Transcript Depression - Kari Walker

Depression
In the Elderly Population
Presented by Kim Monkman & Kari Walker
The Faces of Depression
What is Depression

Is a mood disorder often goes undiagnosed in the older adult

Many people have felt depressed, sad or down at some point in their lives…however,
these symptoms only last for a short time and are self-limited

More than just feeling sad and is not just the blues

It affects the whole person – their emotions, thoughts, physical health and behaviours

These feelings lasting for more than two weeks and begin to interfere with work,
family, and other aspects of life may be a sign of a major depressive disorder known as
clinical depression

In elderly this can be under recognized; it may be seen as symptom of another medical
condition; friends/family/doctors may see it as a normal part of the aging process

Elderly persons are less likely to complain due to their upbringing, they often work
hard to solve their own problems

Some seniors may not even realize that depression is a diagnosable, treatable illness
Statistics

1 in 8 Canadians will suffer from depression at some point
in their lives

For seniors living in community, it is estimated that 5-10%
will experience a depressive disorder that is serious
enough to require treatment

30-40% of those living in institutional care will have a
depressive episode

80% of those diagnosed and treated will respond to
treatment that will result in a complete and lasting
recovery

90% do not seek help or their depression is missed or
ignored
Signs & Symptoms – Physical Changes

Moving more slowly

Being fidgety, restless, agitated

Significant changes in appetite or weight (loss or gain)

Decreased energy

Psychogenic or phantom pain

Preoccupied with physical complaints

Stomach upset – constipation or diarrhea
Signs & Symptoms – Emotional Changes

Feeling tired or having little energy

Feelings of guilt, worthlessness, or hopelessness

Thoughts that life is not worth living, or that you are no
good to anyone

Decreased interest in sex

Flat affect

Low self-esteem

Sad feelings that are worse in the morning, often lifting as
the day progresses

Crying without reason

Feeling irritable, angry, or aggressive
Signs & Symptoms – Behavioral Changes

Disrupted sleep (trouble falling asleep, staying
asleep, or sleeping too much)

Withdrawal from social activities

Neglecting every day duties (housework, paying
bills, etc.)

Decreased desire to exercise or be physically
active

Reduced self-care (poor meals, hygiene, etc.)

Increased use of alcohol & drugs (Rx and non-Rx)
Signs & Symptoms – Changes in Thinking

Difficulty concentrating, making decisions, or remembering
important information

Speaking more slowly than usual, slower thought process

Avoiding making difficult decisions

Thoughts of suicide, self-harm and death which are
persistent

Sense of “impending doom”

Obsessive ruminations

Loss of self-confidence due to the perception of personal
failures or inadequacies

Self-critical or extremely judgemental

Loss of reality, hallucinations and delusions in extreme cases
Why it is Important to Get Help

Depression robs ones sense of well being, sense of hope,
and ability to find pleasure in life

It increases risk of suicide, especially in the elderly and
more specifically in older men

It can last longer in the elderly patient and result in
premature or unnecessary institutional care

Can lead to feelings of anger and aggression which can
have a negative impact on relationships

Depression that is untreated can lead to the development
of other conditions (such as heart disease or infections)
that can increase the risk of disability or premature death
Factors That Increase Risk of Depression
in the Elderly

Comorbid illnesses that affect the ability to be
independent and get out

Medication side effects or interactions

Isolation, without a support network, friends, or
family

Chronic pain

Previous history of depression or suicide attempts

Family history of major depression
Medications that are Associated with
Depression or the Worsening of Depression

Any medications that affect the central nervous
system (CNS) may have an effect on brain
chemistry that could result in mood changes

Any medication that reduces blood pressure can
result in fatigue & lethargy

Close monitoring of medication in the elderly is
extremely important
Medications that are Associated with
Depression or the Worsening of Depression

Antidepressants – although meant to treat depression, some

Antipsychotics -

Antihypertensives– any medication the reduces blood pressure can

Digoxin – the effect digoxin plays in reducing heart rate and blood
antidepressants work on specific neurotransmitters. This alteration in
brain chemistry can result in impairment of cognitive function or
mood variants in each individual.
block dopamine and serotonin receptors
result in fatigue & lethargy; close monitoring of medication in the
elderly is extremely important
could result in the fatigue and lethargy often associated with
depression. The elderly patient is often at risk for falls while taking
this medication; this concern alone can cause worry in the patient and
can affect their mobility. More a secondary or indirect effect, but
should not be ignored
Medications that are Associated with
Depression or the Worsening of Depression

