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Doha Rasheedy Mental disorders in elderly May 2017
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Depression:
Epidemiology: Prevalence over 65: About 5% of community-dwelling older adults meet the criteria for a
major depression diagnosis. In institutional settings, the incidence of depression in the elderly
ƉŽƉƵůĂƟŽŶƌĂŶŐĞƐĨƌŽŵ ϭϮй ƚŽϯϬй .
Late onset vs. early onset major depression:
Late-life depression is the occurrence of major depressive disorder in adults 60 years of age or older.
Characteristics of depression in elderly: (how different from young?) atypical
presentation, masked depression:
1. D ŽƌĞůŝŬĞůLJƚŽĞdžƉƌĞƐƐƐŽŵ ĂƟĐĐŽŵ ƉůĂŝŶƚƐ͗ϲϱй ŚĂǀĞŚLJƉŽĐŚŽŶĚƌŝĂĐĂůƐLJŵ ƉƚŽŵ Ɛ
Often present with a chief complaint of chronic pain, weight loss, headache, or gastrointestinal
symptoms
2.
3. More anxiety
4. Less likely to report guilt feelings
5. Cognitive impairment more common: Cognitive impairment is predictive of a poor response to
antidepressants
6. Psychosis more common: Typical delusions more common, Somatic, persecution, nihilism, poverty
7. Increased risk for suicide.
Depression is under-reported, under- diagnosed: due to:
Communication issues (eg. hearing impairment)
Presence of dementia: Symptom overlap
-morbid illness
The elderly often dismiss their less severe depressive symptoms as an acceptable response to life
stress or a normal part of aging
THEREFORE YOU MUST SCREEN IN THOSE AT HIGHER RISK!
Risk factors for major depression in the elderly:
1. Recently bereaved
2. Female gender
3. a family history of depression
4. Single/widowed (recently)
5. Stressful life events (eg. prolonged hospitalization, Relocation: recent move to nursing home)
6. Social isolation
7. Persistent complaints of memory difficulties, diagnosis of dementia
Doha Rasheedy Mental disorders in elderly May 2017
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8.
9. Chronic sleep problems or anxiety
10. use of certain medications
11.lower socioeconomic status
A number of medical illnesses have been reported to have the highest rates linked to late life
ĚĞƉƌĞƐƐŝŽŶ͘E ĞĂƌůLJϮϱй ƚŽϱϬй ŽĨĂůůƐƚƌŽŬĞƉĂƟĞŶƚƐĚĞǀĞůŽƉĚĞƉƌĞƐƐŝŽŶƉŽƐƚƐƚƌŽŬĞ͘Major depression
ĂůƐŽŵ ĂLJĂīĞĐƚϮϬй ƚŽϮϱй ŽĨƉĂƟĞŶƚƐǁ ŝƚŚůnjŚĞŝŵ Ğƌs disease. Other medical illnesses include cancer
(18% 39%), Parkinson s disease (10% 37%), ƌŚĞƵŵ ĂƚŽŝĚĂƌƚŚƌŝƟƐ;ϭϯй Ϳ͕ĚŝĂďĞƚĞƐ;ϱй 11%), and
ŵ LJŽĐĂƌĚŝĂůŝŶĨĂƌĐƟŽŶ;D /Ϳ;ϭϱй 19%)
Common psychiatric comorbidities of depression includes anxiety related disorders included any anxiety
(41%), social phobia (19.6%), agoraphobia (10.8%), generalized anxiety disorder (10.6%), and panic
disorder (7.7%)
Physical Disorders Associated with Depression
Acquired immunodeficiency syndrome
Angina
Cancer (particularly of the pancreas)
Cerebral arteriosclerosis, cerebral infarction
Diabetes
Electrolyte abnormalities (e.g.,
hypernatremia, hypercalcemia, hypokalemia,
hyperkalemia)
Folate and thiamine deficiencies
Hepatitis
Hypoglycemia
Hypothyroidism, hyperthyroidism,
hyperparathyroidism
Influenza
Intracranial tumors (malignant or benign)
Multiple sclerosis
Myocardial infarction
Pernicious anemia
Porphyria
Renal disease
Rheumatoid arthritis
Senile dementia
Syphilis
Systemic lupus erythematosus
Temporal arteritis
Temporal lobe epilepsy
Viral pneumonia
The following medications are linked with depression: antipsychotics, digoxin, hydralazine, efavirenz,
antineoplastic agents, beta blockers, corticosteroids, benzodiazepines, anti-
altering drugs, stimulants, triptan antimigraine medications, anticonvulsants, proton pump inhibitors
and H blockers, statins and other lipid lowering drugs, and anticholinergic drugs.
Medications That May Cause Depression
Cardiovascular drugs
Clonidine (Catapres)
Digitalis
Hydralazine (Apresoline)
Methyldopa (Aldomet)
Procainamide (Pronestyl)
Propranolol (Inderal)
Reserpine (Serpasil)
Thiazide diuretics
Antiparkinsonian drugs
Amantadine (Symmetrel)
Bromocriptine (Parlodel)
Levodopa (Larodopa)
Antipsychotic drugs
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Sedatives and antianxiety drugs
Barbiturates
Anti-inflammatory/
anti-infective agents
Ampicillin
Cycloserine (Seromycin)
Dapsone
Ethambutol (Myambutol)
Griseofulvin (Grisactin)
Isoniazid (INH)
Metronidazole (Flagyl)
Doha Rasheedy Mental disorders in elderly May 2017
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Chemotherapeutics
6-Azauridine
Azathioprine (Imuran)
Bleomycin (Blenoxane)
Cisplatin (Platinol)
Cyclophosphamide (Cytoxan)
Doxorubicin (Adriamycin)
Mithramycin (Mithracin)
Vinblastine (Velban)
Vincristine
Hormones
Adrenocorticotropin
Anabolic steroids
Glucocorticoids
Oral contraceptives
Benzodiazepines
Chloral hydrate
Ethanol
Anticonvulsants
Carbamazepine (Tegretol)
Ethosuximide (Zarontin)
Phenobarbital
Phenytoin (Dilantin)
Primidone (Mysoline)
Other drugs
Cimetidine (Tagamet)
Disulfiram (Antabuse)
Methysergide (Sansert)
Phenylephrine (Neo-Synephrine)
Physostigmine (Antilirium)
Ranitidine (Zantac)
Metoclopramide (Reglan)
Nalidixic acid (NegGram)
Nitrofurantoin (Furadantin)
Nonsteroidal anti-inflammatory
agents
Penicillin G procaine
Streptomycin
Sulfonamides
Tetracycline
Stimulants
Amphetamines (withdrawal)
Caffeine
Cocaine (withdrawal)
Methylphenidate (Ritalin)
Differential Diagnosis
Bereavement: depressed mood, which may be appropriate given a patient's recent loss.
However, if depressive symptoms persist longer than 2-3 months, a diagnosis of major
depression should be considered. both can be differentiated by the effect on functioning. The
bereaved individual does not become functionally impaired or is minimally impaired. Grief and
bereavement also do not typically involve active suicidal thinking rather; the bereaved may
have passive thoughts about
Complicated Grief: a protracted, severe form of grieving in which a person experiences strong
feelings of anger or s death, feelings of emptiness, a persistent
longing to be with the loved one, recurring intrusive thoughts about the loss, and reclusiveness
from family and friends. These symptoms must persist for 6 months or more. Complicated grief
differs presenting symptoms are more focused on
the loss. Although both diagnoses carry some level of dysfunction, the distinction is important
because persons experiencing complicated grief have inconsistent responses to antidepressants
and psychotherapeutic treatments
Dementia:
Depression and dementia are frequently intertwined in older people, with high rates of
depression in patients with dementia, and depression itself being a risk factor for dementia.
