Presentation is loading. Please wait.

Presentation is loading. Please wait.

Depression in Elderly Kalpana P. Padala, MD, MS Research Geriatrician Assistant Professor Dept. of Family Medicine University of Nebraska Medical Center.

Similar presentations


Presentation on theme: "Depression in Elderly Kalpana P. Padala, MD, MS Research Geriatrician Assistant Professor Dept. of Family Medicine University of Nebraska Medical Center."— Presentation transcript:

1 Depression in Elderly Kalpana P. Padala, MD, MS Research Geriatrician Assistant Professor Dept. of Family Medicine University of Nebraska Medical Center

2 Disclosures None None

3 Goals and Objectives Identify the variation in presentation of depression in various age groups Identify the variation in presentation of depression in various age groups Overview of assessment of depression along with use of common rating scale Overview of assessment of depression along with use of common rating scale Selection of antidepressants in management of depression Selection of antidepressants in management of depression Special considerations with antidepressant use in elderly Special considerations with antidepressant use in elderly Overview of risk factors for Suicide Overview of risk factors for Suicide

4

5 Epidemiology Men: 5-12% Men: 5-12% Women: 10-25% Women: 10-25% Prevalence 1-2% in elderly Prevalence 1-2% in elderly –6-10% in Primary Care setting –12-20% in Nursing home setting –11-45% in Inpatient setting –>40% of outpt. Psychiatry clinic and inpt. psychiatry Peak age of onset 3rd decade Peak age of onset 3rd decade Late-life depression: secondary to vascular etiology Late-life depression: secondary to vascular etiology

6 Patho-physiology Elevated stress levels Elevated stress levels Decreased levels or activity of Decreased levels or activity of nor-epinephrine and/or serotonin Decreased latency to 1 st rapid eye movement sleep phase and hypoperfusion of the frontal lobes Decreased latency to 1 st rapid eye movement sleep phase and hypoperfusion of the frontal lobes Cerebro-vascular disease Cerebro-vascular disease Deep white matter hyperintensity Deep white matter hyperintensity

7 Etiology Biological factors Biological factors Social factors Social factors Psychological factors Psychological factors

8 Biological factors Genetic Genetic –High prevalence in first degree relatives –High concordance with monozygotic twins –Short allele of serotonin transported gene Medical Illness: Medical Illness: –Parkinson's, Alzheimer's, cancer, diabetes or stroke Vascular changes in the brain Vascular changes in the brain Chronic or severe pain Chronic or severe pain Previous history of depression Previous history of depression Substance abuse Substance abuse

9 Social factors Loneliness, isolation Loneliness, isolation Recent bereavement Recent bereavement Lack of a supportive social network Lack of a supportive social network Decreased mobility Decreased mobility –Due to illness or loss of driving privileges

10 Psychological factors Traumatic experiences Traumatic experiences –Abuse Damage to body image Damage to body image Fear of death Fear of death Frustration with memory loss Frustration with memory loss Role transitions Role transitions

11 Common precipitants Arguments with friends/relatives Arguments with friends/relatives Rejection or abandonment Rejection or abandonment Death or major illness of loved one Death or major illness of loved one Loss of pet Loss of pet Anniversary of a (-) event Anniversary of a (-) event Major medical illness or age-related deterioration Major medical illness or age-related deterioration Stressful event at work Stressful event at work Medication Noncompliance Medication Noncompliance Substance use Substance use

12 Definition A syndrome complex characterized by mood disturbance plus variety of cognitive, psychological, and vegetative disturbances

13 Clinical Features DSM IV-TR criteria DSM IV-TR criteria –5/9 should be present for at least two weeks –Must be a change from previous functioning –Presence of decreased interest or low/depressed mood is must feature SIGECAPS SIGECAPS

14 SIG(M)ECAPS Sleep disturbance: decreased or increased Sleep disturbance: decreased or increased Interest or pleasure*: decreased Interest or pleasure*: decreased Guilt or feeling worthless Guilt or feeling worthless Mood* : sustained low or depressed Mood* : sustained low or depressed Energy loss or fatigue Energy loss or fatigue Concentration problems or problems with memory Concentration problems or problems with memory Appetite disturbance, weight loss or gain Appetite disturbance, weight loss or gain Psychomotor agitation or retardation Psychomotor agitation or retardation Suicidal ideation, thoughts of death Suicidal ideation, thoughts of death

15 MINOR Depression Also known as Also known as –subsyndromal depression –subclinical depression –mild depression times more common than major depression times more common than major depression Associated with: Associated with: –subsequent major depression –greater use of health services –reduced physical, social functioning –loss of quality of life Responds to same treatments! Responds to same treatments!

16 Atypical depression Somatic complaints Somatic complaints Hyperphagia, Hyperphagia, Hypersomnia, Hypersomnia, Hypersensitivity to rejection Hypersensitivity to rejection “Heavy” feeling in upper or lower extremities (leaden paralysis) “Heavy” feeling in upper or lower extremities (leaden paralysis)

17 Simon GE, et al. N Engl J Med. 1999;341(18): Depression – the physical presentation 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 compliant 1

18 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

19 Bipolar Disorder People with this type of illness change back and forth between periods of depression and periods of mania (an extreme high). People with this type of illness change back and forth between periods of depression and periods of mania (an extreme high). Symptoms of mania may include: Symptoms of mania may include: –Less need for sleep –Overconfidence –Racing thoughts –Reckless behavior –Increased energy –Mood changes are usually gradual, but can be sudden

20 Season Affective Disorder Results from changes in the season. Most cases begin in the fall or winter, or when there is a decrease in sunlight Results from changes in the season. Most cases begin in the fall or winter, or when there is a decrease in sunlight Pattern of onset at the same Pattern of onset at the same time each year Full remissions occur at a Full remissions occur at a characteristic time of year

21 Pseudo-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

22 Psychotic depression A bnormal thought process – psychotic thinking A bnormal thought process – psychotic thinking Frank hallucinations and delusions Frank hallucinations and delusions

23 Depression in Elderly NOT a normal part of aging NOT a normal part of aging 2 million Americans over age 65 have depressive illness 2 million Americans over age 65 have depressive illness Sub-syndromal depression increases the risk of developing depression Sub-syndromal depression increases the risk of developing depression –Leads to early relapse and chronicity Often co-occurs with other serious illnesses Often co-occurs with other serious illnesses Under-diagnosed and under- treated Under-diagnosed and under- treated Suicide rates in the elderly are the highest of any age group. Suicide rates in the elderly are the highest of any age group.

24 Facts in Elderly Only 11 percent : in community receive adequate antidepressant treatment Only 11 percent : in community receive adequate antidepressant treatment The direct and indirect costs – The direct and indirect costs – $43 billion each year Late life depression is particularly costly because of the excess disability that it causes and its deleterious interaction with physical health Late life depression is particularly costly because of the excess disability that it causes and its deleterious interaction with physical health

25 Depression in Elderly Difficult to diagnose Difficult to diagnose Low/depressed mood need not be present Low/depressed mood need not be present Persistent loss of pleasure and interest in previously enjoyable activities (anhedonia) must be present Persistent loss of pleasure and interest in previously enjoyable activities (anhedonia) must be present Reject diagnosis of depression Reject diagnosis of depression Masked depression or depression without sadness- mainly somatic complaints Masked depression or depression without sadness- mainly somatic complaints

26 Depression in Elderly Symptoms of minor depression Symptoms of minor depression Somatic complaints: Persistent, vague, unexplained physical complaints Somatic complaints: Persistent, vague, unexplained physical complaints Agitation, anxiety Agitation, anxiety Memory problems, difficulty concentrating Memory problems, difficulty concentrating Social withdrawal Social withdrawal A high degree of suspicion and specific inquiry is necessary for its detection and treatment A high degree of suspicion and specific inquiry is necessary for its detection and treatment

