GERIATRIC DEPRESSION

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GERIATRIC DEPRESSION

• November 13, 2001
• Eric Troyer, M.D.
• Swedish Family Medicine

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Case 1

• Eva is an 80 y.o. female
• Complaints Poor sleep, mild weight loss due to
  poor appetite, slowing down recently.
  
• History of incontinence, cardiovascular disease,
  and diabetes.
  
• How might you approach this patients problems?

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DSM-IV DIAGNOSTIC CRITERIA

• 5 or more symptoms lasting 2 wk, change from
  previous functioning
  
• Depressed mood and/or loss of interest
• Altered sleep, loss of energy, appetite change or
  weight loss, feelings of worthlessness/guilt,
  psychomotor changes, loss of concentration and
  focus, recurrent thoughts of death

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SIG E CAPS

• Sleep
• Interest
• Guilt (Are you a burden to others?)
• Energy
• Concentration
• Appetite
• Psychomotor changes
• Suicidality (Do you wish you could die?)

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Vegetative Symptoms

• Sleep
• Interest
• Guilt (Are you a burden to others?)
• Energy
• Concentration
• Appetite
• Psychomotor changes
• Suicidality (Do you wish you could die?)

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Vegetative Symptoms

• These can often occur in other medical illnesses
• Not discriminating or sensitive

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Psychological Symptoms

• Sleep
• Interest
• Guilt (Are you a burden to others?)
• Energy
• Concentration
• Appetite
• Psychomotor changes
• Suicidality (Do you wish you could die?)

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Psychological Symptoms

• More reliable and are independent of age
• But, elderly patients less willing to talk about
  psychological problems
  
• Pay attention to
• anxiety
• physical discomfort
• adaptation to a new lifestyle

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SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION

• SYMPTOMS
• MOOD
• COGNITIVE
• VEGETATIVE
• VOLITIONAL

• SIGNS
• APPEARANCE
• BEHAVIORS
• PSYCHOMOTOR RETARDATION
• PHYSCHOMOTOR AGITATION

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Case 1

• SIG E CAPS DM for Eva
• Positives Sleep, Appetite, Psychomotor
  retardation
  
• Negatives Interests, Guilt, Energy,
  Concentration, Suicidality, Depressed mood

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Case 1

• Poor sleep due to nocturia.
• Appetite changes due to decreased taste and
  smell.
  
• Slowing down due to new claudication.

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Case 2

• George is a 74 y.o. male
• Complaints Sore muscles, dizziness,
  constipation. Repeated visits to doctor with
  vague symptoms.
  
• Daughter reports patient impossibly uncooperative
  and has angry outbursts.
  
• Wife died 2 years ago he moved in with daughter
  3 months ago after a fall.

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INCIDENCE IN ELDERLY

• MAJOR DEPRESSION
• 3 community dwelling
• 14 two years after spouse dies
• 15 medically ill
• 25 long-term-care settings
• DEPRESSIVE SXS
• 17-37 in primary care settings
• 42 in long-term-care settings

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How is Depression Different in the Elderly?

• Less verbalization of emotions or guilt
• Minimize or deny depressed mood (masked
  depression)
  
• Preoccupied with somatic symptoms
• 65 have hypochondriacal symptoms
• Cognitive impairment can be marked
• Hopelessness appears to be persistent

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How is Depression Different in the Elderly?

• Depressive ideation, anxiety, psychomotor
  retardation, and weight loss have high assoc.
  with disability
  
• More anxiety, agitation and psychosis
• esp. delusions with themes of guilt, nihilism,
  persecution, jealousy
  
• Medical Conditions can mask or cause depression

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How is Depression Different in the Elderly?

• Subsyndromal depression is more common and
  presents as
  
• new medical complaints
• exacerbation of GI sxs or arthritic pain
• cardiovascular sxs
• preoccupation with health
• diminished interest, fatigue, poor concentration

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Case 3

• Francine is a 67 y.o. female
• Complaints Sad, decreased interests, shaky,
  falling apart.
  
• Your nurse mentions that she took a while to
  bring back, esp. out in the lobby.
  
• Your exam shows tremor and cogwheel rigidity.

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Medical Conditions Mask or Cause Depression

• Autoimmune
• Cerebrovascular
• Chronic pain
• Degenerative Disease
• Endocrine
• Metabolic
• Neoplasms
• Infections

• DRUGS
• Propranolol
• Cimetidine
• Clonidine
• Benzodiazepines
• Steroids
• Tamoxifen
• Many more...

