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DEPRESSION IN THE ELDERLY Module developed by James T. Birch, Jr., MD, MSPH Assistant Clinical Professor Dept. of Family Medicine, Division of Geriatric Medicine – PowerPoint PPT presentation

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  • Module developed by
  • James T. Birch, Jr., MD, MSPH
  • Assistant Clinical Professor
  • Dept. of Family Medicine, Division of Geriatric
  • Landon Center on Aging
  • University of Kansas Medical Center

  • Review the diagnostic criteria for depression
  • Increase awareness of the prevalence and
    consequences of untreated depression in the older
  • Discuss screening, treatment, and follow-up for
    those who have depression

  • 1. Define depression
  • 2. Review the epidemiology of depression in the
  • 3. Risk Factors
  • 4. Recognition of signs and symptoms
  • 5. Differential Diagnosis
  • 6. Screening Tools
  • 7. Treatment
  • 8. Review the consequences/complications of
    inadequately treated depression.
  • 9. ACOVE 3 Indicators

  • Depression is under-recognized and undertreated
    in the older adult
  • 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(1) of the symptoms must be depressed mood or
    loss of interest or pleasure
  • Geriatric Nursing (26)32005

What is Depression?
  • DSM-IV-TR (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 (anhedonia)
  • Appetite change or weight loss
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation

What is Depression?
  • DSM-IV-TR (cont.)
  • 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

What is Depression?
  • For Major Depression, these symptoms
  • Produce social impairment
  • Are not related to substance abuse
  • Are not related to bereavement

What is Depression?
  • Types of Depressive Disorders (DSM-IV)
  • Mild episode of major depression
  • Moderate episode of major depression
  • Severe episode of major depression
  • Severe episode of major depression with psychotic
  • AMDA Clinical Practice Guideline

What is Depression?
  • Minor depression is common
  • 15 of older persons
  • Causes ? use of health services, excess
    disability, poor health outcomes, including ?
  • Major depression is not common
  • 12 of physically healthy community dwellers
  • Elders less likely to recognize or endorse
    depressed mood

What is Depression
  • 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
  • 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
  • Nursing Home
  • 10-26
  • Permanent Placement Up to 43
  • Hospitalized
  • 11 45

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

Risk factors
  • Medical diagnosis or diagnoses associated with a
    high risk of depression
  • New admission or change of environment
  • New stressful losses (loss of autonomy, privacy,
    functional status, body part, family member or
  • Personal or family history of depression or mood

  • What medications do YOU prescribe for older
    adults that might place them at risk for

Medications that may cause symptoms of Depression
  • Anabolic steroids
  • Anti-arrhythmic medications (amiodarone,
  • Anticonvulsant medications
  • Barbiturates
  • Benzodiazepines
  • Carbidopa or levodopa
  • Certain beta-adrenergic antagonists (i.e.

Medications that may cause symptoms of Depression
  • Clonidine
  • Cytokines (specifically IL-2)
  • Digitalis preparations
  • Glucocorticoids (prednisone)
  • H2 blockers
  • Metoclopramide
  • Opioids

Laboratory Tests for Evaluation
  • CMP (lytes, BUN, creat, Ca, glucose)
  • CBC
  • Serum levels of anticonvulsant drugs, TCAs,
    digoxin, theophylline
  • Thyroid function (T3, T4, TSH)
  • EKG
  • Folate level
  • UA
  • Vitamin B12

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

Differential Diagnosis
  • Subacute onset
  • Family recognition early
  • Rapid progression
  • Impairment inconsistent over time
  • Pt admits deficits
  • Appears depressed
  • Anhedonia
  • Abstract thought usually normal
  • I dont know response to questions
  • Pt often unconcerned
  • Insidious onset
  • Delayed family recognition
  • Slow progression
  • Impairment consistent slow, gradual decline
  • Pt denies/unaware of deficits
  • Not depressed
  • Can experience pleasure
  • Abstract thought impaired
  • Near miss answers
  • Pt tries to cover up

  • What is the most commonly used and validated
    screening tool for diagnosis of Depression in the
    elderly patient?
  • The Geriatric Depression Scale

