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DEPRESSION IN GERIATRICS    SHYAM SUNDAR
Introduction   Depression is under-recognized and    undertreated in the older people.   Many older adults who die by su...
What is Depression?   DSM-IV-TR Definition       Five or more of the following must have been        present during the ...
What is Depression?(a.k.a. “core symptoms”; occur most of the day nearly every day)     Depressed mood     Loss of inter...
   Loss of energy or fatigue   Feelings of worthlessness or excessive guilt   Difficulty with thinking, concentration, ...
   For Major Depression, these symptoms     Produce social impairment     Are not related to substance abuse     Are n...
   Types of Depressive Disorders       Mild episode of major depression       Moderate episode of major depression    ...
   Minor depression is common       15% of older persons       Causes ↑ use of health services, excess disability,     ...
   “Late-life” depression (a geriatric syndrome)       is a recurrence of depressive symptoms that        initially occu...
Epidemiology (of major depression)   Community-            Primary Care    Dwelling 1 - 9 %       Settings 10 – 12 %    ...
Risk Factors   Alcohol or substance abuse   Current use of a medication associated with    a high risk of depression   ...
Causes   As you grow older, you face significant life changes that    can put you at risk for depression.   Health probl...
What medications do YOUprescribe for older adults that might place them at risk for     DEPRESSION ?
Medications that may cause symptomsof Depression   Anabolic steroids   Anti-arrhythmic medications (amiodarone,    mexil...
Differential Diagnosis   Thyroid disorders (hypo- and hyper-thyroidism)   Dementia (or mild cognitive impairment)   Ber...
What is the most commonly used and validated screening tool for diagnosis of Depression in the         geriatrics patient?...
Screening Tools Two – item scale  During the previous 2 weeks……..  1. Have you often been bothered by feeling      down, ...
TREATMENT   Ttreatment is effective in about 80% of    identified cases, when treatment is    provided. Effective managem...
Pharmacotherapy   Selective Serotonin Reuptake Inhibitors   : fluoxetine   Tricyclic Antidepressants : imipramine and  ...
Consequences and Complications ofInadequately Treated Depression   Recurrence, partial recovery, and chronicity . . .    ...
Consequences and Complications ofInadequately Treated Depression Which demographic in the elderly  population has the high...
Consequences and Complications ofInadequately Treated Depression   Suicide:    Ask the patients about    thoughts of hurt...
Consequences and Complications ofInadequately Treated Depression   Risk factors for suicide:       depression       old...
Consequences and Complications ofInadequately Treated Depression   Violent suicides (e.g. firearms, hanging) are    more ...
Summary   All health care workers should maintain a high    index of suspicion for the presence of depression    or depre...
Summary   Suicide is a serious concern in depressed older    patients, particularly older white males   Treatment (acute...
THANK YOU
QUESTION   Pharmacotherapy for depression include    these except?   A] Selective serotonin reuptake inhibitors   B] Tr...
   All of these denote depression except?    A.   Anhedonia    B.   Appetite change    C.   Apnea    D.   Psychomotor agi...
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Depression in the geriatric

