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

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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

What medications do YOU prescribe for older adults that might place them at

risk for DEPRESSION ?

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

How evaluate symptoms? Mood Symptoms?

Cognitive symptoms?

Behavioral symptoms?

Mood Symptom:onset?Stressor?New medical illness?New events?Motor sign?Cognitive signe?

Behavioral Symptoms:Cognitive evaluation(acute change? Incidious? )PsychosisMood

Cognitive symptomsacute? : Dlirium(retard psychomotor-

agitation)Chronic :dementia evaluationFocal sign?

Differential diagnosisPsychiatric disorders:

Medical illness especial neurological disease

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

TreatmentPharmacotherap

y

Psychotherapy

Electroconvulsive therapy (ECT)

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:Depends :Psychiatric co morbidityMedical illness But , drug of choice

SSRIS

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