Differentiating Dementia and Depression
Dementia depression
Onset Insidious, indeterminate Relatively rapid, associated with
mood changes
Duration of symptoms long short
Doha Rasheedy Mental disorders in elderly May 2017
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Orientation, mood, behavior,
affect
Impaired, inconsistent,
fluctuating
Intact, diurnal variation
depressed/anxious,
complaints worse than on
testing
Cognitive impairment Consistent; stable or worsening Inconsistent, fluctuating
Neurologic defects Often present (e.g., agnosia,
dysphasia, apraxia)
Absent
Disabilities Concealed by patient Highlighted by patient
Depressive symptoms Present Present
Memory impairment
events, often unaware of
memory loss. Onset of memory
loss occurs before mood change
Concentration poor, patient
complains of memory loss of
recent and remote events,
follows onset of depressed mood
Psychiatric history None Often, history of depression
Answers to questions Near answers
Performance Tries hard but is unconcerned
about losses
Does not try hard but is more
distressed by losses
Associations Unsociability,
uncooperativeness, hostility,
emotional instability, reduced
alertness, confusion,
disorientation
Appetite and sleep disturbances,
suicidal thoughts
Delirium (hypoactive type)
Other comorbid psychiatric illnesses must also be considered, such as anxiety disorder, substance
abuse disorder, or personality disorders
Chronic fatigue syndrome
Depression Due to a General Medical Condition
Substance-Induced Depression
Effects of depression:
Depression is associated with poorer self-care and slower recovery after acute medical illnesses.
It can accelerate cognitive and physical decline and leads to an increased use and cost of health care
services.
Less effective rehabilitation
Lower quality of life, higher level of chronic pain, and increased disability (is the fourth leading cause
of disability in the United States).
The mortality rate coincided with the level of depression even when controlling for other factors.
Evaluation
1. History of:
Medical disorders, medications, psychiatric diseases, alcohol, substance abuse, cognitive impairment,
social factors, stressful life events, symptoms suggesting depression. asking about a history of mania, suicide
Obtaining a corroborating history from confidants or family members is highly recommended
2. A- Tools to screen for depression:,
Doha Rasheedy Mental disorders in elderly May 2017
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Clinicians should use validated measures, such as the 9WĂƟĞŶƚ, ĞĂůƚŚY ƵĞƐƟŽŶŶĂŝƌĞ , that
reflect diagnostic criteria, /ŶŝƟĂůϮƋƵĞƐƟŽŶƐĐĂŶďĞƵƐĞĚĨŽƌƐĐƌĞĞŶŝŶŐ, 2/ŶŝƟĂů ƋƵĞƐƟŽŶƐĐĂŶďĞ
used for screening
Serial administrations can be used to reliably assess response to treatment
Not reliable in patients with moderate to severe dementia
Beck Depression Inventory:
dŚĞ/ĐŽǀĞƌƐƚŚĞϮǁ ĞĞŬƐƉƌŝŽƌƚŽĞǀĂůƵĂƟŽŶ͘/ƚĐŽŶƐŝƐƚƐŽĨϮϭŝƚĞŵ Ɛ͕ĞĂĐŚĐĂƚĞŐŽƌŝƐĞĚŝŶƚŽ
various level of severity (with a range of score from 0 to 3). The total score is the sum of items. A
total score 9 indicates no or minimal depression. A total score 30 indicates severe depression
The Geriatric Depression Scale: Lacks suicidal ideation query, Not useful for assessing treatment
response
Hamilton depression scale (HAM-D): It has two versions: 17-item scale and 21-items scale. The
17-item version covers mood, suicide, guilt, sleep, appetite, energy, somatic complaints, sexual
ĨƵŶĐƟŽŶĂŶĚǁ ĞŝŐŚƚ͘dŚĞϮϭ-ŝƚĞŵ ĐŽŶƐŝƐƚƐŽĨĂĚĚŝƟŽŶϰŝƚĞŵ ƐŽŶĚŝƵƌŶĂůǀĂƌŝĂƟŽŶŽĨŵ ŽŽĚ͕
derealisation / depersonalisation, paranoid idea and obsession / compulsions. The HAM-D scale
monitors changes in the severity of symptoms during treatment. The HAM-D scale is not
diagnostic and its validity is affected if the person has concurrent physical illness. The total
scores range from 0 (no depression), 0-10 (mild depression), 10-23 (moderate depression) and
over 23 (severe depression).
3. Cognitive screening (e.g., with the Mini Mental State Examination) is warranted in
personsreporting memory problems and may reveal deficits in visuospatial processing or
memory even if the total score is in the normal range. Neuropsychological testing may help
identify early dementia, but because acute depression negatively affects performance, testing
should be postponed until depressive symptoms diminish.
4. Laboratory tests depression is a clinical diagnosis but tests
Should include electrocardiography, urinalysis, general blood chemistry screen, complete blood count,
and determination of thyroid-stimulating hormone, 12vitamin B , folate, Vitamin D, glucose level and
medication levels
Types of depression
DSM-V DIAGNOSTIC CRITERIA for major depression:
Require the presence of either sadness or anhedonia with a total of five or more symptoms over 2a -
week period
diagnosis)
1. Depressed mood most of the day
2. Anhedonia or markedly decreased interest or pleasure in almost all activities
Additional symptoms
3. Clinically significant weight loss or increase or decrease in appetite
Doha Rasheedy Mental disorders in elderly May 2017
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4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death or suicidal ideation
MINOR DEPRESSION (subsyndromal depression)
Minor depression is a clinically significant depressive disorder that does not fulfill the duration criterion
or the number of symptoms necessary for the diagnosis of major depression.
1. more common than major depression in elderly patients
2. May follow a major depressive episode. It also can be a reaction to routine stressors in older
populations.
3. ŝŌĞĞŶƚŽϱϬƉĞƌĐĞŶƚŽĨƉĂƟĞŶƚƐǁ ŝƚŚŵ ŝŶŽƌĚĞƉƌĞƐƐŝŽŶĚĞǀĞůŽƉŵ ĂũŽƌĚĞƉƌĞƐƐŝŽŶǁ ŝƚŚŝŶƚǁ Ž
years
4. Untreated, the natural course of minor depression is one to two years.
5. Patients with minor depression are less likely to require hospitalization or to commit suicide
than patients with major depression but report more disability days than persons with major
depression
BIPOLAR DISORDER:
Elevated, irritable, or expansive mood persisting for 1at least week, plus Three of the following:
1. Inflated self-esteem, grandiosity
2. Hypersexuality
3. Marked increase in activity
4. Marked decreased need for sleep
5. Pressured speech
6. Racing thoughts, flight of ideas
7. Distractibility
Dysthymic disorder:
is a chronic depression of mood (for at least 2 years) that is variably accompanied by two or more of
the following symptoms appetite disturbance, sleep disturbance, low energy or fatigue, low self-
esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.
It occurs in about 1.8% of elderly individuals during any given month.
Dysthymic disorder is similar to but less severe and more chronic than major depression
younger age of onset, may persist from midlife into late life
Pathophysiology/Pathogenesis
1. A genetic basis for depression in persons of all ages.
Doha Rasheedy Mental disorders in elderly May 2017
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2. In younger adults, the stress-diathesis model is one of the more popular explanations for why
people develop depression. This theory suggests that both genetic vulnerability and
psychosocial factors play important roles. In contrast, whereas psychosocial factors play a part
in the development of late-life depression, there is less consistent evidence for genetic
predisposition, with studies showing little correlation between family history and late-onset
depression
3. Other biological factors are important. For example, compromises in brain neurocircuitry,
particularly in frontolimbic pathways in elderly persons with depressionexplain the high
incidence of depression in patients with neurologic conditions affecting these pathways such as
disease (AD)
4. vascular disease may contribute to depression
5. Medical comorbidity is frequent.
Treatment
a) PATIENT  FAMILY EDUCATION/SUPPORTIVE CARE
Educating patients and families about depression is the cornerstone of successful treatment, deal
with stigma of depression in different cultures
Involving families in the care of elderly patients is crucial
Music therapy and exercise can prevent and improve depression (A recommendation).
Regardless of the therapy chosen, it is important to consider the social and environmental
context of each patient
If sleep is a problem, doctor should offer sleep hygiene advice.
b) Pharmacological therapy:
Treatment should be considered in 3 phases:
1. an acute treatment phase to achieve remission of symptoms;
2. a continuation phase to prevent recurrence of the same episode of illness (relapse);( 6 months)
3. a maintenance (prophylaxis) phase to prevent future episodes (recurrence)(18-24 months)
Follow-up visits should be arranged at 3- to 6-mo intervals. For a first time depressive
ĞƉŝƐŽĚĞ͕ƚƌĞĂƚŵ ĞŶƚĨŽƌƵƉƚŽϮLJĞĂƌƐŵ ĂLJďĞƌĞƋƵŝƌĞĚ͘/ŶƉĂƟĞŶƚƐǁ ŝƚŚϯŽƌŵ ŽƌĞ
episodes, lifelong maintenance treatment may be considered.
