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ObjectivesReview the diagnostic criteria for depressionIncrease awareness of the prevalence and
consequences of untreated depression in the older adult
IntroductionDepression is under-recognized and
undertreated in the older adultMany 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
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
What is Depression?DSM-IV-TR (“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 lossInsomnia or hypersomniaPsychomotor agitation or retardation
What is Depression?DSM-IV-TR
Loss of energy or fatigueFeelings of worthlessness or excessive
guiltDifficulty with thinking, concentration,
or decision makingRecurrent thoughts of death or suicide
Special clinical features in late lifeDepression without sadnessLack of feeling or emotionProminent cognitive compliants prominent somatic compliantsMultiple primary care visits without
resolution of problemSocial withdrawal,avoidance of social
intraction
What is Depression? For Major Depression, these
symptomsProduce social impairmentAre not related to substance abuseAre not related to bereavement
What is Depression?Types of Depressive Disorders (DSM-IV)
Mild episode of major depressionModerate episode of major depressionSevere episode of major depressionSevere episode of major depression
with psychotic features
What is Depression?Minor depression is common
15% of older personsCauses use of health services, excess
disability, poor health outcomes, including mortality
Major depression is not common1%–2% of physically healthy community
dwellers Elders less likely to recognize or endorse
depressed mood
But in Geriatric depression:Classical major depression is less frequent:M.d.d about 1-2%Dysthymic disorder 2%Depressive symptoms 15-25%
Vulnerable GroupsMedically ill Disabled and institutionalized elderlySpousal deathOlder adult with malignancies,neurologic and
endocrine:one half of post strok,onefourth of cancer inpatients, one third of MI
-
Risk FactorsAlcohol or substance abuseCurrent use of a medication associated with a
high risk of depressionHearing or vision impairment severe enough
to affect functionHistory of attempted suicideHistory of psychiatric hospitalization
Risk factorsMedical diagnosis or diagnoses
associated with a high risk of depressionchange of environmentNew stressful losses (loss of autonomy,
privacy, functional status, body part, family member or friend)
Personal or family history of depression or mood disorder
CO MORBID CONDITIONS TO CONCIDER IN LATE LIFE DEP.Substance,dementia,chronic painMetabolic disease,malnutrition,endocrine
dysfunctionCerebral disorderCardiovascular disorder,hypotensive episodesCHFPulmonary diseaseCancer Physical abuse or emotional abuse by
caregivers/relative
Medications that may cause symptoms of DepressionAnabolic steroidsAnti-arrhythmic medicationsAnticonvulsant medicationsBarbituratesBenzodiazepinesCarbidopa or levodopaCertain beta-adrenergic antagonists (i.e.
propranol)
Medications that may cause symptoms of DepressionClonidineDigitalis preparationsGlucocorticoids (prednisone)H2 blockersMetoclopramideOpioids
Laboratory Tests for Evaluation, BUN, creat, Ca++, glucose)CBC Serum levels of anticonvulsant drugs, TCAs,
digoxin, theophyllineThyroid function (T3, T4, TSH)EKG
Differential DiagnosisThyroid disorders (hypo- and hyper-thyroidism)Dementia (or mild cognitive impairment)BereavementAnxiety Disorder Substance Abuse DisorderPersonality DisorderDiabetes mellitusUnderlying malignancyAnemiaMedication side effects
Differential DiagnosisDEPRESSIONSubacute onsetFamily recognition earlyRapid progression
Appears depressedAnhedoniaAbstract thought usually
normal“I don’t know” response to
questionsPt often unconcerned
DEMENTIAInsidious onsetDelayed family recognitionSlow progression; slow, gradual declinePt denies/unaware of deficitsNot depressedCan experience pleasureAbstract thought impairedNear miss answersPt tries to cover up
Cognitive symptomsacute? : Dlirium(retard psychomotor-
agitation)Chronic :dementia evaluationFocal sign?
TreatmentGoals of therapy: improve mood, function,
and quality of lifeGoals 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.
TreatmentAcute 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
TreatmentPatients should be monitored for response
to treatment by:Observation for resolution of signs and symptoms of
depressionAlso monitor patients carefully for side
effects and interactions with other medications
Pharmachotherapy :50-60% improve with antidepressantsAge related change influence pharmakietic:Longer time for responseMore side effects
Pharmachotherapy:
Sertraline:25-50mg dailyFluoxetine:10 mgCitalopram :10mgLess intraction :sertraline and citalopram
Fluoxetine increase nortriptyline,verapamil,B blokersBetter tolerated than tricyclicsSIADH at high doses and sexual side effectsInteract with CYP-450 isoenzymes by inhibitionCan increase the anticoagulant effect of warfarinDo not discontinue abruptly; taper the dose
,
Treatment : PharmacotherapyAntidepressants (SSRIs continued)
Nausea and diarrhea might occurFluoxetine 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
pharmachotherapyTCA : nortriptyline.desipramine Caution:
cardiac .prostatic,glaucoma,cognitive,falling risk
10-25mgPotential for anticholinergic and sedative effectsAvoid in pts. who are prone to constipation,
orthostatic hypotension, glaucoma, or who have BPHMay cause ventricular conduction delays and heart
blockMay be fatal in overdose
Pharmachotherapy: SNRI: Velnafaxin 37/5mg_75mg up 112.5-
225mgCaution :hypertentionSide effects:nausea,(slow titration) special for chronic pain
Treatment : PsychotherapyCognitive-behavioralInterpersonalShort-term
psychodynamicLife review, reminisceProblem solvingSupportiveBereavement therapyBehavioralDialectical-behavioral
therapy
Consequences and Complications of Inadequately Treated DepressionRisk factors for suicide:
depression older agephysical illness living alone (single, divorced, or separated and
without children)male genderdrug abuse or alcoholismhaving a personal or family history of suicide
attempt severe anxiety or stress specific plan with access to firearms or other
means.
SummaryIn older adults, depression is:
Common (especially “minor” depression)Associated with morbidityDifficult to diagnose because of atypical
presentation, more somatic concerns, overlap with symptoms of other illnesses
Differential diagnoses include other medical illnesses, dementia, bereavement
SummarySuicide is a serious concern in depressed
older patients, particularly older white males
Treatment (acute & preventive) should be individualized and may include:PharmacotherapyPsychotherapyECT
Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions