Managing Depression in the Older Adult

1. Managing Depression in the Older Adult NR601-Primary Care of the Maturing and Aged Family Practicum

2. Objectives • Describe the epidemiology of depression in older adults • Diagnosis depression in older adults • Select treatment options for older adults with depression

3. Facts about Depression in Older Adults • Depression is NOT a normal consequence of aging • Healthy community dwelling elders have a lower prevalence rate that the general adult population • Females have a greater incidence of depression than males, but the gender gap decreases with age

4. Prevalence of Depression in Older Adults • 20-30% inpatient settings • >40% with stroke, MI and cancer patients • 50-75% cognitively impaired in nursing home residents

5. Depression Risk Factors • Widowed, divorced, or separated • Female • Cognitive impairment • Lower socioeconomic status • Comorbid medical conditions • Insomnia • Uncontrolled pain • Functional limitations • Social isolation

6. Predictors of Poor Outcome • More severe depressive symptoms • Dysthymia • Cognitive impairment • Stress • Poor social support • Functional limitations • Age, sex and previous episodes of depression are not predictive

7. Impact of Depression • Disability, poor quality of life • Increase in medical visits • Increase in alcohol use, illicit drug use, prescription and over OTC drugs • Increase in medical morbidity/mortality • 4 fold increase in death post MI • 4 times more likely to die post-stroke in 10 year follow-up • Increased one year mortality in nursing homes if depressed at time of admit

8. Risk of Suicide • Older adults are 13% of U.S. population but account for 24% of completed suicides • Older adults attempt less but complete more suicides • Rates decrease in women later in life • Typical older adult who commits suicide presents as below: • WM> 85 y.o. has the highest rate of completed suicides • Most elderly suicide victims in their first episode of depressionand had seen an MD within the last month of life

9. To Diagnose Depression, Must Know the Types of Depression

10. Major Depressive Disorder (MDD) • Many Variants • Psychotic depression • Vascular depression • Depression secondary Dysthymia (more common than MDD) Subsyndromal or minor depression Bereavement

11. Complicating Factors When Diagnosing Depression in the Older Adult • Concurrent medical illness or medication SE with overlapping symptoms of depression • Cognitive impairment • Lack of time due to complex medical conditions • Impaired communication skills in some older adults • Therapeutic nihilism by patient, family, provider • Multiple somatic complaints • Patient’s lack of reporting due to stigma

12. DSM-IV Criteria for MDD • > 5 symptoms listed below in same 2-week period and must include depressed mood or anhedonia • Sleep changes (insomnia or oversleeping) • Suicidality (preoccupation with death, hopelessness) • Guilt feelings of worthlessness (rare) • Loss of energy, fatigue (common) • Psychomotor retardation or agitation • Changes in appetite, weight loss or gain • Diminished ability to concentrate, think or make decisions

13. DSM-IV Criteria Continued • Symptoms: • Cause clinically significant distress or impairment in function • Do not meet criteria for a mixed episode of bipolar disorder • Are not due to substance abuse or a medical condition • Are not due to bereavement

14. Diagnostic Variations in the Older Adult • Less depressed mood, more anhedonia (enjoying family/grandkids is not enough) • Somatic complaints • Cognitive impairment without dementia (attention, speed of mental processing, executive dysfunction) • Even with complete recovery of cognitive function after remission of depressive episode, 40% will meet criteria for dementia in 3 years

15. Diagnosing Depression in the Oldest Old > 85 years of age • Anhedonia for 2 weeks or more • Social regression or incapacity • Physical symptoms out of proportion to illness • Depression is less likely if: • Responds to affection from caregivers and family • Retains sense of humor • Looks forward to doctor visits • Accepts assistance and care

16. Differential Diagnosis of MDD • Mood disorder due to general medical condition • Substance induced mood disorder • Dementia • Manic episode with irritable mood or mixed episode • ADHD • Adjustment disorder with depressed mood • Bereavement

