Transcript Psychiatric Disorders in Seniors

Paula Bordelon, DO
 Dr. Bordelon has no disclosures.
 Increased knowledge of comorbidities
and risk factors associated with
depression in seniors
 Ability to recognize signs and
symptoms of depression in seniors
 Review of USPSTF recommendation as
it relates to screening adults for
depression
 15% of people age 65 and older suffer
from depression
 Present in 25% of those with chronic
illness (e.g. CHF, DM)
 Increased risk of mortality
 Costly, with direct and indirect costs
totaling $43 billion/year

Geriatric Mental Health Foundation;
http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.htm
l; last accessed 09/19/14
 With less than 4000 geropsychiatrists in
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U.S., primary care physicians treat
75% depressed elderly present to PCP, not
psychiatrists
Increases functional decline
Decreases quality of life
Increased mortality
Extreme burden on family and caregivers
 Prior personal hx depression
 Female
 Increased stressors (e.g. moved to
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assisted living)
Lower socioeconomic
Cognitive Impairment
Substance Use (e.g. alcohol)
Bereavement
 Depression lasting > 2 years considered
chronic & has poor prognosis
 Depressive symptoms or minor depression
 Community
 Long-term care
 In-patient (OABH)
8-15%
30-50%
60-70%
 Major Depression
 Community 1 yr prev
 Primary Care
 Long-term care
2.7%
5.6%
6-25%
 Unipolar
 Bipolar
 Major Depression
 I
 Dysthymia
 II
 Depression NOS
 Cyclothymia
 Bipolar NOS
 Must have depressed mood or
anhedonia (without mania or
hypomania or substance use or
another medical condition)
PLUS:
 4 other “SIGECAPS”
 Present at least 2 weeks
 Cause significant distress
 Seniors are not always aware of
their emotional feelings. May not
relay “depression”
 SIG E CAPS
 Sleep d/o
 Interest
 Guilt
 Energy
 Concentration
 Appetite/weight
 Psychomotor
agitation or
retardation
 Suicidal ideation
 Experience anhedonia or depressive mood for
at least 2 years (think of it as long-lasting
and not lifting)
 Plus at least 2 symptoms (not lifting > 2
mths):
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy
 Low self-esteem
 Poor concentration
 Hopelessness
 Rare in seniors to have its initial onset in
late life
 Dysthymia frequently persists from midlife
to late life
 Do not give this dx if senior ever met
criteria for bipolar D/O or cyclothymic D/O
 Less frequent than nonpsychotic depression
when considering all age groups
 Psychotic depression much more common in
elderly
 Approximately 20 to 45% hospitalized
depressed seniors suffer from psychotic
depression
 Symptoms associated with such include
hallucinations or delusions
 Antidepressants alone not enough
 Warrants antidepressant and
antipsychotic or
 ECT
 considered first-line
 Effective in treatment resistant
patients
Symptom
Description
Depressed mood or anhedonia
Senior won’t state “I am depressed” but
exhibits loss of interest or anxiety
Guilt, low self-esteem, or worthlessness
Not common in seniors
Somatic Complaints
At risk of delayed diagnosis or
misdiagnosed
Psychomotor changes
Elderly more likely to exhibit
Insomnia or hypersomnia
Hypersomnia much more common in
younger adults
Weight loss, anorexia
Very common for seniors
Suicidal ideation
Elderly make fewer attempts; more
likely to be successful
 68 year-old retired nurse with no past psychiatric or
substance abuse reports a 4-week hx of hearing the
voice of her recently deceased husband telling her that
he misses her. Her husband suffered an MI while the
extended family was on a cruise celebrating their 40th
wedding anniversary. The auditory hallucinations
occur at night. Ruth feels guilty, because as a RN, she
believes she should have “seen this coming.” She
reports being “down,” poor appetite and has lost 4
pounds over 45 days, difficulty concentrating resulting
in errors at work, insomnia, and fatigue.
