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  • We also want to watch for MINOR DEPRESSION, which is also called “subclinical” or “subsydromal” depression because it does not meet the full “criteria” for MAJOR depression. For example, “Sally” complains that “nothing is enjoyable anymore” and doesn’t want to participate in any activities, including coming to meals (e.g., has lost the ability to experience pleasure in nearly all activities). She wakes up early every morning and cannot return to sleep (e.g., sleep disturbance). She has lost 5 pounds in a month because she is not eating right (e.g., appetite change, weight loss), and complains of being tired all the time (e.g., fatigue) – which is another reason she doesn’t want to attend activities. These are all changes for Sally; all occur nearly every day; and all have persisted for 2 weeks. But Sally has four, but not five of the targeted signs and symptoms, so does have “major depression.”
    Is Sally’s quality of life compromised by these changes? YES! Will supportive therapy, talking therapy (e.g., individual or group psychotherapy) or even antidepressant medication therapy help relieve Sally’s symptoms? YES!! In short, identifying ALL people with significant symptoms of depression is important to restoring quality of life!
  • Depression

    1. 1. Depression in ElderlyDepression in Elderly Kalpana P. Padala, MD, MSKalpana P. Padala, MD, MS Research GeriatricianResearch Geriatrician Assistant ProfessorAssistant Professor Dept. of Family MedicineDept. of Family Medicine University of Nebraska Medical CenterUniversity of Nebraska Medical Center Email: kpadala@unmc.eduEmail:
    2. 2. DisclosuresDisclosures  NoneNone
    3. 3. Goals and ObjectivesGoals and Objectives  Identify the variation in presentation ofIdentify the variation in presentation of depression in various age groupsdepression in various age groups  Overview of assessment of depressionOverview of assessment of depression along with use of common rating scalealong with use of common rating scale  Selection of antidepressants in managementSelection of antidepressants in management of depressionof depression  Special considerations with antidepressantSpecial considerations with antidepressant use in elderlyuse in elderly  Overview of risk factors for SuicideOverview of risk factors for Suicide
    4. 4. EpidemiologyEpidemiology  Men: 5-12%Men: 5-12%  Women: 10-25%Women: 10-25%  Prevalence 1-2% in elderlyPrevalence 1-2% in elderly – 6-10% in Primary Care setting6-10% in Primary Care setting – 12-20% in Nursing home setting12-20% in Nursing home setting – 11-45% in Inpatient setting11-45% in Inpatient setting – >40% of outpt. Psychiatry clinic and inpt. psychiatry>40% of outpt. Psychiatry clinic and inpt. psychiatry  Peak age of onset 3rd decadePeak age of onset 3rd decade  Late-life depression: secondary to vascularLate-life depression: secondary to vascular etiologyetiology
    5. 5. Patho-physiologyPatho-physiology  Elevated stress levelsElevated stress levels  Decreased levels or activity ofDecreased levels or activity of nor-epinephrine and/or serotoninnor-epinephrine and/or serotonin  Decreased latency to 1Decreased latency to 1stst rapid eyerapid eye movement sleep phase and hypoperfusionmovement sleep phase and hypoperfusion of the frontal lobesof the frontal lobes  Cerebro-vascular diseaseCerebro-vascular disease  Deep white matter hyperintensityDeep white matter hyperintensity
    6. 6. EtiologyEtiology  Biological factorsBiological factors  Social factorsSocial factors  Psychological factorsPsychological factors
