1. DEPRESSION IN THE ELDERLY
Module developed by
James T. Birch, Jr., MD, MSPH
Assistant Clinical Professor
Dept. of Family Medicine, Division of Geriatric Medicine
Landon Center on Aging
University of Kansas Medical Center

2. Objectives Review the diagnostic criteria for depression
Increase awareness of the prevalence and consequences of untreated depression in the older adult
Discuss screening, treatment, and follow-up for those who have depression

3. Content 1. Define depression
2. Review the epidemiology of depression in the elderly.
3. Risk Factors
4. Recognition of signs and symptoms
5. Differential Diagnosis
6. Screening Tools
7. Treatment
8. Review the consequences/complications of inadequately treated depression.
9. ACOVE – 3 Indicators

4. Introduction
Depression is under-recognized and undertreated in the older adult
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

5. 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(1) of the symptoms must be depressed mood or loss of interest or pleasure
Geriatric Nursing (26)3;2005
The illustrated definition of depression is lifted from the DSM-IV-TR (Text Revision) published in 2000 containing updates on diagnostic categories and modified to reflect terminology that is consistent with ICD9 coding.

6. What is Depression?
DSM-IV-TR (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 (anhedonia)
Appetite change or weight loss
Insomnia or hypersomnia
Psychomotor agitation or retardation

7. What is Depression? DSM-IV-TR (cont.) 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

8. What is Depression? For Major Depression, these symptoms
Produce social impairment
Are not related to substance abuse
Are not related to bereavement

9. What is Depression? Types of Depressive Disorders (DSM-IV)
Mild episode of major depression
Moderate episode of major depression
Severe episode of major depression
Severe episode of major depression with psychotic features
AMDA Clinical Practice Guideline
Mild episode of major depression: minor impairment in social activities, relationships and overall function that persists for at least 2 weeks. Patient does NOT have more than five diagnostic symptoms
Moderate episode of major depression: symptoms or functional impairment between mild and severe, persisting for at least 2 weeks.
Severe episode of major depression: marked interference with and impairment of social activities, relationships, and overall functioning, persisting for at least 2 weeks. Patient has five or more diagnostic symptoms.
Severe episode of major depression with psychotic features: symptoms include delusions and hallucinations

10. What is Depression? 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

11. What is Depression “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.

12. Epidemiology (of major depression)
Community-Dwelling %
Primary Care Settings 10 – 12 %
Nursing Home
10-26%
Permanent Placement Up to 43%
Hospitalized
11 – 45 %
These are estimated prevalence rates of depression across various settings

13. 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

14. Risk factors
Medical diagnosis or diagnoses associated with a high risk of depression
New admission or change of environment
New stressful losses (loss of autonomy, privacy, functional status, body part, family member or friend)
Personal or family history of depression or mood disorder

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

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

17. Medications that may cause symptoms of Depression
Clonidine
Cytokines (specifically IL-2)
Digitalis preparations
Glucocorticoids (prednisone)
H2 blockers
Metoclopramide
Opioids
When new or worsening symptoms of depression are recognized, medication should be considered as a potential cause and withdrawn, then replaced with a drug less likely to cause depression. When this is not possible or withdrawal does not result in resolution of symptoms, consider pharmacotherapy for the depression.

18. Laboratory Tests for Evaluation
CMP (lytes, BUN, creat, Ca++, glucose)
CBC
Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline
Thyroid function (T3, T4, TSH)
EKG
Folate level UA
Vitamin B12
The purpose of doing laboratory tests, is to identify medical conditions and diseases that produce depressive symptoms or carry an independent risk for causing depression. These conditions need to be taken into account when a patient is assessed for depression.

19. 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

20. Differential Diagnosis
DEPRESSION
Subacute onset
Family recognition early
Rapid progression
Impairment inconsistent over time
Pt admits deficits
Appears depressed
Anhedonia
Abstract thought usually normal
“I don’t know” response to questions
Pt often unconcerned
DEMENTIA
Insidious onset
Delayed family recognition
Slow progression
Impairment consistent; slow, gradual decline
Pt denies/unaware of deficits
Not depressed
Can experience pleasure
Abstract thought impaired
Near miss answers
Pt tries to cover up
This slide illustrates the differences between depression and dementia.

