This document discusses the treatment of depression in the elderly. It notes that while healthy older adults are not at greater risk of depression than younger adults, risk factors in the elderly include multiple losses, medical illness, and a history of previous depression. Depression is common in elderly patients with medical conditions like stroke, cancer, and heart disease. Treatment includes addressing any underlying medical causes or drugs that may be contributing, starting with low doses of selective serotonin reuptake inhibitors which have fewer side effects in older patients, and considering psychotherapy, electroconvulsive therapy, or mood stabilizers if needed. Close monitoring for side effects and compliance is important when medicating elderly patients.

1. TREATMENT OF DEPRESSION IN THETREATMENT OF DEPRESSION IN THE
ELDERLYELDERLY
Dr. Ibrahim Mahamoud (Al-Omary)
11/3/2012
Geriatric department
Rumailah Hospital

2. Our population is Aging!Our population is Aging!
 2/3 of all the people in the history of the world who
have reached age 65 are alive today!
 1/2 the women who are 65 today will survive to age 85.
 1980-1990 population over 85 increased by 40%;
centenarians doubled.
 Avg. lifespan in 1900=47, today=75

3. Healthy functioning older adults areHealthy functioning older adults are
at no greater risk for depression thanat no greater risk for depression than
younger adultsyounger adults

4. Risk FactorsRisk Factors
Depression increases in the elderly due to:
◦ Multiple losses
◦ Medical illness
◦ Cognitive dysfunction
The greatest risk factor for depression in
the elderly is history of previous
depression

5. Compounding of Adverse LifeCompounding of Adverse Life
Events in AgingEvents in Aging
Jobs
Money
Homes
Friends
Abilities
Health
Hopes
Bereavement

6. Prevalence of Depression in MedicalPrevalence of Depression in Medical
IllnessIllness
Stroke 26-61%
Cancer 18-39%
Myocardial infarct 15-19%
Rheumatoid Arthritis 13%
Parkinson’s Disease 10-37%
Diabetes 5-11%

7. Categories of Medical Problems inCategories of Medical Problems in
elderly inpatients with Majorelderly inpatients with Major
DepressionDepression
Circulatory 69%
Digestive 61%
Endocrine, metabolic 45%
Other 25%
Genitourinary 24%

8. Common Secondary Causes ofCommon Secondary Causes of
Depression in the ElderlyDepression in the Elderly
Alzheimer’s
Vascular and other
dementia
Common infections
(i.e. pneumonia or
UTI)
Substance abuse
Endocrine disorders
Electrolyte imbalance
Tumor
Endocrine
Prescription
meds

9. Drugs That Cause DepressionDrugs That Cause Depression
Cyclosporine
Corticosteroids
MAOIs
Anticonvulsants
Barbiturates
Benzodiazepines
Beta-adrenergic blockers
Bromocriptine (Parlodel)•
Calcium-channel blockers
Estrogens
Fluoroquinolone antibiotics
Interferon alfa
Opioids
 Others.......................

10. Dementia and DepressionDementia and Depression
Alzheimer’s - 20-40%
Similar rates with other dementia's
◦ Vascular
◦ Parkinson’s
◦ Huntington’s
◦ Brain injury
◦ B12,folate
Depression may precede other symptoms

11. Having a mental disorder in late lifeHaving a mental disorder in late life
increases mortalityincreases mortality
by 1.6 - 2.5 timesby 1.6 - 2.5 times

12. Rates of MI are 4.5 times greater inRates of MI are 4.5 times greater in
patients with history of majorpatients with history of major
depressiondepression

13. SuicideSuicide
15% of severely depressed persons
commit suicide
Elderly males are at greatest risk
80% consult physician in the month
before death
Elderly are less likely to have had
previous attempts or to complain of
suicidal thoughts--more likely to
complete it.