Screening Tools
  • Geriatric Depression Scale (GDS validated) 15
    item scale ( gt 5 points or positive responses is
  • Cornell Scale for Depression in Dementia (scoring
    system gt12 means probable depression)
  • Center for Epidemiologic Studies of Depression
    Scale (CES-D)
  • Patient Health Questionnaire 9 (9 item
    self-rating scale)
  • AMDA Clinical Practice Guideline

Screening Tools
  • Two item scale (PHQ-2)
  • 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)
  • Sensitivity 100 Specificity77 PPV 14
  • NEJM 35722 11/29/07

  • The consequences of depression in the elderly
    require serious attention because of the
    disproportionately high risk of suicide
  • For the year 2000, 13 of the U.S. population was
    65 and older, and the suicide rate accounted for
    18 of all suicides
  • Geriatric Nursing (26)3 2005
  • http//

  • Goals of therapy improve mood, function, and
    quality of life
  • Goals of treatment of an acute depressive episode
    are to achieve recovery and prevent future
    episodes of depression
  • The intended outcome should be complete
    resolution of symptoms, not simply a reduction in
    depressive symptoms.
  • Three phases of treatment are generally required
    to achieve these goals.

  • Acute Phase (reverse current episode)
  • Duration about 3 months Goal is complete
    recovery from signs and sx of acute episode
  • Continuation Phase (prevent a relapse)
  • Duration 4-6 months Goal is to prevent relapse
    as sx continue to decline and functionality
  • Maintenance Phase (prevent future recurrence)
  • Duration 3 months or longer Goal is to prevent
    recurrence of a new depressive episode

  • Pharmacotherapy
  • Psychotherapy
  • Electroconvulsive therapy (ECT)

  • Patients should be monitored for response to
    treatment by
  • Observation for resolution of signs and symptoms
    of depression
  • Documenting improvement in scores on screening
  • Improvement in attendance at and participation in
    usual activities
  • Improvement in sleep pattern
  • Also monitor patients carefully for side effects
    and interactions with other medications

Treatment Pharmacotherapy
  • Antidepressants
  • SSRIs
  • Celexa (citalopram) 20-40mg/day
  • Lexapro (ecitalopram) 10-20mg/day
  • Prozac (fluoxetine) 20-40mg q am
  • Paxil (paroxetine) 10-40mg q am or q hs
  • Zoloft (sertraline) 50-200mg q am
  • Better tolerated than tricyclics
  • SIADH at high doses and sexual side effects
  • Interact with CYP-450 isoenzymes by inhibition
  • Can increase the anticoagulant effect of warfarin
  • Do not discontinue abruptly taper the dose

Treatment Pharmacotherapy
  • Antidepressants (SSRIs continued)
  • Nausea and diarrhea might occur
  • Fluoxetine is not a preferred drug for use in the
    elderly due to a prolonged half life (4-6 days
    metabolite 9.3 days) and potential for many drug
    interactions. It might also induce anxiety, sleep
    disturbance, and/or agitation
  • Paroxetine is also not favored due to
    anti-cholinergic properties and other effects
    noted with fluoxetine

Treatment Pharmacotherapy
  • Antidepressants
  • Tricyclics (secondary amines)
  • Norpramin (desipramine) 20-150 qd / q hs
  • Pamelor, Aventyl (nortriptyline) 20 100 mg q hs
  • Potential for anticholinergic and sedative
  • Avoid in pts. who are prone to constipation,
    orthostatic hypotension, glaucoma, or who have
  • May cause ventricular conduction delays and heart
  • May be fatal in overdose

Treatment Pharmacotherapy
  • Antidepressants
  • Bicyclics
  • Effexor (venlafaxine) 75 mg BID
  • Effexor XR 75 100mg qd
  • Fewer drug interactions
  • Can cause or aggravate hypertension
  • Pts. are at risk for withdrawal syndrome

