Depression in the elderly (Psychiatry)

1. Depression In Elderly
Slam
201002414
71913993

2. Presentation Outline
• Definition
• Introduction
• Epidemiology
• Causes and Risk Factors
• Diagnosis
• Approach
• Screening
• Differential diagnosis
• Treatment
• Prognosis

3. Definition Depression
• A spectrum of mood disorders characterized
by a sustained disturbance in emotional,
cognitive, behavioral, or somatic regulation
and associated with significant functional
impairment and a reduction in the capacity for
pleasure and enjoyment

4. INTRODUCTION
• Depression in older adults is a widespread
problem,
• but it is not a normal part of aging.
• It is often not recognized or treated.

5. What are the differences between older and
younger persons with mental illness?
• Assessment is different: e.g. cognitive assessment needed,
recognize sensory impairments, allow more time
• Symptoms of disorders may be different: e.g. different
symptoms in depression
• Treatment is different: e.g. different doses of meds,
different psychotherapeutic approaches
• Outcome may be different: e.g. psychopathology in
schizophrenia may improve with age

6. EPIDEMIOLOGY AMONG
OLDER ADULTS
 Minor depression is
common
• 15% of older persons
overall
• 50% long-term care
• Causes  use of health
services, excess disability,
poor health outcomes,
including  mortality
 Major depression is not
common
– 1%–2% of physically
healthy community
dwellers
– 12-16% in long-term
care
– Elders less likely to
recognize or endorse
depressed mood

7. Prevalence of Depression

10. Causes
• Unlike depression in early life, genetic factors
are less important in depression that starts
later in life.
• Late onset depression is associated with a
higher frequency of :
– Cognitive impairment
– Cerebral atrophy
– Deep white matter changes

11. Major Depression in Neurologic
Disorders Associated with Aging
• Stroke 40-60%
• Parkinson Disease 30-
40%
• Alzheimer’s Disease 20-
40%

12. Risk Factors for Late Life Depression
• female sex, being single or divorced
• Recent bereavement
• Fear of death
• Role transition
• Frustration with memory loss
• stressful life events

13. Comorbid Conditions with
High Risk Depression
• Alcohol dependency/Substance abuse
• Cerebrovascular/neurodegenerative disease
• Cancer
• COPD
• Chronic pain
• CHF/CAD/MI
• DM/electrolyte imbalance
• Head trauma/ Orthostatic hypotension
• Abuse
• Schizophrenia

15. • Vascular depression
(depression due to
vascular lesions):
• more common in late-
onset disease.
• Increasingly evident that
cerebrovascular disease
seemingly plays a role in
depression beginning in
late life.
• Cerebrovascular disease may
predispose or perpetuate some
geriatric depressive syndromes.
– Such patients seem more
resistant to treatment.
– Supported by comorbidity of
depression and vascular risk
factors and the association of
ischemic lesions to distinctive
behavioral symptoms.
– Vascular lesions include
periventricular hyperintensity,
deep matter hyperintensity, and
subcortical gray matter
hyperintensity.
– Disruption of prefrontal systems
may be responsible.

16. DSM-IV DIAGNOSTIC CRITERIA
FOR MAJOR DEPRESSION
• Gateway symptoms
(must have 1)
• Depressed mood
• Sad
• Emptiness
• Helpless
• Hopelessness
• Loss of interest or
pleasure (anhedonia)
• Other symptoms
• Appetite change or
weight loss
• Insomnia or
hypersomnia
• Psychomotor agitation
or retardation
• Fatigue and Loss of
energy
• Feelings of
worthlessness or guilt
• Difficulty concentrating,
making decisions
• Recurrent thoughts

17. ICD 10 DIAGNOSTIC CRITERIA
FOR MAJOR DEPRESSION
• Depressed mood,
• loss of interest and
enjoyment, and
• reduced energy leading to
increased
• fatiguability and diminished
activity.
• Marked tiredness after only
slight effort is common.
• reduced concentration and
attention;
• reduced self-esteem and
self-confidence;
• ideas of guilt and
unworthiness (even in a
mild type of episode);
• bleak and pessimistic views
of the future;
• ideas or acts of self-harm or
suicide;
• disturbed sleep
• diminished appetite.

18. Diagnostic Approach to Clinical
Depression

19. Screening for Depression
• Recommended screening adults for
depression to assure accurate diagnosis,
effective treatment, and follow-up
– Patient Health Questionnaire (PHQ9)
– Geriatric Depression Scale
– Beck Depression Inventory

20. DIFFERENTIAL DIAGNOSIS
• Medical illness can mimic
depression
– Thyroid disease
– Conditions that promote
apathy
• Dementia has overlapping
symptoms
– Impaired concentration
– Lack of motivation, loss of
interest, apathy
– Psychomotor retardation
– Sleep disturbance
• PSYCHOTIC DEPRESSION
– Occurs in 20-45% of
hospitalized elderly
depressed patients and 15%
of elderly depressives in the
community.
– Patients have sustained
paranoid, guilty, or somatic
delusions (plausible but
inexplicably irrational beliefs
– Delusions are more
commonly mood-congruent
– Auditory hallucinations are
less common

21. Medications causing
symptoms of depression
• Anabolic steroids
• Anti-arrythmics
• Anti-convulsants
• Barbituates
• Benzodiazepenes
• Carbidopa/Levodopa
• Clonidine
• Digitalis
• Glucocorticoids
• H2 Blockers
• Metoclopramide
• Opioids
• Some Beta-blockers

22. STEPS IN TREATING DEPRESSION
• Acute — reverse current episode
• Continuation—prevent a relapse
 Continue for 6 months
• Prophylaxis or maintenance—prevent future
recurrence
 Continue for 3 years or longer

23. TYPES OF THERAPY FOR DEPRESSION
• Non Medical Interventions
• Medical Intervention
– Psychotherapy
– Pharmacotherapy
– Vagal Nerve stimulation
– Electroconvulsive therapy (ECT)
– Combination therapy

25. Thank You