Under-recognized Depression in Late Life: Consequences and Prevalence

1. به نام خدا

2. DEPRESSION IN THE LATE LIFE

3. Objectives • Review the diagnostic criteria for depression • Increase awareness of the prevalence and consequences of untreated depression in the older adult

4. Introduction • Depression is under-recognized and undertreated in the older adult • Many older adults who die by suicide (up to 75%) suffer with depression and most visited a physician within a month before death • Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality • Depression is NOT a part of normal aging

5. What is Depression? • DSM-IV-TR Definition • Five or more of the following must have been present during the same 2-week interval and represent a change from baseline functioning • One(1) of the symptoms must be depressed mood or loss of interest or pleasure

6. What is Depression? • DSM-IV-TR(“core symptoms”; occur most of the day nearly every day) • Depressed mood • Loss of interest in all or almost all activities or pleasure (anhedonia) • Appetite change or weight loss • Insomnia or hypersomnia • Psychomotor agitation or retardation

7. What is Depression? • DSM-IV-TR • Loss of energy or fatigue • Feelings of worthlessness or excessive guilt • Difficulty with thinking, concentration, or decision making • Recurrent thoughts of death or suicide

8. Special clinical features in late life • Depression without sadness • Lack of feeling or emotion • Prominent cognitive compliants • prominent somatic compliants • Multiple primary care visits without resolution of problem • Social withdrawal,avoidance of social intraction

9. What is Depression? • For Major Depression, these symptoms • Produce social impairment • Are not related to substance abuse • Are not related to bereavement

10. What is Depression? • Types of Depressive Disorders (DSM-IV) • Mild episode of major depression • Moderate episode of major depression • Severe episode of major depression • Severe episode of major depression with psychotic features

11. What is Depression? • Minor depression is common • 15% of older persons • Causes  use of health services, excess disability, poor health outcomes, including  mortality • Major depression is not common • 1%–2% of physically healthy community dwellers • Elders less likely to recognize or endorse depressed mood

12. But in Geriatric depression: • Classical major depression is less frequent: • M.d.d about 1-2% • Dysthymic disorder 2% • Depressive symptoms 15-25%

13. Vulnerable Groups • Medically ill • Disabled and institutionalized elderly • Spousal death • Older adult with malignancies,neurologic and endocrine:one half of post strok,onefourth of cancer inpatients, one third of MI • -

14. Risk Factors • Alcohol or substance abuse • Current use of a medication associated with a high risk of depression • Hearing or vision impairment severe enough to affect function • History of attempted suicide • History of psychiatric hospitalization

15. Risk factors • Medical diagnosis or diagnoses associated with a high risk of depression • change of environment • New stressful losses (loss of autonomy, privacy, functional status, body part, family member or friend) • Personal or family history of depression or mood disorder

16. CO MORBID CONDITIONS TO CONCIDER IN LATE LIFE DEP. • Substance,dementia,chronic pain • Metabolic disease,malnutrition,endocrine dysfunction • Cerebral disorder • Cardiovascular disorder,hypotensive episodes • CHF • Pulmonary disease • Cancer • Physical abuse or emotional abuse by caregivers/relative

17. What medications do YOU prescribe for older adults that might place them at risk for DEPRESSION ?

18. Medications that may cause symptoms of Depression • Anabolic steroids • Anti-arrhythmic medications • Anticonvulsant medications • Barbiturates • Benzodiazepines • Carbidopa or levodopa • Certain beta-adrenergic antagonists (i.e. propranol)

19. Medications that may cause symptoms of Depression • Clonidine • Digitalis preparations • Glucocorticoids (prednisone) • H2 blockers • Metoclopramide • Opioids

20. Laboratory Tests for Evaluation • , BUN, creat, Ca++, glucose) • CBC • Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline • Thyroid function (T3, T4, TSH) • EKG

21. Differential Diagnosis • Thyroid disorders (hypo- and hyper-thyroidism) • Dementia (or mild cognitive impairment) • Bereavement • Anxiety Disorder • Substance Abuse Disorder • Personality Disorder • Diabetes mellitus • Underlying malignancy • Anemia • Medication side effects

22. Differential Diagnosis • DEPRESSION Subacute onset Family recognition early Rapid progression Appears depressed Anhedonia Abstract thought usually normal “I don’t know” response to questions Pt often unconcerned • DEMENTIA Insidious onset Delayed family recognition Slow progression ; slow, gradual decline Pt denies/unaware of deficits Not depressed Can experience pleasure Abstract thought impaired Near miss answers Pt tries to cover up