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

22. Screening Tools
Geriatric Depression Scale (GDS; validated) 15 item scale ( > 5 points or positive responses is diagnostic)
Cornell Scale for Depression in Dementia (scoring system: >12 means probable depression)
Center for Epidemiologic Studies of Depression Scale (CES-D)
Patient Health Questionnaire 9 (9 item self-rating scale)
AMDA Clinical Practice Guideline
There are many tools for diagnosing depression. They are often referred to as depression rating scales. Use of these tools at the beginning of treatment is the only reliable way to obtain an objective measure of the severity of a patient’s depression. This information is essential to monitor the effectiveness of treatment and to aid in decisions about whether or continue, change or terminate treatment. The Geriatric Depression Scale (GDS) is the most common of them all. We use it in our Geriatric Assessment clinics. It has been validated in many research studies. It is a 15-item scale where 5 or more positive responses is considered diagnostic of depression. It is limited in detecting depression in patients with moderate or severe dementia, learning disabilities, or low education level.
In addition to the GDS, we have the Cornell Scale for Depression in Dementia (scoring system: >12 means probable depression),
The Center for Epidemiologic Studies of Depression Scale (CES-D) can be especially useful for evaluating depression in African Americans and Native Americans….
and the Patient Health Questionnaire 9.

23. Screening Tools Two – item scale (PHQ-2):
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)
Sensitivity: 100%; Specificity:77%; PPV: 14%
NEJM: 357:22; 11/29/07
We strongly encourage the use of one of the scales for diagnosis and management, but if you need to do a real quick screen, you can use the two-item scale illustrated here. This 2-item scale is also known as the Patient Health Questionnaire 2 (PHQ-2), which asks about depressed mood and anhedonia. It is easily administered by an office staff member or a physician during a primary care visit.

24. Treatment
The consequences of depression in the elderly require serious attention because of the disproportionately high risk of suicide
For the year 2000, 13% of the U.S. population was 65 and older, and the suicide rate accounted for 18% of all suicides
Geriatric Nursing (26)3: 2005

25. Treatment
Goals of therapy: improve mood, function, and quality of life
Goals of treatment of an acute depressive episode are to achieve recovery and prevent future episodes of depression
The intended outcome should be complete resolution of symptoms, not simply a reduction in depressive symptoms.
Three phases of treatment are generally required to achieve these goals.

26. Treatment Acute Phase (reverse current episode)
Duration: about 3 months: Goal is complete recovery from signs and sx of acute episode
Continuation Phase (prevent a relapse)
Duration: 4-6 months: Goal is to prevent relapse as sx continue to decline and functionality improves
Maintenance Phase (prevent future recurrence)
Duration: 3 months or longer: Goal is to prevent recurrence of a new depressive episode

27. Treatment Pharmacotherapy Psychotherapy
Electroconvulsive therapy (ECT)

28. Treatment Patients should be monitored for response to treatment by:
Observation for resolution of signs and symptoms of depression
Documenting improvement in scores on screening tools
Improvement in attendance at and participation in usual activities
Improvement in sleep pattern
Also monitor patients carefully for side effects and interactions with other medications
Before discussing details of pharmacotherapy, it is important to remember the importance of monitoring patients during treatment.

29. Treatment : Pharmacotherapy
Antidepressants
SSRI’s
Celexa (citalopram) 20-40mg/day
Lexapro (ecitalopram) 10-20mg/day
Prozac (fluoxetine) 20-40mg q am
Paxil (paroxetine) 10-40mg q am or q hs
Zoloft (sertraline) mg q am
Better tolerated than tricyclics
SIADH at high doses and sexual side effects
Interact with CYP-450 isoenzymes by inhibition
Can increase the anticoagulant effect of warfarin
Do not discontinue abruptly; taper the dose
Note to faculty: I do not recommend stressing dosage recommendations on the above slide or the following slides. Focus on drug classes and their effects.