Bereavement leads to adverse mental and
physical outcomes
Associated increased mortality in the surviving
conjugal partner when compared to married
persons of the same age
Highest relative risk of mortality occurred 7 –
12 months after spousal loss
 Also associated with anxiety, substance use,
suicide
 Symptoms seen:
 Marked functional impairment
 Morbid preoccupation with worthlessness
 Psychotic symptoms
 Psychomotor retardation
 Psychosis

Rosenzweig AS, Pasternak R, et al. Bereavement-Related Depression in the Elderly. Is Drug Treatment Justified?
Drug & Aging. 1996 May; 8 (5): 323-326.
 Functional decline
 Increased use of non-mental health services1
 Increased medical mortality rate in those
mood d/o
 Overall2: > 4x rate of death over 15 months
 Cardiac3: 4x rate of death within 4 mos
after MI
1. Beekman et al. Psychol Med 19997;27:1397-1409. 2. Bruce and Leaf. Am J Public
Health. 1989;79:727-730. 3. Romanelli e al. J Am Geriatr Soc 2002;50:817-822.
 Is a state of chronic stress
 Risk factor for developing:
 diabetes,
 cognitive impairment,
 coronary disease (“CAD”)
 osteoporosis
 Depression activates Hypothalamic
Pituitary Axis (HPA)
 Increased levels of cortisol
 Greater in those hospitalized vs outpatient
 No differences between sexes
 HPA hyperactivity varies but does
increase risk of diseases, including
diabetes by increasing FBS and insulin
levels

Stetler C, Miller GE. Depression and hypothalamic-pituitary adrenal activation: a
quantitative summary of four decades of research. Psychosom Med. 2011. Feb-Mar; 73(2):
14-26.
 Depression is independent risk factor for
CAD
 At increased risk subclinical
atherosclerosis
 Hospitalized depressed patients are at
increased risk
 of having a myocardial infarction (“MI”)
 Death from MI
 Individuals suffering MI & depression are
at increased risk of another cardiac event
 Neurodegeneration leads to depression
 Determine if it is dementia syndrome of
depression or depression causing
cognitive inabilities
 Seniors represent 13% of the U.S. population
but 18% of suicides
 U.S. suicide rate 12.3/100,000 overall in 2011;
 Age 85+: 16.9/100,000 (41% higher)
 Among depressed elderly seen by PCP during
a 12 mth period, < 10% received tx for
depression before attempted suicide or
suicide
 70% of suicides occur within 1 month of a visit
to PCP

American Foundation for Prevention of Suicide: New Data Issued by CDC
Releases 2011 Suicide Statistics.
 Seniors have higher ratio of suicide
completions to attempts
 Higher rates of double suicides
 Higher use of firearms in seniors as
means to end life
 White male
 Bereavement (e.g. Widow or Widower)
 Terminal or chronic illness, including
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perceived ill health
Poor sleep
Psychiatric Disorder
Social isolation
Hx prior suicide attempt(s)
 Less frequent in seniors
 Symptoms are not typically classic (i.e.
hyperactivity, decreased sleep, flight of
ideas, grandiose delusions, hypersexual)
 Several “unusual” presentations when we
think of what we learned in medical
school
 Syndrome of reversible cognitive
impairment which is confused with
Alzheimer’s is seen
 Take a psychiatric history
 Speak to informant (esp. if depressed male)
 Get past history (i.e. Is this the first episode
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of depression?)
Suicide attempt hx
If prior hx of depression, obtain previous tx
successes and failures
ASK ABOUT SUBSTANCE ABUSE!
ASK ABOUT FIREARMS!
Investigate if hallucinations
Never assume patient is compliant with
therapy
 In fellowship, taught to use an objective
depression scale (there are quite a few Center
for Epidemiologic Studies-Depression Scale) is
quantitative so can trend it
 Review PHQ-9, GDS, Cornell
 Have high degree of sensitivity and specificity
 USPSTF states sufficiency in “asking 2 simple
questions:
 1. Over the past 2 weeks, have you felt
down, depressed, or hopeless?