If the patient and physician agree to a trial discontinuation of therapy, medications should be tapered
over a 2- to 3-mo period, with at least monthly follow-up by telephone or in person. If symptoms return,
ƚŚĞƉĂƟĞŶƚƐŚŽƵůĚďĞƌĞƐƚĂƌƚĞĚŽŶŵ ĞĚŝĐĂƟŽŶƐĨŽƌĂƚůĞĂƐƚϯ-6 mo.
Start at half the dose of younger people ƟƚƌĂƚĞĚŽƐĞĞǀĞƌLJϰ-7 days, Aim to reach an
average dose at one month
Doha Rasheedy Mental disorders in elderly May 2017
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The elderly respond to therapy as well as younger patients, the time to full response may
patients respond should be maintained
Change in medication should be considered if patients 4ŚĂǀĞŶŽƌĞƐƉŽŶƐĞĂŌ Ğƌ weeks on
the maximum dose or 8ŚĂǀĞŽŶůLJƉĂƌƟĂůƌĞƐƉŽŶƐĞĂŌ Ğƌ weeks of treatment (C
recommendation).Checking adherence is important
Augmentation usually involves addition of another antidepressant, lithium, or an atypical
antipsychotic.
ŽŶůLJĂďŽƵƚϱϬй ŽĨƉĂƟĞŶƚƐƌĞƐƉŽŶĚƚŽƚŚĞĮƌƐƚĂŶƟĚĞƉƌĞƐƐĂŶƚƉƌĞƐĐƌŝďĞĚ
When switching among SSRIs or between TCAs and SSRIs, no wash-out period is required (with the
exception of switching from fluoxetine, because of its long half-life). However, abrupt cessation of
shorter acting antidepressants (eg, citalopram, paroxetine, sertraline, or venlafaxine) may result in a
discontinuation syndrome with tinnitus, vertigo, or paresthesias
Indefinite treatment should be considered for patients who have severe depression, have a
history of recurrent depression, require electroconvulsive therapy (ECT), or have only partial
resolution of symptoms
Factors to guide antidepressant choice:
1. previous response
2. concurrent conditions (eg, avoiding anticholinergic agents in men with benign prostatic
hypertrophy),
3. type of depression (eg, bipolar versus unipolar, presence of psychotic features),
4. other medications, and risk of overdose
5. There is some evidence that choices can also be guided by concurrent symptoms (eg,
nortriptyline or duloxetine for concurrent pain and mirtazapine with anxiety).
Selective serotonin-reuptake inhibitors (SSRIs)
First-line treatments for late-life depression
Side effects:
syndrome of inappropriate secretion of antidiuretic hormone, sexual dysfunction, nausea and
headache, Anxiety, agitation, nausea  diarrhea, pseudoparkinsonism, warfarin effect, other drug
interactions Of concern are reports noting a higher risk of stroke among persons taking SSRIs than
Ăŵ ŽŶŐŶŽŶƵƐĞƌƐŽĨĂŶƟĚĞƉƌĞƐƐĂŶƚƐ;ĂŶŶƵĂůŝnjĞĚƐƚƌŽŬĞƌĂƚĞŽĨĂƉƉƌŽdžŝŵ ĂƚĞůLJϰǀƐ͘ϯƉĞƌϭϬϬϬ
person-years in one report However, a similar increase in the risk of stroke has been noted with
other antidepressant classes
Falls and fractures in nursing-home residents
Higher doses of citalopram and escitalopram, citing concerns about prolongation of QT
If fluoxetine is the initial antidepressant, a wash-out of several weeks will be needed given
(better avoid due to long half life, ŝŶŚŝďŝƟŽŶŽĨƚŚĞWϰϱϬƐLJƐƚĞŵ ͘)
Doha Rasheedy Mental disorders in elderly May 2017
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Serotonin norepinephrine reuptake inhibitors (SNRIs)
commonly used as second-line agents when remission is not obtained with SSRIs, Effective for major
depression  generalized anxiety
The benefits of SSRIs are similar to those of SNRIs, although adverse effects may be more frequent
with SNRIs.
Side effects: Nausea, Hypertension, Sexual dysfunction, dizziness
DeluxeƟŶĞ͗ϮϬ 60 mg/day(used for neuropathic pain)
Venlafaxine:75-300(desvenalfaxine 25-50)
Tricyclic antidepressants (TCA)
have efficacy similar to that of SSRIs in the treatment of late-life depression but are less commonly
used owing to their greater side effects, included in the Beers Criteria list of potentially
inappropriate medications associated with high rates of adverse drug events among older adults
If SSRIs or SNRIs are ineffective, tricyclic antidepressants may be considered (either as monotherapy
or as augmentation).
nortriptyline and desipramine (secondary amines) have the lowest anticholinergic burden
Side effects: Cognitive impairment, orthostatic hypotension, anticholinergic effects and cardiac
conduction abnormalities, alpha-adrenergic blockade
ion,
Confusion
ECG before start treatment
Monoamine oxidase inhibitors (MAoI)
Use if patient is resistant to other antidepressants
Side effects:
Orthostatic hypotension, falls
Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies (pressor
amine)
Fatal serotonin syndrome possible if taken with SSRI, meperidine
Bupropion:
Wellbutrin: activity of dopamine  norepinephrine,
Dose range: 150 300 mg/day,
Side effects: Insomnia, anxiety, tremor, myoclonus, Associated with 0.4% risk of seizures
Mirtazapine
Remeron: Norepinephrine, 5-HT2 , and 5-HT3 antagonist.
Given as single bedtime dose (sedative side effects
Dose:15-45 mg
weight gain, increases appetite
Doha Rasheedy Mental disorders in elderly May 2017
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Psychostimulants
dextroamphetamine (5-10 mg/day) or methylphenidate Ritalin (2.5-5 mg/day)
are not well studied in the elderly and have the potential to contribute to tachycardia, agitation and
insomnia.
May have role in reversing apathy, lack of energy in patients with dementia or disabling medical
conditions
can be effective within hours, for depression At the end of life
c) Non pharmacological therapy:
1. Psychotherapy:
Effective treatments for late life depression and may be considered as first line therapy, depending
on availability and patient preference. effective treatments for major depression either alone or in
combination with pharmacotherapy
The potential benefit of psychotherapy is not diminished by increasing age.
In patients with severe depression, combination therapy with psychotherapy and pharmacotherapy
is superior to either treatment alone.
6once or twice weekly for -16sessions
Psychotherapies recommended for geriatric depression include behavior therapy, cognitive-
behavioural therapy, problem-solving therapy, brief dynamic therapy, interpersonal therapy, and
reminiscence therapy (A recommendation).
Psychoanalytic and psychodynamic therapies have not proved effective for treatment of major
depression
Cognitive behavioral therapy focuses on identifying negative thoughts and behaviors that contribute
to depression and replacing them with positive thoughts and rewarding activities. It may have a weaker
effect in physically ill or cognitively impaired persons
Problem-solving therapy focuses on the development of skills to improve the ability to cope with life
problems (can be used in cognitive impaired (specifically, coexisting executive dysfunction)
Reminiscence therapy, a psychotherapy focusing on the evaluation and reframing of past life events.
Interpersonal therapy for older adults with depression focuses focuses on recognizing and attempting
to resolve personal stressors and relationship conflicts that lead to depressive symptoms.
Supportive psychotherapy
2. Electroconvulsive therapy (ECT)
is the most effective treatment for severely depressed patients, is first-line therapy for suicidal
patient, psychotic depression, life-threatening refusal of food, fluids, medications
Indications:
ϭͿ^ĞǀĞƌĞĚĞƉƌĞƐƐŝǀĞĚŝƐŽƌĚĞƌǁ ŚŝĐŚĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽĂŶĂĚĞƋƵĂƚĞƚƌŝĂůŽĨĂŶƟĚĞƉƌĞƐƐĂŶƚƐ͘
2) Life threatening depressive illness (e.g. high suicide risk).
3) Stupor or catatonia
ϰͿD ĂƌŬĞĚƉƐLJĐŚŽŵ ŽƚŽƌƌĞƚĂƌĚĂƟŽŶ
ϱͿWƐLJĐŚŽƟĐĚĞƉƌĞƐƐŝŽŶ
6) Treatment resistant mania
Doha Rasheedy Mental disorders in elderly May 2017
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7) Treatment resistant schizophrenia.
