Treating Depression in the Elderly

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Treating Depression in the Elderly

• A Multi-disciplinary Approach
• 12/11/2003

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Who are the elderly?

• Over 65 years old, but less than 75 young
  elderlyoften still active and independent
• Over 75
• Frail elderly many living in institutions with
  multiple chronic conditions

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Major Depression Episode

• At least 2 weeks of sustained symptoms
• Feelings of sadness or loss of interest PLUS at
  least four other symptoms
• Agitation or Fatigue
• Loss or increase in appetite
• Insomnia or hypersomnia
• Feelings of worthlessness, hopelessness,
  powerlessness
• Inability to concentrate, memory problems, and
  distractability

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Rule Out

• Caused by medical condition such as
  hypothyroidism, hormonal imbalance, metabolic
  disorder, anemia, stroke etc
• Caused by substance such as alcohol, prescription
  medication, drugs or toxin exposure
• Other mood disorders
• Dementia

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Manifestations in the Elderly

• Present with somatic complaints rather than mood
  dysfunction
• Loss of function, ability to get things done

• Irritability or anxiety
• Social withdrawal
• Changes in hygiene or grooming
• Feelings of uselessness and loneliness

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Manifestations in Elderly

• Cognitive function impairment
• Confusion
• Disorientation
• Memory impairment
• Lack of concentration

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Risk Factors

• Significant loss(es), sometimes concurrent
• Spouse due to death
• Friends and other family
• Mobility and/or stamina
• Hearing and vision
• General health
• Income
• Sense of identity
• Independence
• Home and/or neighborhood due to relocation

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Risk Factors

• Chronic medical conditions
• Arthritis
• Anemia
• Stroke
• Metabolic disorders
• Hormonal imbalances
• Parkinsons disease
• Cardiac conditions
• Hypertension
• Glaucoma or cataracts

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Risk Factors

• Female
• Lack of social supports
• Family or personal history of depression
• Alcohol or substance abuse
• Family conflict

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Special Concerns

• Depression is undiagnosed or misdiagnosed in
  elderly
• Can exacerbate existing medical conditions due to
  degeneration of self care, poor eating habits,
  and increased perception of pain
• Social withdrawal and increasing isolation
  compound feelings of loneliness
• Increases dependence

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Special Concerns

• Increased risk for falls and injury, infections,
  and poor nutrition
• Increased risk for premature admission to a
  nursing facility
• Can lead to a downward spiral in general health
  and functioning
• Economic problems
• Reduced mobility

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Assessment Critical

• Make sure medical issues, including drug side
  effects and interactions, have been ruled out.
• Because the elderly tend to have multiple issues
  occurring simultaneously, it is important to do a
  thorough evaluation to determine all the factors
  involved in the situation.
• May need to use a modified version of Beck
  depression assessment tool, the Geriatric
  Depression Scale, developed particularly for
  elderly.

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Treatment Options

• Drug Therapy Only
• Psychotherapy Only
• Combination of Psychotherapy and Drug Therapy
• Electroconvulsive Therapy (ECT)

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Treatment Phases

• Acute or Initial Phase
• 6 to 8 weeks, longer for psychotherapy alone (16
  20 weeks)
• Fully resolve depressive symptoms
• Phase 2, Continuation of Treatment
• Maintenance Phase
• Can be a year or more, depending on history

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Medication

• Types of medication used to treat depression
• Cyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs)
• Lithium salts
• Serotonin reuptake inhibitors (SSRIs)
• Each medication has its own side effects and
  dosage requirements

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Psychotherapy Options

• Interpersonal
• Cognitive
• Behavioral
• Cognitive-Behavioral (CBT)
• Reminiscence or Life Review
• Family Therapy

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Combination Therapy

• Use medication to reduce acute symptoms of
  depression
• Type of medication depends on evaluation
• Follow with psychotherapy
• Type of therapy depends on evaluation, however,
  CBT is shown to be effective
• Monitor for adverse reactions to medication and
  compliance
• Address psychosocial stressors

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Treatment Issues

• If dementia is present, effectiveness of
  treatment is affected for psychotherapy as well
  as drug therapy
• Side effects of medications can lead to
  non-compliance
• In psychotherapy, inconvenience, conflict, and
  resistance may lead to lack of attendance to
  sessions

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Summary

• Depression is not an inevitable part of aging
• Depression is highly treatable through different
  approaches
• Once acute symptoms are reduced through drug
  therapy, some form of psychotherapy can help
  person address other factors that are
  contributing to the situation