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Depression in the Elderly
Matthew J. Beelen, MD
Geriatric Specialists
Lancaster General Health
June 18, 2014
What is depression…?
A Common Scenario…

Before your office visit with your 82 year-old
male patient, you receive the following
message from his daughter:
 “Over
the last few months Dad has been really
irritable and gets angry with us when we try to talk
about getting him more help. My siblings and I
wonder if an antidepressant would help? Can
you talk to him about this at your visit?”
Another scenario…


You’re going to see a 78 year-old woman with
moderate dementia who recently moved to
skilled care from home after having a fall and
suffering a spinal fracture. She is getting
therapy and pain management.
Staff is concerned because she is not
motivated to leave her room, is resisting
participation in therapy, and is only eating 25%
of meals. She is often tearful and cries, “My
kids put me away in a home!”
Objectives





Discuss diagnostic criteria for major depressive
disorder and related conditions
Assess depressive symptoms looking at the
overall patient context
List other medical conditions that can produce
depressive symptoms or mimic depression
Discuss non-medication strategies of treatment
Discuss approaches to medical treatment
Epidemiology


5% of community dwelling older adults age 65 and older
meet criteria for Major Depressive Disorder (MDD)
“Clinically significant” depression is more common



Under-recognized and under-treated




10-15% of older adults in primary care
30-50% in institutional settings and long-term care
Stigma
Symptoms may be considered part of normal aging
Harder to diagnose in the setting of other medical problems and
cognitive impairment
Normal emotions over-treated?
JAMA 2012;308:909-918.
Significance of Depression






Poor quality of life
Difficulty with social, physical, and cognitive
functioning
Poor adherence to medical treatment
Worsening of chronic medical problems
Increased healthcare utilization
Increased morbidity and mortality from suicide
and other causes

Estimated rate of suicide: 5-10% of depressed elderly
N Engl J Med 2007;357:2269-2276.
Ann Clin Psychiatry 2007;19:221-238.
Spectrum of Mood Disorders








Major Depressive Disorder (MDD)
Minor Depression
Dysthymic Disorder
Bereavement
Adjustment Disorder
Depression concurrent with Alzheimer’s disease
Bad Days…
A word about checklists…
Diagnostic Criteria
Criteria for Major Depression









Depressed mood (core)
Significant loss of interest
or pleasure - anhedonia
(core)
Sleep disturbance
Appetite Disturbance or
significant weight gain/loss
Persistent fatigue or loss of
energy
Difficulty with concentration or
decisiveness
Feelings of worthlessness or
excessive guilt
Psychomotor retardation or
agitation
Recurrent thoughts of death
or suicidal thoughts



1 core and at least 5
total - nearly every
day for at least 2
weeks
Other medical and
psychiatric conditions
ruled out
Impaired function as a
result of these
symptoms
DSM IV
Late Onset Major Depression

Late onset: (>age 60?)
recurrent “young” onset
 Less likely to have positive family history
 More likely to have vascular risk factors
 More likely to have cognitive impairment
 Precursor to dementia?
 vs

30% of MDD in older adults is late onset
Ann Clin Psychiatry 2007;19:221-238.
Annu Rev Clin Psychol 2009;5:363-389.
Criteria for Minor Depression

Periods of depression similar to Major
Depression
 Fewer
symptoms
 Still
require either sadness or anhedonia
 2-4 symptoms total
 Less
impairment
 Clinically
significant distress, or
 Can have impaired function or near normal function
with considerably increased effort
 “Sub-syndromal
DSM IV
depression”
Dysthymic Disorder

Depressed mood most days for at least 2 years


No gap > 2 months without symptoms
At least 2 additional symptoms when depressed:
Appetite disturbance
 Sleep disturbance
 Low energy
 Low self-esteem
 Poor concentration or decision-making ability
 Feelings of hopelessness


Symptoms cause significant distress or impaired
functioning
DSM IV
Bereavement

In response to death of a loved one
Many symptoms of Major Depression
Consider Major Depression if symptoms
persist beyond 2 months, or if there are severe
symptoms

What is normal bereavement?


DSM IV
Adjustment Disorder


Emotional / behavioral symptoms (depression,
anxiety, or conduct) in response to an identifiable
stressor occurring within 3 months of the stressor
Clinically significant symptoms
Greater than expected distress
 Symptoms lead to significant impairment in function



Not bereavement
Symptoms do not last longer than 6 months after
the stressor has terminated
DSM IV
Bipolar Disorders

Evidence of Mania
 Abnormally
and persistently elevated, expansive,
or irritable mood
 Examples – grandiosity, excessive spending or
sexual activity, racing thoughts, excessive
productivity


Usually psychiatrist input is helpful
Not covered further in this talk
Perspective…

Video Clip
The Elderly in Context

Consideration of an older person’s life history
along with recent and current circumstances
can be helpful in evaluating symptoms of
depression

82 year-old man in the office…

78 year-old woman in the nursing home…
Mental Health Context and Risk Factors

Personal history
 Mood
disorders
 Anxiety
 Life-long personality and coping styles

Family history

Substance use and abuse
Medical Context and Risk Factors





Prior stroke,
myocardial infarction,
vascular disease
Parkinson’s
Alzheimer’s Disease
or other cognitive
disorders
Hypothyroidism
Significant pain and
pain medications





Medications:
sedatives, CNS
acting meds
Urinary incontinence
Vision loss
Sleep disorders
Overall burden of
medical illness
Social Context and Risk Factors






Marriage Status
Support network – family, friends, church, faith
Functional Status and Independence
Being a caregiver
Lower socioeconomic status or lower education
Recent Losses or Stressors
Death of loved one
 Move from long-time home / community
 Retirement
 Loss of driver’s license
 Unable to continue hobbies
 Financial stress

Diagnostic Challenges

Sadness/depression – reported less by elderly
 Hopelessness,
irritability, anhedonia, anxiety,
apathy may be more common
 More common somatic symptoms




Fatigue or low energy?
Appetite and weight changes?
Sleeping problems?
Apathy?
Ann Clin Psychiatry 2007;19:221-238.
-
Mojtabai R. NEJM 2014;370:1180-82.
Is DSM wrong?
Big Pharma impact?
“Pills for Ills”?
Doctors getting sloppy?
Diagnosis - PHQ


Patient Health Questionnaire
Covers the 9 Criteria of DSM for MDD


First 2 items are the core symptoms (PHQ-2)
Patient reported frequency of each symptom over
the last 2 weeks
“Not at all” = 0
 “Several days” = 1
 “More than half the days” = 2
 “Nearly every day” = 3


Overall Score is totaled
Diagnosis - PHQ


Scores correlate with diagnosis, severity, and
response to treatment
PHQ-2 and PHQ-9 (used on MDS 3.0)
 PHQ-2
(cut off of 3): 83-100% sensitivity, 77-92%
specificity – if positive, a more in-depth evaluation
should be done – a screening test
 PHQ-9 (cut off of 10)
 Sensitivity
of 88% for significant depression
 Specificity of 88%
N Engl J Med 2007;357:2269-2276.
JAMA 2012;308:909-918.
Diagnosis – Geriatric Depression Scale


GDS 5, 15, 30 item
“Yes” and “No” questions based on common
symptoms of depression
 Does
not cover physical/somatic symptoms (e.g.
sleep)

In primary care elderly (15 item, cut-off of 6)
 81%

sensitive, 78% specific
Well validated in cognitively intact ECF
patients
Arthritis Care and Research 2011;63:S454-S466.
PHQ and GDS Pitfalls



Completion by staff caregivers may not be as
accurate
Not accurate for patients with significant
cognitive impairment or poor insight
Numbers versus diagnoses
 Consider
other
contributing factors
 Consider function
AMC Case

78 year old woman, MOCA 19/30, mild to
moderate mixed dementia (AD+microvascular)
Recently paranoid, agitated, tearful, lonely. Per
husband: “She doesn’t want to live this way, she
hopes I pray that she will die…”

PHQ-9 = 3 (normal)!

What do we make of that?

Depression and Cognitive Impairment


Between 30-50% of patients with Alzheimer’s
may have significant depression
Common underlying pathology?
 Depression



as a prodrome to dementia
One can cause the other
Cognitive impairment can make evaluation of
depression more difficult
Unclear if treating depression in dementia
helps
Nelson JC et al. J Am Geriatr Soc 2011;59:577-585.
2011 Meta-analysis looking at treating depression in dementia
- 7 trials, 330 patients
- “all trials significantly underpowered…inconclusive findings”
Nelson JC et al. J Am Geriatr Soc 2011;59:577-585.
Evaluation of Depression in Dementia

Cornell Scale for Depression in Dementia
 Uses
report of informed caregiver with possible
contribution of patient
 19 questions looking at frequency of symptoms
over the last week
 Primarily a screening test
 Scores correlate with major and minor depression
 8-11:
minor depression
 12 and greater: major depression
 Limited
research in ECF settings
Dement Geriatr Cogn Disorders 2010;29(5):438-47
AMC case:
Cornell Scale = 11
Evaluation of Depression in Dementia

NIMH Provisional Criteria for Depression in AD (NIMH-dAD)

3 of the following – present in the previous 2 weeks (at least 1
must be *) – caregiver and patient responses