17. Coexisting Disorders Anxiety disorders Alcohol dependence Other substance related disorders Medical conditions

18. Diagnostic Work-Up • Careful history and physical • Screening instruments • Labs • CBC • Urinalysis • Thyroid screen • Chemistry • Electrocardiogram • B12 • Imaging (vascular depression)

19. Depression with Dementia • Depressive signs/symptoms are present in 50% of patients with dementia • More common in subcortical (such as vascular) than cortical (such as AD) dementias • Late life depression may be a prodrome to a dementia disorder • Early life depression is now recognized as a risk factor for later development of dementia

20. Planning Treatment of Depression in Older Adult • Evaluate safety of patients/others • SI or HI • Access to weapons • Psychosis or severe anxiety • Alcohol or substance abuse • Previous suicide attempts or violence • Family history or recent exposure to suicide

21. Planning Treatment of Depression in Older Adult-Continued • Evaluate functional impairments • Determine treatment settings • Establish therapeutic alliance • Educate consumer and family about: • Concern for medication dependence • Rejection of concept of depression as a medical illness • Fear medication will inhibit normal emotions

22. Planning Treatment of Depression in Older Adult • Enhance treatment adherence by discussing the following with the patient: • When and how to take the medication • Need to treat for 4-6 weeks before benefits (elderly may need 8-16 weeks) • Need to continue medication after feeling better • Before stopping medication, discuss with doctor • What to do if problems arise

23. Duration of treatment • 6-12 months following achievement of full remission • 1 MDE, 50% will have recurrent; 2 MDE’s, 75% will have recurrence • Rates of relapse higher in older adult, if relapse after withdraw the anti-depressant, consider long-term continuation of medications • Continuation dose is the same dose as used during acute episodes

24. General Principles About Antidepressants • What really differentiates these medications is their side effect profile • Effectiveness is comparable between classes and within classes of medication • In older adult, cut starting dose in half (due to decreased drug clearance) • Aim for monotherapy • Follow-up with patient within 2 weeks of initiating treatment

25. Four Groups of Antidepressants • SSRI’s • TCA’s • Atypical Antidepressants • MAOIs

26. SSRIs • Paroxitine- starting dose 10 mg, average daily dose 10-40 mg • Citalopram- starting dose 10 mg, average daily dose 10-40 mg • Escitalipra- starting dose 5 mg, average daily dose 5-20 mg • Sertraline- Starting dose 25 mg, average daily dose 50-200 mg

27. SSRI’s • Are first line medications; safe in overdose, well-tolerated • Paxil discontinuation syndrome • Zoloft activating (dopaminergic activity) • Zoloft, Paxil, Prozac can inhibit the metabolism of other drugs through cytochrome p-450 system • SIADH (confusion, check Na) • Seratonin Syndrome occurs when SSRIs are used along with other SSRI’s, SNRI’s, TCA’s, MAOI’s, some cough medication

28. SSRI Side Effects • Nausea • Sexual dysfunction • Increased time to orgasm, decreased libido, problems with erection • Anxiety/insomnia • Sedations • Decreased appetite and weight loss • Headache

29. Atypical Antidepressants-Venlafaxine • Is an SNRI • Starting dose-37.5 mg, average daily dose 75-150 mg bid • Mechanism-inhibits SE and NE reuptake, but is more selective for SE reuptake inhibition at lower doses • Sustained increase in diastolic BP in 10% -dose dependent • Discontinuation syndrome • Nausea-is best taken with food

30. Atypical Antidepressants-Burpropion • Starting dose- 75 mg, avg daily dose 150-450 mg • Increase DA and NE • Seizure risk 4/1000 (regular release) with doses >450 mg/day. Avoid in bulimia • Safest for cardiac disease • Adjunct for SSRI induced sexual dysfunction • Activating insomnia; avoid with anxiety disorder • Used for smoking cessations (Zyban) • Lower switch rate to mania

31. Atypical Antidepressants-Duloxetine (SNRI) • Starting dose 10-20 mg, average daily dose 20-60 mg • Mechanism-inhibits SF and NF reuptake equally • No effects on BP or weight • Approved for pain • Can cause orthostatic hypotension, nausea

