Depression is underrecognized and undertreated in older adults. It is not a normal part of aging and can worsen medical illnesses. Symptoms include depressed mood, loss of interest, changes in appetite, insomnia, fatigue, guilt, and suicidal thoughts. Depression is diagnosed if five or more symptoms are present for two weeks. Treatment involves pharmacotherapy such as SSRIs or SNRIs for at least six months, psychotherapy like CBT, and other somatic therapies for severe cases. Untreated depression can have serious consequences so screening and treatment is important for older adults.

1. DEPRESSION IN
ELDERLY
ROLL No. – 87 to 100

2.  INDRODUCTION:
• 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.  WHAT IS DEPRESSION ?
•DSM-V-TR DEFINITION:
- The individual must be experiencing five or more symptoms
during the same 2-week period and at least one of the
symptoms should be either
1. Depressed mood
2. loss of interest or pleasure

4.  Core Symptoms:
• Depressed mood
• Loss of interest all or almost all activities or pleasure
• Appetite change or weight loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Loss of energy or fatigue
• Feelings of worthlessness or guilt
• Thoughts of wishing you were dead

5.  TYPES OF DEPRESSION:
• EXOGENOUS DEPRESSION ENDOGENOUS DEPRESSION
- It is precipitated by events in - It occurs in external life
Individuals life such as severe stressors
Traumatic events in life - Characterized by severe
Eg; loss of home in fire, anhedonia, severe
- It resolves itself vegetative symptoms,
profound guilt and
suicidal thoughts

6. Epidemiology
• Community dwelling (1-9%).
• Hospitalised (11-45%).
• Primary care settings(10-12%).
• Nursing home(10-26%).
• Permanent placement up to 43%.

7. 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 hospitalisation.

8. Etiology
• A. Biological factors:
Neurotransmitters disturbances: Decreased levels of serotonin and
norepinephrine are most important factors implicated in the pathophysiology of
depression. Dopamine has also been found to be decreased in a subset of
patients.
Hormonal disturbances: Elevated HPA activity (hypothalamic-pituitary-adrenal
axis activity) has been documented. Also, hypothyroidism is a common cause
of depression.
.Neuroanatomical considerations: Decreased activity in dorsolateral prefrontal
cortex and increased activity in amygdala (and other limbic
tissue) has been found in depression.

9. • B. Genetic factors: Gene mapping studies have found
evidence of linkage to locus for cAMP response element
binding protein (CREB 1) on chromosome 2. Serotonin
transporter gene has also shown linkage.
• C. Psychological theories:
• Cognitive theory: It was proposed by Aaron Beck
According to this theory negative thoughts have a central role
in development of depression. He proposed that there are three
central thoughts/ideas in depression, the so called cognitive
triad of depression

10. • These include:
1. Negative view of self (ideas of worthlessness)
2. Negative views about environment-A tendency to
experience world as hostile (ideas of helplessness")
3. Negative view about future (ideas of hopelessness).
• Learned helplessness According to this theory, due to
repeated adverse events, patient starts believing that he has no
control over events happening around him and loses the
motivation to act which results in depression.

11. Symptoms of Depression: (must last >2weeks for
diagnosis of depression)
• Sleep Disturbance- Usually Insomnia is seen however
hypersomnia can also be a symptom. Two characteristic
features are Early morning awakening & reduced latency of
REM sleep.
• Loss of Interest- Looses interest in activities that used to
interest him earlier. (Anhedonia)

12. • Guilt- May have excessive guilty feelings & may blame
themselves for trivial matters.
• Lack of Energy- Decreased energy levels & easy
fatiguability.
• Cognition/Concentration- May have negative cognition
(Negative thoughts) & may have poor concentration.
• Appetite- Usually appetite & weight are lost. Some may
gain weight.

13. • Psychomotor agitation or retardation- Term psychomotor
refers to changes in motor activity 2o to physical causes.
May be increased (restless patient) or decreased.
• Suicidal Thoughts & sadness of mood.
Out of these Suicidality, Weight loss, Anhedonia & Guilty feelings are
very suggestive of depression.