Common side effects include headache, muscle pain, jaw pain, drowsiness, loss of recent memories
persistent (retrograde amnesia), anterograde amnesia (less common than retrograde amnesia),
prolonged ƐĞŝnjƵƌĞƐ;ůŽŶŐĞƌƚŚĂŶϭŵ ŝŶƵƚĞͿĂŶĚĐŽŶĨƵƐŝŽŶĂŌĞƌdƐ͘
Current administration techniques, such as unilateral electrode placement with a brief pulse,
substantially reduce the cognitive symptoms
Mechanism of actions:
1) Release of noradrenaline, serotonin, dopamine but reduction of acetylcholine release.
2) Increase in permeability of the blood-brain barrier.
ϯͿD ŽĚƵůĂƟŽŶŽĨŶĞƵƌŽƚƌĂŶƐŵ ŝƩ ĞƌƌĞĐĞƉƚŽƌƐƐƵĐŚĂƐ' ŽƌĂĐĞƚLJůĐŚŽůŝŶĞ.
Contraindications: recent myocardial infarction, brain tumor, Increased intracranial pressure,
cerebral aneurysm, and uncontrolled heart failure.
Continue pharmacotherapy following completion of ECT treatment
īĞĐƟǀĞƌĞƐƉŽŶƐĞƌĂƚĞсϴϬй
3. Transcranial magnetic stimulation
is a newer treatment for depression that uses a focal electromagnetic field generated by a coil held
over the scalp, most commonly positioned over the left prefrontal cortex.
^ĞƐƐŝŽŶƐĂƌĞƐĐŚĞĚƵůĞĚĮǀĞƟŵ ĞƐĂǁ ĞĞŬŽǀĞƌĂƉĞƌŝŽĚŽĨϰƚŽϲǁ ĞĞŬƐ.
Does not have cognitive side effects.
d) 4ZĞĂƐƐĞƐƐĂŌ Ğƌ -6weeks:
Increase dose, augment with second agent, add psychotherapy
e) Referral: Indications for Psychiatric Referral in Elderly Patients with Depression
Bipolar disorder
Suicidal ideation
Psychosis
Unresponsive or intolerant to adequate trial of first-line treatment
Diagnostically complex or uncertain
Candidate for electroconvulsive therapy
Severely ill
Need for treatment beyond drug therapy
Double depression (i.e., episodes of major depression superimposed on dysthymic disorder
Managing partial response, or non- response
1. Check compliance
2. The most common prescribing error is failure to increase the dose to the recommended
level within the first 2 weeks of treatment
3. For non-response or intolerance, switch to another SSRI or another drug class
4. For partial response to an SSRI, add bupropion or buspirone
Doha Rasheedy Mental disorders in elderly May 2017
12
SUICIDE
Older age associated with increasing risk of suicide
One fourth of all suicides occur in people 65 years
Risk factors: depression, physical illness,pain, living alone, white male, older age; marital status of
single, divorced, or separated and without children; personal or family history of a suicide attempt;
drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with
access to firearms or other lethal means (eg, stockpiled medications).
Violent suicides (eg, firearms, hanging) are more common than non-violent methods among older
adults, despite the potential for drug overdosing
Herbal remedies
St. John's wort have a role in the treatment of depression, should not be used in conjunction with SSRIs
because the combination may lead to serotonergic syndrome, which is characterized by changes in
mental status, tremor, gastrointestinal upset, headache, myalgia, and restlessness. It may lower the
concentration of certain drugs, such as warfarin, digoxin, theophylline, cyclosporine, and HIV-1 protease
inhibitors.
Other common herbal remedies such as kavakava and valerian root have not been proven effective for
treating depression
TREATMENT OF MANIA AND BIPOLAR DEPRESSION
1. Antipsychotic agents:
olanzapine and aripiprazole used in augmentation for treatment-resistant depression (even in non-
psychotic depression), bipolar depression
2. Lithium Carbonate:
dĂƌŐĞƚƉůĂƐŵ ĂůĞǀĞůƐĨŽƌŽůĚĞƌƉĂƟĞŶƚƐ͗Ϭ͘ϲ 1.0 mEq/L
Use cautiously with renal insufficiency
Delay of up to 2 weeks to achieve steady state
The following may increase lithium levels:
NSAIDs, thiazide- and K+-sparing diuretics, furosemide
Dehydration, salt depletion
Side effects: fine resting tremor, myoclonus, intention tremor, DI
3. Anticonvulsants:
Valoproic acid:
dĂƌŐĞƚĐŽŶĐĞŶƚƌĂƟŽŶƐŽĨϱϬ 100 g/mL
Efficacy comparable to lithium
Delay of up to 2 weeks to achieve steady state
Side effects:
Sedation, rashes, platelet counts  functioning
Liver toxicity may develop in patients with hepatic disease
Reduce dosage in renal insufficiency
Lab monitoring of CBC, liver enzymes, and chemistries required
Carbamazepine
FDA-approved for bipolar disorder
Doha Rasheedy Mental disorders in elderly May 2017
13
Side effects:
Mild bone marrow suppression with leukopenia  thrombocytopenia in 5% ϭϬй ǁ ŝƚŚŝŶĮƌƐƚϮ
weeks
Rare: life-threatening agranulocytosis, aplastic anemia
Lab monitoring required
Lamotrigine
FDA-approved for bipolar depression
Little data on use in late life
Associated with Stevens-Johnson syndrome
Reduce dose in liver dysfunction
TREATMENT OF BIPOLAR DEPRESSION  MIXED MANIA WITH DEPRESSION
Primary mood stabilizer: lamotrigine or lithium
Attain adequate dose or therapeutic level
For inadequate response add:
Mixed mania and depression
Lithium
Aripiprazole
Valproate
Risperidone
Olanzapine Mania frequent
Rapid cycling
Hx of antidepressant-induced mania
Lithium
Valproate
Lamotrigine
Olanzapine
Mania rare
Not rapid cycling
No hx of antidepressant-induced
mania
Bupropion or SSRI
Not TCA, not SNRI
Depressive episode
Doha Rasheedy Mental disorders in elderly May 2017
14
Appendix
History:
1. Psychiatric history
Past psychiatric diagnoses and treatment Allows confirmation of diagnosis and can guide treatment
decisions
Current suicidal thoughts and past suicide attempts: Crucial in assessing safety; past suicide
attempts indicate increased risk of future attempts
Substance use Indicates contributing factors, such as alcohol use, for which additional intervention
may be needed
Problems with memory Initial screen for cognitive problems; should address with both patient and
family if possible
2. Medical history
Presence of chronic pain May exacerbate depression and indicate need for additional treatment
Polypharmacy May complicate antidepressant treatment
Problems with medication adherence May lead to nonresponse to antidepressant treatment
Review of current medications To identify any medications that may confer a predisposition to
depression (e.g., propranolol, prednisone)
3. Social history
Recent stressors or losses Factors contributing to depression
Available social support Indicates extent of social engagement or isolation
Access to transportation and ability to drive: Indicates ability to engage socially and to meet basic
needs such as shopping for groceries
Access to guns Indicates increased risk that a suicide attempt would be lethal
4. Family history
Dementia Indicates increased risk of dementia for the patient
Suicide Indicates increased risk of suicide for the patient
Doha Rasheedy Mental disorders in elderly May 2017
15
Antidepressant choices for older patients
Generic Name Start ing
dose,
mg/d
Average
Dose,
mg/d
Maximum
Recommended
Dose, mg/d
SSRI
Citalopram 10 20-40 20 for those
older than 65 y
40 for others
QTc prolongation
Escitalopram 5 10-20 10 for those
older than 65 y
20 for others
QTc prolongation
Sertraline Modapex 25 50-150 200 Like all SSRIs, risk of nausea,
SIADH
Fluoxetine Prozac
20 80
SNRI
Venlafaxine Effexor 37.5 75
225