Depressed mood*
Anhedonia*
Social isolation
Concentration is not one of the criteria
Poor appetite
Poor sleep
Psychomotor changes
Irritability
Fatigue and loss of energy
Feelings of worthlessness, hopelessness, or excessive guilt
Suicidal thoughts or recurrent thought of death
94% sensitive, 85% specific for major+minor depression

Overdiagnosis?
Am J Geriatr Psychiatry 2008;16:469-47.
Treatment of Depression
Treatment of Depression

Most of the studies on treatment have been
done on people who meet the criteria for major
depression

The best approach is unclear for people who
do not meet full criteria
 Watchful
waiting with close monitoring may be
appropriate in milder cases
Non-pharmacologic Treatment



Psychotherapy
Exercise
Community Resources
Psychotherapy


Many patients may prefer this over medications
Main Types:






Cognitive-behavioral therapy – to correct negative thoughts
Interpersonal therapy – focuses on interpersonal causes of
depression
Problem-solving treatment – learning new strategies for solving
everyday problems associated with depression
Shorter types: activity scheduling, behavioral activation
Work with patient preferences
Establish relationship with local mental health specialists
who can provide this therapy
JAMA 2012;308:909-918
Psychotherapy - Efficacy



May be as effective as medications
45-70% have significant improvement,
compared to 25-35% of controls
Combined therapy with medications may be
better than either therapy alone
N Engl J Med 2007;357:2269-2276.
Exercise and Physical Activity




Mode, duration, and intensity varies among
studies
Any amount may help – tailor to person’s
abilities and interests
Better for mild-moderate depression in those
motivated to do it
May be hard for older, more frail patients or
those with severe depression
JAMA 2012;308:909-918
Other Options




Community Crisis Phone Lines
Insurance Company Mental Health Support
Pastoral Support
Support groups
 Bereavement
 Caregiver
 Widow
/ widower
 Condition specific (e.g. cancer, Parkinson’s)
Medications…
Treatment - Medications




Relatively few placebo-controlled studies
examining efficacy in late-life depression
Much of the information we have is from studies in
younger patients with few numbers of elderly, with
the results extrapolated to the elderly
Some studies do not show benefit in late life
depression
Generalizing from studies to our individual
patients can be hard as the studies often exclude
patients with multiple comorbidities or cognitive
impairments
Ann Clin Psychiatry 2007;19:221-238.
Moderators of Therapy

Which elderly respond best? (Meta-analysis, 7
studies, 2300 patients) – Better response when:
 Longer
duration of depression (> 10 years)
 More severe depression



Older brains may respond less well to medication
Longer duration of treatment may be needed
Augmentation with second medication may be
needed
Nelson JC et al. Am J Psychiatry 2013;170:651-659.
Medical Treatment






“Start low, go slow”
Titrate to full adult doses
Titrate off rather than stopping abruptly
Elderly are more prone to side effects
All classes of antidepressants have similar
efficacy in the elderly
Best choice depends on side effect profile,
prior treatment history, treatment history of
close family members
Ann Clin Psychiatry 2007;19:221-238.
A Proper Medication Trial

Right drug, right dose, right duration
 Trials
should last at least 4-6 weeks
 If some response by 4 weeks, usually full
response can be expected
 If no response by 4 weeks, unlikely to get
adequate response
 Often 12 weeks needed to see full response

Close follow up by phone or in person is
helpful during initiation phase
Neurotransmitters in Depression
mirtazapine (high dose)
SNRI (higher dose)
bupropion
TCA
SSRI
SNRI (lower dose)
mirtazapine
(TCA)
bupropion (high dose)
sertraline
Selective Serotonin Reuptake Inhibitors



SSRI - Usually first line agents in the elderly
GI side effects (nausea or dyspepsia) most
common – usually resolve in 7-10 days.
Other side effects
Sweating
 Weight loss
 Sexual dysfunction
 Sedation or restlessness
 Low sodium
 Risk of falls

Harv Rev Psychiatry 2009;17:242-253.
SSRI Choices




Citalopram (Celexa)
Escitalopram (Lexapro)
Sertraline (Zoloft)
Fluoxetine (Prozac)
Better choices in the elderly
 More
drug interactions
 Very long acting

Paroxetine (Paxil)
 More
drug interactions
 More anticholinergic and short acting
Harv Rev Psychiatry 2009;17:242-253.
Serotonin-Norepinephrine Reuptake Inhibitors

SNRI’s
 May
be more activating (agitation, insomnia, high
blood pressure)
 Short half life, may work more quickly
 May give more side effects compared to SSRI