14. Suicide,Suicide, cont.cont.
10 years after stroke
◦ Mortality for non-depressed is 40%
◦ Mortality for depressed is 70%

15. Diagnosing Depression in theDiagnosing Depression in the
ElderlyElderly
DSM-IV criteria may not be met
◦ Deny most mood symptoms, but may appear
fearful or sad
◦ Loss of interest in usual activities
◦ Irritable, brooding
◦ Somatic

16. Diagnosing Depression in theDiagnosing Depression in the
Elderly,Elderly, cont.cont.
DSM-IV criteria may not be met
◦ Sleep and appetite changes
◦ Fatigue
◦ Less suicidal complaints, but highest rate in
elderly males
◦ Social withdrawal

17. The Diagnosis of Depression in theThe Diagnosis of Depression in the
Elderly is Often MissedElderly is Often Missed
Symptoms of medical illness may be the
same as depression
◦ low energy
◦ loss of interest
◦ anorexia
◦ fatigue

18. The Diagnosis of Depression in theThe Diagnosis of Depression in the
Elderly is Often Missed,Elderly is Often Missed, cont.cont.
Study at Duke University
◦ Assessment given to elderly medical admits
◦ Of those meeting criteria for depression, only
40.5% received an anti-depressant

19. Pseudo dementiaPseudo dementia
Cognitive problems related to depression
Higher incidence of development of
dementia
Past hx of mood disorder
Depressive sx precede cognitive sx
Acute onset
Increase in dependency

20. Pseudodementia,Pseudodementia, cont.cont.
Slow psychomotor response,low
motivation and social interaction
Improve with antidepressant
Better to risk over-diagnosis and treat
for depression
Use clinical judgement based on patient
history and function

21. Treatment of Depression in theTreatment of Depression in the
ElderlyElderly
Treat co-morbid conditions and
etiologies of secondary depression
Choose appropriate level of care
Choose therapies appropriate to age and
cognitive functioning
Psychosocial interventions

22. Watch for Signs of Elder Abuse andWatch for Signs of Elder Abuse and
NeglectNeglect
Malnutrition and dehydration
Bruises, fractures, burns
Mental abuse
Neglected medical care

23. PharmacologyPharmacology
START LOW -- GO SLOW

24. Pharmacologic Complications in thePharmacologic Complications in the
ElderlyElderly
Pharmacokinetics
Pharmacodynamics
End-organ physiological change
Medical illness
Cognitive decline
Poly-pharmacy
Compliance
Life adversity

25. Pharmacokinetics and the ElderlyPharmacokinetics and the Elderly
↓ Gastric motility and pH
◦ Causes ↓ absorption
↑ Fat/lean body ratio
◦ Causes ↑ volume of distribution and ↑
half-life
↓ Hepatic blood flow
◦ Causes ↓ breakdown

26. Pharmacokinetics and the Elderly,Pharmacokinetics and the Elderly,
cont.cont.
↓ Activity of some catabolic enzymes
◦ Causes ↑ plasma levels and half-life
↓ GFR
◦ Causes ↓ clearance and ↑ accumulation

27. Pharmacodynamics and the ElderlyPharmacodynamics and the Elderly
Increased sensitivity to:
◦ Sedation
◦ Cardiovascular effects
◦ Anticholinergic effects

28. Noncompliance in the ElderlyNoncompliance in the Elderly
40-70% noncompliance
10% take drugs prescribed for others
20% take drugs not currently prescribed
40% stop drugs too soon

29. Principles of PharmacologicPrinciples of Pharmacologic
TreatmentTreatment
Use medications with minimal
Anticholinergic, cardiovascular and
orthostatic effects
Begin with low dose
Monitor compliance
Monitor side effects
Increase dose slowly, but use adequate
amounts

30. Use the More Selective Drugs withUse the More Selective Drugs with
Less Side Effects FirstLess Side Effects First
Selective Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine (Prozac) 10-80 mg/d
Fluvoxetine (Luvox) 25-250 mg/d
Paroxetine (Paxil) 10-60 mg/d
Sertraline (Zoloft) 25-200 mg/d
Citalopram (Celexa) 25-200 mg/d
Escitalopvam (Lexapro) 10-20 mg/d
◦ Safe, effective
◦ Side effects--Activation,GI, headache, sexual, enzyme
inhibition (Cyt P450)

31. Use the More Selective Drugs with LessUse the More Selective Drugs with Less
Side Effects First, cont.Side Effects First, cont.
◦ Serotonin Syndrome
◦ Myoclonus, hyperreflexia, tremor
◦ Confusion, agitation, hypomania
◦ Fever, sweating, shivering
◦ Diarrhea
Stop or reduce drug
Propranolol, clonazepam