375* Might increase blood pressure
deluxetine
Tricyclic (secondary) better than tertiary in elderly
Desipramine Norpramin 10 25 50
150
300 Anticholinergic properties;
cardiovascular side effects;
monitor
blood levels
Nortriptyline Aventyl 10 25 40
100
200
Tricyclic (tertiary)
Imipramine Tofranil 25 300 Anticholinergic properties;
cardiovascular side effects;
monitor
blood levels
Amitriptyline Elavil 25 300
other
Bupropion Wellbutrin 100 100,
twice
daily
150, twice
daily
Might cause seizures
Mirtazapine Remeron 15 30 45 45 Might cause sedation,
especially at
lower doses
Trazodone Trittico 50 600 Sedation, orthostatic
hypotension, priapism
nefazodone serozone 50 mg
bid
150 mg bid
Methylphenidate Ritalin 2.5mg
at7am,
noon
5-10
mg at
7am,
noon
MAOIs
Phenelzine Nardil Orthostatic hypotension,
hypertensive crisis, Fatal
serotonin syndrome possible if
taken with SSRI, meperidine
Tranylcypromine Parnate

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Depression in elderly

  • 1. Doha Rasheedy Mental disorders in elderly May 2017 1 Depression: Epidemiology: Prevalence over 65: About 5% of community-dwelling older adults meet the criteria for a major depression diagnosis. In institutional settings, the incidence of depression in the elderly ƉŽƉƵůĂƟŽŶƌĂŶŐĞƐĨƌŽŵ ϭϮй ƚŽϯϬй . Late onset vs. early onset major depression: Late-life depression is the occurrence of major depressive disorder in adults 60 years of age or older. Characteristics of depression in elderly: (how different from young?) atypical presentation, masked depression: 1. D ŽƌĞůŝŬĞůLJƚŽĞdžƉƌĞƐƐƐŽŵ ĂƟĐĐŽŵ ƉůĂŝŶƚƐ͗ϲϱй ŚĂǀĞŚLJƉŽĐŚŽŶĚƌŝĂĐĂůƐLJŵ ƉƚŽŵ Ɛ Often present with a chief complaint of chronic pain, weight loss, headache, or gastrointestinal symptoms 2. 3. More anxiety 4. Less likely to report guilt feelings 5. Cognitive impairment more common: Cognitive impairment is predictive of a poor response to antidepressants 6. Psychosis more common: Typical delusions more common, Somatic, persecution, nihilism, poverty 7. Increased risk for suicide. Depression is under-reported, under- diagnosed: due to: Communication issues (eg. hearing impairment) Presence of dementia: Symptom overlap -morbid illness The elderly often dismiss their less severe depressive symptoms as an acceptable response to life stress or a normal part of aging THEREFORE YOU MUST SCREEN IN THOSE AT HIGHER RISK! Risk factors for major depression in the elderly: 1. Recently bereaved 2. Female gender 3. a family history of depression 4. Single/widowed (recently) 5. Stressful life events (eg. prolonged hospitalization, Relocation: recent move to nursing home) 6. Social isolation 7. Persistent complaints of memory difficulties, diagnosis of dementia
  • 2. Doha Rasheedy Mental disorders in elderly May 2017 2 8. 9. Chronic sleep problems or anxiety 10. use of certain medications 11.lower socioeconomic status A number of medical illnesses have been reported to have the highest rates linked to late life ĚĞƉƌĞƐƐŝŽŶ͘E ĞĂƌůLJϮϱй ƚŽϱϬй ŽĨĂůůƐƚƌŽŬĞƉĂƟĞŶƚƐĚĞǀĞůŽƉĚĞƉƌĞƐƐŝŽŶƉŽƐƚƐƚƌŽŬĞ͘Major depression ĂůƐŽŵ ĂLJĂīĞĐƚϮϬй ƚŽϮϱй ŽĨƉĂƟĞŶƚƐǁ ŝƚŚůnjŚĞŝŵ Ğƌs disease. Other medical illnesses include cancer (18% 39%), Parkinson s disease (10% 37%), ƌŚĞƵŵ ĂƚŽŝĚĂƌƚŚƌŝƟƐ;ϭϯй Ϳ͕ĚŝĂďĞƚĞƐ;ϱй 11%), and ŵ LJŽĐĂƌĚŝĂůŝŶĨĂƌĐƟŽŶ;D /Ϳ;ϭϱй 19%) Common psychiatric comorbidities of depression includes anxiety related disorders included any anxiety (41%), social phobia (19.6%), agoraphobia (10.8%), generalized anxiety disorder (10.6%), and panic disorder (7.7%) Physical Disorders Associated with Depression Acquired immunodeficiency syndrome Angina Cancer (particularly of the pancreas) Cerebral arteriosclerosis, cerebral infarction Diabetes Electrolyte abnormalities (e.g., hypernatremia, hypercalcemia, hypokalemia, hyperkalemia) Folate and thiamine deficiencies Hepatitis Hypoglycemia Hypothyroidism, hyperthyroidism, hyperparathyroidism Influenza Intracranial tumors (malignant or benign) Multiple sclerosis Myocardial infarction Pernicious anemia Porphyria Renal disease Rheumatoid arthritis Senile dementia Syphilis Systemic lupus erythematosus Temporal arteritis Temporal lobe epilepsy Viral pneumonia The following medications are linked with depression: antipsychotics, digoxin, hydralazine, efavirenz, antineoplastic agents, beta blockers, corticosteroids, benzodiazepines, anti- altering drugs, stimulants, triptan antimigraine medications, anticonvulsants, proton pump inhibitors and H blockers, statins and other lipid lowering drugs, and anticholinergic drugs. Medications That May Cause Depression Cardiovascular drugs Clonidine (Catapres) Digitalis Hydralazine (Apresoline) Methyldopa (Aldomet) Procainamide (Pronestyl) Propranolol (Inderal) Reserpine (Serpasil) Thiazide diuretics Antiparkinsonian drugs Amantadine (Symmetrel) Bromocriptine (Parlodel) Levodopa (Larodopa) Antipsychotic drugs Fluphenazine (Prolixin) Haloperidol (Haldol) Sedatives and antianxiety drugs Barbiturates Anti-inflammatory/ anti-infective agents Ampicillin Cycloserine (Seromycin) Dapsone Ethambutol (Myambutol) Griseofulvin (Grisactin) Isoniazid (INH) Metronidazole (Flagyl)
  • 3. Doha Rasheedy Mental disorders in elderly May 2017 3 Chemotherapeutics 6-Azauridine Azathioprine (Imuran) Bleomycin (Blenoxane) Cisplatin (Platinol) Cyclophosphamide (Cytoxan) Doxorubicin (Adriamycin) Mithramycin (Mithracin) Vinblastine (Velban) Vincristine Hormones Adrenocorticotropin Anabolic steroids Glucocorticoids Oral contraceptives Benzodiazepines Chloral hydrate Ethanol Anticonvulsants Carbamazepine (Tegretol) Ethosuximide (Zarontin) Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline) Other drugs Cimetidine (Tagamet) Disulfiram (Antabuse) Methysergide (Sansert) Phenylephrine (Neo-Synephrine) Physostigmine (Antilirium) Ranitidine (Zantac) Metoclopramide (Reglan) Nalidixic acid (NegGram) Nitrofurantoin (Furadantin) Nonsteroidal anti-inflammatory agents Penicillin G procaine Streptomycin Sulfonamides Tetracycline Stimulants Amphetamines (withdrawal) Caffeine Cocaine (withdrawal) Methylphenidate (Ritalin) Differential Diagnosis Bereavement: depressed mood, which may be appropriate given a patient's recent loss. However, if depressive symptoms persist longer than 2-3 months, a diagnosis of major depression should be considered. both can be differentiated by the effect on functioning. The bereaved individual does not become functionally impaired or is minimally impaired. Grief and bereavement also do not typically involve active suicidal thinking rather; the bereaved may have passive thoughts about Complicated Grief: a protracted, severe form of grieving in which a person experiences strong feelings of anger or s death, feelings of emptiness, a persistent longing to be with the loved one, recurring intrusive thoughts about the loss, and reclusiveness from family and friends. These symptoms must persist for 6 months or more. Complicated grief differs presenting symptoms are more focused on the loss. Although both diagnoses carry some level of dysfunction, the distinction is important because persons experiencing complicated grief have inconsistent responses to antidepressants and psychotherapeutic treatments Dementia: Depression and dementia are frequently intertwined in older people, with high rates of depression in patients with dementia, and depression itself being a risk factor for dementia. Differentiating Dementia and Depression Dementia depression Onset Insidious, indeterminate Relatively rapid, associated with mood changes Duration of symptoms long short
