depression in the geriatric

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DEPRESSION IN GERIATRICS SHYAM SUNDAR

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Page 1: Depression in the geriatric

DEPRESSION IN GERIATRICS

SHYAM SUNDAR

Page 2: Depression in the geriatric

Introduction Depression is under-recognized and

undertreated in the older people. 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

Page 3: Depression in the geriatric

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 of the symptoms must be depressed mood or loss of interest or pleasure

Page 4: Depression in the geriatric

What is Depression?

(a.k.a. “core symptoms”; occur most of the day nearly every day) Depressed mood Loss of interest in all or almost all

activities or pleasure Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation

Page 5: Depression in the geriatric

Loss of energy or fatigue Feelings of worthlessness or excessive guilt Difficulty with thinking, concentration, or

decision making Recurrent thoughts of death or suicide Preoccupation with somatic symptoms, health

status, or physical limitations Feelings of guilt or worthlessness Thoughts of wishing you were dead

Page 6: Depression in the geriatric

For Major Depression, these symptoms Produce social impairment Are not related to substance abuse Are not related to bereavement

[the loss of a loved one by death]

Page 7: Depression in the geriatric

Types of Depressive Disorders Mild episode of major depression Moderate episode of major depression Severe episode of major depression Severe episode of major depression with

psychotic features

Page 8: Depression in the geriatric

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

Page 9: Depression in the geriatric

“Late-life” depression (a geriatric syndrome) is a recurrence of depressive symptoms that

initially occurred during early adulthood. there is no known or identifiable precipitating

factor. patients usually have no family history of

depression. Depressed mood is not required to meet criteria for major depressive disorder.

Page 10: Depression in the geriatric

Epidemiology (of major depression)

Community-Dwelling 1 - 9 %

Primary Care Settings 10 – 12 %

Hospitalized

11 – 45 %

Nursing Home

10-26%

Permanent Placement Up to 43%

Page 11: Depression in the geriatric

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

Page 12: Depression in the geriatric

Causes As you grow older, you face significant life changes that

can put you at risk for depression. Health problems – Illness and disability; chronic or

severe pain; cognitive decline; damage to body image due to disease.

Loneliness and isolation – Living alone; a dwindling social circle due to deaths or relocation;

Reduced sense of purpose – Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities.

Fears – Fear of death or dying; anxiety over financial problems or health issues.

Recent bereavement – The death of friends, family members, and pets; the loss of a spouse or partner.

Page 13: Depression in the geriatric

What medications do YOU prescribe for older adults that might place them at risk for

DEPRESSION ?

Page 14: Depression in the geriatric

Medications that may cause symptoms of Depression Anabolic steroids Anti-arrhythmic medications (amiodarone,

mexilitine) Anticonvulsant medications Carbidopa or levodopa Certain beta-adrenergic antagonists (i.e.

propranol)

Page 15: Depression in the geriatric

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

Page 16: Depression in the geriatric

What is the most commonly used and validated screening tool for diagnosis of Depression in the

geriatrics patient?

The Geriatric Depression Scale

Page 17: Depression in the geriatric

Screening Tools Two – item scale

During the previous 2 weeks……..1. Have you often been bothered by feeling

down, depressed or hopeless?2. Have you often been bothered by having

little interest or pleasure in doing things?(“Yes” answer to either is considered positive)

is highly sensitive for detecting major depression in persons over age 65.

Page 18: Depression in the geriatric

TREATMENT Ttreatment is effective in about 80% of identified

cases, when treatment is provided. Effective management requires a biopsychosocial approach, combining pharmacotherapy and psychotherapy. Therapy generally results in improved quality of life, enhanced functional capacity, possible improvement in medical health status, increased longevity, and lower health care costs.

Page 19: Depression in the geriatric

Pharmacotherapy Selective Serotonin Reuptake Inhibitors : fluoxetine Tricyclic Antidepressants : imipramine and

amitriptyline Monoamine Oxidase Inhibitors Other Antidepressants: mirtazapine and

trazo

Page 20: Depression in the geriatric

Consequences and Complications of Inadequately Treated Depression Recurrence, partial recovery, and chronicity . . .

disability use of health care resources

morbidity and mortality Suicide (one fourth of

all suicides occur in

persons 65)

Page 21: Depression in the geriatric

Consequences and Complications of Inadequately Treated Depression

Which demographic in the elderly population has the highest risk

and incidence of suicide?Highest: white males age 80 & olderNext highest: white males between 65

and 80

Page 22: Depression in the geriatric

Consequences and Complications of Inadequately Treated Depression Suicide:

Ask the patients about thoughts of hurting themselves; if YES, ask whether they have a plan; if YES, ask what it is; then ask about stockpiled medications or weapons in the home. Patients with a plan require emergent psychiatric evaluation in ER or local crisis unit.

Page 23: Depression in the geriatric

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.

Page 24: Depression in the geriatric

Consequences and Complications of Inadequately Treated Depression

Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing

Page 25: Depression in the geriatric

Summary All health care workers should maintain a high

index of suspicion for the presence of depression or depressive symptoms in their patients.

Screen older

adults for

depression

at the initial

visit

Page 26: Depression in the geriatric

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

Page 27: Depression in the geriatric

THANK YOU

Page 28: Depression in the geriatric

QUESTION Pharmacotherapy for depression include

these except? A] Selective serotonin reuptake inhibitors B] Tricyclic antidepressants C] Triptans D] Monoamine oxidase inhibitors

Page 29: Depression in the geriatric

All of these denote depression except?A. Anhedonia

B. Appetite change

C. Apnea

D. Psychomotor agitation