Treatment Pharmacotherapy
  • Antidepressants
  • SNRI and SSRI
  • Cymbalta (duloxetine) 30-60 mg/day
  • Norepinephrine, 5HT2 and 5HT3 antagonist
  • Remeron (mirtazapine) 15-45 mg q hs
  • Can cause serotonin syndrome when given with
    other SSRIs

Treatment Pharmacotherapy
  • Antidepressants
  • Norepinephrine-dopamine reuptake inhibitor
  • Wellbutrin (bupropion) 100 mg TID
  • Wellbutrin SR 150 mg BID
  • Serotonin antagonist and reuptake inhibitor
  • Serzone (nefazodone) 150mg BID
  • Desyrel (trazodone) 50 200mg q hs

Treatment Pharmacotherapy
  • Antidepressants
  • Stimulants
  • Ritalin (methylphenidate) 20mg BID
  • Provigil (modafinil) 400mg q am
  • Dexedrine (dextroamphetamine)
  • 2.5-5mg 7am and noon

Treatment Pharmacotherapy
  • Antidepressants
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Marplan (isocarboxazid) 30 mg/day
  • Nardil (phenelzine) 3045 mg/day
  • Parnate (tranylcypromine) 3040 mg/day
  • Orthostatic hypotension, falls
  • Life-threatening hypertensive crisis if taken
    with tyramine-rich foods, cold remedies (pressor
  • Fatal serotonin syndrome possible if taken with
    SSRI, meperidine

  • Should the elderly patient experiencing
    bereavement be treated for Depression?
  • NO!
  • However, if symptoms of MAJOR DEPRESSION persist
    for more than 2 months after the loss, treatment
    for depression should be strongly considered.
  • Unutzer, J. NEJM, Nov. 29, 2007

Treatment Psychotherapy
  • Cognitive-behavioral
  • Interpersonal
  • Short-term psychodynamic
  • Life review, reminisce
  • Problem solving
  • Supportive
  • Bereavement therapy
  • Behavioral
  • Dialectical-behavioral therapy

Treatment Psychotherapy
  • Individualize standard approaches
  • Cognitive-behavioral therapy
  • Interpersonal psychotherapy
  • Problem-solving therapy
  • Combination with an antidepressant has been shown
    to extend remission after recovery
  • Watch for depressive syndromes in caregivers, who
    might benefit from therapy

Treatment Psychotherapy
  • Individualize choice of drug on basis of
  • Patients comorbidities
  • Drugs side-effect profile
  • Patients sensitivity to these effects
  • Drugs potential for interacting with other

Treatment ECT
  • For depression with pronounced psychotic features
    and resistance to standard medical therapy
  • Effective for treatment of major depression
    mania response rates exceed 70 in older adults

Treatment ECT
  • First-line treatment for patients at serious risk
    for suicide, life-threatening poor intake
  • Standard for psychotic depression in older
    adults response rates 80

Treatment ECT
  • Side Effects
  • Anterograde amnesia improves rapidly after
  • Retrograde amnesia is more persistent recall of
    events just before treatment may be lost
  • Lasting effects not shown in longitudinal studies
  • Right unilateral treatment fewer side effects
    but less effective than bilateral

Treatment ECT
  • Contraindications
  • Increased intracranial pressure
  • Recent MI or CVA and unstable CAD increase risk
    of complications
  • Continue pharmacotherapy following completion of
    ECT treatment
  • May use maintenance ECT to prevent relapse

Treatment Response
Responsive to initial pharmacotherapy 40
  • 40 of cases of major depression respond to
    initial pharmacotherapy within 6 weeks
  • Additional 15 to 25 achieve remission with
    continued treatment for 6 weeks
  • GRS, 2006

Monotherapy fails 35-45
Responsive to continued treatment 15-25
Treatment Response
  • The most common prescribing error is failure to
    increase the dose to the recommended level within
    the first 2 weeks of treatment
  • When monotherapy fails
  • Consider switch to another drug class
  • Combine lithium carbonate, methylphenidate, or
    triiodothyronine with secondary amine TCA
  • Add psychotherapy
  • Consult a geriatric psychiatrist

