Beating the Blues: Depression in Older Patients

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Beating the BluesDepression in Older Patients

• Thomas Magnuson, M.D.
• Assistant Professor
• Division of Geriatric Psychiatry
• Department of Psychiatry
• UNMC

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Goals

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

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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)

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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,

2 wks
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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

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www.efmoody.com/longterm/depression.html
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Epidemiology of Geriatric Depression

• Influence on general health
• CV disease, cancer, infection, falls
• Mortality

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Epidemiology of Geriatric Depression

• MDD in special populations of elderly
• Medical outpatient rate is 7-35
• 5x higher in the doctors office than in the
  community
• Medically hospitalized rate is 40

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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 (Parkinsons Disease, e.g.)

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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

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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 ones feelings

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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

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MDS 3.0 criteria mood disorder

• Corresponds closest to the diagnosis of major
  depression.

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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,

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MDS 3.0 Depression DefinitionPHQ-9 2 or more sx
occurring gt 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

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You suspect DepressionWhat next?
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Is it Medication?

• Pain medications
• codeine, darvon
• High blood pressure medications
• clonidine, reserpine
• Hormones
• estrogen, progesterone, prednisone
• Cardiac medications
• digitalis, propranolol
• Alcohol

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Is it medications?

• Anticancer agents
• cycloserine
• tamoxifen
• Nolvadex, Velban, Oncovin
• Parkinsons disease medications
• L-dopa and bromocriptine
• Arthritis
• indomethacin
• Anti-anxiety drugs
• Valium and Halcion

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Is it a medical condition?

• Hypothyroidism
• Calcium
• B12
• Vitamin D deficiency
• Heart disease
• Neurological illnesses
• Cancer
• COPD.

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Is it due to dementia?

• Higher rate of depression than the general
  population
• Varying intensity in 50
• Alzheimers 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

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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
• Alzheimers patients have little appetite, lose
  concentration, become isolative
• Parkinsons 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

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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 patients past medical and psychiatric
  history

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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

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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

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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

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Psychotic depression

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

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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

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Medications to Treat Geriatric Depression

• SSRIs most common
• Fluoxetine
• Sertraline
• Paroxetine
• Fluvoxamine
• Citalopram
• Escitalopram
• SNRIs
• Venlafaxine
• duloxetine

• Tricyclics
• Nortriptyline
• MAOI
• Selegeline patch
• Others
• mirtazepine
• bupropion
• trazodone

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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

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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

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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

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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

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Are Antidepressants used for other purposes?

• Anxiety/sleep- FDA approval for mirtazapine,
  nortriptyline
• Pain- duloxetine, venlafaxine, nortriptyline
• Appetite-mirtazapine, nortriptyline

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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

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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

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Treatment

• ECT
• Works rapidly for those who cant 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

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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

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Goals

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

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