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GERIATRIC DEPRESSION

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But, elderly patients less willing to talk about psychological problems. Pay attention to: ... How is Depression Different in the Elderly? ... – PowerPoint PPT presentation

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Title: GERIATRIC DEPRESSION


1
GERIATRIC DEPRESSION
  • November 13, 2001
  • Eric Troyer, M.D.
  • Swedish Family Medicine

2
Case 1
  • Eva is an 80 y.o. female
  • Complaints Poor sleep, mild weight loss due to
    poor appetite, slowing down recently.
  • History of incontinence, cardiovascular disease,
    and diabetes.
  • How might you approach this patients problems?

3
DSM-IV DIAGNOSTIC CRITERIA
  • 5 or more symptoms lasting 2 wk, change from
    previous functioning
  • Depressed mood and/or loss of interest
  • Altered sleep, loss of energy, appetite change or
    weight loss, feelings of worthlessness/guilt,
    psychomotor changes, loss of concentration and
    focus, recurrent thoughts of death

4
SIG E CAPS
  • Sleep
  • Interest
  • Guilt (Are you a burden to others?)
  • Energy
  • Concentration
  • Appetite
  • Psychomotor changes
  • Suicidality (Do you wish you could die?)

5
Vegetative Symptoms
  • Sleep
  • Interest
  • Guilt (Are you a burden to others?)
  • Energy
  • Concentration
  • Appetite
  • Psychomotor changes
  • Suicidality (Do you wish you could die?)

6
Vegetative Symptoms
  • These can often occur in other medical illnesses
  • Not discriminating or sensitive

7
Psychological Symptoms
  • Sleep
  • Interest
  • Guilt (Are you a burden to others?)
  • Energy
  • Concentration
  • Appetite
  • Psychomotor changes
  • Suicidality (Do you wish you could die?)

8
Psychological Symptoms
  • More reliable and are independent of age
  • But, elderly patients less willing to talk about
    psychological problems
  • Pay attention to
  • anxiety
  • physical discomfort
  • adaptation to a new lifestyle

9
SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION
  • SYMPTOMS
  • MOOD
  • COGNITIVE
  • VEGETATIVE
  • VOLITIONAL
  • SIGNS
  • APPEARANCE
  • BEHAVIORS
  • PSYCHOMOTOR RETARDATION
  • PHYSCHOMOTOR AGITATION

10
Case 1
  • SIG E CAPS DM for Eva
  • Positives Sleep, Appetite, Psychomotor
    retardation
  • Negatives Interests, Guilt, Energy,
    Concentration, Suicidality, Depressed mood

11
Case 1
  • Poor sleep due to nocturia.
  • Appetite changes due to decreased taste and
    smell.
  • Slowing down due to new claudication.

12
Case 2
  • George is a 74 y.o. male
  • Complaints Sore muscles, dizziness,
    constipation. Repeated visits to doctor with
    vague symptoms.
  • Daughter reports patient impossibly uncooperative
    and has angry outbursts.
  • Wife died 2 years ago he moved in with daughter
    3 months ago after a fall.

13
INCIDENCE IN ELDERLY
  • MAJOR DEPRESSION
  • 3 community dwelling
  • 14 two years after spouse dies
  • 15 medically ill
  • 25 long-term-care settings
  • DEPRESSIVE SXS
  • 17-37 in primary care settings
  • 42 in long-term-care settings

14
How is Depression Different in the Elderly?
  • Less verbalization of emotions or guilt
  • Minimize or deny depressed mood (masked
    depression)
  • Preoccupied with somatic symptoms
  • 65 have hypochondriacal symptoms
  • Cognitive impairment can be marked
  • Hopelessness appears to be persistent

15
How is Depression Different in the Elderly?
  • Depressive ideation, anxiety, psychomotor
    retardation, and weight loss have high assoc.
    with disability
  • More anxiety, agitation and psychosis
  • esp. delusions with themes of guilt, nihilism,
    persecution, jealousy
  • Medical Conditions can mask or cause depression

16
How is Depression Different in the Elderly?
  • Subsyndromal depression is more common and
    presents as
  • new medical complaints
  • exacerbation of GI sxs or arthritic pain
  • cardiovascular sxs
  • preoccupation with health
  • diminished interest, fatigue, poor concentration

17
Case 3
  • Francine is a 67 y.o. female
  • Complaints Sad, decreased interests, shaky,
    falling apart.
  • Your nurse mentions that she took a while to
    bring back, esp. out in the lobby.
  • Your exam shows tremor and cogwheel rigidity.

18
Medical Conditions Mask or Cause Depression
  • Autoimmune
  • Cerebrovascular
  • Chronic pain
  • Degenerative Disease
  • Endocrine
  • Metabolic
  • Neoplasms
  • Infections
  • DRUGS
  • Propranolol
  • Cimetidine
  • Clonidine
  • Benzodiazepines
  • Steroids
  • Tamoxifen
  • Many more...

