Geriatric Depression


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Geriatric Depression

  1. 1. GERIATRIC DEPRESSION November 13, 2001 Eric Troyer, M.D. Swedish Family Medicine
  2. 2. Case 1 <ul><li>Eva is an 80 y.o. female </li></ul><ul><ul><li>Complaints: Poor sleep, mild weight loss due to poor appetite, slowing down recently. </li></ul></ul><ul><ul><li>History of incontinence, cardiovascular disease, and diabetes. </li></ul></ul><ul><ul><li>How might you approach this patient’s problems? </li></ul></ul>
  3. 3. DSM-IV DIAGNOSTIC CRITERIA <ul><li>5 or more symptoms lasting >2 wk, change from previous functioning: </li></ul><ul><ul><li>Depressed mood and/or loss of interest </li></ul></ul><ul><ul><li>Altered sleep, loss of energy, appetite change or weight loss, feelings of worthlessness/guilt, psychomotor changes, loss of concentration and focus, recurrent thoughts of death </li></ul></ul>
  4. 4. SIG E CAPS <ul><ul><li>Sleep </li></ul></ul><ul><ul><li>Interest </li></ul></ul><ul><ul><li>Guilt (“Are you a burden to others?”) </li></ul></ul><ul><ul><li>Energy </li></ul></ul><ul><ul><li>Concentration </li></ul></ul><ul><ul><li>Appetite </li></ul></ul><ul><ul><li>Psychomotor changes </li></ul></ul><ul><ul><li>Suicidality (“Do you wish you could die?”) </li></ul></ul>
  5. 5. Vegetative Symptoms <ul><ul><li>Sleep </li></ul></ul><ul><ul><li>Interest </li></ul></ul><ul><ul><li>Guilt (“Are you a burden to others?”) </li></ul></ul><ul><ul><li>Energy </li></ul></ul><ul><ul><li>Concentration </li></ul></ul><ul><ul><li>Appetite </li></ul></ul><ul><ul><li>Psychomotor changes </li></ul></ul><ul><ul><li>Suicidality (“Do you wish you could die?”) </li></ul></ul>
  6. 6. Vegetative Symptoms <ul><ul><li>These can often occur in other medical illnesses </li></ul></ul><ul><ul><li>Not discriminating or sensitive </li></ul></ul>
  7. 7. Psychological Symptoms <ul><ul><li>Sleep </li></ul></ul><ul><ul><li>Interest </li></ul></ul><ul><ul><li>Guilt (“Are you a burden to others?”) </li></ul></ul><ul><ul><li>Energy </li></ul></ul><ul><ul><li>Concentration </li></ul></ul><ul><ul><li>Appetite </li></ul></ul><ul><ul><li>Psychomotor changes </li></ul></ul><ul><ul><li>Suicidality (“Do you wish you could die?”) </li></ul></ul>
  8. 8. Psychological Symptoms <ul><ul><li>More reliable and are independent of age </li></ul></ul><ul><ul><li>But, elderly patients less willing to talk about psychological problems </li></ul></ul><ul><ul><li>Pay attention to: </li></ul></ul><ul><ul><ul><li>anxiety </li></ul></ul></ul><ul><ul><ul><li>physical discomfort </li></ul></ul></ul><ul><ul><ul><li>adaptation to a new lifestyle </li></ul></ul></ul>
  9. 9. SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION <ul><li>SYMPTOMS </li></ul><ul><ul><li>MOOD </li></ul></ul><ul><ul><li>COGNITIVE </li></ul></ul><ul><ul><li>VEGETATIVE </li></ul></ul><ul><ul><li>VOLITIONAL </li></ul></ul><ul><li>SIGNS </li></ul><ul><ul><li>APPEARANCE </li></ul></ul><ul><ul><li>BEHAVIORS </li></ul></ul><ul><ul><li>PSYCHOMOTOR RETARDATION </li></ul></ul><ul><ul><li>PHYSCHOMOTOR AGITATION </li></ul></ul>
  10. 10. Case 1 <ul><li>SIG E CAPS & DM for Eva: </li></ul><ul><ul><li>Positives: Sleep, Appetite, Psychomotor retardation </li></ul></ul><ul><ul><li>Negatives: Interests, Guilt, Energy, Concentration, Suicidality, Depressed mood </li></ul></ul>
  11. 11. Case 1 <ul><ul><li>Poor sleep due to nocturia. </li></ul></ul><ul><ul><li>Appetite changes due to decreased taste and smell. </li></ul></ul><ul><ul><li>Slowing down due to new claudication. </li></ul></ul>
  12. 12. Case 2 <ul><li>George is a 74 y.o. male </li></ul><ul><ul><li>Complaints: Sore muscles, dizziness, constipation. Repeated visits to doctor with vague symptoms. </li></ul></ul><ul><ul><li>Daughter reports patient impossibly uncooperative and has angry outbursts. </li></ul></ul><ul><ul><li>Wife died 2 years ago; he moved in with daughter 3 months ago after a fall. </li></ul></ul>
  13. 13. INCIDENCE IN ELDERLY <ul><li>MAJOR DEPRESSION </li></ul><ul><ul><li>3% community dwelling </li></ul></ul><ul><ul><li>14% two years after spouse dies </li></ul></ul><ul><ul><li>15% medically ill </li></ul></ul><ul><ul><li>25% long-term-care settings </li></ul></ul><ul><li>DEPRESSIVE SX’S </li></ul><ul><ul><li>17-37% in primary care settings </li></ul></ul><ul><ul><li>42% in long-term-care settings </li></ul></ul>