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Depression in the geriatric

  1. 1. DEPRESSION IN GERIATRICS SHYAM SUNDAR
  2. 2. Introduction Depression is under-recognized and undertreated in the older people. Many older adults who die by suicide (up to 75%) suffer with depression and most visited a physician within a month before death Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality Depression is NOT a part of normal aging
  3. 3. What is Depression? DSM-IV-TR Definition  Five or more of the following must have been present during the same 2-week interval and represent a change from baseline functioning  One of the symptoms must be depressed mood or loss of interest or pleasure
  4. 4. What is Depression?(a.k.a. “core symptoms”; occur most of the day nearly every day)  Depressed mood  Loss of interest in all or almost all activities or pleasure  Appetite change or weight loss  Insomnia or hypersomnia  Psychomotor agitation or retardation
  5. 5.  Loss of energy or fatigue Feelings of worthlessness or excessive guilt Difficulty with thinking, concentration, or decision making Recurrent thoughts of death or suicide Preoccupation with somatic symptoms, health status, or physical limitations Feelings of guilt or worthlessness Thoughts of wishing you were dead
  6. 6.  For Major Depression, these symptoms  Produce social impairment  Are not related to substance abuse  Are not related to bereavement [the loss of a loved one by death]
  7. 7.  Types of Depressive Disorders  Mild episode of major depression  Moderate episode of major depression  Severe episode of major depression  Severe episode of major depression with psychotic features
  8. 8.  Minor depression is common  15% of older persons  Causes ↑ use of health services, excess disability, poor health outcomes, including ↑ mortality Major depression is not common  1%–2% of physically healthy community dwellers  Elders less likely to recognize or endorse depressed mood
  9. 9.  “Late-life” depression (a geriatric syndrome)  is a recurrence of depressive symptoms that initially occurred during early adulthood.  there is no known or identifiable precipitating factor.  patients usually have no family history of depression. Depressed mood is not required to meet criteria for major depressive disorder.
  10. 10. Epidemiology (of major depression) Community-  Primary Care Dwelling 1 - 9 % Settings 10 – 12 %  Nursing Home Hospitalized 10-26% 11 – 45 % Permanent Placement Up to 43%
  11. 11. Risk Factors Alcohol or substance abuse Current use of a medication associated with a high risk of depression Hearing or vision impairment severe enough to affect function History of attempted suicide History of psychiatric hospitalization
  12. 12. Causes As you grow older, you face significant life changes that can put you at risk for depression. Health problems – Illness and disability; chronic or severe pain; cognitive decline; damage to body image due to disease. Loneliness and isolation – Living alone; a dwindling social circle due to deaths or relocation; Reduced sense of purpose – Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities. Fears – Fear of death or dying; anxiety over financial problems or health issues. Recent bereavement – The death of friends, family members, and pets; the loss of a spouse or partner.
  13. 13. What medications do YOUprescribe for older adults that might place them at risk for DEPRESSION ?
  14. 14. Medications that may cause symptomsof Depression Anabolic steroids Anti-arrhythmic medications (amiodarone, mexilitine) Anticonvulsant medications Carbidopa or levodopa Certain beta-adrenergic antagonists (i.e. propranol)
  15. 15. Differential Diagnosis Thyroid disorders (hypo- and hyper-thyroidism) Dementia (or mild cognitive impairment) Bereavement Anxiety Disorder Substance Abuse Disorder Personality Disorder Diabetes mellitus Underlying malignancy Anemia Medication side effects
  16. 16. What is the most commonly used and validated screening tool for diagnosis of Depression in the geriatrics patient?The Geriatric Depression Scale
  17. 17. Screening Tools Two – item scale During the previous 2 weeks…….. 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things? (“Yes” answer to either is considered positive)is highly sensitive for detecting major depression in persons over age 65.
  18. 18. TREATMENT Ttreatment is effective in about 80% of identified cases, when treatment is provided. Effective management requires a biopsychosocial approach, combining pharmacotherapy and psychotherapy. Therapy generally results in improved quality of life, enhanced functional capacity, possible improvement in medical health status, increased longevity, and lower health care costs.
  19. 19. Pharmacotherapy Selective Serotonin Reuptake Inhibitors : fluoxetine Tricyclic Antidepressants : imipramine and amitriptyline Monoamine Oxidase Inhibitors Other Antidepressants: mirtazapine and trazo
  20. 20. Consequences and Complications ofInadequately Treated Depression Recurrence, partial recovery, and chronicity . . .  ↑ disability  ↑ use of health care resources  ↑ morbidity and mortality  Suicide (one fourth of all suicides occur in persons ≥ 65)
  21. 21. Consequences and Complications ofInadequately Treated Depression Which demographic in the elderly population has the highest risk and incidence of suicide?Highest: white males age 80 & olderNext highest: white males between 65 and 80
  22. 22. Consequences and Complications ofInadequately Treated Depression Suicide: Ask the patients about thoughts of hurting themselves; if YES, ask whether they have a plan; if YES, ask what it is; then ask about stockpiled medications or weapons in the home. Patients with a plan require emergent psychiatric evaluation in ER or local crisis unit.
  23. 23. Consequences and Complications ofInadequately Treated Depression Risk factors for suicide:  depression  older age  physical illness  living alone (single, divorced, or separated and without children)  male gender  drug abuse or alcoholism  having a personal or family history of suicide attempt  severe anxiety or stress  specific plan with access to firearms or other means.
  24. 24. Consequences and Complications ofInadequately Treated Depression Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing
  25. 25. Summary All health care workers should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. Screen older adults for depression at the initial visit
  26. 26. Summary Suicide is a serious concern in depressed older patients, particularly older white males Treatment (acute & preventive) should be individualized and may include:  Pharmacotherapy  Psychotherapy  ECT Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions
  27. 27. THANK YOU
  28. 28. QUESTION Pharmacotherapy for depression include these except? A] Selective serotonin reuptake inhibitors B] Tricyclic antidepressants C] Triptans D] Monoamine oxidase inhibitors
  29. 29.  All of these denote depression except? A. Anhedonia B. Appetite change C. Apnea D. Psychomotor agitation

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