Depression/symptoms/types/epidemiology/Risk factors/medication causes/test/diagnosis/Geriatric scale/treatment- pharmacotherapy, psychotherapy, ECT/treatment response.

1. Overview of Depressive
disorders in Elderly
SUBMITTED TO
DR. SHANIKA SHARMA
SUBMITED BY
DIVYA KUMARI
BPT 5TH SEM.
UG1888006004
SUBJECT- GERIATRICS (PAM428)

2. What is Depression?
• DSM-IV-TR Definition , Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, text revision.
• It is a american psychiatric association.
• Five or more of the following must have been present during the same
2-week interval and represent a change from baseline functioning
• One(1) of the symptoms must be depressed mood or loss of interest or
pleasure.

3. Depressed mood
Loss of interest in all or almost all activities or
pleasure (anhedonia)
Appetite change or weight loss
Insomnia or hypersomnia
Psychomotor agitation or retardation
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

4. Depression can be in old adult also
• Depression is under-recognized and undertreated
in the older adult
• Untreated depression can delay recovery or worsen
the outcome of other medical illnesses via
increased morbidity or mortality
• Many older adults who die by suicide (up to 75%)
suffer with depression and most visited a physician
within a month before death
• Depression is NOT a part of normal aging

5.  Types of Depressive Disorders (DSM-IV)
Mild episode of major depression
Moderate episode of major depression
Severe episode of major depression
Severe episode of major depression with
psychotic features

6. • Minor depression is common
• 15% of older persons
• Causes increase use of health services, excess
disability, poor health outcomes, including increase
mortality.
• Major depression is not common
• 1%–2% of physically healthy community dwellers
• Elders less likely to recognize or endorse depressed
mood

7. “Late-life” depression (a geriatric
syndrome)
• It 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.

8. Epidemiology (of major depression)
• Community-Dwelling 1 - 9 %
• Primary Care Settings 10 – 12 %
• Hospitalized
• 11 – 45 %
• Nursing Home
• 10-26%
• Permanent Placement Up to 43%

9. 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
• Medical diagnosis or diagnoses associated with a high risk of
depression
• New admission or change of environment
• New stressful losses (loss of autonomy, privacy, functional
status, body part, family member or friend)
• Personal or family history of depression or mood disorder

10. Medications that may cause
symptoms of Depression
• Anabolic steroids
• Anti-arrhythmic medications (amiodarone, mexilitine)
• Anticonvulsant medications
• Barbiturates
• Benzodiazepines
• Carbidopa or levodopa
• Certain beta-adrenergic antagonists (i.e. propranol)Clonidine
• Cytokines (specifically IL-2)
• Digitalis preparations
• Glucocorticoids (prednisone)
• H2 blockers
• Metoclopramide
• Opioids

11. Laboratory Tests for Evaluation
• CMP (lytes, BUN, creat, Ca++, glucose)
• CBC
• Serum levels of anticonvulsant drugs, TCAs, digoxin,
theophylline
• Thyroid function (T3, T4, TSH)
• EKG
• Folate level
• UA
• Vitamin B12

12. 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

13. DEPRESSION
• Subacute onset
• Family recognition early
• Rapid progression
• Impairment inconsistent
over time
• Appears depressed
• Anhedonia
• Abstract thought usually
normal
• “I don’t know” response
to questions
DEMENTIA
• Insidious onset
• Delayed family
recognition
• Slow progression
• Impairment consistent;
slow, gradual decline
• Not depressed
• Can experience pleasure
• Abstract thought
impaired
• Near miss answers

14. The Geriatric Depression Scale
Screening Tools
• Geriatric Depression Scale (GDS; validated) 15 item
scale ( > 5 points or positive responses is
diagnostic)
• Cornell Scale for Depression in Dementia (scoring
system: >12 means probable depression)
• Center for Epidemiologic Studies of Depression
Scale (CES-D)
• Patient Health Questionnaire 9 (9 item self-rating
scale)

15. • Two – item scale (PHQ-2):
• 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)

16. Treatment
• The consequences of
depression in the elderly
require serious attention
because of the
disproportionately high risk of
suicide
• For the year 2000, 13% of the
U.S. population was 65 and
older, and the suicide rate
accounted for 18% of all
suicides

17. • Goals of therapy: improve mood, function, and
quality of life
• Goals of treatment of an acute depressive episode
are to achieve recovery and prevent future
episodes of depression
• The intended outcome should be complete
resolution of symptoms, not simply a reduction in
depressive symptoms.
• Three phases of treatment are generally
required to achieve these goals.

18. • Acute Phase (reverse current episode)
• Duration: about 3 months: Goal is complete
recovery from signs
• Continuation Phase (prevent a relapse)
• Duration: 4-6 months: Goal is to prevent relapse
• Maintenance Phase (prevent future recurrence)
• Duration: 3 months or longer: Goal is to prevent
recurrence of a new depressive episode

19. Treatment
• Pharmacotherapy
• Psychotherapy
• Electroconvulsive therapy (ECT)

20. • Patients should be monitored for response to
treatment by:
• Observation for resolution of signs and symptoms
of depression
• Documenting improvement in scores on screening
tools
• Improvement in attendance at and participation in
usual activities
• Improvement in sleep pattern
• Also monitor patients carefully for side effects and
interactions with other medications

21. Treatment : Pharmacotherapy
• Antidepressants
• SSRI’s
• Celexa (citalopram) 20-40mg/day
• Lexapro (ecitalopram) 10-20mg/day
• Prozac (fluoxetine) 20-40mg q am
• Paxil (paroxetine) 10-40mg q am or q hs
• Zoloft (sertraline)50-200mg q am

22. Treatment : Psychotherapy
• Cognitive-behavioral
• Interpersonal
• Short-term psychodynamic
• Life review, reminisce
• Problem solving
• Supportive
• Bereavement therapy
• Behavioral
• Dialectical-behavioral therapy

23. • Individualize standard approaches
• Cognitive-behavioral therapy
• Interpersonal psychotherapy
• Problem-solving therapy
Combination with an antidepressant has been
shown to extend remission after recovery
Watch for depressive syndromes in caregivers,
who might benefit from therapy

24. • Individualize choice of drug on basis of:
• Patient’s comorbidities
• Drug’s side-effect profile
• Patient’s sensitivity to these effects
• Drug’s potential for interacting with other
medications

25. Treatment : ECT (electroconvulsive
therapy)
• For depression with
pronounced psychotic
features and resistance
to standard medical
therapy
• Effective for treatment of
major depression &
mania; response rates
exceed 70% in older
adults

26. • First-line treatment for patients at serious risk for
suicide, life-threatening poor intake
• Standard for psychotic depression in older adults;
response rates 80%

27. • Contraindications
• Increased intracranial pressure
• Recent MI or CVA and unstable CAD increase risk
of complications
Continue pharmacotherapy following
completion of ECT treatment
May use maintenance ECT to prevent
relapse

28. Treatment Response
• 40% of cases of major
depression respond to
initial pharmacotherapy
within 6 weeks
• Additional 15% to 25%
achieve remission with
continued treatment for 6
weeks
Responsive to
continued treatment
15-25%
Responsive to
initial
pharmacotherapy
40%
Monotherapy
fails
35-45%

29. • When monotherapy fails:
• Consider switch to another drug class
• Combine lithium carbonate, methylphenidate, or
triiodothyronine with secondary amine TCA
• Add psychotherapy
• Consult a geriatric psychiatrist