depression in the geriatric
TRANSCRIPT
DEPRESSION IN GERIATRICS
SHYAM SUNDAR
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
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
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
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
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]
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
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
“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.
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%
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
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.
What medications do YOU prescribe for older adults that might place them at risk for
DEPRESSION ?
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)
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
What is the most commonly used and validated screening tool for diagnosis of Depression in the
geriatrics patient?
The Geriatric Depression Scale
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.
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.
Pharmacotherapy Selective Serotonin Reuptake Inhibitors : fluoxetine Tricyclic Antidepressants : imipramine and
amitriptyline Monoamine Oxidase Inhibitors Other Antidepressants: mirtazapine and
trazo
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)
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
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.
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.
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
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
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
THANK YOU
QUESTION Pharmacotherapy for depression include
these except? A] Selective serotonin reuptake inhibitors B] Tricyclic antidepressants C] Triptans D] Monoamine oxidase inhibitors
All of these denote depression except?A. Anhedonia
B. Appetite change
C. Apnea
D. Psychomotor agitation