Depression in elderly people

1. DEPRESSION IN
GERIATRICS
SHYAM SUNDAR

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. 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. 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.  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.  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.  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.  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.  “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. 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%

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. 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. What medications do YOU
prescribe for older adults that
might place them at risk for
DEPRESSION ?

14. Medications that may cause symptoms
of Depression
 Anabolic steroids
 Anti-arrhythmic medications (amiodarone,
mexilitine)
 Anticonvulsant medications
 Carbidopa or levodopa
 Certain beta-adrenergic antagonists (i.e.
propranol)

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. What is the most commonly used
and validated screening tool for
diagnosis of Depression in the
geriatrics patient?
The Geriatric Depression Scale

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. 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. Pharmacotherapy
 Selective Serotonin Reuptake Inhibitors
 : fluoxetine
 Tricyclic Antidepressants : imipramine and
amitriptyline
 Monoamine Oxidase Inhibitors
 Other Antidepressants: mirtazapine and
trazo

20. Consequences and Complications of
Inadequately 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. Consequences and Complications of
Inadequately Treated Depression
Which demographic in the elderly
population has the highest risk
and incidence of suicide?
Highest: white males age 80 & older
Next highest: white males between 65
and 80

22. Consequences and Complications of
Inadequately 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. Consequences and Complications of
Inadequately 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. Consequences and Complications of
Inadequately 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. 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. 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. THANK YOU

28. QUESTION
 Pharmacotherapy for depression include
these except?
 A] Selective serotonin reuptake inhibitors
 B] Tricyclic antidepressants
 C] Triptans
 D] Monoamine oxidase inhibitors

29.  All of these denote depression except?
A. Anhedonia
B. Appetite change
C. Apnea
D. Psychomotor agitation