Paula Bordelon, DO

Dr. Bordelon has no disclosures.

Increased knowledge of comorbidities and risk factors associated with depression in seniors

Ability to recognize signs and symptoms of depression in seniors

Review of USPSTF recommendation as it relates to screening adults for depression

15% of people age 65 and older suffer from depression

Present in 25% of those with chronic illness (e.g. CHF, DM)

Increased risk of mortalityCostly, with direct and indirect costs totaling $43 billion/year

Geriatric Mental Health Foundation; http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.html; last accessed 09/19/14

With less than 4000 geropsychiatrists in U.S., primary care physicians treat

75% depressed elderly present to PCP, not psychiatrists

Increases functional declineDecreases quality of lifeIncreased mortalityExtreme burden on family and caregivers

Prior personal hx depressionFemale Increased stressors (e.g. moved to assisted living)

Lower socioeconomic Cognitive ImpairmentSubstance Use (e.g. alcohol)Bereavement

Depression lasting > 2 years considered chronic & has poor prognosis

Depressive symptoms or minor depressionCommunity 8-15%Long-term care 30-50%In-patient (OABH) 60-70%

Major DepressionCommunity 1 yr prev2.7%Primary Care 5.6%Long-term care 6-25%

Must have depressed mood or anhedonia (without mania or hypomania or substance use or another medical condition)

PLUS:4 other “SIGECAPS”Present at least 2 weeksCause significant distress

Seniors are not always aware of their emotional feelings. May not relay “depression”

SIG E CAPS Sleep d/o Interest Guilt Energy Concentration Appetite/weight Psychomotor

agitation or retardation

Suicidal ideation

Experience anhedonia or depressive mood for at least 2 years (think of it as long-lasting and not lifting)

Plus at least 2 symptoms (not lifting > 2 mths):Poor appetite or overeatingInsomnia or hypersomniaLow energyLow self-esteemPoor concentrationHopelessness

Rare in seniors to have its initial onset in late life

Dysthymia frequently persists from midlife to late life

Do not give this dx if senior ever met criteria for bipolar D/O or cyclothymic D/O

Less frequent than nonpsychotic depression when considering all age groups

Psychotic depression much more common in elderly

Approximately 20 to 45% hospitalized depressed seniors suffer from psychotic depression

Symptoms associated with such include hallucinations or delusions

Antidepressants alone not enoughWarrants antidepressant and antipsychotic or

ECTconsidered first-lineEffective in treatment resistant patients

Symptom Description

Depressed mood or anhedonia Senior won’t state “I am depressed” but exhibits loss of interest or anxiety

Guilt, low self-esteem, or worthlessness

Not common in seniors

Somatic Complaints At risk of delayed diagnosis or misdiagnosed

Psychomotor changes Elderly more likely to exhibit

Insomnia or hypersomnia Hypersomnia much more common in younger adults

Weight loss, anorexia Very common for seniors

Suicidal ideation Elderly make fewer attempts; more likely to be successful

68 year-old retired nurse with no past psychiatric or substance abuse reports a 4-week hx of hearing the voice of her recently deceased husband telling her that he misses her. Her husband suffered an MI while the extended family was on a cruise celebrating their 40th wedding anniversary. The auditory hallucinations occur at night. Ruth feels guilty, because as a RN, she believes she should have “seen this coming.” She reports being “down,” poor appetite and has lost 4 pounds over 45 days, difficulty concentrating resulting in errors at work, insomnia, and fatigue.

Bereavement leads to adverse mental and physical outcomesAssociated increased mortality in the surviving conjugal partner when compared to married persons of the same ageHighest relative risk of mortality occurred 7 – 12 months after spousal loss

Also associated with anxiety, substance use, suicide

Symptoms seen:Marked functional impairmentMorbid preoccupation with worthlessnessPsychotic symptomsPsychomotor retardationPsychosis

Rosenzweig AS, Pasternak R, et al. Bereavement-Related Depression in the Elderly. Is Drug Treatment Justified? Drug & Aging. 1996 May; 8 (5): 323-326.

Functional declineIncreased use of non-mental health services1

Increased medical mortality rate in those mood d/oOverall2: > 4x rate of death over 15 monthsCardiac3: 4x rate of death within 4 mos after MI

1. Beekman et al. Psychol Med 19997;27:1397-1409. 2. Bruce and Leaf. Am J Public Health. 1989;79:727-730. 3. Romanelli e al. J Am Geriatr Soc 2002;50:817-822.