 2. Over the past 2 weeks, have you felt
little interst in doing things?”
 Recommends screening adults for depression
when staff-assisted depression care supports
are in place to assure accurate diagnosis,
treatment, and followup
(Grade B recommendation)
 There may be considerations supporting
screening for depression in an individual
patient
(Grade C recommendation)
 Positive screen should trigger full diagnostic
interview and examination
 Cornell Scale for Depression in Dementia –
caretaker or family member rates severity
of symptoms:
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mood-related signs
Behavioral disturbances
Physical signs
Cyclic functions
Ideational disturbances
 Geriatric Depression Scale – patient
answers subjective questions and
validated in many studies
 Looks at attitudes and cognition
 Less focus on vegetative symptoms
 Depression is a prodrome
 Again: depression is linked to cognitive
impairment, especially if first episode of
depression ever
 Depression leads to disturbance in
executive function; can have
“pseudodementia”
 Use MMSE or Montreal Cognitive
assessment (MOCA)
 Take a Medical History
 Medication side-effects
 Drug or alcohol abuse
 Infection
 Endocrinopathy (e.g. hypothyroidism)
 Malignancy
 Nutritional disorders
 Sleep disorders (don’t miss sleep
apnea)
 Acyclovir
 ACE-I
 B Blocker
 CCB
 Corticosteroids
 Digoxin
 H2-receptor blockers
 Interferon alpha
 L-dopa
 Methyldopa and clonidine

Patten SB, Love EJ. Can Drugs Cause Depression: A review of the evidence. J
Psychiatr Neurosci. Vol 18. No. 3. 1993.
 Study
 MRI
 Sleep Study (sleep apnea/MCI/Malaise)
 UA C&S
 Chemistry
 LFTs
 Thyroid Fxn Tests
 Bun/Cr, GFR
 FBS
 Vitamin B-12 and folate
 Antidepressant medications are the
foundation for treatment of moderate and
severe late life depression
 When considering an antidepressant, is
based on
 Efficacy
 Side effects
 Drug interactions
 Cost
Diagnosis
Treatment/therapy
Nonpsychotic MDD
SSRI (SNRI) or venlafaxine XR +
psychotherapy
Psychotic MDD
SSRI (SNRI) or venlafaxine XR +
Atypical Antipsychotic OR
ECT
Dysthymia
SSRI (SNRI) + psychotherapy + tx
concurrent medical conditions
MDD + insomnia
Sedating antidepressant
Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older
Patients. Postgrad. Med Sp Report 2001 (Oct.): 1-86. PMID: 17205639
 FDA-indicated antidepressants are effective in treating
late-life depression; don’t choose “off label”
medication if unnecessary
 Response rate (defined as 50% decrease in symptoms)
 Remission rate (defined as > 90% symptom decrease)
 Typically only achieved in 30 -40% with medication
versus 15% for placebo
 NNT for remission (drug vs placebo): 4
 Avoid TCAs in seniors unless refractory depression
because of side effects
 Discontinuation 2d to SE is frequent in tx studies
 TCA
 SSRI
24%
17%
Side effect
TCA (%)
SSRI (%)
Dry mouth
28
7
N/V
7.5
17
Drowsiness
15.3
6.5
Vertigo
12.2
7.8
Sleep disturbance
4
2.6
SIADH – most likely as result of SSRI
Easy bruising – SSRIs reduce platelet
aggregation
GI bleed Bowel Dysfunction (i.e. constipation)
Weight Gain (e.g. with TCAs)
Decreased libido (not unique to elderly)
 Polypharmacy: avg adult > age 65 is on 5 or more
medications
 Age exacerbates potential for side effects
 Renal elimination of drugs decreases
 Hepatic inactivation of drugs decreases
 Anticholinergic vunerability increases
 Careful treatment initiation can reduce
side effects and PREMATURE withdrawal!
