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LateLife Depression

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Loss of physical, cognitive or social function from illness. Grief and Bereavement ... Modalities (Individual, Couples, Family or group therapy) ... – PowerPoint PPT presentation

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Title: LateLife Depression


1
Late-Life Depression
  • Seki Balogun, MD
  • Assistant Professor of Internal Medicine
  • Div. of General Medicine, Geriatrics, Palliative
    Care

2
Introduction
  • Serious health concern
  • Significant impact on
  • morbidity and mortality
  • health care costs and utilization
  • In older adults, depressive illness is
  • Under diagnosed
  • Under treated
  • Over 80 of mental health treatment for depressed
    elderly is delivered by physicians other than
    psychiatrists

3
Introduction
  • Not a normal consequence of aging!
  • Different from grief and bereavement
  • Normal responses to life events
  • Loss of a loved one
  • Loss of physical, cognitive or social function
    from illness

4
Grief and Bereavement
  • Usually in response to death of a loved one
  • Causes both somatic and emotional distress
  • Normal grief
  • Distress gradually diminishes over months
  • The bereaved develops a sense of acceptance
  • Considerable range in the duration and intensity
    of process

5
Complicated Grief
  • Persistence of disruptive emotional reactions and
    four of eight symptoms, for at least six months
  • Difficulty moving on
  • Numbness/detachment
  • Bitterness
  • Feelings that life is empty without the deceased
  • Trouble accepting the death
  • Sense that the future holds no meaning without
    deceased
  • Agitation, being on edge
  • Difficulty trusting others since loss
  • Others social withdrawal, difficulty in
    returning to productive living

6
Bereavement related depression
  • Those with complicated grief, who meet the
    diagnostic criteria for major depression and/or
    generalized anxiety disorder
  • Difficult to differentiate
  • Persistence of severe symptoms of early grief
  • Medical sequelae
  • Higher mortality and morbidity (especially in
    men)
  • Substance abuse (alcohol, sedatives, tobacco)
  • Disease exacerbation (CHF, COPD)
  • Treated for depression if symptoms persist for at
    least 2 8 weeks after a major loss

7
Epidemiology
  • Prevalence varies with medical co-morbidities and
    functional status

8
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9
Prevalence
  • Nursing Homes
  • Cognitive impairment increases incidence of
    depression and makes diagnosis difficult
  • In cognitively intact 10 20 percent
  • In cognitively impaired 50 -70 percent

10
Risk Factors
  • Depression in early life
  • Usually have a familial history
  • Female sex
  • Social isolation
  • Marital status
  • Widowed, divorced, separated
  • Lower socioeconomic status
  • Medical comorbidities
  • Uncontrolled pain
  • Insomnia
  • Functional and Cognitive Impairment

11
Impact
  • Increased health utilization and costs
  • Increased office and ER visits
  • Increased drug use
  • Higher risk of substance abuse
  • Increased length of hospital stay
  • Medical comorbidity
  • Fourfold increase in death post- MI
  • 3.4 times more likely to die over 10 years after
    a stroke
  • Increased one year mortality after admission to a
    nursing home

12
Impact
  • Psychiatric comorbidity
  • Anxiety
  • Somatization
  • Suicide risk
  • Less suicide attempt than younger pts, but more
    likely to succeed
  • Highest suicide rate in white men age 85 yrs and
    older 55 per 100,000
  • Most were in 1st depression episode
  • Had seen a physician within last month of life

13
Pathogenesis Late-Life Depression
  • Theories
  • Hormonal mechanism (serotonin, norepinephrine,
    dopamine)
  • Damage to frontal sub cortical pathways
    implicated in some subtypes
  • Neurodegeneration
  • Cerebrovascular disease

14
Classification
  • Major Depression
  • Dysthmia
  • Subsyndromal depression
  • Psychotic depression
  • Vascular depression
  • Dementia related Depression

15
Major Depression
  • DSM IV criteria
  • 5 or more of the following, present for at least
    two weeks
  • Depressed mod
  • Loss of interest or pleasure in activities
  • Changes in appetite or weight
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Difficulty thinking, concentrating or making
    decisions
  • Recurrent thoughts of death or suicidal ideation
    or attempts
  • In late life more likely to be chronic
  • Recovery more transient, frequent relapses
  • More so with extensive comorbidity

