Beating the Blues: Depression in Older Patients

1. Beating the Blues:Depression in Older Patients Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry Department of Psychiatry UNMC

2. Goals • Discuss depressed mood as a problem in the nursing home • Discuss recognition of depression • Discuss treatments of depression.

3. Mood Problems • Several diagnoses for depressed mood • Major depressive disorder • Dysthymia • Bipolar affective disorder • Mood disorder due to a general medical dx • Substance induced mood disorder • Adjustment disorder with depression • Complicated bereavement • Mood disorder not other wise specified (NOS)

4. Major Depressive Disorder • More intense than being blue • Lasts for an extended time • Dysfunction • DSM IV criteria for Major Depressive Disorder • Must have 1 of these 2 • Depressed mood, more often than not, for 2W • Loss of interest • Plus these other symptoms to equal 5 total • Sleep, energy, appetite, worthlessness,concentration, suicidal ideation, helpless, hopeless, guilt, 2wks

5. Epidemiology of Geriatric Depression • Of 35 million seniors in the US • An estimated 2 million have a depressive illness • 5 million have subsyndromal depression • Less than 10% are treated • 1 in 10 Americans over 65 will be depressed • 19% of all suicides are by patients over 65 • Seniors comprise 13% of the population • The highest suicide rates in the U.S. are found in white men over age 85. • Seniors have 50% higher health care costs if depressed

6. www.efmoody.com/longterm/depression.html

7. Epidemiology of Geriatric Depression • Influence on general health • CV disease, cancer, infection, falls • Mortality

8. Epidemiology of Geriatric Depression • MDD in special populations of elderly • Medical outpatient rate is 7-35% • 5x higher in the doctor’s office than in the community • Medically hospitalized rate is 40%

9. Epidemiology of Geriatric Depression • Nursing Homes’ rate for MDD is 12.4-20% • But 30-35% have other depressive disorders • Dementia with depression • Adjustment disorder with depressed mood • Complicated bereavement • Depression due to GMC (Parkinson’s Disease, e.g.)

10. Epidemiology of Geriatric Depression • Geriatric depression is associated with: • Female gender • Though this declines with age • Above age 80 gender differences rapidly fade • Low socio-economic level • Less social support • Especially those divorced or widowed • Recent adverse life events • Death and other losses • Severe impairment in medical health • Especially neurological disorders, endocrine disorders, COPD, MI, cancers

11. Epidemiology of Geriatric Depression • Underutilization of psychiatric services • Common in those over 65 • A matter of “will power” • Cost of medicines, copays • Depressed people went to the asylum • Not socially acceptable to discuss one’s feelings

12. Underutilization of psychiatric services • Contributes to the high suicide rate in this group • Over 65, white males have the highest rate of completed suicide in the United States • 0.02%/yr for men, 0.005%/yr for women over 65 • Rate for white men over 85 is FIVE TIMES the national rate • 59 per 100,000 versus 10.6 per 100,000

13. MDS 3.0 criteria mood disorder • Corresponds closest to the diagnosis of major depression.

14. Major Depressive Disorder • DSM IV criteria for Major Depressive Disorder • Must have 1 of these 2 • Depressed mood, more often than not, for 2W • Loss of interest • Plus these other symptoms to equal 5 total • Sleep, energy, appetite, worthlessness,concentration, suicidal ideation, helpless, hopeless, guilt,

15. MDS 3.0 Depression DefinitionPHQ-92 or more sx occurring >= 50% time • Over the last 2 wks have you been bothered by any of the following problems? • Little interest • Feeling down • Sleep • Energy • Appetite • Feeling bad about yourself (worthlessness) • Concentration • Moving slowly (psychomotor retardation) • Thoughts you would be better off dead

16. You suspect DepressionWhat next?

17. Is it Medication? • Pain medications • codeine, darvon • High blood pressure medications • clonidine, reserpine • Hormones • estrogen, progesterone, prednisone • Cardiac medications • digitalis, propranolol • Alcohol

18. Is it medications? • Anticancer agents • cycloserine • tamoxifen • Nolvadex, Velban, Oncovin • Parkinson’s disease medications • L-dopa and bromocriptine • Arthritis • indomethacin • Anti-anxiety drugs • Valium and Halcion

19. Is it a medical condition? • Hypothyroidism • Calcium • B12 • Vitamin D deficiency • Heart disease • Neurological illnesses • Cancer • COPD.