    7. 7. Biological factorsBiological factors  GeneticGenetic – High prevalence in first degree relativesHigh prevalence in first degree relatives – High concordance with monozygotic twinsHigh concordance with monozygotic twins – Short allele of serotonin transported geneShort allele of serotonin transported gene  Medical Illness:Medical Illness: – Parkinson's, Alzheimer's, cancer, diabetes or strokeParkinson's, Alzheimer's, cancer, diabetes or stroke  Vascular changes in the brainVascular changes in the brain  Chronic or severe painChronic or severe pain  Previous history of depressionPrevious history of depression  Substance abuseSubstance abuse
    8. 8. Social factorsSocial factors  Loneliness, isolationLoneliness, isolation  Recent bereavementRecent bereavement  Lack of a supportive social networkLack of a supportive social network  Decreased mobilityDecreased mobility – Due to illness or loss of driving privilegesDue to illness or loss of driving privileges
    9. 9. Psychological factorsPsychological factors  Traumatic experiencesTraumatic experiences – AbuseAbuse  Damage to body imageDamage to body image  Fear of deathFear of death  Frustration with memory lossFrustration with memory loss  Role transitionsRole transitions
    10. 10. Common precipitantsCommon precipitants  Arguments with friends/relativesArguments with friends/relatives  Rejection or abandonmentRejection or abandonment  Death or major illness of loved oneDeath or major illness of loved one  Loss of petLoss of pet  Anniversary of a (-) eventAnniversary of a (-) event  Major medical illness or age-related deteriorationMajor medical illness or age-related deterioration  Stressful event at workStressful event at work  Medication NoncomplianceMedication Noncompliance  Substance useSubstance use
    11. 11. DefinitionDefinition A syndrome complex characterized byA syndrome complex characterized by mood disturbance plus variety ofmood disturbance plus variety of cognitive, psychological, andcognitive, psychological, and vegetative disturbancesvegetative disturbances
    12. 12. Clinical FeaturesClinical Features  DSM IV-TR criteriaDSM IV-TR criteria – 5/9 should be present for at least two5/9 should be present for at least two weeksweeks – Must be a change from previousMust be a change from previous functioningfunctioning – Presence of decreased interest orPresence of decreased interest or low/depressed mood is must featurelow/depressed mood is must feature  SIGECAPSSIGECAPS
    13. 13. SIG(M)ECAPSSIG(M)ECAPS  SSleep disturbance: decreased or increasedleep disturbance: decreased or increased  IInterest or pleasure*: decreasednterest or pleasure*: decreased  GGuilt or feeling worthlessuilt or feeling worthless  MMood* : sustained low or depressedood* : sustained low or depressed  EEnergy loss or fatiguenergy loss or fatigue  CConcentration problems or problems withoncentration problems or problems with memorymemory  AAppetite disturbance, weight loss or gainppetite disturbance, weight loss or gain  PPsychomotor agitation or retardationsychomotor agitation or retardation  SSuicidal ideation, thoughts of deathuicidal ideation, thoughts of death
    14. 14. MINOR DepressionMINOR Depression  Also known asAlso known as – subsyndromalsubsyndromal depressiondepression – subclinicalsubclinical depressiondepression – mild depressionmild depression  2 - 4 times more2 - 4 times more common than majorcommon than major depressiondepression  Associated with:Associated with: – subsequent majorsubsequent major depressiondepression – greater use of healthgreater use of health servicesservices – reduced physical,reduced physical, social functioningsocial functioning – loss of quality of lifeloss of quality of life  Responds to sameResponds to same treatments!treatments!
