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GERIATRIC DEPRESSION

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How is Depression Different in the Elderly? Less verbalization of emotions or guilt ... MEDICAL THERAPY IN GERIATRIC DEPRESSION ... – PowerPoint PPT presentation

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Title: GERIATRIC DEPRESSION


1
GERIATRIC DEPRESSION
  • July 11, 2000
  • Pat Borman, M.D.
  • Swedish Family Medicine

2
Case 1
  • JT is an 80 y.o. white male
  • Complaints - bad taste in mouth, sore muscles,
    dizziness, constipation. Repeated visit to
    doctor with vague symptoms.
  • Daughter reports impossibly uncooperative with
    angry outbursts.
  • Widowed 3 years ago, moved in with daughter 3
    months ago

3
CASE 2
  • MG is a 78 y.o. asian female
  • Complains bitterly of a left facial pain or
    fullness to you, her family and her friends
  • On her own saw a neurologist, rheumatologist, ENT
    specialist, accupuncturist, massage therapist
  • Trails of NSAIDS, narcs, neurontin, capsaicin,
    ice, heat, steroids have failed

4
CASE 3
  • AR is an 85 y.o. black female
  • Large CVA last year, required nursing home
    placement
  • Withdrawn, makes no friends, no interest in
    activities
  • Poor sleep, loosing weight
  • Anxious, fretful, afraid her son will not come to
    visit

5
INCIDENCE OF DEPRESSION
  • GERIATRIC
  • 3 community dwelling
  • 14 two years after spouse dies
  • 15 medically ill
  • 25 chronic care facilities
  • 25-35 have depressive symptoms

6
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, wt loss, feelings
    of worthlessness/guilt, loss of concentration and
    focus, recurrent thoughts of death

7
How is Depression Different in the Elderly?
  • Less verbalization of emotions or guilt
  • Minimize or deny depressed mood
  • Preoccupied with somatic symptoms
  • Cognitive impairment can be huge
  • More anxiety, agitation and psychosis
  • Medical Conditions can mask OR cause depression

8
Medical Conditions Mask or Cause Depression
  • Metabolic
  • Endocrine
  • Autoimmune
  • Disorders
  • Infections
  • Neoplasms
  • Cerebrovascular
  • Disease
  • Degenerative Neurological Disease
  • DRUGS
  • Propranolol
  • Cimetidine
  • Clonidine
  • Benzodiazepines
  • Steroids
  • MANY,MANY MORE

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

10
INTERVENTIONS
  • Seek out medical illness
  • Recognize medical side effects
  • Rehab services to maximize remaining function
  • Involve Family/care taker
  • Counseling role transitions, grief, family
  • Medications
  • ECT

11
SUICIDE IS THE REAL RISK
  • 25 of all completed suicides are 65
  • Suicide rate for depressed men over 65 is 5 times
    higher than for younger men
  • Men60 complete guns or hanging
  • Women70 attempt with drugs
  • Increased risk financial problems, physical
    illness, recent loss, ETOH, abuse, isolation

12
GERIATRIC PRESCRIBING PRINCIPLES
  • C Caution, Compliance
  • A Adjust dose for Age
  • R Review, Remove, Reduce
  • E Educate
  • START LOW GO SLOW

13
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

14
PREFERRED ANTIDEPRESSANTS
  • SSRIs
  • Celexa, Paxil
  • Zoloft, Prozac
  • TCA
  • Nortriptyline
  • HCA
  • Wellbutrin
  • Serzone
  • Least side effects
  • good safety record
  • cost can be a problem
  • Least expensive
  • activation, tremor
  • anxiolytic

15
ACCEPTABLE ANTIDEPRESSANTS
  • TCA
  • Despiramine
  • HCA
  • Trazodone
  • Remeron
  • SNRI
  • Effexor
  • Sedation, hypotension
  • cognitive slowing
  • appetite, wt gain
  • constipation
  • Dizzy, anorexia, nausea, BP increase

16
ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY
  • Too many side effects
  • TCA
  • Amitriptyline, doxipine, protriptyline,
    Amozapine, trimipramine
  • MAOI
  • Phenalizine, trancypromine

17
CASE 1 Treatment Options
  • Consider Serzone for anxiolytic properties
  • Much too expensive for him
  • Start Nortriptyline 10 mg q d
  • Family Counseling for role transitions, and grief
    counseling
  • Excellent response, household happier

18
CASE 2 Treatment Options
  • After 14 months of exhausting all the specialists
    and unhappy with the side effects off all the
    drugs
  • Start PAXIL 10 mg q d
  • Pain and facial pressure completely resolved in
    14 days

19
CASE 3 Treatment Options
  • Given wt loss, inability to sleep
  • Select Remron 15 mg q hs
  • In 8 weeks she is up 7 pounds, starting to make
    friends, went on her first nursing home outing,
    such a good response to rehab the family is
    considering taking her home.
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