8/9/2017

Are All Older Adults Depressed? Common Mental Health Disorders in

Older Adults

Cherie Simpson, PhD, APRN, CNS-BC

Myth vs Fact ➢ All old people get depressed.

➢ Depression in late life is more enduring and difficult to treat than depression at younger ages.

➢ Depression in late life is typically due to psychological factors.

➢ If an older person does not look depressed, he/she does not feel depressed.

➢ If an older person looks depressed, he or she must feel depressed.

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Objectives Gain knowledge: • of the common mental health disorders in the older

adult • on how mental health disorders impact the older adult. • on common pharmacological approaches and not so

common non-pharmacological treatments • on the challenges in treatment of mental health

disorders in older adults

Significance of Mental Health Disorders in the Aging Adult

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Significance: Mental Health Problems in Aging Adults

➔ 1 out of 5 people age 55 years or older experience some type of mental health concern

➔ Mood disorders (such as depression and bipolar) are among the most common conditions

➔ Depression is the most prevalent mental health condition among older adults

➔ More than 50% of nursing home residents have some form of cognitive impairment

Impact of Mental Health Disorders ➔ Mental health issues (particularly depression) are a risk factor

for suicide ➔ Older men have the highest suicide rate of any group

◆ Men > 85 years have a suicide rate of 45.23 per 100,000 vs. overall rate of 11.01 per 100,000

➔ Untreated or undertreated mental health problems adversely affect physical health and ability to function

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* DSM 5 = Diagnostic and Statistical Manual for Mental Disorders 5th Edition

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Depression in the Older Adult

Not normal

aging!

DSM 5: Major Depressive Disorder (Depression)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a

change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of

interest or pleasure. 3. Significant unintentional weight loss/ gain , or decrease or increase in appetite nearly every day.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by

others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt

or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important

areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

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• Elderly less likely to report being sad

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Depression in the Elderly

• Hypochondria features, agitation, suspiciousness or frank paranoia

Depression in Young vs. Old Adults Young Elderly

– Cognitive & physical sx – Emotional sx – Apathy, exaggeration of – Hopelessness, uselessness and

helplessness helplessness – Emptiness, loss of interest, – Negative toward self

social withdrawal – Insomnia

– Hypersomnia, early AM – Eating disorders wakening – Verbal expression of SI

– Anorexia, wt loss – Passive means of suicide

– Less talk of SI > more successful and violent means

(Miller, 2009)

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Differentiating Depression, Delirium, & Dementia

Onset Duration/ Attention Psychomot Mood Psychotic Course Span or activity features

Depression gradual Persistent, normal decreased depressed rarely improves with

treatment

Delirium sudden short decreased Increased Normal to hallucinatio or anxious ns

decreased

Dementia insidio Slowly normal Normal to Normal, Paranoid us progressive decreased apathy delusions

common

Treatments for Depression

• First line: SSRI (Selective Serotonin Reuptake Inhibitor)

Examples are Prozac, Zoloft, Celexa, Lexapro, Viibryd

SNRI (Serotonin-norepinephrine reuptake inhibitors)

Examples are Cymbalta and Effexor

Remeron

Wellbutrin (increases norepinephrine)

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Treatment of Depression

Non medication interventions New ideas

– Psychotherapy: • Transcranial magnetic important even with stimulation medication!! • Genetic testing

– Exercise and diet • L-methylfolate – Increased socialization

– Education about depression

Anxiety • Common symptoms

– Fearfulness – Difficulty thinking, speaking, forming thoughts – Persistent, excessive, and unrealistic worry – May have physical problems such as dizziness,

weakness, poor appetite, excessive appetite, restlessness

– May have panic attacks

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Non Pharmocological Treatment for Anxiety

Talk therapy

Cognitive-behavior therapy: helps to identify and challenge the negative thinking patterns

Exposure therapy: Confront fears in a safe, controlled environment

Treatment for Anxiety – Antidepressants: SSRI, Remeron, SNRI – Benzodiazepines:

• Ativan, Xanax are short acting • Clonazepam and Valium are longer acting • In seniors watch for gait disturbance, delirium, psychosis,

increased depressive symptoms. • Cannot be stopped. Must be tapered to prevent discontinuation

syndrome

– Buspar: • Sometimes it works, sometimes it doesn’t. May take a few weeks

to be effective.

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Benzodiazipines

• Use initially until antidepressant works

• Choose shorter acting – lorazepm

• Alprazolam most abused

• Watch for paradoxical effect

DSM 5: Bipolar I Disorder Characterized by a MANIC episode

Abnormally/persistently elevated, expansive or irritable mood, increased goal-directed activity or energy

3 or more •Inflated self-esteem or grandiosity •Decreased need for sleep •More talkative than usual or pressure to keep talking •Flight of ideas or subjective experience that thoughts are racing •Distractibility •Increase in goal directed activity •Excessive involvement in activities that have high potential for painful consequence

Marked impairment in social or occupational function

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DSM 5: Bipolar II Disorder Hypomanic – same characteristics as manic episode except: •Period is 4 days versus a week •Episode is an unequivocal change in functioning but not to the

level of causing marked impairment (mania) •Observable by others

•If psychotic features are present by definition – mania

•DEPRESSION: occurs in both but not required for diagnosis of Bipolar I but required for Bipolar II

Texas Medical Algorithm (2007) Mania or Hypomania Depression

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DSM 5: Schizophrenia and Schizoaffective Disorder

Schizophrenia - 2 or more for a month • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic

behavior • Negative symptoms (diminished

emotional expression, avolition Must have ruled out schizoaffective

disorder

Schizoaffective disorder • Uninterrupted period of illness with

a major mood episode of either depression or mania with Concurrent with Criteria A of schizophrenia

• Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness.

Proper Use of Antipsychotics FDA Approved Uses of

Antipsychotics Schizophrenia Schizoaffective disorder Delusional Disorder Mood disorder (depression or

mania) with psychotic features

Acute Psychotic Episodes

● An appropriate indication for

use

● A specific and documented

goal of therapy

● Ongoing monitoring of the

effectiveness, achievement of

goal and adverse side effects

● Use only for the duration

needed and at the lowest

effective dose.

CMS Schizophrenia Huntington’s Disease Tourette's Syndrome

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