    15. 15. Atypical depressionAtypical depression  Somatic complaintsSomatic complaints  Hyperphagia,Hyperphagia,  Hypersomnia,Hypersomnia,  Hypersensitivity to rejectionHypersensitivity to rejection  ““Heavy” feeling in upper or lowerHeavy” feeling in upper or lower extremities (leaden paralysis)extremities (leaden paralysis)
    16. 16. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335. Depression – the physicalDepression – the physical presentationpresentation In primary care, physical symptoms are often the chief complaint in depressed patients N = 1146 Primary care patients with major depression In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1
    17. 17. Dysthymia  More chronic, low intensity mood disorder  By definition, symp must be present > 2 yrs consecutively  It is characterized by anhedonia, low self- esteem, & low energy  It may have a more psychologic than biologic etiology  It tends to respond to Rx & psychotherapy equally  Long-term psychotherapy is frequently able to bring about lasting change in dysthymic individuals
    18. 18. Bipolar DisorderBipolar Disorder  People with this type of illness changePeople with this type of illness change back and forth between periods ofback and forth between periods of depression and periods of mania (andepression and periods of mania (an extreme high).extreme high).  Symptoms of mania may include:Symptoms of mania may include: – Less need for sleepLess need for sleep – OverconfidenceOverconfidence – Racing thoughtsRacing thoughts – Reckless behaviorReckless behavior – Increased energyIncreased energy – Mood changes are usually gradual, but canMood changes are usually gradual, but can be suddenbe sudden
    19. 19. Season Affective DisorderSeason Affective Disorder  Results from changes in the season. MostResults from changes in the season. Most cases begin in the fall or winter, or whencases begin in the fall or winter, or when there is a decrease in sunlightthere is a decrease in sunlight  Pattern of onset at the samePattern of onset at the same time each yeartime each year  Full remissions occur at aFull remissions occur at a characteristic time of yearcharacteristic time of year
    20. 20. Pseudo-dementiaPseudo-dementia  A syndrome of cognitive impairment that mimics dementia but is actually depression  Poor attention and concentration  Symptoms resolve as the depression is treated effectively  If considerable cognitive impairment remains, an underlying dementia is suspected  Even “completely recovered” patients have higher rates of dementia (20% /year of f/u)  This is 2.5 to 6 times higher than population risk
    21. 21. Psychotic depressionPsychotic depression  AAbnormal thought process – psychoticbnormal thought process – psychotic thinkingthinking  Frank hallucinations and delusionsFrank hallucinations and delusions
    22. 22. Depression in ElderlyDepression in Elderly  NOTNOT a normal part of aginga normal part of aging  2 million Americans over age 652 million Americans over age 65 have depressive illnesshave depressive illness  Sub-syndromal depressionSub-syndromal depression increases the risk of developingincreases the risk of developing depressiondepression – Leads to early relapse andLeads to early relapse and chronicitychronicity  Often co-occurs with otherOften co-occurs with other serious illnessesserious illnesses  Under-diagnosed and under-Under-diagnosed and under- treatedtreated  Suicide rates in the elderly areSuicide rates in the elderly are the highest of any age group.the highest of any age group.
    23. 23. Facts in ElderlyFacts in Elderly  Only 11 percent : in community receiveOnly 11 percent : in community receive adequate antidepressant treatmentadequate antidepressant treatment  The direct and indirect costs –The direct and indirect costs – $43 billion each year$43 billion each year  Late life depression is particularlyLate life depression is particularly costly because of the excess disabilitycostly because of the excess disability that it causes and its deleteriousthat it causes and its deleterious interaction with physical healthinteraction with physical health
    24. 24. Depression in ElderlyDepression in Elderly  Difficult to diagnoseDifficult to diagnose  Low/depressed mood need not be presentLow/depressed mood need not be present  Persistent loss of pleasure and interest inPersistent loss of pleasure and interest in previously enjoyable activities (anhedonia)previously enjoyable activities (anhedonia) must be presentmust be present  Reject diagnosis of depressionReject diagnosis of depression  Masked depression or depression withoutMasked depression or depression without sadness- mainly somatic complaintssadness- mainly somatic complaints
