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Late Life Depression

Late Life Depression. Epidemiology. Early Onset Depression – first episode before the age of 60 yr vs Late onset depression – first episode after the age of 60 yr Age cut-off – 55- 65 years Incidence

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Late Life Depression

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  1. Late Life Depression

  2. Epidemiology • Early Onset Depression – first episode before the age of 60 yr • vs • Late onset depression – first episode after the age of 60 yr • Age cut-off – 55- 65 years • Incidence • 10% Major depressive disorders (MDD) in primary care patients 15% in medical in-patients • Point Prevalence (LKO survey Ind J Med Res 2013) • 7.6% (CI 6.5-8.8) on SPAS and Mood Disorder Questionnaire • Life Time Prevalence • MDD : 10 - 25% Women, 5 – 12% Men • Dysthymia : 4 - 6% • Cyclothymia : 0.4 – 1.0%

  3. USA Study • 8012 community dwellers >60 yr age • Sampled 2000-1 and 2004-5 • Incidence rates (on CES-D) • Nicotine dependence 3.38% • Major depression 3.28% • Drugs use 0.29% • Bipolar II 0.34% • Depression more in women • Substance abuse more in men

  4. Systematic review of all published literature from India 53 studies Community 34 Psychiatric clinics 1 Inpatients 3 Outpatient medical 4 Old Age Homes 4 Instruments used GDS, ICD-10, Patient Health Questionnaire-9, Zung depression scale, Case detection schedule Sample size 70 - >7000 Age cut-off 50 -70 years Overall revalence Rates 8.9 – 63% Median prevalence rates – 18.2%

  5. Long-term Course Jhingran et al [International Psychogeriatrics, March 2001] N=50 Age >60 yr DSM IIIR diagnosis 12 months outcome Full recovery 28% Partial recovery 30% Relapsed 23% Continuously ill 6% Death 11% Factors associated with good prognosis Shorter duration of episode Living in joint family system

  6. Journal of Geriatric Mental Health 2015 Dec Chart Review, N=48 Overall 30% response at any point

  7. Factors Associated with LLD • Grover & Malhotra 2015

  8. Association with Physical Illness Gupta et al [Journal of Indian Academy of Geriatrics, 2010,6,18-22] N=200 Age >65 yr GDS-H>22 (not for diagnosis) Depression seen more in: rural, females, illiterate, living alone, non-pensioners, and those with >3 medical disorders

  9. Organic Causes of Depression • Respiratory Disorders • Chronic Obstructive • Pulmonary Disease • Asthma • Pulmonary embolism Others • Anemias • Systemic Lupus • Erythematosis • Neurological Disorders • Subdural haematoma • Seizure • Transient Ischemic attacks • CNS Infections and tumors • Parkinsons’s Disease Chronic Pain • Rheumatic disease • Osteoarthritis • Fibromyalgias

  10. Organic Causes of Depression • Endocrine & metabolic Disorders • Hypo and hyperthyroidism • Caushing’s Disease • Porphyrias • Sodium and Calcium disturbances • Cardiovascular Disorders • Myocardial Infection • Angina Pectoris • Paroxysmal Atrial Tachycardia • Arrhythmias • Congestive Heart Failure • Mitral Valve Prolapse

  11. Specially for Older Adults • Marked motor symptoms • Reluctance to disclose symptoms of depression • Misattribution • Symptoms assumed to be part of ageing • Somatization & Hypochondriasis • Predominant somatic complaints • ‘Gastric Symptoms’ • gas ascending to head • gas not being cleared • constipation • ‘Low blood pressure’ • ‘Non-recordable Fever’

  12. Symptoms - Middle (<60 y) vs Older (>60 y) • Hybels et al (2012) • N=664, CES-D & DIS • Older Adults less likely to report: • crying spells, sadness, feeling fearful, being bothered, feeling life a failure, enjoying life, feeling as good as others, feeling worthless, wanting to die, and thinking about suicide • Older adults more likely to report: • poor appetite and loss of interest in sex.

  13. Symptoms – DGMH OPD data (2008-12)

  14. Middle (<60 y) vs Older (>60 y) - Course • LOD (over 1 yr, Ntp + ITP) [Reynolds et al (1998), N-178] • Earlier time to remission • Less suicide attempts • No increased risk of relapse • All patients – Nortryptyline + IPT • Residual Symptoms increase recurrence [Dombrovski et al 2006] • Anxiety • Sleep quality

  15. Treatment – EOD vs LOD • STAR*D study – [Kozel et al 2008, American Journal of Geriatric Psychiatry] • N=574 (EOD – 72%, LOD - 28%) • Age 55-75 yr • HAMD >14 • Citalopram upto 14 weeks • Remission was defined by a 16-item Quick Inventory of Depressive Symptomatology-Self-Rated score of < or =5 at study exit. • Remission EOD = 31%, LOD = 32%

  16. Citalopram Metanalysis • Seitz et al 2010 • 7 studies comparing citalopram (N=647) to other antidepressants (N=641) • TCA – 4 studies • Mianserin/RBX/VFX – 1 each study • No significant differences between citalopram and comparator • Odds Ratio: • Remission 0.84; 95%CI:0.56–1.28] • Dropouts 0.70; 95%CI: 0.48–1.02].