14. PHYSICAL SIGNS OF DEPRESSION
 VERAGUTH FOLD :- Described by otto veraguth
It’s a triangular shape of fold in the nasal corner of upper eyelid due to
contracture of orbicularis occuli muscle
Looks like as if the patient is staring
 OMEGA SIGN :- Described by charles darwin
It’s a omega shaped fold in the forehead above the root of nose
Due to contracture of procerus and corrugator muscle

16. GRADING OF DEPRESSION
ACCORDING TO ICD 11
Mild Moderate Severe
Symptoms Present Prominent Very prominent
Vegetative
symptoms ( sleep
& appetite)
Not affected Affected Severely affected
Functionality Not much
affected
Just able to
function
Severely affected

17. SCREENING TOOLS

19. TREATMENT

20. Pharmacotherapy
• The use of specific pharmacotherapy doubles the chances that a depressed
patient will recover in 1 month.
• All the available antidepressants take up to 3–4 weeks to exert significant
therapeutic effects.
• The available antidepressants do not differ in the overall efficacy, speed of
response or long-term effectiveness and the choice of antidepressants is
mostly determined by the side effect profile of the drugs.

21. • Antidepressant treatment should be maintained for at least 6 months or equal
to the duration of a previous episode, whichever is greater.
• Prophylactic treatment with antidepressants is effective in reducing the
number and severity of episodes.
• It should be given to patients who have had three or more prior depressive
episodes or who have chronic major depressive disorder (> 2 years duration
is chronic depression).

22. Tricyclic and tetracyclic antidepressants (TCAs):
• They act by blocking the transporters of serotonin and norepinephrine and hence
increase the levels of these neurotransmitters in synapses.
• Secondary effects of TCAs include antagonism of muscarinic, histaminic H1, a1
and a2 adrenergic receptors and blockage of cardiac sodium channels.
• Imipramine, desipramine, trimipramine, amitriptyline, nortriptyline,
protriptyline, amoxapine, doxepin, maprotiline and clomipramine.
• Side effects: Constipation,urinary retention, blurred vision, dry mouth,
decreased sweating, delirium, seizures, sedation, postural hypertension, cardiac
arrythmias, etc. Should be avoided in glaucoma and prostate hypertrophy.

23. Selective serotonin reuptake inhibitors (SSRIs):
• They act by blocking the reuptake of serotonin.
• Include fluoxetine, fluvoxamine, citalopram, escitalopram, sertraline,
paroxetine and vilazodone.
• Side effects of the SSRIs include: nausea (most common) followed by
anxiety and diarrhoea.
• Other side effects include delayed ejaculation, decreased libido, sedation,
delayed platelet aggregation, sweating and weight gain.

24. SNRIs (Serotonin Norepinephrine Reuptake Inhibitors):
• These drugs produce blockade of neuronal serotonin and norepinephrine
uptake transporters and hence are also referred as dual reuptake inhibitors.
• Include venlafaxine, duloxetine, milnacipran, levomilnacipran.
• The side effect profile is quite similar to SSRIs. In addition, SNRIs can cause
hypertension at higher dosages.
Monoamine oxidase inhibitors:
• These drugs act by inhibiting the metabolism of monoamines.
• The nonselective MAO inhibitors which includes tranylcypromine, phenelzine
and isocarboxazid inhibits both the isoforms irreversibly.
• Side Effects: Hypertensive Crisis, Cheese reaction.

25. Psychotherapy

26. Psychotherapy
• It is treatment using psychological techniques.
• The following techniques are useful in depression:
A) Cognitive behavioral therapy
B) Interpersonal therapy
C) Others like behavior therapy, family therapy and
psychoanalytically oriented therapy.

27. A) Cognitive behavioral therapy:
Aims at correcting cognitive distortions
(faulty ways of thinking and faulty behaviours)
Most effective psychotherapeutic technique
B) Interpersonal therapy:
Focus is on management of patient’s current interpersonal
problems. (relationship problems)

28. Other somatic treatments
A. Electroconvulsive therapy:
Indications:
Severe depression with suicide risk.
Severe depression with stupor.
Others indications include psychotic symptoms, refractoriness
to other treatment modalities.

29. B) Transcranial magnetic stimulation:
Newer modalities uses magnetic energy to stimulate nerve cells.
C) Vagal nerve stimulation
D) Deep brain stimulation