION AND
OTHER MOOD
DISORDERS (Bipolar)
in the Elderly
S t e v e n Ta m , M D , U C I G e r i a t r i c s
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OBJECTIVES
Know and understand:
• Incidence and morbidity of depressive disorders
among older adults
• Diagnostic criteria for depression and mania
• Treatment options for older adults with
depression or mania
• Actions and side effects of drugs for depression
and mania in older adults
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TO P I C S C O V E R E D
• Epidemiology
• Diagnosis
• Clinical Course
• Suicide
• Treatment: Psychotherapy, Drugs, ECT
• Managing Non-response
• Treating Bipolar Disorder
Case Presentation
• Geriatrics Eval: 75 year old female, resident of Blythe,
previously independent and healthy, presented with
daughter with concerns about changes in her cognition
(inattentiveness, spotty short term memory, some
repetitiveness)
• Also with sadness, social withdrawal, decreased
appetite and 10 pound weight loss in the past 6 months
or so
• Previously independent, loved working on her large
yard – no longer doing now. No interest, also
complains of fatigue no energy to do anything
Case Presentation
• Additionally had thoughts that the world was coming to
an end soon, persistent.
• Denied any suicidal thoughts
• No significant PMHx (-HTN, DM, CAD, Stroke, CKD,
hypo thyroid)
• No alcohol/drugs
• Widowed x 2 years
• Son and daughter about an hour away
• Stable vitals, and non-revealing physical exam
• MMSE -4 on orientation, -2 on recall, -3 on attention
21/30 Sentence “The end is near.”
EPIDEMIOLOGY AMONG
O L D E R A D U LT S
• Minor depression
 15% of older people
 Causes  use of health services, excess disability, poor health
outcomes, including  mortality
• Major depression
 6%–10% of older adults in primary care clinics
 12%–20% of nursing home residents
 11%–45% of hospitalized older adults
• Bipolar disorder
 Remains a common diagnosis among aged psychiatric patients;
does not “burn out” in old age
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D S M- I V D I A G N O S T I C C R I T E R I A
FOR 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
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DSM-V
• New depressive disorders for classification
(disruptive mood dysregulation disorder and
premenstrual dysphoric disorder)
– Dysthymia now under category of persistent
depressive disorder (includes chronic major
depressive disorder); 2 years • No change in required symptoms, nor duration
• Bereavement exclusion (2 months) removed
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SCREENING (1 of 4)
Geriatric Depression Scale (GDS)
• Yes/No format
• Lacks suicidal ideation query
• Not useful for assessing treatment response
• Not reliable in patients with moderate or severe
dementia
GDS
•
•
•
•
Are you basically satisfied with your life?
Do you often get bored?
Do you often feel helpless?
Do you prefer to stay at home rather than
going out and doing new things?
• Do you feel pretty worthless the way you
are now?
• 2/5 suggest the diagnosis of depression
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SCREENING (2 of 4)
9-Item Patient Health Questionnaire (PHQ-9)
• 9 items cover diagnostic criteria for major
depression
• Initial 2 questions can be used for screening
• Serial administrations can be used to reliably assess
response to treatment
• Not reliable in patients with moderate to severe
dementia
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SCREENING (3 of 4)
PHQ-9 score
Depression severity
Clinician response
1–4
None
None
5–9
Mild to moderate
If not currently treated, rescreen in
2 weeks. If currently treated,
optimize antidepressant and
rescreen in 2 weeks
10–14
Major depressive disorder
Start antidepressant therapy
≥15
Major depressive disorder
Start antidepressant therapy; obtain
psychiatric consultation if suicidality
or psychosis suspected
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SCREENING (4 of 4)
Prescriber response guidelines
at 4 weeks based on PHQ-9
and sequenced treatment alternatives
PHQ-9 score or change
Outcome
Clinician response
1–4
Nonresponse
Switch medication
Decrease of 2–4 points
Partial response
Add medication
Decrease of ≥5 points
Response
Maintain medication
Score <5
Remission
Maintain medication
D I A G N O S I S I N O L D E R PAT I E N T S I S
D I F F I C U LT B E C A U S E T H E Y . . .