Is a state of chronic stressRisk factor for developing:

diabetes, cognitive impairment, coronary disease (“CAD”)osteoporosis

Depression activates Hypothalamic Pituitary Axis (HPA)

Increased levels of cortisolGreater in those hospitalized vs outpatientNo differences between sexes

HPA hyperactivity varies but does increase risk of diseases, including diabetes by increasing FBS and insulin levels

Stetler C, Miller GE. Depression and hypothalamic-pituitary adrenal activation: a quantitative summary of four decades of research. Psychosom Med. 2011. Feb-Mar; 73(2): 14-26.

Depression is independent risk factor for CAD

At increased risk subclinical atherosclerosis

Hospitalized depressed patients are at increased risk of having a myocardial infarction (“MI”)Death from MI

Individuals suffering MI & depression are at increased risk of another cardiac event

Neurodegeneration leads to depression

Determine if it is dementia syndrome of depression or depression causing cognitive inabilities

Seniors represent 13% of the U.S. population but 18% of suicides

U.S. suicide rate 12.3/100,000 overall in 2011;Age 85+: 16.9/100,000 (41% higher)

Among depressed elderly seen by PCP during a 12 mth period, < 10% received tx for depression before attempted suicide or suicide

70% of suicides occur within 1 month of a visit to PCP

American Foundation for Prevention of Suicide: New Data Issued by CDC Releases 2011 Suicide Statistics.

Seniors have higher ratio of suicide completions to attempts

Higher rates of double suicidesHigher use of firearms in seniors as means to end life

White maleBereavement (e.g. Widow or Widower)Terminal or chronic illness, including perceived ill health

Poor sleepPsychiatric DisorderSocial isolationHx prior suicide attempt(s)

Less frequent in seniorsSymptoms are not typically classic (i.e. hyperactivity, decreased sleep, flight of ideas, grandiose delusions, hypersexual)

Several “unusual” presentations when we think of what we learned in medical school

Syndrome of reversible cognitive impairment which is confused with Alzheimer’s is seen

Take a psychiatric historySpeak to informant (esp. if depressed male)Get past history (i.e. Is this the first episode of depression?)

Suicide attempt hxIf prior hx of depression, obtain previous tx successes and failures

ASK ABOUT SUBSTANCE ABUSE!ASK ABOUT FIREARMS! Investigate if hallucinationsNever assume patient is compliant with therapy

In fellowship, taught to use an objective depression scale (there are quite a few Center for Epidemiologic Studies-Depression Scale) is quantitative so can trend it

Review PHQ-9, GDS, Cornell

Have high degree of sensitivity and specificity

USPSTF states sufficiency in “asking 2 simple questions:1. Over the past 2 weeks, have you felt down, depressed, or hopeless?

2. Over the past 2 weeks, have you felt little interst in doing things?”

Recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, treatment, and followup (Grade B recommendation)

There may be considerations supporting screening for depression in an individual patient (Grade C recommendation)

Positive screen should trigger full diagnostic interview and examination

Cornell Scale for Depression in Dementia – caretaker or family member rates severity of symptoms: mood-related signsBehavioral disturbancesPhysical signsCyclic functionsIdeational disturbances

Geriatric Depression Scale – patient answers subjective questions and validated in many studiesLooks at attitudes and cognitionLess focus on vegetative symptoms

Depression is a prodromeAgain: depression is linked to cognitive impairment, especially if first episode of depression ever

Depression leads to disturbance in executive function; can have “pseudodementia”

Use MMSE or Montreal Cognitive assessment (MOCA)

Take a Medical HistoryMedication side-effectsDrug or alcohol abuseInfection Endocrinopathy (e.g. hypothyroidism)

MalignancyNutritional disordersSleep disorders (don’t miss sleep apnea)

AcyclovirACE-IB BlockerCCBCorticosteroidsDigoxinH2-receptor blockersInterferon alphaL-dopaMethyldopa and clonidine Patten SB, Love EJ. Can Drugs Cause Depression: A review of the evidence.

J Psychiatr Neurosci. Vol 18. No. 3. 1993.

StudyMRI Sleep Study (sleep apnea/MCI/Malaise)UA C&S

ChemistryLFTsThyroid Fxn TestsBun/Cr, GFRFBSVitamin B-12 and folate

Antidepressant medications are the foundation for treatment of moderate and severe late life depression

When considering an antidepressant, is based onEfficacySide effectsDrug interactionsCost

Diagnosis Treatment/therapy

Nonpsychotic MDD SSRI (SNRI) or venlafaxine XR + psychotherapy

Psychotic MDD SSRI (SNRI) or venlafaxine XR + Atypical Antipsychotic ORECT

Dysthymia SSRI (SNRI) + psychotherapy + tx concurrent medical conditions

MDD + insomnia Sedating antidepressant

Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Patients. Postgrad. Med Sp Report 2001 (Oct.): 1-86. PMID: 17205639