Treatment Response
  • Reasons for partial response or treatment failure
  • Dementia that is confused with or accompanied by
    late life depression
  • Concurrent psychosis (interferes with diagnosis
    and treatment of depression)
  • Compliance is difficult when patients are

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 older
  • Next highest white males between 65 and 80
  • AMDA Guidelines

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
  • severe anxiety or stress
  • specific plan with access to firearms or other

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

ACOVE 3 Quality Indicators
  • Total of 20 IF-THEN-BECAUSE directives for care
    of Depression they include
  • Screening for and Recognizing Depression
  • Documenting Depression Symptoms
  • Suicidal Ideation
  • Evaluate for Comorbid condition
  • Initiating Depression Treatment
  • Antidepressant Choice

ACOVE 3 Quality Indicators
  • Psychotic Depression
  • Electrocardiogram for Tricyclic Use
  • Interactions with MAOIs
  • Depression Follow-Up
  • The First 12 Weeks of Depression Treatment
  • Continuing Depression Therapy

ACOVE 3 Quality Indicators
  • Indicators 4 thru 7 were selected for review

ACOVE 3 Quality Indicators
  • Indicator 4 IF a VE receives a diagnosis of a
    new depression episode, THEN the medical record
    should document at least three of the nine DSM-IV
    target symptoms for major depression within 2
    weeks of diagnosis, BECAUSE monitoring depression
    treatment requires identification and reevalution
    of the presenting depression symptoms.

ACOVE 3 Quality Indicators
  • Indicator 5 IF a VE receives a diagnosis of a
    new depression episode, THEN the medical record
    should document on the day of diagnosis the
    presence or absence of suicidal ideation and
    psychosis, BECAUSE suicidal patients may require
    hospitalization, and patients with psychotic
    depression may need antipsychotic medication or
    ECT and referral to a psychiatrist.

ACOVE 3 Quality Indicators
  • Indicator 6 IF a VE has thoughts of suicide,
    THEN the medical record should document, on the
    same date, that the patient has no immediate plan
    for suicide or was referred for evaluation for
    psychiatric hospitalization AND..

ACOVE 3 Quality Indicators
  • Indicator 7 IF a VE has thoughts of suicide,
    THEN the medical record should document on the
    same date, that the patient was asked about
    access to firearms, BECAUSE the likelihood of
    suicide increases if the patient has a specific
    plan to commit suicide and access to firearms,
    and it decreases if the patient is hospitalized
    to receive psychiatric care.

  • 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

  • In older adults, depression is
  • Common (especially minor depression)
  • Associated with morbidity
  • Difficult to diagnose because of atypical
    presentation, more somatic concerns, overlap with
    symptoms of other illnesses
  • Differential diagnoses include other medical
    illnesses, dementia, bereavement

  • 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

Final thought
  • On the Threshold of Eternity. In 1890, Vincent
    van Gogh painted this picture seen by some as
    symbolizing the despair and hopelessness felt in
    depression. Van Gogh himself suffered from
    depression and committed suicide later that same

  • Geriatrics Review Syllabus, 6th Edition American
    Geriatrics Society, 2006, Chap. 35, pp. 269-79
  • Nakajima, G.A., Wenger, N.S. Quality Indicators
    for the Care of Depression in Vulnerable Elders
    JAGS (55)S2S302-11 Oct. 2007
  • Current Geriatric Diagnosis and Treatment
    Landefeld, C.S., et al McGraw-Hill Co., 2004.
    Chap. 14, pp. 100-107
  • Depression Clinical Practice Guideline American
    Medical Directors Association
  • Buffum, M.D., et al Treating Depression in the
    Elderly An Update on Antidepressants Geriatric
    Nursing 26(3) 138-142
  • Kotylar, M. Update on Drug-Induced Depression in
    the Elderly Am J of Geriatric Pharmacotherapy
    3(4)Dec. 2005 288-300
  • http//
  • Update on Depression in the Elderly
  • Retrieved 02/19/2009
  • National Institute of Mental Health Older
    Adults Depression and Suicide Facts
  • http//
  • Unutzer, J. Late-Life Depression NEJM 357(22)
    Nov. 29, 2007 pp2269-76