• 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
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DIAGNOSTIC CHALLENGES IN
MEDICAL SETTINGS
• Symptoms of depressive and physical disorders often
overlap, for example:
 Fatigue
 Disturbed sleep
 Diminished appetite
• Seriously ill or disabled people may focus on thoughts
of death or worthlessness, but not suicide
• Side effects of drugs for other illnesses may be
confused with depressive symptoms
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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
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DIFFERENTIAL DIAGNOSIS
• Medical illness can mimic depression
 Thyroid disease
 Conditions that promote apathy
• Dementia has overlapping symptoms
 Impaired concentration or sleep
 Lack of motivation, loss of interest, apathy
 Psychomotor retardation
 Sleep disturbance
• Bereavement is different because:
 Most disturbing symptoms resolve in 2 months
 Not associated with marked functional impairment
CLINICAL COURSE IN
MAJOR DEPRESSION
Recurrence, partial recovery, and chronicity . . .
 disability
 use of health care resources
 morbidity and mortality
suicide
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O L D E R A D U LT S A N D S U I C I D E
• Older age is associated with increasing risk of suicide
• One fourth of all suicides occur in people  65
• Risk factors: depression, physical illness, living alone,
male gender, alcoholism
• Violent suicides (eg, firearms, hanging) are more
common than nonviolent methods among older adults,
despite the potential for drug overdosing
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S T E P S I N T R E AT I N G D E P R E S S I O N
•
Acute: reverse current episode
•
Continuation: prevent a relapse
 Continue for 6 months
•
Prophylaxis or maintenance: prevent
recurrence
 Continue for 3 years or longer
TYPES OF THERAPY
FOR DEPRESSION
• Psychotherapy
• Pharmacotherapy
• Electroconvulsive therapy (ECT)
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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
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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
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ANTIDEPRESSANTS
• Selective serotonin-reuptake inhibitors (SSRIs) and
selective serotonergic and noradrenergic reuptake
inhibitors (SSRI/SNRI)
• Tricyclic antidepressants (TCAs)
• Others: bupropion, mirtazapine, MAOIs,
methylphenidate
S E L E C T I V E S E R O TO N I N - R E U P TA K E
I N H I B I TO R S ( S S R I s )
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• 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
 Higher doses of citalopram with FDA warning of cardiac events
(prolonged QT interval)
TRICYCLIC ANTIDEPRESSANTS
(TCAs)
• Secondary amine TCAs most appropriate for older
patients are nortriptyline and desipramine
• For severe depression with melancholic features
• Avoid in the presence of conduction disturbance, heart
disease, intolerance to anticholinergic side effects
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BUPROPION
• Generally safe & well tolerated
•  activity of dopamine & norepinephrine
• Side effects:
 Insomnia, anxiety, tremor, myoclonus
 Associated with 0.4% risk of seizures
• Dose range: 150–300 mg/day
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S S R I / S N R I : V E N L A FA X I N E
• Acts as SSRI at low doses; at higher doses SNRI
• Effective for major depression & generalized anxiety
• Side effects:
 Nausea
 Hypertension
 Sexual dysfunction
• Dose range: 75–300 mg/day
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S S R I / S N R I : D E S V E N L A FA X I N E
•
Active metabolite of venlafaxine
•
Side effects:
 Nausea
 Headache
 Hypertension
•
Dose range 25–50 mg/day
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SSRI/SNRI: DULOXETINE
• Equally SSRI and SNRI
• Effective for major depression and FDA-approved for
neuropathic pain
• Precautions: drug interactions (CYP450 1A2, 2D6
substrate), chronic liver disease, alcoholism, serum
transaminase elevation
• Dose range: 20–60 mg/day
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M I R TA Z A P I N E
• 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
• Dose range: 15–45 mg/day
• May be given as single bedtime dose (sedative side
effects)
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M O N O A M I N E O X I D A S E I N H I B I TO R S
(MAOIs)
• Use if patient is resistant to other antidepressants
• Side effects:
 Orthostatic hypotension, falls
 Life-threatening hypertensive crisis if taken with
tyramine-rich foods, cold remedies (pressor
amine)
 Fatal serotonin syndrome possible if taken with
SSRI, meperidine
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M E T H Y L P H E N I D AT E
• No controlled data demonstrating efficacy for depression
• Has been used for decades to treat major depression
• May have role in reversing apathy, lack of energy in
patients with dementia or disabling medical conditions