  14. 14. How is Depression Different in the Elderly? <ul><li>Less verbalization of emotions or guilt </li></ul><ul><li>Minimize or deny depressed mood (“masked depression”) </li></ul><ul><li>Preoccupied with somatic symptoms </li></ul><ul><ul><li>65% have hypochondriacal symptoms </li></ul></ul><ul><li>Cognitive impairment can be marked </li></ul><ul><li>Hopelessness appears to be persistent </li></ul>
  15. 15. How is Depression Different in the Elderly? <ul><li>Depressive ideation, anxiety, psychomotor retardation, and weight loss have high assoc. with disability </li></ul><ul><li>More anxiety, agitation and psychosis </li></ul><ul><ul><li>esp. delusions with themes of guilt, nihilism, persecution, jealousy </li></ul></ul><ul><li>Medical Conditions can mask or cause depression </li></ul>
  16. 16. How is Depression Different in the Elderly? <ul><li>Subsyndromal depression is more common and presents as: </li></ul><ul><ul><li>new medical complaints </li></ul></ul><ul><ul><li>exacerbation of GI sx’s or arthritic pain </li></ul></ul><ul><ul><li>cardiovascular sx’s </li></ul></ul><ul><ul><li>preoccupation with health </li></ul></ul><ul><ul><li>diminished interest, fatigue, poor concentration </li></ul></ul>
  17. 17. Case 3 <ul><li>Francine is a 67 y.o. female </li></ul><ul><ul><li>Complaints: Sad, decreased interests, shaky, “falling apart.” </li></ul></ul><ul><ul><li>Your nurse mentions that she took a while to bring back, esp. out in the lobby. </li></ul></ul><ul><ul><li>Your exam shows tremor and cogwheel rigidity. </li></ul></ul>
  18. 18. Medical Conditions Mask or Cause Depression <ul><li>Autoimmune </li></ul><ul><li>Cerebrovascular </li></ul><ul><li>Chronic pain </li></ul><ul><li>Degenerative Disease </li></ul><ul><li>Endocrine </li></ul><ul><li>Metabolic </li></ul><ul><li>Neoplasms </li></ul><ul><li>Infections </li></ul><ul><li>DRUGS </li></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><li>Cimetidine </li></ul></ul><ul><ul><li>Clonidine </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Tamoxifen </li></ul></ul><ul><ul><li>Many more... </li></ul></ul>
  19. 19. Parkinson’s Disease <ul><li>About 50% of patients develop depression </li></ul><ul><li>Useful treatment includes TCA’s </li></ul><ul><li>ECT helps depression and PD sx’s: </li></ul><ul><ul><li>tremors, rigidity, & bradykinesia improved with 3-4 sessions </li></ul></ul><ul><ul><li>depression improved after 7-9 sessions </li></ul></ul>
  20. 20. Early Alzheimer’s Dz <ul><li>Presents with: </li></ul><ul><ul><li>insomnia </li></ul></ul><ul><ul><li>fatigue </li></ul></ul><ul><ul><li>agitation </li></ul></ul><ul><ul><li>psychomotor retardation </li></ul></ul><ul><ul><li>decreased interest & energy </li></ul></ul><ul><ul><li>concentration problems </li></ul></ul><ul><li>50% of AD pt’s have depressive sx’s (15-20% with major depression) </li></ul>
  21. 21. Vascular Depression <ul><li>Cerebrovascular disease can precipitate or perpetuate depression </li></ul><ul><li>Caused by ischemia (“silent strokes”) in prefrontal cortex and basal ganglia; motor & sensory deficits usu. not found. </li></ul><ul><li>Apathy, psychomotor retardation, cognitive decline </li></ul><ul><li>May explain incr. depression s/p CABG </li></ul>
  22. 22. Pseudodementia <ul><li>aka “dementia of depression” </li></ul><ul><li>cognitive decline that clears if depression is treated </li></ul><ul><li>however, dementia rate in these patients is still 20%/year even after full recovery of intellectual function </li></ul>
  23. 23. Workup <ul><li>It might include: </li></ul><ul><ul><li>H & P </li></ul></ul><ul><ul><li>CBC, TSH, testosterone </li></ul></ul><ul><ul><li>ESR, renal/liver function </li></ul></ul><ul><ul><li>U/A </li></ul></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>brain imaging if tumor or vascular disease suspected </li></ul></ul>