FDA-indicated antidepressants are effective in treating late-life depression; don’t choose “off label” medication if unnecessary

Response rate (defined as 50% decrease in symptoms)

Remission rate (defined as > 90% symptom decrease)Typically only achieved in 30 -40% with medication versus 15% for placebo

NNT for remission (drug vs placebo): 4

Avoid TCAs in seniors unless refractory depression because of side effects

Discontinuation 2d to SE is frequent in tx studiesTCA 24%SSRI 17%Side effect TCA (%) SSRI (%)

Dry mouth 28 7

N/V 7.5 17

Drowsiness 15.3 6.5

Vertigo 12.2 7.8

Sleep disturbance

4 2.6

SIADH – most likely as result of SSRIEasy bruising – SSRIs reduce platelet aggregationGI bleed -Bowel Dysfunction (i.e. constipation)Weight Gain (e.g. with TCAs)Decreased libido (not unique to elderly)

Polypharmacy: avg adult > age 65 is on 5 or more medications

Age exacerbates potential for side effectsRenal elimination of drugs decreasesHepatic inactivation of drugs decreasesAnticholinergic vunerability increases

Careful treatment initiation can reduce side effects and PREMATURE withdrawal! Dosing initiation rule: ½ adult dose

Start low and go slowTreatment takes more time:

Acute treatment: 8 weeksIncrease dose: after 6 weeksRemission: MonthsContinuation: 6-12 MonthsMaintenance: 1-5 years vs lifetime

Even with maintenance, there is a high recurrence rate

Maintenance pharmacotherapy reduces recurrence risk (Maintenance means beyond 12 months)

Slower initial responders may do better with combined therapy in maintenance 1

1. Dew et al. J Affect Disord 2001;65:155-166

Psychotherapy is under-prescribed (avoid in the demented because of lack of efficacy)

Effective for non-psychotic MDD and in dysthymia

Several approaches are evidence-basedCognitive Behavior Therapy (CBT)Problem Solving Therapy (PST)Interpersonal Therapy (IPT)

Adequacy of treatmentDuration of treatmentDosage of medicationSolo therapy versus dual therapy

Behavioral factorsPersonality disorderPsychosocial stressors

ComplianceEducation provided

DiagnosisMissed medical conditions

Nonadherence (33-81%) facilitated by:Preference for different treatment (e.g. no medications)

Complexity of medication regimenCost (e.g. too expensive so skip doses)Side effects (e.g. too severe)Cognitive impairment (i.e. noncompliance)

Patterns: underuse, overuse, altered use

Recognition and treatment is poor-missed in 50% of the ambulatory population

Among those treated, treated “inappropriately”:Inappropriate use of medicationsToo low doses for fear of side effectsToo short durationInadequate followup (don’t see often enough)

Delusional depression is more prevalent in older depressives vs younger depressives

Associated with:HypochondriasisDelusional relapsesWorse response to monotherapyLonger hospitalizationsHigher relapse rates

Optimize current therapySwitch therapy to new agentAugment with additional medication or co-prescribe

ECT

SlowerSimpler, less costly

Avoids drug-drug interaction

Reduces SEIntroduce “different mechanism”

QuickerMore complex, costly

Risks drug-drug interaction

Can increase SEAvoids loss of earlier partial response

Augmentation

Venlafaxine when ANXIETY is prominentBupropion when APATHY is prominentMirtazapine when INSOMNIA/ANXIETY are prominent

Aripiprazole is atypical antipsychotic approved for major depressive disorder and bipolar disorder

Challenging in treating depressed older adults who have not responded to multiple trials of antidepressant medications

Elderly with psychotic symptoms who failed antidepressant therapy often do respond to ECT

Some studies suggest that ECT is in fact the SUPERIOR treatment in late life compared to midlife

Underused!Some indications:

Antidepressant intolerance and/or nonresponse

Prior positive response to ECTPsychosisCatatoniaManiaProfound weight loss

Relative contraindications:Cardiac: Recent MI, unstable angina, uncompensated CHF, arrhythmias, severe valvular disease

Neurologic: intracranial lesions “increase” risk, recent CVA

Major concern of patients (transient retrograde amnesia)

ECT may improve depression-impaired cognition but exacerbate impaired cognition of dementia

Preparation:EducationPre-screen to establish baselineMonitor memory throughout treatment Decrease treatment frequency when pronounced

The diagnosis of late-life depression is as valid as any other significant medical disorder.

MDD in seniors is associated with psychiatric and medical morbidity, increased utilization of health care, and increased mortality.

Late-life depression is treatable but may be refractory to a single intervention.

Late-life depression often coexists with cognitive impairment.