20. Is it due to dementia? Higher rate of depression than the general population • Varying intensity in 50% • Alzheimer’s range 0-87%, mean 17-31% • Mild to moderate stages report depression • GDS • Useful for mild to moderate dementia • Patient answers 15 questions with yes or no • Cornell Scale for Depression in Dementia • Useful for moderate to severe dementia • No self-report so rater must be well-trained

21. Diagnosis of Geriatric Depression in Dementia • Confusion can often arise as to mood symptoms in dementia • Communication issues • Patients with moderate to severe dementias do not verbally communicate their mood • Symptoms of other disorders can overlap with depression • Alzheimer’s patients have little appetite, lose concentration, become isolative • Parkinson’s patients lose affect, have slowed speech and movements • Frontal lobe injuries present with apathy, often misinterpreted as depression, or frequent crying not related to mood

22. Diagnosis of Geriatric Depression in Dementia • Useful to use: • Frequent, dysfunctional sad, downcast mood • New agitation and/or sudden loss of interest • Psychic rather than vegetative features • Vegetative features often are multifactoral • i.e. poor sleep may have four or five causes • Use caregiver reports from home or the NH • The patient’s past medical and psychiatric history

23. Diagnosis of Geriatric Depression in Dementia • If unsure, TREAT FOR DEPRESSION • Medications safer and more effective these days • ECT a viable option • Much worse to miss than overtreat

24. Diagnosis of Geriatric Depression in Dementia • Apathy is a common symptom in dementia • Often mistaken for depression- • How to tell them apart? • In apathy, no emotional changes or lasting emotional feelings. • Treatment? (none with FDA approval) • Amphetamine if pt sleeps too much-provigil • Antidepressants

25. Course of Geriatric Depression • More chronic than early onset depression • Adult rate for chronic depression is 20% • Geriatric rate for chronic depression near 30% • 13-19% relapse at one year • Risks for relapse after age 65 • Frequent episodes • Late age at onset • Dysthymia • Medical illness • High severity of first episode • Hospitalization, suicide attempt • Rationale for long term use of antidepressants in this population

26. Psychotic depression • Psychotic depression a problem in the elderly • 20-45% of geriatric psychiatric inpatients • 4% of depressed elders in the community

27. Psychotic depression • Presentation • Primarily delusions, hallucinations less so • Guilt, hypochondriasis, nihilism, persecution, jealousy • Highly systematized, mood-congruent delusions • Delusion often frightening or catastrophic • Needs treatment for depression and psychosis • These patients require antipsychotic treatment • fluvoxamine (Luvox) may be useful alone • Often require electroconvulsive therapy (ECT) • Especially when their condition compromises their physical health

28. SSRIs –most common Fluoxetine Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram SNRI’s Venlafaxine duloxetine Tricyclics Nortriptyline MAOI Selegeline patch Others mirtazepine bupropion trazodone Medications to Treat Geriatric Depression

29. Treatment for Depression • Medications • All have data or reports in use in elderly pts. • All have some positive report in dementia pts. • Depression harder to treat in older patients

30. What should you expect from medication Treatment of Geriatric Depression? • How long does it take to work? • 8 to 12 weeks in 30 year olds • May stretch to 12-16 weeks in the elderly • Can you see changes earlier? • Some yes. • Vegetative-sleep appetite energy • Good sign of response

31. What should you expect from medication Treatment of Geriatric Depression? • Are they dangerous? • Not long-term • Drug-drug interactions minimal in most cases • Not addictive

32. What should you expect from medication Treatment of Geriatric Depression? • Do they have side effects? • SSRI- GI, dec. sex drive, anxiety headache • SNRI-HTN, anxiety • TCAs-bladder, bowel, cardiac, confusion • MAOI-Tyramine reaction • Mirtazapine-sedation weight gain • Buproprion-anxiety, HTN • Trazodone-sedation, orthostatic BP

33. Are Antidepressants used for other purposes? • Anxiety/sleep- FDA approval for mirtazapine, nortriptyline • Pain- duloxetine, venlafaxine, nortriptyline • Appetite-mirtazapine, nortriptyline

34. Are other medications used for depression? • Methyphenidate • No FDA approved, literature supports used in medically ill, apathetic, those with poor appetite • Lamictal- • FDA approved for bipolar depression

35. Treatment • Psychotherapy • Cognitive-behavioral and Interpersonal • Manual-driven • Easy to study • Effective in combination and alone • Psychodynamic • Long-term issues; less studied • Problem solving and Supportive • Mild-moderate dementia • Coping day-to-day

36. Treatment • ECT • Works rapidly for those who can’t wait • Psychotic depression, especially • Hospital venue • Anesthesia • 30-60 second seizure; 6-12 treatments • Maintenance treatment • Adverse effects minimal • Short-term memory loss; lasts less than 2 mos. • Mortality rate 0.01%

37. Treatment • ECT • How does it work? • Win the Nobel Prize in Medicine • Cerebrovascular contraction • Increased BBB permeability • Increased brain O2 concentration • No absolute contraindications • Relative are brain tumor, MI in the last 3-6 mos. • Response level is 90% • Trick is maintaining the response

38. Goals • Geriatric depression is common in NH • Rates are different than the general population • Various effective treatments do exist

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