  • 4. Doha Rasheedy Mental disorders in elderly May 2017 4 Orientation, mood, behavior, affect Impaired, inconsistent, fluctuating Intact, diurnal variation depressed/anxious, complaints worse than on testing Cognitive impairment Consistent; stable or worsening Inconsistent, fluctuating Neurologic defects Often present (e.g., agnosia, dysphasia, apraxia) Absent Disabilities Concealed by patient Highlighted by patient Depressive symptoms Present Present Memory impairment events, often unaware of memory loss. Onset of memory loss occurs before mood change Concentration poor, patient complains of memory loss of recent and remote events, follows onset of depressed mood Psychiatric history None Often, history of depression Answers to questions Near answers Performance Tries hard but is unconcerned about losses Does not try hard but is more distressed by losses Associations Unsociability, uncooperativeness, hostility, emotional instability, reduced alertness, confusion, disorientation Appetite and sleep disturbances, suicidal thoughts Delirium (hypoactive type) Other comorbid psychiatric illnesses must also be considered, such as anxiety disorder, substance abuse disorder, or personality disorders Chronic fatigue syndrome Depression Due to a General Medical Condition Substance-Induced Depression Effects of depression: Depression is associated with poorer self-care and slower recovery after acute medical illnesses. It can accelerate cognitive and physical decline and leads to an increased use and cost of health care services. Less effective rehabilitation Lower quality of life, higher level of chronic pain, and increased disability (is the fourth leading cause of disability in the United States). The mortality rate coincided with the level of depression even when controlling for other factors. Evaluation 1. History of: Medical disorders, medications, psychiatric diseases, alcohol, substance abuse, cognitive impairment, social factors, stressful life events, symptoms suggesting depression. asking about a history of mania, suicide Obtaining a corroborating history from confidants or family members is highly recommended 2. A- Tools to screen for depression:,
  • 5. Doha Rasheedy Mental disorders in elderly May 2017 5 Clinicians should use validated measures, such as the 9WĂƟĞŶƚ, ĞĂůƚŚY ƵĞƐƟŽŶŶĂŝƌĞ , that reflect diagnostic criteria, /ŶŝƟĂůϮƋƵĞƐƟŽŶƐĐĂŶďĞƵƐĞĚĨŽƌƐĐƌĞĞŶŝŶŐ, 2/ŶŝƟĂů ƋƵĞƐƟŽŶƐĐĂŶďĞ used for screening Serial administrations can be used to reliably assess response to treatment Not reliable in patients with moderate to severe dementia Beck Depression Inventory: dŚĞ/ĐŽǀĞƌƐƚŚĞϮǁ ĞĞŬƐƉƌŝŽƌƚŽĞǀĂůƵĂƟŽŶ͘/ƚĐŽŶƐŝƐƚƐŽĨϮϭŝƚĞŵ Ɛ͕ĞĂĐŚĐĂƚĞŐŽƌŝƐĞĚŝŶƚŽ various level of severity (with a range of score from 0 to 3). The total score is the sum of items. A total score 9 indicates no or minimal depression. A total score 30 indicates severe depression The Geriatric Depression Scale: Lacks suicidal ideation query, Not useful for assessing treatment response Hamilton depression scale (HAM-D): It has two versions: 17-item scale and 21-items scale. The 17-item version covers mood, suicide, guilt, sleep, appetite, energy, somatic complaints, sexual ĨƵŶĐƟŽŶĂŶĚǁ ĞŝŐŚƚ͘dŚĞϮϭ-ŝƚĞŵ ĐŽŶƐŝƐƚƐŽĨĂĚĚŝƟŽŶϰŝƚĞŵ ƐŽŶĚŝƵƌŶĂůǀĂƌŝĂƟŽŶŽĨŵ ŽŽĚ͕ derealisation / depersonalisation, paranoid idea and obsession / compulsions. The HAM-D scale monitors changes in the severity of symptoms during treatment. The HAM-D scale is not diagnostic and its validity is affected if the person has concurrent physical illness. The total scores range from 0 (no depression), 0-10 (mild depression), 10-23 (moderate depression) and over 23 (severe depression). 3. Cognitive screening (e.g., with the Mini Mental State Examination) is warranted in personsreporting memory problems and may reveal deficits in visuospatial processing or memory even if the total score is in the normal range. Neuropsychological testing may help identify early dementia, but because acute depression negatively affects performance, testing should be postponed until depressive symptoms diminish. 4. Laboratory tests depression is a clinical diagnosis but tests Should include electrocardiography, urinalysis, general blood chemistry screen, complete blood count, and determination of thyroid-stimulating hormone, 12vitamin B , folate, Vitamin D, glucose level and medication levels Types of depression DSM-V DIAGNOSTIC CRITERIA for major depression: Require the presence of either sadness or anhedonia with a total of five or more symptoms over 2a - week period diagnosis) 1. Depressed mood most of the day 2. Anhedonia or markedly decreased interest or pleasure in almost all activities Additional symptoms 3. Clinically significant weight loss or increase or decrease in appetite
  • 6. Doha Rasheedy Mental disorders in elderly May 2017 6 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death or suicidal ideation MINOR DEPRESSION (subsyndromal depression) Minor depression is a clinically significant depressive disorder that does not fulfill the duration criterion or the number of symptoms necessary for the diagnosis of major depression. 1. more common than major depression in elderly patients 2. May follow a major depressive episode. It also can be a reaction to routine stressors in older populations. 3. ŝŌĞĞŶƚŽϱϬƉĞƌĐĞŶƚŽĨƉĂƟĞŶƚƐǁ ŝƚŚŵ ŝŶŽƌĚĞƉƌĞƐƐŝŽŶĚĞǀĞůŽƉŵ ĂũŽƌĚĞƉƌĞƐƐŝŽŶǁ ŝƚŚŝŶƚǁ Ž years 4. Untreated, the natural course of minor depression is one to two years. 5. Patients with minor depression are less likely to require hospitalization or to commit suicide than patients with major depression but report more disability days than persons with major depression BIPOLAR DISORDER: Elevated, irritable, or expansive mood persisting for 1at least week, plus Three of the following: 1. Inflated self-esteem, grandiosity 2. Hypersexuality 3. Marked increase in activity 4. Marked decreased need for sleep 5. Pressured speech 6. Racing thoughts, flight of ideas 7. Distractibility Dysthymic disorder: is a chronic depression of mood (for at least 2 years) that is variably accompanied by two or more of the following symptoms appetite disturbance, sleep disturbance, low energy or fatigue, low self- esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. It occurs in about 1.8% of elderly individuals during any given month. Dysthymic disorder is similar to but less severe and more chronic than major depression younger age of onset, may persist from midlife into late life Pathophysiology/Pathogenesis 1. A genetic basis for depression in persons of all ages.