32. Atypical Antidepressants-Mirtazapine • Starting dose 7.5 mg, average daily dose 15-45 mg • Antagonizes inhibitory presynaptic alpha-adrenergic receptors, increasing NE and SE • Side effects include sedation, dry mouth, weight gain, constipation, orthostatic hypotension • Less sedating at higher doses

33. Atypical Antidepressants-Trazadone • Starting dose 50 mg, average daily dose 100-300 mg • Mechanism-inhibits SE ruptake, blocks SE receptors, SE agonist, antagonizes alpha-adrenergic receptors • Side effetcs include sedation, orthostatic hypotension, headaches, arrhythmia (rare) • Priaprism • Most common use is for insomnia

34. Tricyclic Antidepressants • MOA- predominantly inhibits norepinephrine reuptake (also increase SE) • Amitryptaline • Clomipramine • Desipramine-with starting dose 10mg, average daily dose 25-100 mg • Imipramine • Nortryptyline-starting dose 10 mg with average daily dose 25-100 mg • Secondary amine TCAs better tolerated because less alpha-blockade and anti-cholinergic effects

35. Atypical Antidepressants • TCA Side Effects • Anti-Cholinergic • Dry mouth, urinary retention, constipation, blurred vision • Sedation • Weight gain • Confusion • Alpha-adrenergic blockade (arrhythmia, orthostatic hypotension, changes on EKG_ • Use caution with patients who have cardiac conduction abnormalities, narrow angle glaucoma, urinary retention, BPH, dementia

36. TCA Clinical Pearls • Get an EKG before initiating treatment • Can be LETHAL in overdose • May be more beneficial in melancholic or delusional depression • Only antidepressants shown to reduce the risk of relapse after ECT (nortriptyline) • Monitor levels of medication • TCAs not generally well tolerated due to their side effects

37. MAOIs • Mechanism: Increase synaptic monoamine concentrations (DA, NE, SE, tyramine) by inhibit MAO on cellular membrane of mitochondria • Examples: • Phenelzine • Tranylcypromine • Indication for atypical depression (reverses neurovegetative depression)

38. MAOIs continued • MUST have patient modify diet to avoid a hypertensive crisis • Avoid foods containing tyramine (aged cheeses, dried meats, fava beans, tap beers, soy products) • Combination with other drugs can also lead to hypertensive crisis (Wellbutrin, cough syrup) • Drug-drug interactions-serotonin syndrome if combined with other drugs that increase SE • Myoclonus, tremor, hypertension, confusion, diarrhea • Washout required • Can be LETHAL in overdose • Rarely used in clinical practice

39. Augmentation Strategies • Stimulants • Ritalin, Dextroamphetamine • Useful for apathetic geriatric patients (start Ritalin 5 mg bid, increase to 10 mg bid if tolerated) • Antipsychotics • MDE with psychosis • Lithium • Anti-suicidal • Daily dose 150-900 mg (levels can be lower) • Thyroid hormone • Benzodiazepines

40. Psychotherapy Options • Cognitive Behavioral Therpay (CBT) • Behavior Therapy • Interpersonal Therapy • Psychodynamic Psychotherapy • Marital Therapy • Family Therapy • Group Therapy

41. Psychotherapy • As effective as medication in acute treatment of depression • Will reduce recurrence of MDE when combined with antidepressant • For moderate to severe depression, must use antidepressant ot prevent relapse • Choose a more structured or supportive therapy for more severe symptoms (CBT, Interpersonal) and transition to psychodynamic as symptoms improve

42. Supportive Family Intervention • Talk with family members and caregivers about: • Suicide risk • Preventive strategies • Guidance in managing patient’s dysfunctional behaviors • Interpreting changes in older adult’s behavior

43. Summary and Recommendations • Depression is NOT a normal consequence of aging • Vascular depression is characterized by psychomotor retardation, anhedonia, executive dysfunction, poor insight • Psychotherapy is effective • Medication monotherapy • Medications take 4-12 weeks to be effective • SSRIs are first line of medications • TCAs are third line due to arrhythmic and anticholinergic SE