23. How evaluate symptoms? • Mood Symptoms? • Cognitive symptoms? • Behavioral symptoms?

24. Mood Symptom: • onset? • Stressor? • New medical illness? • New events? • Motor sign? • Cognitive signe?

25. Behavioral Symptoms: • Cognitive evaluation • (acute change? Incidious? ) • Psychosis • Mood

26. Cognitive symptoms • acute? : Dlirium(retard psychomotor-agitation) • Chronic :dementia evaluation • Focal sign?

27. Differential diagnosis • Psychiatric disorders: • Medical illness especial neurological disease

28. Treatment • Goals of therapy: improve mood, function, and quality of life • Goals of treatment of an acute depressive episode are to achieve recovery and prevent future episodes of depression • The intended outcome should be complete resolution of symptoms, not simply a reduction in depressive symptoms. • Three phases of treatment are generally required to achieve these goals.

29. Treatment • Acute Phase (reverse current episode) • Duration: about 3 months: Goal is complete recovery from signs and sx of acute episode • Continuation Phase (prevent a relapse) • Duration: 4-6 months: Goal is to prevent relapse as sx continue to decline and functionality improves • Maintenance Phase (prevent future recurrence) • Duration: 3 months or longer: Goal is to prevent recurrence of a new depressive episode

30. Treatment • Pharmacotherapy • Psychotherapy • Electroconvulsive therapy (ECT)

31. Treatment • Patients should be monitored for response to treatment by: • Observation for resolution of signs and symptoms of depression • Also monitor patients carefully for side effects and interactions with other medications

32. Pharmachotherapy : • 50-60% improve with antidepressants • Age related change influence pharmakietic: • Longer time for response • More side effects

33. Pharmachotherapy: • Depends : • Psychiatric co morbidity • Medical illness • But , drug of choice • SSRIS

34. Pharmachotherapy: • Sertraline:25-50mg daily • Fluoxetine:10 mg • Citalopram :10mg • Less intraction :sertraline and citalopram • Fluoxetine increase nortriptyline,verapamil,B blokers • Better tolerated than tricyclics • SIADH at high doses and sexual side effects • Interact with CYP-450 isoenzymes by inhibition • Can increase the anticoagulant effect of warfarin • Do not discontinue abruptly; taper the dose • ,

35. Treatment : Pharmacotherapy • Antidepressants (SSRIs continued) • Nausea and diarrhea might occur • Fluoxetine is not a preferred drug for use in the elderly due to a prolonged half life (4-6 days; metabolite 9.3 days) and potential for many drug interactions. It might also induce anxiety, sleep disturbance, and/or agitation • Paroxetine is also not favored due to anti-cholinergic properties and other effects noted with fluoxetine

36. pharmachotherapy • TCA : nortriptyline.desipramine • Caution: cardiac .prostatic,glaucoma,cognitive,falling risk • 10-25mg • Potential for anticholinergic and sedative effects • Avoid in pts. who are prone to constipation, orthostatic hypotension, glaucoma, or who have BPH • May cause ventricular conduction delays and heart block • May be fatal in overdose

37. Pharmachotherapy: • SNRI: Velnafaxin 37/5mg_75mg up 112.5-225mg • Caution :hypertention • Side effects:nausea,(slow titration) • special for chronic pain

38. Treatment : Psychotherapy • Cognitive-behavioral • Interpersonal • Short-term psychodynamic • Life review, reminisce • Problem solving • Supportive • Bereavement therapy • Behavioral • Dialectical-behavioral therapy

39. Consequences and Complications of Inadequately Treated Depression • Risk factors for suicide: • depression • older age • physical illness • living alone (single, divorced, or separated and without children) • male gender • drug abuse or alcoholism • having a personal or family history of suicide attempt • severe anxiety or stress • specific plan with access to firearms or other means.

40. Summary • In older adults, depression is: • Common (especially “minor” depression) • Associated with morbidity • Difficult to diagnose because of atypical presentation, more somatic concerns, overlap with symptoms of other illnesses • Differential diagnoses include other medical illnesses, dementia, bereavement

41. Summary • Suicide is a serious concern in depressed older patients, particularly older white males • Treatment (acute & preventive) should be individualized and may include: • Pharmacotherapy • Psychotherapy • ECT • Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions