1. Depression in the Elderly

3. Prevalence 2-5% in elderly Peak age of onset 3rd decade
Epidemiology
Men: 5-12%
Women: 10-25%
Prevalence 2-5% in elderly
Peak age of onset 3rd decade
Elderly depression: secondary to vascular etiology
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

4. Psychological factors
Etiology
Biological factors
Social factors
Psychological factors

5. Biological factors Genetic Medical Illness:
First degree relatives; twins
Medical Illness:
Parkinson's, Alzheimer's, cancer, diabetes or stroke
Vascular changes in the brain
Pain
Substance abuse

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

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

8. Common precipitants Arguments Rejection or abandonment
Death or major illness of loved one
Loss of pet
Anniversary of a (-) event
Stressful event at work
Medication Noncompliance
Substance use

9. Definition of Depression
A syndrome characterized by mood disturbance plus variety of cognitive, psychological, and vegetative disturbances

10. SIG(M)ECAPS Sleep disturbance Interest or pleasure*: decreased
Guilt or feeling worthless
Mood*
Energy loss or fatigue
Concentration problems
Appetite disturbance,
Psychomotor agitation or retardation
Suicidal ideation
5/9 should be present for at least two weeks

11. Seasonal Affective Disorder
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
time each year
Full remissions occur at a
characteristic time of year

12. 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

13. NOT a normal part of aging
Depression in Elderly
NOT a normal part of aging
2 million Americans over age 65 have depressive illness
Often co-occurs with other illnesses
Under-diagnosed and under-treated
Suicide rates in the elderly are the highest

14. Differential diagnosis in Elderly
Medical illness:
Hyperthyroidism
Parkinson’s disease
Dementia
Bereavement:
Time limited resolves within few months
14% develop depression w/in 2 yrs of loss
Look for functional impairment

15. Assessment

16. Geriatric Depression Scale
Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time?

17. 8. Do you often feel helpless?
9. Do you prefer to stay home, rather than going out, doing new things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?

18. Why treat likelihood of death from other illnesses
impairment from a medical illness and impedes its improvement
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.
Lasts longer in the elderly.

19. Treatment
Non-medical
Medical

20. Non-Medical interventions
Balanced diet
Fluids
Exercise
Avoid alcohol
Family/social support
Focus on positives
Promote autonomy
Promote creativity
Inform about depression
Avoid stressors
“Pace yourself”
Pet therapy

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

22. Very helpful in mild to moderate depression Response time slower
Psychotherapy
Very helpful in mild to moderate depression
Response time
slower
Less relapse

23. Electro-convulsive Therapy
Indications:
Failure or poor tolerability of oral medications
Severe depression
High risk of suicide
Response rates from 70-90%
Most efficacious antidepressant
Side effects: Short term memory loss

24. SUICIDE: DON’T FORGET
Ask about
suicidal ideation
intent

25. Suicide risk in elderly
Very Important, Easy to miss
Firearms at home
Many older adults who commit suicide have visited a primary care physician
On the same day (20%)
Within one week of the suicide (40%)

26. Suicide risk in elderly
Older patients
make 2-4 attempts per completed suicide
Younger patients
100 to 200 attempts per completion
When they decide - they are serious

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

28. How Does Suicide Risk Change with Improvement in Depression?
Paradoxically ↑ as patient begins to respond to treatment

29. Questions