Steroids - use can reduce serotonin levels which can lead to depression

Anticholinergics - CNS depressants can cause cognitive sedation and cognitive
impairment

Antiparkinsonians – can influence the CNS and may induce psychotic and
suicidal episodes; especially Levodopa-carbidopa

Analgesics - opioids in particular depress the CNS; use with alcohol and other
CNS drugs is not recommended

Sedatives - sedatives such as benzodiazepines are CNS depressants that, in the
elderly, can build up to toxic levels causing a “hangover effect” and feelings of
depression

Alcohol - is a depressant that many seniors use for self- medication; it has been
linked to worsening depressive symptoms
Illnesses that Increase the Risk of
Depression

Heart Problems – 33 % of heart and stroke patients develop some sort of
depression. This is usually related to pain, loss of mobility, and thoughts
concerning mortality

Hypothyroidism – found to be present in 20% of women over 65. Low
thyroid function is related to cognitive and mood disturbances including
depression

Cancer – The majority of people with cancer suffer depression due to the
psychological stress and chronic pain of the disease

Diabetes – Major depression is found in approximately 15% of people with
Diabetes. This is often associated with, poor blood glucose management, poor
self-care, health complications, psychological stress, and lower quality of life
Illnesses that Increase the Risk of
Depression

Decreased Vitamin B12 or Folic Acid –

Low Blood Pressure – There is a 40% increase in the risk of
Low levels can result
in deep depression as these vitamins are needed for good nerve
function. Depression is often related to the neurotransmitters
serotonin, dopamine, and norepinephrine uptake
major depression in individuals with low blood pressure. The actual
low blood pressure may not be the cause. It is more likely an indirect
effect with links to neurotransmitter function in the brain that can
have effects on blood pressure and mood, or could also involve
differences in levels of physical activity and stress reactivity

Rheumatoid Arthritis – 13- 20% of patients suffering from RA
have depression and are twice as likely to have depression as the
general population. This is usually related to chronic pain and fatigue
Treatments

The majority of people will improve with effective treatment

Truly effective treatment should also reduce the chance of a
relapse or recurrence of depression

There are two main types of treatment options (considered
first-line therapies):
1.
Antidepressant medication
2.
Psychotherapy

A combination of medication and psychotherapy should be
considered for people with chronic or severe depression, who
have concurrent mental or physical disorders, or for those who
are not benefiting from psychotherapy by itself

Additionally there are many alternative treatments that can be
utilized
Treatment - Medications

There are about 20 different antidepressant medications currently available

They fall into the following categories:
1.
Selective Serotonin Reuptake Inhibitors (SSRI’s), and 2nd and 3rd Generation
Antidepressants
2.
Tricyclic Antidepressants (TCA’s)
3.
Monoamine Oxidase Inhibitors (MAOI’s)

However, TCA’s and MAOI’s are generally contraindicated in the elderly patient
due to their adverse side effects – specifically anticholinergic and
cardiovascular side effects

Effectiveness of medications may be hindered in elderly patients when other
physical conditions exist (changes in the way the body functions)

Use of antidepressant medications may be contraindicated in the elderly
depending on other medications that the individual is currently taking
Selective Serotonin Reuptake Inhibitors (SSRI’s)
& 2nd and 3rd Generation Antidepressants




Are the first-line drug therapy and are considered to be
superior to TCA’s and MAOI’s
These medications are safer and have few drug-drug and
drug-food interactions
Mechanism of Action:

SSRI’s – inhibit the reuptake of serotonin; may also have weak
effects on norepinephrine and dopamine reuptake

2nd and 3rd Generation Antidepressants – less selective and have
activity on brain serotonin as well as norepinephrine and dopamine
receptors
Time to reach optimum therapeutic effect: 4-6 weeks
Treatment - Psychotherapy

If depression is mild-moderate in the elderly patient
psychotherapy may be considered the first line therapy

For those suffering from a severe major depressive
disorder psychotherapy can be utilized in conjunction with
antidepressant medication

