Transcript Geriatric Depression

Beating the Blues:
Depression in Older
Patients
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
UNMC
Goals
 Discuss
depressed mood as a problem in
the nursing home
 Discuss recognition of depression
 Discuss treatments of depression.
Mood Problems
 Several
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diagnoses for depressed mood
Major depressive disorder
Dysthymia
Bipolar affective disorder
Mood disorder due to a general medical dx
Substance induced mood disorder
Adjustment disorder with depression
Complicated bereavement
Mood disorder not other wise specified (NOS)
Major Depressive Disorder
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More intense than being blue
2 wks
 Lasts for an extended time
 Dysfunction
 DSM IV criteria for Major Depressive Disorder
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Must have 1 of these 2
• Depressed mood, more often than not, for 2W
• Loss of interest
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Plus these other symptoms to equal 5 total
• Sleep, energy, appetite, worthlessness, concentration,
suicidal ideation, helpless, hopeless, guilt,
Epidemiology of Geriatric
Depression
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Of 35 million seniors in the US
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19% of all suicides are by patients over 65
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An estimated 2 million have a depressive illness
5 million have subsyndromal depression
Less than 10% are treated
1 in 10 Americans over 65 will be depressed
Seniors comprise 13% of the population
The highest suicide rates in the U.S. are found in
white men over age 85.
Seniors have 50% higher health care costs if
depressed
www.efmoody.com/longterm/depression.html
Epidemiology of Geriatric
Depression
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Influence on general health
 CV disease, cancer, infection, falls
 Mortality
Epidemiology of Geriatric
Depression
 MDD
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in special populations of elderly
Medical outpatient rate is 7-35%
• 5x higher in the doctor’s office than in the
community
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Medically hospitalized rate is 40%
Epidemiology of Geriatric
Depression
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Nursing Homes’ rate for MDD is 12.4-20%
• But 30-35% have other depressive disorders
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Dementia with depression
Adjustment disorder with depressed mood
Complicated bereavement
Depression due to GMC (Parkinson’s Disease, e.g.)
Epidemiology of Geriatric
Depression
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Geriatric depression is associated with:
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Female gender
• Though this declines with age
• Above age 80 gender differences rapidly fade
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Low socio-economic level
Less social support
• Especially those divorced or widowed
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Recent adverse life events
• Death and other losses
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Severe impairment in medical health
• Especially neurological disorders, endocrine disorders,
COPD, MI, cancers
Epidemiology of Geriatric
Depression
 Underutilization
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of psychiatric services
Common in those over 65
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A matter of “will power”
Cost of medicines, copays
Depressed people went to the asylum
Not socially acceptable to discuss one’s feelings
Underutilization of psychiatric
services
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Contributes to the high suicide rate in this
group
• Over 65, white males have the highest rate of
completed suicide in the United States
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0.02%/yr for men, 0.005%/yr for women over 65
Rate for white men over 85 is FIVE TIMES the national
rate
• 59 per 100,000 versus 10.6 per 100,000
MDS 3.0 criteria mood disorder
 Corresponds
closest to the diagnosis of
major depression.
Major Depressive Disorder
 DSM
IV criteria for Major Depressive
Disorder
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Must have 1 of these 2
• Depressed mood, more often than not, for 2W
• Loss of interest
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Plus these other symptoms to equal 5 total
• Sleep, energy, appetite, worthlessness,
concentration, suicidal ideation, helpless,
hopeless, guilt,
MDS 3.0 Depression Definition
PHQ-9
2 or more sx occurring >= 50% time
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Over the last 2 wks have you been bothered by
any of the following problems?
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Little interest
Feeling down
Sleep
Energy
Appetite
Feeling bad about yourself (worthlessness)
Concentration
Moving slowly (psychomotor retardation)
Thoughts you would be better off dead
You suspect Depression
What next?
Is it Medication?
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Pain medications
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codeine, darvon
High blood pressure medications
• clonidine, reserpine
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Hormones
• estrogen, progesterone, prednisone
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Cardiac medications
• digitalis, propranolol
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Alcohol
Is it medications?
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Anticancer agents
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cycloserine
tamoxifen
Nolvadex, Velban, Oncovin
Parkinson’s disease medications
• L-dopa and bromocriptine
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Arthritis
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indomethacin
Anti-anxiety drugs
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Valium and Halcion
Is it a medical condition?
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Hypothyroidism
Calcium
B12
Vitamin D deficiency
Heart disease
Neurological illnesses
Cancer
COPD
.
Is it due to dementia?