Dosing initiation rule: ½ adult dose
 Start low and go slow
 Treatment takes more time:
 Acute treatment: 8 weeks
 Increase dose:
 Remission:
 Continuation:
 Maintenance:
after 6 weeks
Months
6-12 Months
1-5 years vs lifetime
 Even with maintenance, there is a high
recurrence rate
 Maintenance pharmacotherapy reduces
recurrence risk (Maintenance means
beyond 12 months)
 Slower initial responders may do better
with combined therapy in maintenance 1
1. Dew et al. J Affect Disord 2001;65:155-166
 Psychotherapy is under-prescribed (avoid
in the demented because of lack of
efficacy)
 Effective for non-psychotic MDD and in
dysthymia
 Several approaches are evidence-based
 Cognitive Behavior Therapy (CBT)
 Problem Solving Therapy (PST)
 Interpersonal Therapy (IPT)
 Adequacy of treatment
 Duration of treatment
 Dosage of medication
 Solo therapy versus dual therapy
 Behavioral factors
 Personality disorder
 Psychosocial stressors
 Compliance
 Education provided
 Diagnosis
 Missed medical conditions
 Nonadherence (33-81%) facilitated by:
 Preference for different treatment (e.g. no
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medications)
Complexity of medication regimen
Cost (e.g. too expensive so skip doses)
Side effects (e.g. too severe)
Cognitive impairment (i.e. noncompliance)
Patterns: underuse, overuse, altered use
 Recognition and treatment is poor-missed in 50% of
the ambulatory population
 Among those treated, treated “inappropriately”:
 Inappropriate use of medications
 Too low doses for fear of side effects
 Too short duration
 Inadequate followup (don’t see often enough)
 Delusional depression is more prevalent in older
depressives vs younger depressives
 Associated with:
 Hypochondriasis
 Delusional relapses
 Worse response to monotherapy
 Longer hospitalizations
 Higher relapse rates
 Optimize current therapy
 Switch therapy to new agent
 Augment with additional medication or co-
prescribe
 ECT
Switch
Augmentation
 Slower
 Quicker
 Simpler, less costly
 More complex,
 Avoids drug-drug
interaction
 Reduces SE
 Introduce “different
mechanism”
costly
 Risks drug-drug
interaction
 Can increase SE
 Avoids loss of
earlier partial
response
 Venlafaxine when ANXIETY is prominent
 Bupropion when APATHY is prominent
 Mirtazapine when INSOMNIA/ANXIETY are
prominent
 Aripiprazole is atypical antipsychotic
approved for major depressive disorder and
bipolar disorder
 Challenging in treating depressed older adults who
have not responded to multiple trials of antidepressant
medications
 Elderly with psychotic symptoms who failed
antidepressant therapy often do respond to ECT
 Some studies suggest that ECT is in fact the
SUPERIOR treatment in late life compared to midlife
 Underused!
 Some indications:
 Antidepressant intolerance and/or
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nonresponse
Prior positive response to ECT
Psychosis
Catatonia
Mania
Profound weight loss
 Relative contraindications:
 Cardiac: Recent MI, unstable angina,
uncompensated CHF, arrhythmias, severe
valvular disease
 Neurologic: intracranial lesions “increase”
risk, recent CVA
 Major concern of patients (transient
retrograde amnesia)
 ECT may improve depression-impaired
cognition but exacerbate impaired cognition
of dementia
 Preparation:
 Education
 Pre-screen to establish baseline
 Monitor memory throughout treatment
 Decrease treatment frequency when
pronounced
 The diagnosis of late-life depression is as
valid as any other significant medical
disorder.
 MDD in seniors is associated with
psychiatric and medical morbidity,
increased utilization of health care, and
increased mortality.
 Late-life depression is treatable but may
be refractory to a single intervention.
 Late-life depression often coexists with
cognitive impairment.