Geriatric Depression

Kimothi Cain, MD, MPHPsychiatry Psychosomatic Fellow

Aging Statistics

Persons 65 years or older

39.6 million in 2009 (the latest year for which data is

available) or 12.9% of the U.S. population

72.1 million or 19% of the population estimated in 2030

Department of Health and Human Services, 2012

Epidemiology of Geriatric Depression

Of 39.6 million US seniors:

3 million have a depressive disorder

5 million have subsyndromal depression

Less than 10% are treated

19% of all suicides are by patients over 65The second highest U.S. suicide rates are white men over age 65

More somatic complaints: Persistent, vague, unexplained physical complaints such as pain, GI disturbances, weakness, insomnia, anergyLess likely to present with depressed moodAgitation, anxietyMemory problems, difficulty concentratingSocial withdrawal

Atypical Presentation

In primary care, depressed geriatric patients frequently present with somatic complaints

Simon GE, et al. N Engl J Med. 2012;341(18):1329-1335

Chief complaints of 1043 geriatric patients in a primary care setting who were subsequently diagnosed with Major Depressive Disorder

1st step: Rule out medical etiologyHypothyroidismCalciumB12 deficiencyVitamin D deficiencyHeart diseaseNeurological illnessesCancerCOPDAutoimmune diseasesCVATraumaAlzheimer diseaseOther neurodegenerative diseasesetc. etc.

2nd step: Review med list for depressogenic meds, substance use

Evidence for Drug-Induced Depression associated with drug groups

DRUG CLASS/DRUG LEVEL OF EVIDENCE AVAILABLE LITERATURE COMMENTS

Calcium channel blockers +/- Prescription symmetry analysis,

cohort study examining suicide

rates

Results are conflicting—newer have

fewer reports.

ACE inhibitors +/- Prescription symmetry analysis No comment

ARBs +/- Case reports No comment

Alpha interferons ++ Uncontrolled and controlled

studies

No comment

Beta interferons +/- 4 RCTs and 1 naturalistic study No comment

**Reflects authors’ global assessment of evidence; --- little or no convincing evidence; +/- limited evidence; + moderately strong evidence; ++ strong evidence; +++ very strong/unequivocal evidence

Rogers et al, Psychiatry, 2008; 5(12): 28–41

Corticosteroids + Case control study, cross-sectional

analysis

Results of trials are suggestive of DID,

especially over >65

3rd step: Assess for depressionGeriatric Depression Scale

DSM-V criteria for MDDAt least 5 of 9 symptoms, present nearly every day for 2 or more weeks: 1. Depressed mood or irritable most of the day**2. Decreased interest or pleasure in most activities (anhedonia)**3. Significant weight change (5%) or change in appetite 4. Change in sleep: Insomnia or hypersomnia 5. Change in activity: Psychomotor agitation or retardation 6. Fatigue or loss of energy7. Guilt/worthlessness8. Concentration: diminished ability to think, concentrate, or indecisiveness 9. Suicidality: Thoughts of death or suicide, or has suicide plan** Depressed/irritable or anhedonia required for diagnosis

4th step: Treatment

Geriatric depression can be challenging to diagnose and treatConsider psychotherapy, group therapyHealthy lifestyleBehavior activationConsider an antidressant antidepressant

Why treat geriatric depression?

Increases use of primary care medical resourcesDepressive symptoms significantly reduce survival of medical illnessIncreases risk of suicide

Age-related metabolic changes

Decrease in lean body mass and total body water

Increase in body fat, prolongs half life

Hepatic metabolism decreases, as well as production of albumin

Decrease in renal function

Pearls…..less medication, low and slow

Antidepressant Target sx Starting dose

Incremental increase

Target dose(Not the same for seniors)

Sertraline DepressionAnxietyCardioprotective

25mg qday 25mg q3-6 weeks Usually requires less than 200mg. Max 200mg

Escitalopram DepressionAnxiety

5mg qday 5mg q3-6 weeks Max 20mg

Mirtazapine InsomniaPoor appetiteDepressionAnxiety

7.5mg qhs 7.5mg q3-6 weeks Max 45mg

Avoid

1. Fluoxetine -Long half-life metabolites

-Drug-drug interactions

2. Paroxetine-Anticholinergic-Short-half life with marked withdrawal sx