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PHARMACOLOGIC ALGORITHM
Initiate citalopram, escitalopram, or sertraline
If response is inadequate, switch to paroxetine or fluoxetine,
OR switch class based on symptom profile:
Apathy,
retardation
Insomnia, anxiety,
anorexia
Pain
Atypical, melancholic, anxious




Bupropion
Mirtazapine
Duloxetine
Venlafaxine
If response is inadequate:

Atypical

Melancholic, anxious


MAOI
TCA
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R E A S O N S TO U S E E C T
• Effective for treatment of major depression & mania
• First-line treatment for patients at serious risk for suicide,
life-threatening poor intake
• Standard for psychotic depression in older adults;
response rates exceed 80%
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COGNITIVE SIDE 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
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USING ECT
• Contraindications are few:
 Increased intracranial pressure
 Recent MI or CVA and unstable CAD increase risk
of complications
• Continue pharmacotherapy following completion of ECT
treatment
• May use maintenance ECT to prevent relapse
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INCIDENCE OF RESPONSE
• 40% of pts with
major depression
respond to initial
pharmacotherapy
within 6 weeks
• Additional
15%25% achieve
remission with
continued treatment
for 6 weeks
Monotherapy
fails 35%45%
Responsive to
initial
pharmacotherapy
40%
Responsive to continued
treatment
15%25%
MANAGING NONRESPONSE AND
PA R T I A L R E S P O N S E
• 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 SSRI or other drug class
 Add another drug if response is partial despite adequate dose
and duration of treatment
 Combine lithium carbonate, methylphenidate, or
triiodothyronine with secondary amine TCA
 Add psychotherapy
 Consult a geriatric psychiatrist
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RESPONSE AND REMISSION
S TA R * D “ S w i t c h ” a n d “ A u g m e n t ” A l g o r i t h m s
SWITCH
Initiate Citalopram
(maximum dose)
(20mg)
If intolerant or inadequate response switch to…



Buproprion SR
Sertraline
Venlafaxine ER
(400mg)
(200mg)
(375mg)
AUGMENT
Initiate Citalopram
(maximum dose)
(20mg)
If inadequate response add…


Best choice
Second best choice
Buproprion SR
Buspiron
(400mg)
(60mg)
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BIPOLAR DISORDER
(1 of 4)
• Prevalence is low but increasing in older adults
• Bipolar disorders do not ‘burn out’ in old age
• Few patients recover full function despite symptom
remission
• Mania causes hospitalization more and
depression accounts for more disability
• DSM-IVTR criteria for bipolar disorder type I
(mania with or without depression) and type II
(major depressive disorder without mania but with
hypomania) are unchanged with age
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BIPOLAR DISORDER
(2 of 4)
• Manic episodes often present with confusion,
disorientation, distractibility, and irritability
rather than with elevated, positive mood
• Inflated self-esteem, grandiosity, and contentious
claims of certainty also seen
• Presence of psychosis, sleep disturbance, and
aggressiveness may lead to mistaken
diagnosis of dementia or depressive disorder
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Mania
• A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood, lasting at least one week (or any
duration if hospitalization is necessary) (4 days for hypomania)
• B. During the period of mood disturbance, three (or more) of the
following symptoms have persisted (four if the mood is only irritable)
and have been present to a significant degree
–
–
–
–
–
–
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g. feels rested after only three hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
– 7. Excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g. engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
BIPOLAR DISORDER
(3 of 4)
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• Late-onset mania is more often associated with
medical disorders (stroke, dementia, or
hyperthyroidism) or medications (antidepressants,
steroids, stimulants)
• Treatable components that contribute acutely to
the person’s disability should be pursued
• Careful inquiry of the family may reveal repeated
hypomanic episodes that did not cause serious
impairment but are clear indications of earlier
disease
BIPOLAR DISORDER
(4 of 4)
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• Bipolar disorder type II is characterized by recurrent
major depressive episodes interspersed with periods
of hypomania
• Past episodes of hypomania may be unrecognized
by patient and family
• Mixed states occur in which criteria for both mania
and major depressive disorder are present
T R E AT M E N T O F
BIPOLAR DISORDER
• Most primary providers refer suspected cases to a
psychiatrist due to the frequency of recurrence,
psychosis, and suicidality
• Family-focused treatment prevents recurrent