27 Differential diagnosis in Elderly Differentiation from medical illness: Differentiation from medical illness: –Hyperthyroidism –Parkinson’s disease –Carcinoma of the pancreas –Dementia Bereavement: Bereavement: –Time limited resolves within few months –14% develop depression within 2 yrs of loss –Look for functional impairment

28 Depression associated with Structural Brain Disease Alzheimers disease: Alzheimers disease: – 20% of subjects with early AD have depression CerebroVascular disease: Vascular depression: CerebroVascular disease: Vascular depression: –Anhedonia, executive dysfunction and absence of guilt preoccupations –Late age of onset –Risk factors for vascular disease –Prefrontal or subcortical white matter hyperintensities on T2 weighted MRI –Non-amnestic neuropsychologic deficits in tasks req’ initiation, persistence and self monitoring

29 Assessment

30 Geriatric Depression Scale Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay home, rather than going out, doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO *Underlined items constitute the four item scale

31 Labs: CBC CBC CMP CMP TSH TSH Dementia workup Dementia workup Cognitive testing Cognitive testing EKG EKG

32 Professional treatment must for depression Professional treatment must for depression

33 Why treat Substantially the likelihood of death from physical illnesses Substantially the likelihood of death from physical illnesses impairment from a medical disorder and impedes its improvement impairment from a medical disorder and impedes its improvement When untreated - interferes with a patient's ability to follow the necessary treatment regimen When untreated - interferes with a patient's ability to follow the necessary treatment regimen Healthcare costs of elderly people: 50% higher than those of non-depressed seniors. Healthcare costs of elderly people: 50% higher than those of non-depressed seniors. Lasts longer in the elderly. Lasts longer in the elderly.

34

35 Treatment Non-medical Non-medical Medical Medical

36 Non-Medical interventions Balanced diet Balanced diet Fluids Fluids Exercise Exercise Avoid alcohol Avoid alcohol Family support/social support Family support/social support Focus on positives Focus on positives Promote autonomy Promote autonomy Promote creativity Promote creativity Alternate therapy: Pet therapy, horticulture therapy Alternate therapy: Pet therapy, horticulture therapy Pace appropriately Pace appropriately Inform about depression Inform about depression Avoid stressors Avoid stressors

37 Medical Interventions Medications Medications Psychotherapy Psychotherapy Electro-convulsive therapy Electro-convulsive therapy Vagal Nerve stimulation Vagal Nerve stimulation Combination therapy Combination therapy

38 Medications Serotonergic Serotonergic –SSRIs: Citalopram, Escitalopram, Sertraline, Paroxetine, Fluoxetine Noradrenergic Noradrenergic –TCAs Dopaminergic Dopaminergic –Bupropion Dual mechanism Dual mechanism –Venlafaxine, Mirtazapine, Duloxetine, SSRIs + Buproprion

39 Treatment selection Serotonergic Serotonergic –Anxious, agitated, hostile, –hypochondriac Noradrenergic Noradrenergic –Avoid use in elderly Dopaminergic Dopaminergic –Psychomotor retarded, blunted, apathetic Dual mechanism Dual mechanism –Melancholic, atypical, treatment resistant

40 MedicationStarting Dose (mg/day)Therapeutic Dose (mg/day) TCAs Amitryptyline Nortriptyline Imipramine SSRIs Citalopram Fluoxetine Sertraline Paroxetine Escitalopram MAOIs Phenelzine Tranylcypromine Mixed antidepressants Mirtazapine Venlafaxine XR Bupropion SR Duloxetine

41 Special considerations in elderly Start low and go slow Start low and go slow Dose adjustment based on renal clearance: 30% reduction of mirtazapine clearance with creatinine clearance : Dose adjustment based on renal clearance: 30% reduction of mirtazapine clearance with creatinine clearance : SSRIs are used at the same dose as adults SSRIs are used at the same dose as adults Response time is longer in elderly >6-12 weeks Response time is longer in elderly >6-12 weeks Because of higher risk of relapse in elderly, continue antidepressants for > 2 years after remission of major depressive disorder Because of higher risk of relapse in elderly, continue antidepressants for > 2 years after remission of major depressive disorder