Roles
 If
co-existing chronic pain (neuropathic)
 If “activation” is desired
 First or second line agent
SNRI Medications



Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Mirtazapine (Remeron)


Primarily increases serotonin levels
Associated with
 Sedation
(antihistamine effect)
 Increased appetite
 Weight gain
 No sexual side effects

Potential Roles
 First
or second line (may be combined with SNRI)
 When also treating low appetite, insomnia
 If sexual side effects are a concern
Bupropion (Wellbutrin)


Mechanism – norepinephrine and dopamine
reuptake inhibition
Associated with
– jitteriness and insomnia
 No sexual side effects
 Increased risk of seizures, headaches
 Activation

Potential Roles
 Second
line agent (can be combined with SSRI)
 If activation desired
 If sexual side effects are a concern
Tricyclic Antidepressants – TCA’s




More anticholinergic effects than SSRI, SNRI
Risk of cardiac toxicity – arrhythmia
More side effects than other classes
Potential Roles
 Third
line?
 Intolerant of other drugs
 Previously successful treatment or long-term use
 When there is no concern for cognitive
impairment
TCA Medications

Better options in elderly (less anticholinergic)
 Desipramine
 Nortriptyline

Less desirable options in elderly
 Amitriptyline
 Imipramine
Medication Monitoring




Monitor for relapse
May need treatment for 2 years to prevent
relapse
When stopping, taper slowly
If high risk patients or with recurrent
depression, consider lifetime of treatment
NEJM 2006;354:1130-1138
Medication Reduction




F-329: Federal regulation for skilled nursing
facilities requiring gradual dose reductions for
psychotropic medications
A good general principle for all elderly
Patient circumstances change
Patient physiology changes
Other options for treatment…
Other Options – Psychiatrist

Consider consultation especially if:
 Suicidal
ideation
 Psychosis
 Active bipolar disorder
 Concurrent substance use problems
 Non-response to reasonable trials of treatment
 A patient is an immediate danger to themselves
or others and may need inpatient treatment
Electroconvulsive Therapy: ECT

Consider if

Severe, persistent depression not responding to treatment

Risk of harm (severe weight loss, malnutrition, food refusal, suicidal)

Usually started in inpatient unit: 6-12 treatments over 2-4 weeks

Common side effects/risks

Nausea, HA, jaw pain, muscle aches, increased risk of falls, memory loss

Risk of serious morbidity/mortality less than 1%

Contraindications

Unstable cardiopulmonary disease

Recent intracranial surgery

Intracranial mass with increased ICP

Recent ICH or CVA
JAMA 2012;308:909-918.
What if patient is not improving?
Considerations in Non-Responders






Wrong diagnosis?
Comorbid psychiatric
disorder?
Chronic pain?
Sleep disorder?
ETOH or drug
misuse?
Medical problems or
medications that can
worsen depression?





Severe psychological
or social stressors
Adherence
problems?
Insufficient med trial?
Adverse effects?
Initial treatment
appropriate but just
not effective?
Depression: Step-Wise Approach
1. Assessment, support, psychoeducation for patients
suspected of depression
- Use screening tools
- look at associated factors
2. Active monitoring, support, “low-intensity
psychosocial interventions,” and exercise for those
with recent onset or mild symptoms
- individual guided self help
- basic cognitive-behavioral therapy
Depression: Step-Wise Approach
3. Persistent, moderate symptoms not responding to
step 2, or with significant PMH of depression:
- medications (for at least 6 months) and/or
- high-intensity psychosocial interventions
4. Mental health referral for severe or resistant
symptoms
2009 UK NICE Guidelines
A Common Scenario…

Before your office visit with your 82 year-old
male patient, you receive the following
message from his daughter:
 “Over
the last few months Dad has been really
irritable and gets angry with us when we try to talk
about getting him more help. My siblings and I
wonder if an antidepressant would help? Can
you talk to him about this at your visit?”
Another scenario…


You’re going to see a 78 year-old woman with
moderate dementia who recently moved to
skilled care from home after having a fall and
suffering a spinal fracture. She is getting
therapy and pain management.
Staff is concerned because she is not
motivated to leave her room, is resisting
participation in therapy, and is only eating 25%
of meals. She is often tearful and cries, “My
kids put me away in a home!”
Questions

Handout
Summary





Significant depression in the elderly is
relatively common, likely underdiagnosed, and
often undertreated
Mood symptoms have a variety of causes
Consider whole-patient context when
assessing for depression and planning
treatment
Medications are not always needed
Consider non-drug treatment approaches
Closing Thought…
“He who is of calm and happy nature will hardly
feel the pressure of age, but to him who is of
an opposite disposition youth and age are
equally a burden”
Plato (427-347 BC), The Republic