30. Treatment : Pharmacotherapy
Antidepressants (SSRIs continued)
Nausea and diarrhea might occur
Fluoxetine is not a preferred drug for use in the elderly due to a prolonged half life (4-6 days; metabolite 9.3 days) and potential for many drug interactions. It might also induce anxiety, sleep disturbance, and/or agitation
Paroxetine is also not favored due to anti-cholinergic properties and other effects noted with fluoxetine

31. Treatment : Pharmacotherapy
Antidepressants
Tricyclics (secondary amines)
Norpramin (desipramine) qd / q hs
Pamelor, Aventyl (nortriptyline) 20 – 100 mg q hs
Potential for anticholinergic and sedative effects
Avoid in pts. who are prone to constipation, orthostatic hypotension, glaucoma, or who have BPH
May cause ventricular conduction delays and heart block
May be fatal in overdose

32. Treatment : Pharmacotherapy
Antidepressants
Bicyclics
Effexor (venlafaxine) 75 mg BID
Effexor XR – 100mg qd
Fewer drug interactions
Can cause or aggravate hypertension
Pts. are at risk for withdrawal syndrome

33. Treatment : Pharmacotherapy
Antidepressants
SNRI and SSRI
Cymbalta (duloxetine) mg/day
Norepinephrine, 5HT2 and 5HT3 antagonist
Remeron (mirtazapine) mg q hs
Can cause serotonin syndrome when given with other SSRI’s

34. Treatment : Pharmacotherapy
Antidepressants
Norepinephrine-dopamine reuptake inhibitor
Wellbutrin (bupropion) 100 mg TID
Wellbutrin SR mg BID
Serotonin antagonist and reuptake inhibitor
Serzone (nefazodone) 150mg BID
Desyrel (trazodone) 50 – 200mg q hs

35. Treatment : Pharmacotherapy
Antidepressants
Stimulants
Ritalin (methylphenidate) 20mg BID
Provigil (modafinil) 400mg q am
Dexedrine (dextroamphetamine)
2.5-5mg 7am and noon

36. Treatment : Pharmacotherapy
Antidepressants
Monoamine Oxidase Inhibitors (MAOIs)
Marplan (isocarboxazid) 30 mg/day
Nardil (phenelzine) 30–45 mg/day
Parnate (tranylcypromine) 30–40 mg/day
Orthostatic hypotension, falls
Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies (pressor amine)
Fatal serotonin syndrome possible if taken with SSRI, meperidine

37. Treatment
Should the elderly patient experiencing bereavement be treated for Depression?
NO!
However, if symptoms of MAJOR DEPRESSION persist for more than 2 months after the loss, treatment for depression should be strongly considered.
Unutzer, J. NEJM, Nov. 29, 2007

38. Treatment : Psychotherapy
Cognitive-behavioral
Interpersonal
Short-term psychodynamic
Life review, reminisce
Problem solving
Supportive
Bereavement therapy
Behavioral
Dialectical-behavioral therapy

39. Treatment : Psychotherapy
Individualize standard approaches
Cognitive-behavioral therapy
Interpersonal psychotherapy
Problem-solving therapy
Combination with an antidepressant has been shown to extend remission after recovery
Watch for depressive syndromes in caregivers, who might benefit from therapy

40. Treatment : Psychotherapy
Individualize choice of drug on basis of:
Patient’s comorbidities
Drug’s side-effect profile
Patient’s sensitivity to these effects
Drug’s potential for interacting with other medications

41. Treatment : ECT
For depression with pronounced psychotic features and resistance to standard medical therapy
Effective for treatment of major depression & mania; response rates exceed 70% in older adults

42. Treatment : ECT
First-line treatment for patients at serious risk for suicide, life-threatening poor intake
Standard for psychotic depression in older adults; response rates 80%

43. Treatment : ECT Side Effects
Anterograde amnesia improves rapidly after treatment
Retrograde amnesia is more persistent; recall of events just before treatment may be lost permanently
Lasting effects not shown in longitudinal studies
Right unilateral treatment: fewer side effects but less effective than bilateral

44. Treatment : ECT Contraindications
Increased intracranial pressure
Recent MI or CVA and unstable CAD increase risk of complications
Continue pharmacotherapy following completion of ECT treatment
May use maintenance ECT to prevent relapse

45. Treatment Response
Responsive to initial pharmacotherapy
40%
40% of cases of major depression respond to initial pharmacotherapy within 6 weeks
Additional 15% to 25% achieve remission with continued treatment for 6 weeks
GRS, 2006
Monotherapy fails 35-45%
Responsive to continued treatment
15-25%

46. Treatment Response
The most common prescribing error is failure to increase the dose to the recommended level within the first 2 weeks of treatment
When monotherapy fails:
Consider switch to another drug class
Combine lithium carbonate, methylphenidate, or triiodothyronine with secondary amine TCA
Add psychotherapy
Consult a geriatric psychiatrist
The elderly are prone to treatment failures and recurrences. This is frequently due to lack of adequate follow-up and monitoring.