19
Parkinsons Disease
  • About 50 of patients develop depression
  • Useful treatment includes TCAs
  • ECT helps depression and PD sxs
  • tremors, rigidity, bradykinesia improved with
    3-4 sessions
  • depression improved after 7-9 sessions

20
Early Alzheimers Dz
  • Presents with
  • insomnia
  • fatigue
  • agitation
  • psychomotor retardation
  • decreased interest energy
  • concentration problems
  • 50 of AD pts have depressive sxs (15-20 with
    major depression)

21
Vascular Depression
  • Cerebrovascular disease can precipitate or
    perpetuate depression
  • Caused by ischemia (silent strokes) in
    prefrontal cortex and basal ganglia motor
    sensory deficits usu. not found.
  • Apathy, psychomotor retardation, cognitive
    decline
  • May explain incr. depression s/p CABG

22
Pseudodementia
  • aka dementia of depression
  • cognitive decline that clears if depression is
    treated
  • however, dementia rate in these patients is still
    20/year even after full recovery of intellectual
    function

23
Workup
  • It might include
  • H P
  • CBC, TSH, testosterone
  • ESR, renal/liver function
  • U/A
  • EKG
  • brain imaging if tumor or vascular disease
    suspected

24
Case 4
  • Eugene is a 70 y.o. male
  • Dxd with bladder cancer, had cystectomy and now
    with Indiana pouch. Needs to cath through
    umbilicus q4hr. His wife recently dxd with
    breast cancer.
  • Pt. has single episode of major depression 25
    years ago following tough work situation and
    increased EtOH use.

25
Case 4 (contd)
  • Symptoms Withdrawn, no interest in activities
    (not even Mariners games), sleeping excessively,
    lost 10, constant worry about cath procedure,
    belief he is burden to family.
  • Statements like, I wish I was dead, and, my
    problem will affect this entire hospital.

26
Case 4
  • SIG E CAPS DM for Eugene
  • Positives Sleep, Interests, Guilt/Burden,
    Energy, Concentration, Appetite, Psychomotor
    retardation, Suicidal (passive), Depressed mood
  • Additional findings Nihilistic, Delusional

27
SUICIDE IS A REAL RISK
  • 25 of all completed suicides are 65
  • Suicide rate for depressed men over 65 is 5 times
    higher than for younger men
  • 20 of older people who committed suicide saw a
    physician that day
  • Increased risk financial problems, physical
    illness, recent loss, EtOH, abuse, isolation

28
INTERVENTIONS
  • Seek out medical illness
  • Recognize medical side effects
  • Rehab services to maximize remaining function and
    retrain impaired iADLs
  • Involve family and caretakers
  • Counsel re role transitions, grief, dependency
  • Medications / ECT

29
GERIATRIC PRESCRIBING PRINCIPLES
  • C Caution, Compliance
  • A Adjust dose for Age
  • R Review, Remove, Reduce
  • E Educate
  • START LOW GO SLOW

30
MEDICAL THERAPY IN GERIATRIC DEPRESSION
  • Select based on symptoms, prior response,
    concurrent illness, side effect profile
  • Reassess after 4-6 weeks
  • Increase dose, augment with second agent, add
    psychotherapy
  • Consider psychiatric consult/referral

31
PREFERRED ANTIDEPRESSANTS
  • SSRIs
  • Celexa, Paxil
  • Zoloft, Prozac
  • TCA
  • Nortriptyline
  • Others
  • Wellbutrin
  • Serzone
  • Remeron
  • fewer side effects
  • good safety record
  • more expensive
  • least expensive
  • activation, tremor
  • anxiolytic, somatic
  • sleep, appetite

32
ACCEPTABLE ANTIDEPRESSANTS
  • TCA
  • Desipramine
  • HCA
  • Trazodone
  • SNRI
  • Effexor
  • Sedation, hypotension
  • cognitive slowing
  • Dizzy, anorexia, nausea, BP increase

33
ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY
  • Too many side effects
  • Older TCAs
  • amitriptyline, clomipramine, doxepin, imipramine,
    protriptyline, trimipramine
  • MAOIs
  • phenelzine, tranylcypromine

34
Other Drugs
  • Newer atypical anti-psychotics
  • for jump start or behavior issues
  • Risperdal (risperidone), Seroquel (quetiapine),
    Zyprexa (olanzapine)
  • Psychostimulants
  • for jump start or for severe apathy

35
Electroconvulsive Therapy (ECT)
  • Works well for psychotic depression, high suicide
    risk, Parkinsons-related depression, failed drug
    treatment
  • Very effective short term, but with high relapse
    rates over next 6-12 months.
  • Drug therapy can reduce relapse
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