16
Dysthmia
  • Chronic, low intensity mood disorder.
  • Symptoms must be present for more than two years
    consecutively.
  • Characterized by
  • anhedonia
  • low self-esteem
  • low energy
  • Greater risk of developing major depression
  • Higher prevalence of cardiac disease
  • May be treatment resistant

17
Subsyndromal depression
  • May not meet criteria for major depression or
    dysthmia
  • Fewer symptoms
  • Shorter duration
  • Typically have high disease burden
  • Poorer health and social outcomes
  • Functional impairment
  • Higher health utilization and costs

18
Psychotic Depression
  • More common in elderly
  • Delusions a prominent presentation
  • Can be
  • Congruent with mood (worthlessness,
    impoverishment, guilt, death)
  • Somatic
  • Paranoid or persecutory
  • Hallucinations (uncommon)
  • Tend to be transient

19
Vascular Depression
  • Develops
  • after an acute cerebrovascular event (post
    stroke depression)
  • In association with chronic ischemic changes in
    brain (vascular depression)
  • Factors in development of PSD
  • Location (left hemisphere)
  • Time from stroke (greatest risk - 1st 3 6
    months, up to two years)
  • Higher risk of vascular dementia

20
Dementia related Depression
  • Depression
  • Can be a prodrome to AD
  • Complication of illness
  • Common complication in other dementia syndromes
  • Parkinsons disease
  • Lewy body dementia
  • Frontotemporal Dementia
  • Huntingtons Dementia

21
Depression in Alzheimer-type Dementia
  • AAGP diagnostic criteria
  • A. 3 or more of the following in 2- week period
  • Clinically significant depressed mood
  • Decreased positive affect
  • Social withdrawal
  • Disturbed appetite
  • Disturbed sleep
  • Psychomotor retardation or agitation
  • Irritability
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Recurrent thoughts of death or suicidal ideation,
    or attempt
  • B. Meets criteria for Alzheimers type Dementia
  • C. Symptoms cause significant distress and
    dysfunction
  • D. Symptoms not caused by delirium or another
    condition

22
Diagnosis
  • Challenging!
  • Helpful clues
  • Mood or somatic symptoms out of proportion to
    that expected
  • Change in mood or interest
  • Poor response to medical treatment
  • Poor motivation to participate in treatment
  • Lack of engagement with care givers

23
Screening tools
  • Two question screener
  • During the past month, have you been bothered by
    feeling down, depressed or hopeless?
  • During the past month, have you been bothered by
    little interest or pleasure in doing things?
  • Geriatric depression scale (multiple sites)
  • PHQ-9 (primary care settings)
  • Cornell Scale for Depression in Dementia
  • Center for Epidemiologic Studies Depression Scale

24
Screening tools
25
Treatment
  • Crucial components
  • Addressing comorbid conditions
  • Tailoring treatment interventions to patient
  • Monitoring therapy for side effects and
    effectiveness
  • Assuring close follow up

26
Treatment
  • Complete history guides treatment!
  • Assess for suicide ideation, plan, attempt
  • Urgent psychiatric referral!
  • Assess for psychotic symptoms
  • Is the patient on medications with depressant
    side effects (benzodiazepines, opiates) or
    abusing alcohol?
  • Other medical conditions associated with
    depression (hypothyroidism, diabetes)?
  • Hx of prior depressive episodes, prior drug
    therapy?
  • Family history

27
Treatment
  • Psychotherapy
  • Pharmacotherapy
  • Electroconvulsive therapy
  • Can be used in combination or singly
  • Better outcomes with combination therapy

28
Psychotherapy
  • Useful but underutilized
  • Limiting factors
  • Medicare and other insurances reimburses only 50
    percent of allowable charge
  • Availability of adequately trained therapists
  • Modalities (Individual, Couples, Family or group
    therapy)
  • Effective for older patients and their caregivers

29
Pharmacotherapy
  • Efficacy comparable across medication classes
  • Side effect profile determine medication
    selection
  • All medications typically take 4 6 weeks to
    show efficacy , in elderly patients may take
    longer (8 16 weeks)
  • Monotherapy preferred when possible
  • Start low, go slow!