There are two main forms of psychotherapy that are
particularly effective in the treatment of depression:
1.
Cognitive-Behavioral Therapy (CBT):
2.
Interpersonal Therapy (IPT):
Cognitive-Behavioral Therapy (CBT)
 Works
in 3 ways to help the individual identify patterns of
negative thinking, and then learn to challenge these when
they arise:
1.
In CBT the therapist works with the patient to identify the negative
thought patterns and behaviours as well as situations that cause stress
2.
Together, the patient and therapist make goals to achieve these changes
3.
CBT also aids in the prioritization of these goals to achieve these
changes; re-evaluation of goals are required

Typically CBT lasts for 3-4 months or approximately 12-16
weekly sessions (evidence has shown that briefer sessions can
also be effective)
Interpersonal Therapy (IPT)

Focuses in different kinds of interpersonal problems that
may cause problems for people with depression

These problems may have triggered the depression or
they might be the result of the depression

The therapist will help the patient identify what
difficulties they may be experiencing

Therapy then focuses on resolving these difficulties

Typically IPT lasts for 3-4 months or approximately 12-16
weekly sessions
Treatment – Adjunctive/Alternative Therapies
1. Light Therapy – quite effective for those with seasonal affective
disorder (SAD); involves sitting near a special light for about ½ an hour
a day
2. Electroconvulsive Therapy (ECT) – this is a safe and effective
treatment that utilizes electrical currents through the brain; it is
utilized for those with severe depression, who can’t take medication, or
who haven’t responded to other treatments; requires anesthesia
3. Repetitive Transcranial Magnetic Stimulation (rTMS) – this
newer treatment is particularly effective for severe depression; works
by passing a magnetic field briefly over the left prefrontal lobe (an area
of the brain associated with depression); does not require anesthesia
Treatment – Adjunctive/Alternative Therapies
4. Exercise – effective for the treatment of mild to moderate
depression
5. Herbal Remedies – St. John’s Wort may be effective for the
treatment of mild-moderate depression; it is important to consult a
physician/pharmacist before taking herbal remedies as they may
dangerously interact with other medications
6. Acupuncture – this is a traditional Chinese treatment that is
thought to work by releasing endogenous endorphins which therefore
counteract the effects of depression
7. Relaxation – can include the utilization of relaxation classes,
breathing exercises, and meditation
Thank-you!
Questions?
References

American Heart Association (2013). Depression and heart disease.
Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrok
eNews/Depression-and-Heart-Health_UCM_440444_Article.jsp

BC Partners for Mental Health and Addictions Information (October,
2003). Depression Toolkit. Retrieved from
http://www.heretohelp.bc.ca/sites/default/files/images/dtoolkit.pdf

Canadian Diabetes Association (2013). Diabetes and depression.
Retrieved from http://www.diabetes.ca/diabetes-andyou/living/complications/depression/

Canadian Mental Health Association (2008). Learn about depression.
Retrieved from
http://www.heretohelp.bc.ca/sites/default/files/depression.pdf
References

Dickens, C. & Creed, F. (2001). The burden of depression in patients
with rheumatoid arthritis. Rheumatology, 40 (12). 1327-1330.
Retrieved from
http://rheumatology.oxfordjournals.org/content/40/12/1327.fullOxfo
rdJournalsMedicine

Dodson, H. (August 12, 2012). Is there a connection between very low
blood pressure and major depressive disorder? Retrieved from
http://askyalemedicine.yale.edu/2012/08/12/is-there-a-connectionbetween-very-low-blood-pressure-and-major-depressivedisorder/#sthash.rbF9ZnLt.dpuf

Harvard Medical School (2006). Thyroid deficiency and mental health.
Retrieved from http://health.Harvard.edu/fhg/updates/Thyroiddeficiency-and-mental-health.shtml
References

Lilley, L. Harrington, S., Snyder, J., Swart, B. (2011). Pharmacology
for Canadian Health Care Practice. (2nd ed.). Toronto, ON: Elsevier

Mood Disorders Society of Canada. (2010). Depression in elderly.
Received from
http://www.mooddisorderscanada.ca/Consumer%20and%20Family%20
Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf

Skerrett, P. J.(November 11, 2013). Vitamin B12 deficiency can be
sneaky, harmful. Retrieved from
http://healthharvarf.edu/blog/vitamin-b12-deficiency-can-besneaky-harmful-201301105780

Touhy, T. A., Jett, K. F., Boscart, V., & McCleary, L. (2012). Ebersole
and Hess’ Gerontological nursing & healthy aging. Toronto, ON:
Elsevier