  • 7. Doha Rasheedy Mental disorders in elderly May 2017 7 2. In younger adults, the stress-diathesis model is one of the more popular explanations for why people develop depression. This theory suggests that both genetic vulnerability and psychosocial factors play important roles. In contrast, whereas psychosocial factors play a part in the development of late-life depression, there is less consistent evidence for genetic predisposition, with studies showing little correlation between family history and late-onset depression 3. Other biological factors are important. For example, compromises in brain neurocircuitry, particularly in frontolimbic pathways in elderly persons with depressionexplain the high incidence of depression in patients with neurologic conditions affecting these pathways such as disease (AD) 4. vascular disease may contribute to depression 5. Medical comorbidity is frequent. Treatment a) PATIENT FAMILY EDUCATION/SUPPORTIVE CARE Educating patients and families about depression is the cornerstone of successful treatment, deal with stigma of depression in different cultures Involving families in the care of elderly patients is crucial Music therapy and exercise can prevent and improve depression (A recommendation). Regardless of the therapy chosen, it is important to consider the social and environmental context of each patient If sleep is a problem, doctor should offer sleep hygiene advice. b) Pharmacological therapy: Treatment should be considered in 3 phases: 1. an acute treatment phase to achieve remission of symptoms; 2. a continuation phase to prevent recurrence of the same episode of illness (relapse);( 6 months) 3. a maintenance (prophylaxis) phase to prevent future episodes (recurrence)(18-24 months) Follow-up visits should be arranged at 3- to 6-mo intervals. For a first time depressive ĞƉŝƐŽĚĞ͕ƚƌĞĂƚŵ ĞŶƚĨŽƌƵƉƚŽϮLJĞĂƌƐŵ ĂLJďĞƌĞƋƵŝƌĞĚ͘/ŶƉĂƟĞŶƚƐǁ ŝƚŚϯŽƌŵ ŽƌĞ episodes, lifelong maintenance treatment may be considered. If the patient and physician agree to a trial discontinuation of therapy, medications should be tapered over a 2- to 3-mo period, with at least monthly follow-up by telephone or in person. If symptoms return, ƚŚĞƉĂƟĞŶƚƐŚŽƵůĚďĞƌĞƐƚĂƌƚĞĚŽŶŵ ĞĚŝĐĂƟŽŶƐĨŽƌĂƚůĞĂƐƚϯ-6 mo. Start at half the dose of younger people ƟƚƌĂƚĞĚŽƐĞĞǀĞƌLJϰ-7 days, Aim to reach an average dose at one month
  • 8. Doha Rasheedy Mental disorders in elderly May 2017 8 The elderly respond to therapy as well as younger patients, the time to full response may patients respond should be maintained Change in medication should be considered if patients 4ŚĂǀĞŶŽƌĞƐƉŽŶƐĞĂŌ Ğƌ weeks on the maximum dose or 8ŚĂǀĞŽŶůLJƉĂƌƟĂůƌĞƐƉŽŶƐĞĂŌ Ğƌ weeks of treatment (C recommendation).Checking adherence is important Augmentation usually involves addition of another antidepressant, lithium, or an atypical antipsychotic. ŽŶůLJĂďŽƵƚϱϬй ŽĨƉĂƟĞŶƚƐƌĞƐƉŽŶĚƚŽƚŚĞĮƌƐƚĂŶƟĚĞƉƌĞƐƐĂŶƚƉƌĞƐĐƌŝďĞĚ When switching among SSRIs or between TCAs and SSRIs, no wash-out period is required (with the exception of switching from fluoxetine, because of its long half-life). However, abrupt cessation of shorter acting antidepressants (eg, citalopram, paroxetine, sertraline, or venlafaxine) may result in a discontinuation syndrome with tinnitus, vertigo, or paresthesias Indefinite treatment should be considered for patients who have severe depression, have a history of recurrent depression, require electroconvulsive therapy (ECT), or have only partial resolution of symptoms Factors to guide antidepressant choice: 1. previous response 2. concurrent conditions (eg, avoiding anticholinergic agents in men with benign prostatic hypertrophy), 3. type of depression (eg, bipolar versus unipolar, presence of psychotic features), 4. other medications, and risk of overdose 5. There is some evidence that choices can also be guided by concurrent symptoms (eg, nortriptyline or duloxetine for concurrent pain and mirtazapine with anxiety). Selective serotonin-reuptake inhibitors (SSRIs) First-line treatments for late-life depression Side effects: syndrome of inappropriate secretion of antidiuretic hormone, sexual dysfunction, nausea and headache, Anxiety, agitation, nausea diarrhea, pseudoparkinsonism, warfarin effect, other drug interactions Of concern are reports noting a higher risk of stroke among persons taking SSRIs than Ăŵ ŽŶŐŶŽŶƵƐĞƌƐŽĨĂŶƟĚĞƉƌĞƐƐĂŶƚƐ;ĂŶŶƵĂůŝnjĞĚƐƚƌŽŬĞƌĂƚĞŽĨĂƉƉƌŽdžŝŵ ĂƚĞůLJϰǀƐ͘ϯƉĞƌϭϬϬϬ person-years in one report However, a similar increase in the risk of stroke has been noted with other antidepressant classes Falls and fractures in nursing-home residents Higher doses of citalopram and escitalopram, citing concerns about prolongation of QT If fluoxetine is the initial antidepressant, a wash-out of several weeks will be needed given (better avoid due to long half life, ŝŶŚŝďŝƟŽŶŽĨƚŚĞWϰϱϬƐLJƐƚĞŵ ͘)
  • 9. Doha Rasheedy Mental disorders in elderly May 2017 9 Serotonin norepinephrine reuptake inhibitors (SNRIs) commonly used as second-line agents when remission is not obtained with SSRIs, Effective for major depression generalized anxiety The benefits of SSRIs are similar to those of SNRIs, although adverse effects may be more frequent with SNRIs. Side effects: Nausea, Hypertension, Sexual dysfunction, dizziness DeluxeƟŶĞ͗ϮϬ 60 mg/day(used for neuropathic pain) Venlafaxine:75-300(desvenalfaxine 25-50) Tricyclic antidepressants (TCA) have efficacy similar to that of SSRIs in the treatment of late-life depression but are less commonly used owing to their greater side effects, included in the Beers Criteria list of potentially inappropriate medications associated with high rates of adverse drug events among older adults If SSRIs or SNRIs are ineffective, tricyclic antidepressants may be considered (either as monotherapy or as augmentation). nortriptyline and desipramine (secondary amines) have the lowest anticholinergic burden Side effects: Cognitive impairment, orthostatic hypotension, anticholinergic effects and cardiac conduction abnormalities, alpha-adrenergic blockade ion, Confusion ECG before start treatment Monoamine oxidase inhibitors (MAoI) Use if patient is resistant to other antidepressants Side effects: Orthostatic hypotension, falls Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies (pressor amine) Fatal serotonin syndrome possible if taken with SSRI, meperidine Bupropion: Wellbutrin: activity of dopamine norepinephrine, Dose range: 150 300 mg/day, Side effects: Insomnia, anxiety, tremor, myoclonus, Associated with 0.4% risk of seizures Mirtazapine Remeron: Norepinephrine, 5-HT2 , and 5-HT3 antagonist. Given as single bedtime dose (sedative side effects Dose:15-45 mg weight gain, increases appetite
  • 10. Doha Rasheedy Mental disorders in elderly May 2017 10 Psychostimulants dextroamphetamine (5-10 mg/day) or methylphenidate Ritalin (2.5-5 mg/day) are not well studied in the elderly and have the potential to contribute to tachycardia, agitation and insomnia. May have role in reversing apathy, lack of energy in patients with dementia or disabling medical conditions can be effective within hours, for depression At the end of life c) Non pharmacological therapy: 1. Psychotherapy: Effective treatments for late life depression and may be considered as first line therapy, depending on availability and patient preference. effective treatments for major depression either alone or in combination with pharmacotherapy The potential benefit of psychotherapy is not diminished by increasing age. In patients with severe depression, combination therapy with psychotherapy and pharmacotherapy is superior to either treatment alone. 6once or twice weekly for -16sessions Psychotherapies recommended for geriatric depression include behavior therapy, cognitive- behavioural therapy, problem-solving therapy, brief dynamic therapy, interpersonal therapy, and reminiscence therapy (A recommendation). Psychoanalytic and psychodynamic therapies have not proved effective for treatment of major depression Cognitive behavioral therapy focuses on identifying negative thoughts and behaviors that contribute to depression and replacing them with positive thoughts and rewarding activities. It may have a weaker effect in physically ill or cognitively impaired persons Problem-solving therapy focuses on the development of skills to improve the ability to cope with life problems (can be used in cognitive impaired (specifically, coexisting executive dysfunction) Reminiscence therapy, a psychotherapy focusing on the evaluation and reframing of past life events. Interpersonal therapy for older adults with depression focuses focuses on recognizing and attempting to resolve personal stressors and relationship conflicts that lead to depressive symptoms. Supportive psychotherapy 2. Electroconvulsive therapy (ECT) is the most effective treatment for severely depressed patients, is first-line therapy for suicidal patient, psychotic depression, life-threatening refusal of food, fluids, medications Indications: ϭͿ^ĞǀĞƌĞĚĞƉƌĞƐƐŝǀĞĚŝƐŽƌĚĞƌǁ ŚŝĐŚĚŽĞƐŶŽƚƌĞƐƉŽŶĚƚŽĂŶĂĚĞƋƵĂƚĞƚƌŝĂůŽĨĂŶƟĚĞƉƌĞƐƐĂŶƚƐ͘ 2) Life threatening depressive illness (e.g. high suicide risk). 3) Stupor or catatonia ϰͿD ĂƌŬĞĚƉƐLJĐŚŽŵ ŽƚŽƌƌĞƚĂƌĚĂƟŽŶ ϱͿWƐLJĐŚŽƟĐĚĞƉƌĞƐƐŝŽŶ 6) Treatment resistant mania