Higher rate of depression than the general
population
• Varying intensity in 50%
• Alzheimer’s range 0-87%, mean 17-31%
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Mild to moderate stages report depression
• GDS
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Useful for mild to moderate dementia
Patient answers 15 questions with yes or no
• Cornell Scale for Depression in Dementia
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Useful for moderate to severe dementia
No self-report so rater must be well-trained
Diagnosis of Geriatric
Depression in Dementia
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Confusion can often arise as to mood symptoms
in dementia
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Communication issues
• Patients with moderate to severe dementias do not verbally
communicate their mood
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Symptoms of other disorders can overlap with
depression
• Alzheimer’s patients have little appetite, lose concentration,
become isolative
• Parkinson’s patients lose affect, have slowed speech and
movements
• Frontal lobe injuries present with apathy, often misinterpreted
as depression, or frequent crying not related to mood
Diagnosis of Geriatric
Depression in Dementia
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Useful to use:
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Frequent, dysfunctional sad, downcast mood
New agitation and/or sudden loss of interest
Psychic rather than vegetative features
• Vegetative features often are multifactoral
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i.e. poor sleep may have four or five causes
Use caregiver reports from home or the NH
The patient’s past medical and psychiatric history
Diagnosis of Geriatric Depression
in Dementia
 If
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unsure, TREAT FOR DEPRESSION
Medications safer and more effective these
days
ECT a viable option
Much worse to miss than overtreat
Diagnosis of Geriatric Depression
in Dementia
 Apathy
is a common symptom in dementia
 Often mistaken for depression How to tell them apart?
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In apathy, no emotional changes or lasting
emotional feelings.
 Treatment?
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(none with FDA approval)
Amphetamine if pt sleeps too much-provigil
Antidepressants
Course of Geriatric Depression
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More chronic than early onset depression
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Adult rate for chronic depression is 20%
Geriatric rate for chronic depression near 30%
• 13-19% relapse at one year
• Risks for relapse after age 65
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Frequent episodes
Late age at onset
Dysthymia
Medical illness
High severity of first episode
Hospitalization, suicide attempt
Rationale for long term use of antidepressants in this
population
Psychotic depression
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Psychotic depression a problem in the elderly
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20-45% of geriatric psychiatric inpatients
4% of depressed elders in the community
Psychotic depression
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Presentation
• Primarily delusions, hallucinations less so
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Guilt, hypochondriasis, nihilism, persecution, jealousy
• Highly systematized, mood-congruent delusions
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Delusion often frightening or catastrophic
• Needs treatment for depression and psychosis
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These patients require antipsychotic treatment
• fluvoxamine (Luvox) may be useful alone
Often require electroconvulsive therapy (ECT)
• Especially when their condition compromises their
physical health
Medications to Treat Geriatric
Depression
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SSRIs –most common
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Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Escitalopram
SNRI’s
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Venlafaxine
duloxetine
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Tricyclics
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MAOI
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Nortriptyline
Selegeline patch
Others
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mirtazepine
bupropion
trazodone
Treatment for Depression
 Medications
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All have data or reports in use in elderly pts.
All have some positive report in dementia pts.
Depression harder to treat in older patients
What should you expect from
medication Treatment of Geriatric
Depression?
 How
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8 to 12 weeks in 30 year olds
May stretch to 12-16 weeks in the elderly
 Can
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long does it take to work?
you see changes earlier?
Some yes.
• Vegetative-sleep appetite energy
• Good sign of response
What should you expect from
medication Treatment of Geriatric
Depression?
 Are
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they dangerous?
Not long-term
Drug-drug interactions minimal in most cases
Not addictive
What should you expect from
medication Treatment of Geriatric
Depression?
 Do
they have side effects?
 SSRI- GI, dec. sex drive, anxiety headache
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SNRI-HTN, anxiety
TCAs-bladder, bowel, cardiac, confusion
MAOI-Tyramine reaction
Mirtazapine-sedation weight gain
Buproprion-anxiety, HTN
Trazodone-sedation, orthostatic BP
Are Antidepressants used for other
purposes?
 Anxiety/sleep-
FDA approval for
mirtazapine, nortriptyline
 Pain- duloxetine, venlafaxine, nortriptyline
 Appetite-mirtazapine, nortriptyline
Are other medications used for
depression?
 Methyphenidate
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No FDA approved, literature supports used in
medically ill, apathetic, those with poor
appetite
 Lamictal
FDA approved for bipolar depression
Treatment
 Psychotherapy
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Cognitive-behavioral and Interpersonal
• Manual-driven
• Easy to study
• Effective in combination and alone
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Psychodynamic
• Long-term issues; less studied
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Problem solving and Supportive
• Mild-moderate dementia
• Coping day-to-day
Treatment
 ECT
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Works rapidly for those who can’t wait
• Psychotic depression, especially
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Hospital venue
• Anesthesia
• 30-60 second seizure; 6-12 treatments
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Maintenance treatment
Adverse effects minimal
• Short-term memory loss; lasts less than 2 mos.
• Mortality rate 0.01%
Treatment
 ECT
 How
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does it work?
Win the Nobel Prize in Medicine
• Cerebrovascular contraction
• Increased BBB permeability
• Increased brain O2 concentration
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No absolute contraindications
• Relative are brain tumor, MI in the last 3-6 mos.
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Response level is 90%
• Trick is maintaining the response
Goals
 Geriatric
depression is common in NH
 Rates are different than the general
population
 Various effective treatments do exist
Visit our website and forum
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http://app1.unmc.edu/intmed/geriatrics/index.cfm?c
onref=104
 http://ltcmentalhealth.forumcircle.com/portal.php
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