30
Selective serotonin reuptake inhibitors (SSRIs)
  • First line
  • Better tolerated
  • Potential side effects
  • Parkinsonism
  • Akathisa
  • Anorexia
  • Sinus bradycardia
  • Hyponatriemia
  • Serotonin syndrome (AMS, myoclonus, tremors,
    hyperreflexia, fever, autonomic changes)
  • May be less efficacious than other drugs or ECT
    in severe forms of melancholic and psychotic
    depression

31
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32
Dual action agents
  • Venlafaxine and duloxetine
  • Serotonin norepinephrine reuptake inhibitors
    (SNRIs)
  • 2nd line agents
  • Useful in patients with pain
  • Well tolerated (less in the frail elderly)
  • Potential adverse effects
  • Dose-dependent risk for diastolic hypertension
  • GI distress (less with Venlafaxine XR)
  • Agitation (less with Venlafaxine XR)

33
Dual action agents
  • Miirtazepine
  • Serotonergic and noradrenergic properties
  • Useful in insomnia, agitation, weight loss or
    anorexia
  • Maybe useful in parkinsonism, essential tremors
    or nausea from chemotherapy
  • Side effects
  • Sedation (diminish with prolonged use and higher
    doses)
  • Appetite increase and weight gain
  • Dry mouth
  • Constipation
  • Serotonin syndrome

34
Atypical antidepressants
  • Few studies in the elderly
  • Bupropion
  • Activating maybe useful in lethargy, daytime
    sedation or fatigue
  • Contraindicated in seizure disorders, concurrent
    use of benzodiazepines, alcohol detoxification,
    hx of bulimia
  • Adverse effect dose-dependent diastolic
    hypertension

35
Atypical antidepressants
  • Nefazodone
  • Available in US in generic preparation only
  • Brand Serzone removed from market due to
    hepatotoxicity
  • Useful in depressed pts with insomnia, anxiety,
    agitation
  • Side effects sedation, restlessness,
    hyponatriemia
  • Patent inhibitor of CYP450-3A4 isoenzyme
  • Significant drug- drug interactions with
    macrolide antibiotics, antiarrythimcs and other
    psychotropics

36
Atypical antidepressants
  • Trazodone
  • Sedative effect at low doses
  • Rarely used as a sole agent
  • Antidepressant effect at higher doses
  • Orthostatic hypotension
  • Excessive daytime sleepiness
  • Other side effects hyponatriema, priapism (rare)

37
Tricyclic antidepressants
  • Significant side effects in the elderly
  • Anticholinergic (orthostatic hypotension, urinary
    retention, constipation, increased confusion,
    cardiac conduction effects)
  • May be useful in psychotic depression (severe)
  • May reduce risk of relapse after ECT
  • Secondary amine TCA (nortriptyline, desipramine)
    better tolerated than tertiary amine TCAs
    (amitriptyline, imipramine, doxepin)

38
Monoamine oxidase inhibitors
  • Rarely used in elderly
  • Except
  • if previously tolerated or treatment responsive
  • Resistant to all other antidepressants
  • Special dietary and medication restrictions to
    prevent serotonin syndrome and hyperadrenergic
    crisis
  • Side effects orthostasis, agitation, insomnia

39
Duration of treatment
  • Usual course for first episode in most adults 6
    -12 months after full remission
  • To prevent relapse (higher in elderly)
  • Gradual taper required with most medications
  • Long term treatment may be required in
  • Frequent relapses or recurrence
  • Chronic dysthmia or depression
  • Long term safety data in elderly (esp. with
    comorbities) lacking

40
Electroconvulsive therapy
  • Important and viable treatment option for
    depression in elderly
  • Used in medication resistant cases
  • More commonly used in older patients
  • Poorer tolerance and response to medications
  • May develop more severe complications of
    depression
  • Therapeutic response in majority of cases
  • Adverse effect
  • Confusion post ECT (usually transient)

41
Brain stimulation therapies
  • Being evaluated for treatment of depression
    refractory to ECT
  • Used in Parkinsons disease and epilepsy
  • Limited data in the elderly

42
Summary
  • Late life depression is sometimes difficult to
    diagnose
  • Has significant impact on quality of life and
    health outcomes
  • Not a normal consequence of aging
  • Highest suicide rates in the elderly
  • Excellent response with different treatment
    modalities
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