32. Serotonin SyndromeSerotonin Syndrome

33. Use the More Selective Drugs withUse the More Selective Drugs with
Less Side Effects First, cont.Less Side Effects First, cont.
Venlafaxine (Effexor)
◦ 12.5mg BID-350 mg/d, XR 37.5,75,150 mg/d
◦ Reuptake inhibition of serotonin and
norepinephrine
◦ May be more efficacious in refractory cases
and vegetative depression
◦ Side effects--nausea, activation, serotonin
syndrome, HTN, tremor

34. Use the More Selective Drugs withUse the More Selective Drugs with
Less Side Effects First,Less Side Effects First, cont.cont.
Nefazodone (Serzone)
◦ 50-600 mg divided or HS q Day
◦ Safe, anxiolytic, increases sleep, less sexual
side effects
◦ Side effects--dizziness, sedation, GI, CytoP450
inhibition

35. Use the More Selective Drugs withUse the More Selective Drugs with
Less Side Effects First,Less Side Effects First, cont.cont.
Bupropion (Wellbutron)
◦ 75-150 mg TID, SR 100-150 mg BID
◦ Safe, effective, no sexual side effects.
◦ Side effects--, GI, HA, Seizures

36. Use the More Selective Drugs withUse the More Selective Drugs with
Less Side Effects First,Less Side Effects First, cont.cont.
Mirtazapine (Remeron)
◦ 7.5-45 mg (sedating at the lower doses)
◦ Safe, antidepressant, anti-anxiety, 1X/d
◦ Helps sleep and appetite in elderly at low
dose
◦ Side effects--constipation, dizziness, dry
mouth, somnolence
◦ Agranulocytosis or neutropenia (rare)

37. Tricyclic AntidepressantsTricyclic Antidepressants
Effective antidepressants BUT avoid due to:
◦ Orthostatic hypotension
◦ Slow cardiac conduction
◦ Increase HR
◦ Decreased heart rate variability
◦ Sedation

38. Tricyclic Antidepressants,Tricyclic Antidepressants, cont.cont.
Effective antidepressants BUT avoid due to:
◦ Sexual
◦ Dry mouth
◦ Constipation
◦ Urinary retention

39. If other types of antidepressants fail:If other types of antidepressants fail:
Nortriptyline and desiprimine
◦ Starting at low doses
◦ Monitoring blood levels can be used
Trazodone (Desyrel)
◦ Use for sleep in low doses--very high doses may be
necessary for antidepressant effect
◦ May lead to orthostasis
◦ Less anticholinergic side effects.

40. For depression with psychoticFor depression with psychotic
features:features:
Low doses of higher potency
antipsychotics
◦ .5 - 2 mg haloperidol (Haldol) will often
suffice
◦ 2.5 - 5 mg olanzepine (Zyprexa)
◦ 25 mg quetiapine (Seroquel)
◦ .25 - .5 mg risperidone (Risperdal)
◦ May go higher if tolerated and no response at
lower doses

41. For depression with psychoticFor depression with psychotic
features,features, cont….BIPOLARcont….BIPOLAR
Mood Stabilizers
◦ Lithium
◦ Valproate (Depakote)
◦ Carbemazepine (Tegretol)
Monitor blood levels
Liver enzymes for Depakote and
Tegretol
CBC for Tegretol
TSH, Cr for Lithium

42. For depression with psychoticFor depression with psychotic
features,features, cont.cont.
For agitation:
◦ Lorazepam (Ativan) .5-1 mg TID PO or IM or
IV
 Increased risk for falls with use

43. Electroconvulsive TherapyElectroconvulsive Therapy
For depression which is:
◦ Unresponsive to medication
◦ With psychotic features
◦ Putting the patient at risk due to poor oral
intake or suicidality
More cardiac risks in the elderly, but can
be performed safely

44. PsychotherapyPsychotherapy
Problem Solving
Supportive
Cognitive
Behavioral
Pets
Education
Family
Groups
Psychosocial
Intervention

45. THANK YOUTHANK YOU