    25. 25. Depression in ElderlyDepression in Elderly  Symptoms of minor depressionSymptoms of minor depression  Somatic complaints: Persistent, vague,Somatic complaints: Persistent, vague, unexplained physical complaintsunexplained physical complaints  Agitation, anxietyAgitation, anxiety  Memory problems, difficulty concentratingMemory problems, difficulty concentrating  Social withdrawalSocial withdrawal  A high degree of suspicion and specificA high degree of suspicion and specific inquiry is necessary for its detection andinquiry is necessary for its detection and treatmenttreatment
    26. 26. Differential diagnosis in ElderlyDifferential diagnosis in Elderly  Differentiation from medical illness:Differentiation from medical illness: – HyperthyroidismHyperthyroidism – Parkinson’s diseaseParkinson’s disease – Carcinoma of the pancreasCarcinoma of the pancreas – DementiaDementia  Bereavement:Bereavement: – Time limited resolves within few monthsTime limited resolves within few months – 14% develop depression within 2 yrs of loss14% develop depression within 2 yrs of loss – Look for functional impairmentLook for functional impairment
    27. 27. Depression associated withDepression associated with Structural Brain DiseaseStructural Brain Disease  Alzheimers disease:Alzheimers disease: – 20% of subjects with early AD have depression20% of subjects with early AD have depression  CerebroVascular disease: Vascular depression:CerebroVascular disease: Vascular depression: – Anhedonia, executive dysfunction and absence ofAnhedonia, executive dysfunction and absence of guilt preoccupationsguilt preoccupations – Late age of onsetLate age of onset – Risk factors for vascular diseaseRisk factors for vascular disease – Prefrontal or subcortical white matter hyperintensitiesPrefrontal or subcortical white matter hyperintensities on T2 weighted MRIon T2 weighted MRI – Non-amnestic neuropsychologic deficits in tasks req’Non-amnestic neuropsychologic deficits in tasks req’ initiation, persistence and self monitoringinitiation, persistence and self monitoring
    28. 28. AssessmentAssessment
    29. 29. Geriatric Depression ScaleGeriatric Depression Scale Choose the best answer for how you have felt over the past week:Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life1. Are you basically satisfied with your life?? YESYES // NONO 2. Have you dropped many of your activities and interests?2. Have you dropped many of your activities and interests? YESYES / NO/ NO 3. Do you feel that your life is empty3. Do you feel that your life is empty?? YESYES / NO/ NO 4. Do you often get bored?4. Do you often get bored? YESYES / NO/ NO 5. Are you in good spirits most of the time? YES /5. Are you in good spirits most of the time? YES / NONO 6. Are you afraid that something bad is going to happen to you?6. Are you afraid that something bad is going to happen to you? YESYES / NO/ NO 7. Do you feel happy most of the time?7. Do you feel happy most of the time? YESYES // NONO 8. Do you often feel helpless?8. Do you often feel helpless? YESYES / NO/ NO 9. Do you prefer to stay home, rather than going out, doing new things?9. Do you prefer to stay home, rather than going out, doing new things? YESYES // NONO 10. Do you feel you have more problems with memory than most?10. Do you feel you have more problems with memory than most? YESYES / NO/ NO 11. Do you think it is wonderful to be alive now? YES /11. Do you think it is wonderful to be alive now? YES / NONO 12. Do you feel pretty worthless the way you are now?12. Do you feel pretty worthless the way you are now? YESYES / NO/ NO 13. Do you feel full of energy? YES /13. Do you feel full of energy? YES / NONO 14. Do you feel that your situation is hopeless?14. Do you feel that your situation is hopeless? YESYES / NO/ NO 15. Do you think that most people are better off than you are?15. Do you think that most people are better off than you are? YESYES / NO/ NO *Underlined items constitute the four item scale*Underlined items constitute the four item scale
    30. 30. Labs:Labs:  CBCCBC  CMPCMP  TSHTSH  Dementia workupDementia workup  Cognitive testingCognitive testing  EKGEKG
    31. 31. Professional treatmentProfessional treatment must for depressionmust for depression
    32. 32. Why treatWhy treat  Substantially the likelihood of death fromSubstantially the likelihood of death from physical illnessesphysical illnesses  impairment from a medical disorder andimpairment from a medical disorder and impedes its improvementimpedes its improvement  When untreated - interferes with a patient's abilityWhen untreated - interferes with a patient's ability to follow the necessary treatment regimento follow the necessary treatment regimen  Healthcare costs of elderly people: 50% higherHealthcare costs of elderly people: 50% higher than those of non-depressed seniors.than those of non-depressed seniors.  Lasts longer in the elderly.Lasts longer in the elderly.