episodes of illness and delays hospitalization when
accompanied by pharmacotherapy
• Pharmacotherapy prevents recurrent episodes but is
less effective without family- focused treatment
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PHARMACOTHERAPY FOR MANIA AND BIPOLAR
D E P R E S S I O N : L I T H I U M C A R B O N AT E
• Target plasma levels for older patients: 0.6–1.0 mEq/L
• Use cautiously with renal insufficiency (once-daily
dosing)
• Up to 1–2 wks to achieve steady state
• May increase lithium levels:
 NSAIDs, thiazide- and K+-sparing diuretics, furosemide
 Dehydration, salt depletion
• Side effects: fine resting tremor, myoclonus, intention
tremor
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PHARMACOTHERAPY FOR MANIA AND BIPOLAR
D E P R E S S I O N : VA L P R O I C A C I D
• Target concentrations of 50–100 g/mL
• Efficacy comparable to lithium; FDA-approved for bipolar
disorder
• Up to 1–2 wks to achieve steady state
• Side effects:




Sedation, rashes,  platelet counts & functioning
Liver toxicity may develop in patients with hepatic disease
Reduce dosage in renal insufficiency
Lab monitoring of CBC, liver enzymes, and chemistries
required
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PHARMACOTHERAPY FOR MANIA AND BIPOLAR
DEPRESSION: ANTIEPILEPTIC AGENTS
Carbamazepine
• FDA-approved for bipolar disorder
• Side effects:



Mild bone marrow suppression with leukopenia &
thrombocytopenia in 5%–10% of patients within first 2 wks
Rarely: life-threatening agranulocytosis & aplastic anemia
Lab monitoring required
Lamotrigine
• FDA-approved for bipolar depression
• Little data on use in late life
• Associated with Stevens-Johnson syndrome
• Reduce dose in liver dysfunction
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PHARMACOTHERAPY FOR MANIA AND BIPOLAR
DEPRESSION: ANTIPSYCHOTIC AGENTS
• Risperidone (0.25–6 mg; risk of movement disorder)
 FDA-approved for acute mania and mixed bipolar I
episodes
• Olanzapine (2.5–15 mg; may cause weight gain)
 FDA-approved for acute mania and mixed bipolar I
episodes
• Quetiapine (25–750 mg; may cause sedation)
 FDA-approved for acute mania and bipolar I and II
depression
• Aripiprazole (5–15 mg; little used in older adults)
 FDA-approved for acute mania and mixed bipolar I
episodes
Case Presentation
• Clinical Course
– Workup ordered, full labs including thyroid, within
limits, CT checked without acute findings
– Referral to see Geropsych the following day in the
community
– 2 weeks later had heard that she was on lexapro at
the time
– 2 months later family reported that she was also on
lithium as adjunct therapy and now venlafaxine
– 6 months later, follow up was that she remained on
the lithium and venlafaxine, back to normal now.
Independent and driving, no delusions, MMSE 30/30
Case Presentation
• Lithium mainly for bipolar disorder
• Adjunctive medication in patients with inadequate
response for treatment of depression
– Sometimes used as acute therapy
• Network meta-analysis of 48 randomized trials (N>6000
depressed patients), of efficacy of 11 augmentation
agents
– Response more oftent with lithium than placebo (OR
1.56, 95% credible interval 1.05 – 2.55)
• Watch out in renal impairment, low sodium, dehydration,
CAD.
– Monitor lithium levels, kidney, TFTs
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S U M M A RY ( 1 o f 3 )
• 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
• Suicide is a serious concern in depressed older
patients, particularly older white males
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S U M M A RY ( 2 o f 3 )
• 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
• Bipolar disorder is common in older psychiatric patients
and may be treated with lithium, or antiepileptic or
antipsychotic agents
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S U M M A RY ( 3 o f 3 )
• Family-focused treatment improves the results of
pharmacotherapy
• Patients who do not respond to usual treatment for
depression or mania should be referred to a geriatric
psychiatrist
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CASE 1 (1 of 4)
• An 87-year-old white man comes to the office because he has had
difficulty sleeping since the recent death of his best friend, who was
with him in the army during World War II. He states that bad
memories about the war keep him awake at night.
• History includes chronic left leg pain (consequence of war injury),
hypertension, hypercholesterolemia, and coronary artery bypass
graft.
• Medications include aspirin, simvastatin, and hydrochlorothiazide,
and acetaminophen as needed.
• His wife died 10 years ago; he lives alone and is independent in
ADLs. He attends a senior center daily for lunch, but he is
considering taking a break because the people there “get on his
nerves.”
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CASE 1 (2 of 4)
• The patient has a good relationship with his children and
grandchildren and is well groomed and pleasant during the visit.