  17. Citalopram Metanalysis Therapeutic Effect Dropouts

  18. Duloxetine Systemic Review • Mancini et al 2009 • 4 studies • Duloxetine vs Placebo • Sig. greater improvement: • Depression scores • Cognitive functions • Heath state • Pain and backache also improved

  19. SNRI vs SSRI • Mukai & Tampi 2009 • SSRI vs No. of studies • SSRI/Placebo 10 • TCA 2 • SNRI vs • Placebo 1 • TCA 1 • SSRI 3 • TCA and SSRI – comparable • SNRI equal to SSRI or TCA

  20. Total Sleep Deprivation • Reynolds et al 2005 • 1 night of sleep deprivation • Sample 80 patients – 14 day study

  21. Treatment Resistant Depression Cooper et al 2011 At least 1 treatment failure 10 studies, mean age 55-71 yrs 52% response rate No double blind study

  22. Treatment Resistant Depression Srivastava et al At least 1 treatment failure 367 subjects, age 55-90 yrs 11 studies Design Open label – 8 Single blind – 2 Double blind -1

  23. Treatment Resistant Depression Srivastava et al Second Step Augmentation of Antidepressants =3 Thyroxine x1 Lithium x2 Response rate = 57% Switching =5 Selegelline/Placebo Venlafaxine Duloxetine Paroxetine Phenelzine Response Rate = 38%

  24. Features of Pseudo-dementia and Dementia

  25. Geriatric Vs Adult Depression

  26. Mood Affective Disorders F 30-39 • F 31 Bipolar Affective Disorder • F31.3 Bipolar Affective Disorder, current episode mild or moderate depression • .30 Without somatic syndrome • .31 With somatic syndrome • F31.4 Bipolar Affective Disorder, current episode severe depression without psychotic symptoms • F31.5 Bipolar Affective Disorder, current episode severe depression with psychotic symptoms • F31.6 Bipolar Affective Disorder, current episode mixed • F31.7 Bipolar Affective Disorder, currently in remission

  27. Mood Affective Disorders (Contd.) F 30-39 • F32 Depressive episode • F32.0 Mild depressive episode • .00 Without somatic syndrome • .01 With somatic syndrome • F32.1 Moderate depressive episode • .10 Without somatic syndrome • .11 With somatic syndrome • F32.2 Severe depressive episode without psychotic symptom • F32.3 Severe depressive episode with psychotic symptom

  28. Mood Affective Disorders F 30-39 (Contd.) • F33 Recurrent depressive disorder • F33.0 Recurrent depressive disorder, current episode mild • .00 Without somatic syndrome • .01 With somatic syndrome • F33.1 Recurrent depressive disorder, current episode moderate • .10 Without somatic syndrome • .11 With somatic syndrome • F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms • F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms • F33.4 Recurrent depressive disorder, currently in remission • F34 Persistent mood (affective) disorders • F34.0 Cyclothymia • F34.1 Dysthymiaable

  29. Clinical features (Contd.) • Psychological symptoms • Feeling low, ‘down’, or without one’s usual drive or initiative • Loss of enjoyment of life and of usual interests • A sense of hopelessness about the future – “ what’s the point?” • A sense of helplessness – feeling at the mercy of events in general • Feeling guilty and blaming oneself for all sorts of predicaments (even minor coincidences) • Lack of self-esteem and self –confidence • Thoughts of self – harm, or even suicide – thinking about ways of ending your life

  30. Clinical features (Contd.) • Biological symptoms • Loss of appetite, often with measurable weight loss • Loss of energy and activity – taking to bed during the day • Sleep impairment – often early morning awakening • Being slowed down in thoughts or movements • Being agitated, restless and unable to keep still • Loss of libido and sexual function • Constipation, Headaches, amenorrhoea or other forms of pain or discomfort • Feeling physically ill (and looking unwell, report internal fever)

  31. Clinical features (Contd.) • Endogenous symptoms • Loss of interest or pleasure in activities that are normally enjoyable • Lack of emotional reactivity to normally pleasurable surroundings and events • Waking in the morning 2 hours or more before the usual time • Depression worse in the morning • Objective evidence of definite psychomotor retardation or agitation • Marked loss of appetite • Weight loss (loss 5% of the total weight in past 1 month) • Marked loss of libido

  32. Diagnosing Depression • General criteria • Minimum 2 weeks duration • No hypo-manic or manic symptoms • Not attributable to substance use disorders or to Organic disorders • Typical symptoms • Depressed mood • Loss of interest in pleasurable activities • Low energy/easy fatigability • Additional symptoms • Loss of confidence/self esteem • Negative feelings • Recurrent thoughts of death/suicide • Sleep disturbances • Constipation • Heaviness of head • Diagonal variation

  33. Causes of Depression (Contd.) Biogenic Amine Hypothesis of Depression Serotonin (5HT) MAO enzyme COMT D A Neurotransmission Reuptake pump Post synaptic receptors N E Pre synaptic receptors NeurotransmitterDestroyed by • NOREPINEPHRINE (NE) = MAO + COMT • DOPAMINE (DA) = MAO + COMT • SEROTONIN (5HT) = MAO

  34. Management of Depression • Primary Prevention • Community awareness about depression • Community awareness about psycho-socio environmental causes • Genetic counseling • Secondary Prevention • Early diagnosis • Treatment • Psychotherapy • Cognitive behaviour therapy • Pharmacotherapy • Tertiary Prevention • Rehabilitation

  35. Pharmacotherapy Basic principles of prescribing in depression • Discuss with the patient choice of drug and utility/availability of other, non-pharmacological treatments • Discuss with the patient likely outcome, e.g. gradual relief from depressive symptoms over several weeks • Prescribe a dose of antidepressant (after titration, if necessary) that is likely to be effective • Continue treatment for at least 4-6 months after resolution of symptoms • Withdraw antidepressants gradually; always inform patients of the risk and nature of discontinuation symptoms

  36. Pharmacotherapy (Contd.) Antidepressant drugs (Tri & Tetracyclics)

  37. Pharmacotherapy (Contd.)Newer antidepressants

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