    33. 33. TreatmentTreatment  Non-medicalNon-medical  MedicalMedical
    34. 34. Non-Medical interventionsNon-Medical interventions  Balanced dietBalanced diet  FluidsFluids  ExerciseExercise  Avoid alcoholAvoid alcohol  Family support/socialFamily support/social supportsupport  Focus on positivesFocus on positives  Promote autonomyPromote autonomy  Promote creativityPromote creativity  Alternate therapy: PetAlternate therapy: Pet therapy, horticulture therapytherapy, horticulture therapy  Pace appropriatelyPace appropriately  Inform about depressionInform about depression  Avoid stressorsAvoid stressors
    35. 35. Medical InterventionsMedical Interventions  MedicationsMedications  PsychotherapyPsychotherapy  Electro-convulsive therapyElectro-convulsive therapy  Vagal Nerve stimulationVagal Nerve stimulation  Combination therapyCombination therapy
    36. 36. MedicationsMedications  SerotonergicSerotonergic – SSRIs: Citalopram, Escitalopram, Sertraline,SSRIs: Citalopram, Escitalopram, Sertraline, Paroxetine, FluoxetineParoxetine, Fluoxetine  NoradrenergicNoradrenergic – TCAsTCAs  DopaminergicDopaminergic – BupropionBupropion  Dual mechanismDual mechanism – Venlafaxine, Mirtazapine, Duloxetine, SSRIs +Venlafaxine, Mirtazapine, Duloxetine, SSRIs + BuproprionBuproprion
    37. 37. Treatment selectionTreatment selection  SerotonergicSerotonergic – Anxious, agitated, hostile,Anxious, agitated, hostile, – hypochondriachypochondriac  NoradrenergicNoradrenergic – Avoid use in elderlyAvoid use in elderly  DopaminergicDopaminergic – Psychomotor retarded, blunted, apatheticPsychomotor retarded, blunted, apathetic  Dual mechanismDual mechanism – Melancholic, atypical, treatment resistantMelancholic, atypical, treatment resistant
    38. 38. Medication Starting Dose (mg/day) Therapeutic Dose (mg/day) TCAs Amitryptyline Nortriptyline Imipramine 25-50 25 25-50 100-300 50-200 100-300 SSRIs Citalopram Fluoxetine Sertraline Paroxetine Escitalopram 10-20 10-20 25-50 10-20 10 20-60 20-80 100-200 20-50 20 MAOIs Phenelzine Tranylcypromine 45 20 180 30-60 Mixed antidepressants Mirtazapine Venlafaxine XR Bupropion SR Duloxetine 7.5-15 37.5 100-150 20-30 15-45 75-225 300 60
    39. 39. Special considerations in elderlySpecial considerations in elderly  Start low and go slowStart low and go slow  Dose adjustment based on renal clearance:Dose adjustment based on renal clearance: 30% reduction of mirtazapine clearance with30% reduction of mirtazapine clearance with creatinine clearance : 11-15creatinine clearance : 11-15  SSRIs are used at the same dose as adultsSSRIs are used at the same dose as adults  Response time is longer in elderly >6-12 weeksResponse time is longer in elderly >6-12 weeks  Because of higher risk of relapse in elderly,Because of higher risk of relapse in elderly, continue antidepressants for > 2 years aftercontinue antidepressants for > 2 years after remission of major depressive disorderremission of major depressive disorder
    40. 40. Special considerations in elderlySpecial considerations in elderly  All antidepressants are equally efficaciousAll antidepressants are equally efficacious  SSRIs are better tolerated than TCAsSSRIs are better tolerated than TCAs  Escitalopram, citalopram, sertraline, venlafaxineEscitalopram, citalopram, sertraline, venlafaxine and mirtazapine may have fewer drugand mirtazapine may have fewer drug interactionsinteractions  SSRI related side effects seen in elderlySSRI related side effects seen in elderly – Extrapyramidal side effectsExtrapyramidal side effects – ApathyApathy – AnorexiaAnorexia – SIADHSIADH – Upper GI bleedingUpper GI bleeding
    41. 41. PsychotherapyPsychotherapy  Very helpful in mild to moderate depressionVery helpful in mild to moderate depression  Response time slowerResponse time slower  Relapse less frequentRelapse less frequent  CBTCBT – As effective as antidepressantsAs effective as antidepressants  IPTIPT more effective than antidepressantsmore effective than antidepressants in treating mood suicidal ideations,in treating mood suicidal ideations, and lack of interest, whereasand lack of interest, whereas antidepressants are moreantidepressants are more effective for appetite andeffective for appetite and sleep disturbancessleep disturbances