47. Treatment Response Reasons for partial response or treatment failure
Dementia that is confused with or accompanied by late life depression
Concurrent psychosis (interferes with diagnosis and treatment of depression)
Compliance is difficult when patients are depressed

48. 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)

49. 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
AMDA Guidelines

50. 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.

51. 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.

52. 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

53. ACOVE – 3 Quality Indicators
Total of #20 IF-THEN-BECAUSE directives for care of Depression; they include:
Screening for and Recognizing Depression
Documenting Depression Symptoms
Suicidal Ideation
Evaluate for Comorbid condition
Initiating Depression Treatment
Antidepressant Choice

54. ACOVE – 3 Quality Indicators
Psychotic Depression
Electrocardiogram for Tricyclic Use
Interactions with MAOIs
Depression Follow-Up
The First 12 Weeks of Depression Treatment
Continuing Depression Therapy

55. ACOVE – 3 Quality Indicators
Indicators #4 thru #7 were selected for review

56. ACOVE – 3 Quality Indicators
Indicator #4 : IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document at least three of the nine DSM-IV target symptoms for major depression within 2 weeks of diagnosis, BECAUSE monitoring depression treatment requires identification and reevalution of the presenting depression symptoms.

57. ACOVE – 3 Quality Indicators
Indicator #5: IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document on the day of diagnosis the presence or absence of suicidal ideation and psychosis, BECAUSE suicidal patients may require hospitalization, and patients with psychotic depression may need antipsychotic medication or ECT and referral to a psychiatrist.

58. ACOVE – 3 Quality Indicators
Indicator #6: IF a VE has thoughts of suicide, THEN the medical record should document, on the same date, that the patient has no immediate plan for suicide or was referred for evaluation for psychiatric hospitalization AND…..

59. ACOVE – 3 Quality Indicators
Indicator #7: IF a VE has thoughts of suicide, THEN the medical record should document on the same date, that the patient was asked about access to firearms, BECAUSE the likelihood of suicide increases if the patient has a specific plan to commit suicide and access to firearms, and it decreases if the patient is hospitalized to receive psychiatric care.

60. 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

61. Summary In older adults, depression is:
Common (especially “minor” depression)
Associated with morbidity
Difficult to diagnose because of atypical presentation, more somatic concerns, overlap with symptoms of other illnesses
Differential diagnoses include other medical illnesses, dementia, bereavement

62. 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

63. Final thought:
On the Threshold of Eternity. In 1890, Vincent van Gogh painted this picture seen by some as symbolizing the despair and hopelessness felt in depression. Van Gogh himself suffered from depression and committed suicide later that same year.

64. References
Geriatrics Review Syllabus, 6th Edition; American Geriatrics Society, 2006, Chap. 35, pp
Nakajima, G.A., Wenger, N.S. Quality Indicators for the Care of Depression in Vulnerable Elders; JAGS: (55)S2:S302-11; Oct. 2007
Current Geriatric Diagnosis and Treatment; Landefeld, C.S., et al; McGraw-Hill Co., Chap. 14, pp
Depression: Clinical Practice Guideline; American Medical Directors Association
Buffum, M.D., et al; Treating Depression in the Elderly: An Update on Antidepressants; Geriatric Nursing 26(3):
Kotylar, M. Update on Drug-Induced Depression in the Elderly; Am J of Geriatric Pharmacotherapy 3(4):Dec. 2005;
Update on Depression in the Elderly
Retrieved 02/19/2009
National Institute of Mental Health; Older Adults: Depression and Suicide Facts;
Unutzer, J. Late-Life Depression; NEJM 357(22): Nov. 29, 2007; pp