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Parkinsons Disease

• About 50 of patients develop depression
• Useful treatment includes TCAs
• ECT helps depression and PD sxs
• tremors, rigidity, bradykinesia improved with
  3-4 sessions
  
• depression improved after 7-9 sessions

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Early Alzheimers Dz

• Presents with
• insomnia
• fatigue
• agitation
• psychomotor retardation
• decreased interest energy
• concentration problems
• 50 of AD pts have depressive sxs (15-20 with
  major depression)

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Vascular Depression

• Cerebrovascular disease can precipitate or
  perpetuate depression
  
• Caused by ischemia (silent strokes) in
  prefrontal cortex and basal ganglia motor
  sensory deficits usu. not found.
  
• Apathy, psychomotor retardation, cognitive
  decline
  
• May explain incr. depression s/p CABG

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Pseudodementia

• aka dementia of depression
• cognitive decline that clears if depression is
  treated
  
• however, dementia rate in these patients is still
  20/year even after full recovery of intellectual
  function

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Workup

• It might include
• H P
• CBC, TSH, testosterone
• ESR, renal/liver function
• U/A
• EKG
• brain imaging if tumor or vascular disease
  suspected

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Case 4

• Eugene is a 70 y.o. male
• Dxd with bladder cancer, had cystectomy and now
  with Indiana pouch. Needs to cath through
  umbilicus q4hr. His wife recently dxd with
  breast cancer.
• Pt. has single episode of major depression 25
  years ago following tough work situation and
  increased EtOH use.

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Case 4 (contd)

• Symptoms Withdrawn, no interest in activities
  (not even Mariners games), sleeping excessively,
  lost 10, constant worry about cath procedure,
  belief he is burden to family.
• Statements like, I wish I was dead, and, my
  problem will affect this entire hospital.

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Case 4

• SIG E CAPS DM for Eugene
• Positives Sleep, Interests, Guilt/Burden,
  Energy, Concentration, Appetite, Psychomotor
  retardation, Suicidal (passive), Depressed mood
  
• Additional findings Nihilistic, Delusional

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SUICIDE IS A REAL RISK

• 25 of all completed suicides are 65
• Suicide rate for depressed men over 65 is 5 times
  higher than for younger men
  
• 20 of older people who committed suicide saw a
  physician that day
  
• Increased risk financial problems, physical
  illness, recent loss, EtOH, abuse, isolation

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INTERVENTIONS

• Seek out medical illness
• Recognize medical side effects
• Rehab services to maximize remaining function and
  retrain impaired iADLs
  
• Involve family and caretakers
• Counsel re role transitions, grief, dependency
• Medications / ECT

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GERIATRIC PRESCRIBING PRINCIPLES

• C Caution, Compliance
• A Adjust dose for Age
• R Review, Remove, Reduce
• E Educate
• START LOW GO SLOW

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MEDICAL THERAPY IN GERIATRIC DEPRESSION

• Select based on symptoms, prior response,
  concurrent illness, side effect profile
  
• Reassess after 4-6 weeks
• Increase dose, augment with second agent, add
  psychotherapy
  
• Consider psychiatric consult/referral

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PREFERRED ANTIDEPRESSANTS

• SSRIs
• Celexa, Paxil
• Zoloft, Prozac
• TCA
• Nortriptyline
• Others
• Wellbutrin
• Serzone
• Remeron

• fewer side effects
• good safety record
• more expensive
• least expensive
• activation, tremor
• anxiolytic, somatic
• sleep, appetite

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ACCEPTABLE ANTIDEPRESSANTS

• TCA
• Desipramine
• HCA
• Trazodone
• SNRI
• Effexor

• Sedation, hypotension
• cognitive slowing
• Dizzy, anorexia, nausea, BP increase

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ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY

• Too many side effects
• Older TCAs
• amitriptyline, clomipramine, doxepin, imipramine,
  protriptyline, trimipramine
  
• MAOIs
• phenelzine, tranylcypromine

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Other Drugs

• Newer atypical anti-psychotics
• for jump start or behavior issues
• Risperdal (risperidone), Seroquel (quetiapine),
  Zyprexa (olanzapine)
  
• Psychostimulants
• for jump start or for severe apathy

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Electroconvulsive Therapy (ECT)

• Works well for psychotic depression, high suicide
  risk, Parkinsons-related depression, failed drug
  treatment
  
• Very effective short term, but with high relapse
  rates over next 6-12 months.
  
• Drug therapy can reduce relapse