    42. 42. Electro-convulsive TherapyElectro-convulsive Therapy  Indications:Indications: – Failure of antidepressant trialsFailure of antidepressant trials – Severe depression with catatonic or psychoticSevere depression with catatonic or psychotic featuresfeatures – High risk of suicideHigh risk of suicide – Poor tolerability of oral medsPoor tolerability of oral meds  Response rates from 70-90%Response rates from 70-90%  Most efficacious antidepressantMost efficacious antidepressant  Contraindication: ICP, intracranial tumorsContraindication: ICP, intracranial tumors  3x/wk with avg number of treatments3x/wk with avg number of treatments 8-12, may need maintenance therapy8-12, may need maintenance therapy  Side effects: Short term memory lossSide effects: Short term memory loss
    43. 43. Vagal Nerve StimulationVagal Nerve Stimulation  Electrical pulses applied to the left vagus nerveElectrical pulses applied to the left vagus nerve in the neck for transmission to the brainin the neck for transmission to the brain  Intermittent stimulationIntermittent stimulation – 30 sec on/5 min off30 sec on/5 min off  Implanted in over 11,500 patientsImplanted in over 11,500 patients  Battery life of 8-12years, weighs 38 gms, 10.3Battery life of 8-12years, weighs 38 gms, 10.3 mm thickmm thick  Side effects:Side effects: – hoarse voice, pain or tingling in the throat or neck,hoarse voice, pain or tingling in the throat or neck, cough, headache and ear pain, difficulty sleeping,cough, headache and ear pain, difficulty sleeping, shortness of breath, vomitingshortness of breath, vomiting
    44. 44. Vagal Nerve Stimulator (VNS)Vagal Nerve Stimulator (VNS)
    45. 45. SUICIDE: DON’T FORGETSUICIDE: DON’T FORGET  Ask aboutAsk about –suicidal ideationsuicidal ideation –intentintent
    46. 46. Suicide risk in elderlySuicide risk in elderly  Very Important, Easy to missVery Important, Easy to miss  Always askAlways ask  Firearms at homeFirearms at home  Many older adults who commit suicideMany older adults who commit suicide have visited a primary care physician veryhave visited a primary care physician very close to the time of the suicideclose to the time of the suicide – 20 percent on the same day20 percent on the same day – 40 percent within one week – of the40 percent within one week – of the suicidesuicide
    47. 47. Suicide risk in elderlySuicide risk in elderly  Suicides twice as common as homicides  12% of the population is elderly, they account for 20% of the 30,000 suicides/yr  Older patients make 2 to 4 attempts per completed suicide, younger patients make 100 to 200 attempts per completion  When they decide - they are serious
    48. 48. Assessment tool for suicide risk:Assessment tool for suicide risk: SS- Male Sex- Male Sex AA- Age (young/elderly)- Age (young/elderly) DD- Depression- Depression PP- Previous attempts- Previous attempts EE- ETOH- ETOH RR- Reality testing- Reality testing (Impaired)(Impaired) SS- Social support- Social support (lack of)(lack of) OO- Organized plan- Organized plan NN- No spouse- No spouse SS- Sickness- Sickness
    49. 49. Suicide RiskSuicide Risk  ParadoxicallyParadoxically ↑↑ as patient begins toas patient begins to respond to treatmentrespond to treatment  Somatic or “vegetative” symptoms (sleep,Somatic or “vegetative” symptoms (sleep, appetite, energy) are usually the firstappetite, energy) are usually the first symptoms to improvesymptoms to improve  ““Cognitive” symptoms of depression (lowCognitive” symptoms of depression (low self-esteem, guilt, suicidal thoughts) tendself-esteem, guilt, suicidal thoughts) tend to improve more slowlyto improve more slowly
    50. 50. QuestionsQuestions