• On further questioning, he admits to more frequent concerns about
his health. He denies thoughts of suicide but at times thinks that he
would be better off dead. He does not have a firearm in his home.
• On examination, he has lost 2.3 kg (5 lb) since his last visit 3 months
ago. Cognition is intact.
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CASE 1 (3 of 4)
Which of the following is the most appropriate treatment
recommendation?
A. No treatment is necessary because his symptoms are
minimal.
B. He requires hospitalization because he is expressing
suicidal thoughts.
C. His symptoms of irritability and poor sleep indicate the
need for treatment of bipolar disorder.
D. His comorbidities preclude treatment with
antidepressants.
E. Treatment with an SSRI should begin immediately.
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CASE 1 (4 of 4)
Which of the following is the most appropriate treatment
recommendation?
A. No treatment is necessary because his symptoms are
minimal.
B. He requires hospitalization because he is expressing
suicidal thoughts.
C. His symptoms of irritability and poor sleep indicate the
need for treatment of bipolar disorder.
D. His comorbidities preclude treatment with
antidepressants.
E. Treatment with an SSRI should begin immediately.
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CASE 2 (1 of 3)
The 9-item Patient Health Questionnaire (PHQ-9) and the
Geriatric Depression Scale (GDS) are the screening tests
for geriatric depression with the best validity to support their
use in primary care practice.
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CASE 2 (2 of 3)
Which of the following statements is true?
A. Both the GDS and the PHQ-9 are self-administered.
B. Both the GDS and the PHQ-9 screen for suicidal
thoughts.
C. The PHQ-9 can be used to assess treatment efficacy.
D. The GDS is more influenced by medical comorbidity
than the PHQ-9.
E. The GDS and PHQ-9 each requires >30 minutes to
administer.
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CASE 2 (3 of 3)
Which of the following statements is true?
A. Both the GDS and the PHQ-9 are self-administered.
B. Both the GDS and the PHQ-9 screen for suicidal
thoughts.
C. The PHQ-9 can be used to assess treatment efficacy.
D. The GDS is more influenced by medical comorbidity
than the PHQ-9.
E. The GDS and PHQ-9 each requires >30 minutes to
administer.
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CASE 3 (1 of 4)
• An 80-year-old woman comes to the office to request a
prescription for an antidepressant. Over the past 2 months
she has been sleeping poorly, and her appetite has
decreased. She describes feeling miserable all the time,
crying often, and fighting with everybody. She has no
somatic symptoms.
• History includes obesity, hypothyroidism, osteoarthritis, and
longstanding bipolar disorder. Medications include
levothyroxine and acetaminophen as needed.
• She has been asymptomatic off medication for bipolar
disorder for 2 years; shortly before she stopped, she
experienced lithium toxicity and was hospitalized.
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CASE 3 (2 of 4)
• The patient and her family believe that the bipolar disorder
has abated because of her age.
• Physical examination is unremarkable. She appears restless,
starts to talk of a new hobby, but then switches topic.
• There is a substantial change from her baseline cognition:
she is not sure of the date, and she makes mistakes about
events that are familiar to her.
• CBC and basic chemistry panel are within normal limits.
• Over the next 24 hours, she becomes increasingly tearful,
confused, and restless.
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CASE 3 (3 of 4)
Which of the following is most likely to be true?
A.
B.
C.
D.
E.
Before offering a psychotropic medication, additional tests
are needed to exclude a medical illness that may be
causing delirium.
Treatment with an antidepressant is likely to improve her
symptoms.
The presentation suggests development of dementia with
behavioral problems that is unlikely to respond to
medications.
A mood stabilizer will slowly improve her confusion resulting
from bipolar disorder.
A sedative will improve her anxiety and associated lack of
sleep.
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CASE 3 (4 of 4)
Which of the following is most likely to be true?
A.
B.
C.
D.
E.
Before offering a psychotropic medication, additional tests
are needed to exclude a medical illness that may be
causing delirium.
Treatment with an antidepressant is likely to improve her
symptoms.
The presentation suggests development of dementia with
behavioral problems that is unlikely to respond to
medications.
A mood stabilizer will slowly improve her confusion resulting
from bipolar disorder.
A sedative will improve her anxiety and associated lack of
sleep.
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GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Gary Kennedy, MD
GRS8 Question Writer:
Alessandra Scalmati, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society