  • 11. Doha Rasheedy Mental disorders in elderly May 2017 11 7) Treatment resistant schizophrenia. Common side effects include headache, muscle pain, jaw pain, drowsiness, loss of recent memories persistent (retrograde amnesia), anterograde amnesia (less common than retrograde amnesia), prolonged ƐĞŝnjƵƌĞƐ;ůŽŶŐĞƌƚŚĂŶϭŵ ŝŶƵƚĞͿĂŶĚĐŽŶĨƵƐŝŽŶĂŌĞƌdƐ͘ Current administration techniques, such as unilateral electrode placement with a brief pulse, substantially reduce the cognitive symptoms Mechanism of actions: 1) Release of noradrenaline, serotonin, dopamine but reduction of acetylcholine release. 2) Increase in permeability of the blood-brain barrier. ϯͿD ŽĚƵůĂƟŽŶŽĨŶĞƵƌŽƚƌĂŶƐŵ ŝƩ ĞƌƌĞĐĞƉƚŽƌƐƐƵĐŚĂƐ' ŽƌĂĐĞƚLJůĐŚŽůŝŶĞ. Contraindications: recent myocardial infarction, brain tumor, Increased intracranial pressure, cerebral aneurysm, and uncontrolled heart failure. Continue pharmacotherapy following completion of ECT treatment īĞĐƟǀĞƌĞƐƉŽŶƐĞƌĂƚĞсϴϬй 3. Transcranial magnetic stimulation is a newer treatment for depression that uses a focal electromagnetic field generated by a coil held over the scalp, most commonly positioned over the left prefrontal cortex. ^ĞƐƐŝŽŶƐĂƌĞƐĐŚĞĚƵůĞĚĮǀĞƟŵ ĞƐĂǁ ĞĞŬŽǀĞƌĂƉĞƌŝŽĚŽĨϰƚŽϲǁ ĞĞŬƐ. Does not have cognitive side effects. d) 4ZĞĂƐƐĞƐƐĂŌ Ğƌ -6weeks: Increase dose, augment with second agent, add psychotherapy e) Referral: Indications for Psychiatric Referral in Elderly Patients with Depression Bipolar disorder Suicidal ideation Psychosis Unresponsive or intolerant to adequate trial of first-line treatment Diagnostically complex or uncertain Candidate for electroconvulsive therapy Severely ill Need for treatment beyond drug therapy Double depression (i.e., episodes of major depression superimposed on dysthymic disorder Managing partial response, or non- response 1. Check compliance 2. The most common prescribing error is failure to increase the dose to the recommended level within the first 2 weeks of treatment 3. For non-response or intolerance, switch to another SSRI or another drug class 4. For partial response to an SSRI, add bupropion or buspirone
  • 12. Doha Rasheedy Mental disorders in elderly May 2017 12 SUICIDE Older age associated with increasing risk of suicide One fourth of all suicides occur in people 65 years Risk factors: depression, physical illness,pain, living alone, white male, older age; marital status of single, divorced, or separated and without children; personal or family history of a suicide attempt; drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with access to firearms or other lethal means (eg, stockpiled medications). Violent suicides (eg, firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing Herbal remedies St. John's wort have a role in the treatment of depression, should not be used in conjunction with SSRIs because the combination may lead to serotonergic syndrome, which is characterized by changes in mental status, tremor, gastrointestinal upset, headache, myalgia, and restlessness. It may lower the concentration of certain drugs, such as warfarin, digoxin, theophylline, cyclosporine, and HIV-1 protease inhibitors. Other common herbal remedies such as kavakava and valerian root have not been proven effective for treating depression TREATMENT OF MANIA AND BIPOLAR DEPRESSION 1. Antipsychotic agents: olanzapine and aripiprazole used in augmentation for treatment-resistant depression (even in non- psychotic depression), bipolar depression 2. Lithium Carbonate: dĂƌŐĞƚƉůĂƐŵ ĂůĞǀĞůƐĨŽƌŽůĚĞƌƉĂƟĞŶƚƐ͗Ϭ͘ϲ 1.0 mEq/L Use cautiously with renal insufficiency Delay of up to 2 weeks to achieve steady state The following may increase lithium levels: NSAIDs, thiazide- and K+-sparing diuretics, furosemide Dehydration, salt depletion Side effects: fine resting tremor, myoclonus, intention tremor, DI 3. Anticonvulsants: Valoproic acid: dĂƌŐĞƚĐŽŶĐĞŶƚƌĂƟŽŶƐŽĨϱϬ 100 g/mL Efficacy comparable to lithium Delay of up to 2 weeks to achieve steady state Side effects: Sedation, rashes, platelet counts functioning Liver toxicity may develop in patients with hepatic disease Reduce dosage in renal insufficiency Lab monitoring of CBC, liver enzymes, and chemistries required Carbamazepine FDA-approved for bipolar disorder
  • 13. Doha Rasheedy Mental disorders in elderly May 2017 13 Side effects: Mild bone marrow suppression with leukopenia thrombocytopenia in 5% ϭϬй ǁ ŝƚŚŝŶĮƌƐƚϮ weeks Rare: life-threatening agranulocytosis, aplastic anemia Lab monitoring required Lamotrigine FDA-approved for bipolar depression Little data on use in late life Associated with Stevens-Johnson syndrome Reduce dose in liver dysfunction TREATMENT OF BIPOLAR DEPRESSION MIXED MANIA WITH DEPRESSION Primary mood stabilizer: lamotrigine or lithium Attain adequate dose or therapeutic level For inadequate response add: Mixed mania and depression Lithium Aripiprazole Valproate Risperidone Olanzapine Mania frequent Rapid cycling Hx of antidepressant-induced mania Lithium Valproate Lamotrigine Olanzapine Mania rare Not rapid cycling No hx of antidepressant-induced mania Bupropion or SSRI Not TCA, not SNRI Depressive episode
  • 14. Doha Rasheedy Mental disorders in elderly May 2017 14 Appendix History: 1. Psychiatric history Past psychiatric diagnoses and treatment Allows confirmation of diagnosis and can guide treatment decisions Current suicidal thoughts and past suicide attempts: Crucial in assessing safety; past suicide attempts indicate increased risk of future attempts Substance use Indicates contributing factors, such as alcohol use, for which additional intervention may be needed Problems with memory Initial screen for cognitive problems; should address with both patient and family if possible 2. Medical history Presence of chronic pain May exacerbate depression and indicate need for additional treatment Polypharmacy May complicate antidepressant treatment Problems with medication adherence May lead to nonresponse to antidepressant treatment Review of current medications To identify any medications that may confer a predisposition to depression (e.g., propranolol, prednisone) 3. Social history Recent stressors or losses Factors contributing to depression Available social support Indicates extent of social engagement or isolation Access to transportation and ability to drive: Indicates ability to engage socially and to meet basic needs such as shopping for groceries Access to guns Indicates increased risk that a suicide attempt would be lethal 4. Family history Dementia Indicates increased risk of dementia for the patient Suicide Indicates increased risk of suicide for the patient
  • 15. Doha Rasheedy Mental disorders in elderly May 2017 15 Antidepressant choices for older patients Generic Name Start ing dose, mg/d Average Dose, mg/d Maximum Recommended Dose, mg/d SSRI Citalopram 10 20-40 20 for those older than 65 y 40 for others QTc prolongation Escitalopram 5 10-20 10 for those older than 65 y 20 for others QTc prolongation Sertraline Modapex 25 50-150 200 Like all SSRIs, risk of nausea, SIADH Fluoxetine Prozac 20 80 SNRI Venlafaxine Effexor 37.5 75 225 375* Might increase blood pressure deluxetine Tricyclic (secondary) better than tertiary in elderly Desipramine Norpramin 10 25 50 150 300 Anticholinergic properties; cardiovascular side effects; monitor blood levels Nortriptyline Aventyl 10 25 40 100 200 Tricyclic (tertiary) Imipramine Tofranil 25 300 Anticholinergic properties; cardiovascular side effects; monitor blood levels Amitriptyline Elavil 25 300 other Bupropion Wellbutrin 100 100, twice daily 150, twice daily Might cause seizures Mirtazapine Remeron 15 30 45 45 Might cause sedation, especially at lower doses Trazodone Trittico 50 600 Sedation, orthostatic hypotension, priapism nefazodone serozone 50 mg bid 150 mg bid Methylphenidate Ritalin 2.5mg at7am, noon 5-10 mg at 7am, noon MAOIs Phenelzine Nardil Orthostatic hypotension, hypertensive crisis, Fatal serotonin syndrome possible if taken with SSRI, meperidine Tranylcypromine Parnate