  24. 24. Case 4 <ul><li>Eugene is a 70 y.o. male </li></ul><ul><ul><li>Dx’d with bladder cancer, had cystectomy and now with Indiana pouch. Needs to cath through umbilicus q4hr. His wife recently dx’d with breast cancer. </li></ul></ul><ul><ul><li>Pt. has single episode of major depression 25 years ago following tough work situation and increased EtOH use. </li></ul></ul>
  25. 25. Case 4 (cont’d) <ul><ul><li>Symptoms: Withdrawn, no interest in activities (not even Mariners games), sleeping excessively, lost 10#, constant worry about cath procedure, belief he is burden to family. </li></ul></ul><ul><ul><li>Statements like, “I wish I was dead,” and, “my problem will affect this entire hospital.” </li></ul></ul>
  26. 26. Case 4 <ul><li>SIG E CAPS & DM for Eugene: </li></ul><ul><ul><li>Positives: Sleep, Interests, Guilt/Burden, Energy, Concentration, Appetite, Psychomotor retardation, Suicidal (passive), Depressed mood </li></ul></ul><ul><ul><li>Additional findings: Nihilistic, Delusional </li></ul></ul>
  27. 27. SUICIDE IS A REAL RISK <ul><li>25% of all completed suicides are > 65 </li></ul><ul><li>Suicide rate for depressed men over 65 is 5 times higher than for younger men </li></ul><ul><li>20% of older people who committed suicide saw a physician that day </li></ul><ul><li>Increased risk: financial problems, physical illness, recent loss, EtOH, abuse, isolation </li></ul>
  28. 28. INTERVENTIONS <ul><li>Seek out medical illness </li></ul><ul><li>Recognize medical side effects </li></ul><ul><li>Rehab services to maximize remaining function and retrain impaired iADL’s </li></ul><ul><li>Involve family and caretakers </li></ul><ul><li>Counsel re: role transitions, grief, dependency </li></ul><ul><li>Medications / ECT </li></ul>
  29. 29. GERIATRIC PRESCRIBING PRINCIPLES <ul><li>C Caution, Compliance </li></ul><ul><li>A Adjust dose for Age </li></ul><ul><li>R Review, Remove, Reduce </li></ul><ul><li>E Educate </li></ul><ul><li>START LOW & GO SLOW </li></ul>
  30. 30. MEDICAL THERAPY IN GERIATRIC DEPRESSION <ul><li>Select based on symptoms, prior response, concurrent illness, side effect profile </li></ul><ul><li>Reassess after 4-6 weeks: </li></ul><ul><ul><li>Increase dose, augment with second agent, add psychotherapy </li></ul></ul><ul><ul><li>Consider psychiatric consult/referral </li></ul></ul>
  31. 31. PREFERRED ANTIDEPRESSANTS <ul><li>SSRI’s </li></ul><ul><ul><li>Celexa, Paxil </li></ul></ul><ul><ul><li>Zoloft, Prozac </li></ul></ul><ul><li>TCA </li></ul><ul><ul><li>Nortriptyline </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Wellbutrin </li></ul></ul><ul><ul><li>Serzone </li></ul></ul><ul><ul><li>Remeron </li></ul></ul><ul><li>fewer side effects </li></ul><ul><ul><li>good safety record </li></ul></ul><ul><ul><li>more expensive </li></ul></ul><ul><li>least expensive </li></ul><ul><li>activation, tremor </li></ul><ul><li>anxiolytic, somatic </li></ul><ul><li>sleep, appetite </li></ul>
  32. 32. ACCEPTABLE ANTIDEPRESSANTS <ul><li>TCA </li></ul><ul><ul><li>Desipramine </li></ul></ul><ul><li>HCA </li></ul><ul><ul><li>Trazodone </li></ul></ul><ul><li>SNRI </li></ul><ul><ul><li>Effexor </li></ul></ul><ul><li>Sedation, hypotension </li></ul><ul><li>cognitive slowing </li></ul><ul><li>Dizzy, anorexia, nausea, BP increase </li></ul>
  33. 33. ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY <ul><li>Too many side effects: </li></ul><ul><li>Older TCA’s: </li></ul><ul><ul><li>amitriptyline, clomipramine, doxepin, imipramine, protriptyline, trimipramine </li></ul></ul><ul><li>MAOI’s: </li></ul><ul><ul><li>phenelzine, tranylcypromine </li></ul></ul>
  34. 34. Other Drugs <ul><li>Newer atypical anti-psychotics: </li></ul><ul><ul><li>for “jump start” or behavior issues </li></ul></ul><ul><ul><li>Risperdal (risperidone), Seroquel (quetiapine), Zyprexa (olanzapine) </li></ul></ul><ul><li>Psychostimulants </li></ul><ul><ul><li>for “jump start” or for severe apathy </li></ul></ul>
  35. 35. Electroconvulsive Therapy (ECT) <ul><li>Works well for psychotic depression, high suicide risk, Parkinson’s-related depression, failed drug treatment </li></ul><ul><li>Very effective short term, but with high relapse rates over next 6-12 months. </li></ul><ul><li>Drug therapy can reduce relapse </li></ul>