42 Special considerations in elderly All antidepressants are equally efficacious All antidepressants are equally efficacious SSRIs are better tolerated than TCAs SSRIs are better tolerated than TCAs Escitalopram, citalopram, sertraline, venlafaxine and mirtazapine may have fewer drug interactions Escitalopram, citalopram, sertraline, venlafaxine and mirtazapine may have fewer drug interactions SSRI related side effects seen in elderly SSRI related side effects seen in elderly –Extrapyramidal side effects –Apathy –Anorexia –SIADH –Upper GI bleeding

43 Psychotherapy Very helpful in mild to moderate depression Very helpful in mild to moderate depression Response time slower Response time slower Relapse less frequent Relapse less frequent CBT CBT –As effective as antidepressants IPT IPT more effective than antidepressants in treating mood suicidal ideations, and lack of interest, whereas antidepressants are more effective for appetite and sleep disturbances

44 Electro-convulsive Therapy Indications: Indications: –Failure of antidepressant trials –Severe depression with catatonic or psychotic features –High risk of suicide –Poor tolerability of oral meds Response rates from 70-90% Response rates from 70-90% Most efficacious antidepressant Most efficacious antidepressant Contraindication: ICP, intracranial tumors Contraindication: ICP, intracranial tumors 3x/wk with avg number of treatments 3x/wk with avg number of treatments 8-12, may need maintenance therapy 8-12, may need maintenance therapy Side effects: Short term memory loss Side effects: Short term memory loss

45 Vagal Nerve Stimulation Electrical pulses applied to the left vagus nerve in the neck for transmission to the brain Electrical pulses applied to the left vagus nerve in the neck for transmission to the brain Intermittent stimulation Intermittent stimulation –30 sec on/5 min off Implanted in over 11,500 patients Implanted in over 11,500 patients Battery life of 8-12years, weighs 38 gms, 10.3 mm thick Battery life of 8-12years, weighs 38 gms, 10.3 mm thick Side effects: Side effects: –hoarse voice, pain or tingling in the throat or neck, cough, headache and ear pain, difficulty sleeping, shortness of breath, vomiting

46 Vagal Nerve Stimulator (VNS)

47 SUICIDE: DON’T FORGET Ask about Ask about –suicidal ideation –intent

48 Suicide risk in elderly Very Important, Easy to miss Very Important, Easy to miss Always ask Always ask Firearms at home Firearms at home Many older adults who commit suicide have visited a primary care physician very close to the time of the suicide Many older adults who commit suicide have visited a primary care physician very close to the time of the suicide –20 percent on the same day –40 percent within one week – of the suicide

49 Suicide 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

50 Assessment tool for suicide risk: S- Male Sex A- Age (young/elderly) D- Depression P- Previous attempts E- ETOH R- Reality testing (Impaired) S- Social support (lack of) (lack of) O- Organized plan N- No spouse S- Sickness

51 Suicide Risk Paradoxically ↑ as patient begins to respond to treatment Paradoxically ↑ as patient begins to respond to treatment Somatic or “vegetative” symptoms (sleep, appetite, energy) are usually the first symptoms to improve Somatic or “vegetative” symptoms (sleep, appetite, energy) are usually the first symptoms to improve “Cognitive” symptoms of depression (low self-esteem, guilt, suicidal thoughts) tend to improve more slowly “Cognitive” symptoms of depression (low self-esteem, guilt, suicidal thoughts) tend to improve more slowly

52

53 Questions


Download ppt "Depression in Elderly Kalpana P. Padala, MD, MS Research Geriatrician Assistant Professor Dept. of Family Medicine University of Nebraska Medical Center."

Similar presentations


Ads by Google