Download TREATMENT OF DEPRESSION IN THE ELDERLY

TREATMENT OF DEPRESSION
IN THE ELDERLY
Jackie L. Neel, D.O.
OSU Center for Health Sciences
College of Osteopathic Medicine
(Revised 9/2002)
“It is not enough for a great
nation merely to have added
new years to life--our objective
must also be to add new life to
those years.”
---John F. Kennedy
Depression of the Elderly - - Jackie
L. Neel, D.O.
Our population is Aging!
• 2/3 of all the people in the history of the
world who have reached age 65 are alive
today!
• 1/2 the women who are 65 today will
survive to age 85.
• 1980-1990 population over 85 increased
by 40%; centenarians doubled.
• Avg. lifespan in 1900=47, today=75
Depression of the Elderly - - Jackie
L. Neel, D.O.
Healthy functioning older adults
are at no greater risk for
depression than younger adults
Depression of the Elderly - - Jackie
L. Neel, D.O.
Risk Factors
• Depression increases in the elderly due to:
– Multiple losses
– Medical illness
– Cognitive dysfunction
• The greatest risk factor for depression in
the elderly is history of previous
depression
Depression of the Elderly - - Jackie
L. Neel, D.O.
Compounding of Adverse Life
Events in Aging
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Jobs
Money
Homes
Friends
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Abilities
Health
Hopes
Bereavement
Depression of the Elderly - - Jackie
L. Neel, D.O.
Prevalence of Depression in
Medical Illness
Stroke
Cancer
Myocardial infarct
Rheumatoid Arthritis
Parkinson’s Disease
Diabetes
26-61%
18-39%
15-19%
13%
10-37%
5-11%
Depression of the Elderly - - Jackie
L. Neel, D.O.
Categories of Medical Problems
in elderly inpatients with Major
Depression
Circulatory
69%
Digestive
61%
Endocrine, metabolic
45%
Other
25%
Genitourinary
24%
Mean # of medical problems = 5
Depression of the Elderly - - Jackie
L. Neel, D.O.
Common Secondary Causes of
Depression in the Elderly
• Alzheimer’s
• Vascular and other
dementia
• Common infections
(i.e. pneumonia or
UTI)
• Substance abuse
• Endocrine disorders
• Electrolyte
imbalance
• Tumor
• Endocrine
• Prescription
meds
Depression of the Elderly - - Jackie
L. Neel, D.O.
Dementia and Depression
• Alzheimer’s - 20-40%
• Similar rates with other dementia's
– Vascular
– Parkinson’s
– Huntington’s
– Brain injury
– B12,folate
• Depression may precede other symptoms
Depression of the Elderly - - Jackie
L. Neel, D.O.
Having a mental disorder in late
life increases mortality
by 1.6 - 2.5 times
Depression of the Elderly - - Jackie
L. Neel, D.O.
Rates of MI are 4.5 times
greater in patients with history
of major depression
Depression of the Elderly - - Jackie
L. Neel, D.O.
Suicide
• 15% of severely depressed persons
commit suicide
• Elderly white males are at greatest risk
• 80% consult physician in the month before
death
• Elderly are less likely to have had previous
attempts or to complain of suicidal
thoughts--more likely to complete it.
Depression of the Elderly - - Jackie
L. Neel, D.O.
Suicide,
cont.
• 10 years after stroke
– Mortality for non-depressed is 40%
– Mortality for depressed is 70%
Depression of the Elderly - - Jackie
L. Neel, D.O.
Diagnosing Depression in the
Elderly
• DSM-IV criteria may not be met
– Deny most mood symptoms, but may
appear fearful or sad
– Loss of interest in usual activities
– Irritable, brooding
– Somatic
Depression of the Elderly - - Jackie
L. Neel, D.O.
Diagnosing Depression in the
Elderly, cont.
• DSM-IV criteria may not be met
– Sleep and appetite changes
– Fatigue
– Less suicidal complaints, but highest rate
in elderly males
– Social withdrawal
Depression of the Elderly - - Jackie
L. Neel, D.O.
The Diagnosis of Depression in
the Elderly is Often Missed
• Sx of medical illness may be the same as
depression
– low energy
– loss of interest
– anorexia
– fatigue
Depression of the Elderly - - Jackie
L. Neel, D.O.
The Diagnosis of Depression in
the Elderly is Often Missed, cont.
• Study at Duke University
– Assessment given to elderly medical
admits
– Of those meeting criteria for depression,
only 40.5% received an anti-depressant
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pseudodementia
• Cognitive problems related to depression
• Higher incidence of development of
dementia
• Past hx of mood disorder
• Depressive sx precede cognitive sx
• Acute onset
• Increase in dependency
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pseudodementia,
cont.
• Slow psychomotor response,low
motivation and social interaction
• Improve with antidepressant
• Better to risk over-diagnosis and treat for
depression
• Use clinical judgement based on patient
history and function
Depression of the Elderly - - Jackie
L. Neel, D.O.
Treatment of Depression in the
Elderly
• Treat co-morbid conditions and etiologies
of secondary depression
• Choose appropriate level of care
• Keep in mind that suicide occurs more in
elderly than in any other age group
• Choose therapies appropriate to age and
cognitive functioning
• Psychosocial interventions
Depression of the Elderly - - Jackie
L. Neel, D.O.
Watch for Signs of Elder Abuse
and Neglect
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Malnutrition and dehydration
Bruises, fractures, burns
Mental abuse
Neglected medical care
Sexually transmitted diseases
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacology
START LOW -- GO SLOW
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacologic Complications in
the Elderly
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Pharmacokinetics
Pharmacodynamics
End-organ physiological change
Medical illness
Cognitive decline
Polypharmacy
Compliance
Life adversity
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacokinetics and the
Elderly
•  Gastric motility and pH
– Causes  absorption
•  Fat/lean body ratio
– Causes  volume of distribution and
 half-life
•  Hepatic blood flow
– Causes  breakdown
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacokinetics and the
Elderly, cont.
•  Activity of some catabolic enzymes
– Causes  plasma levels and half-life
•  GFR
– Causes  clearance and  accumulation
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacodynamics and the
Elderly
• Increased sensitivity to:
– Sedation
– Cardiovascular effects
– Anticholinergic effects
Depression of the Elderly - - Jackie
L. Neel, D.O.
Noncompliance in the Elderly
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40-70% noncompliance
10% take drugs prescribed for others
20% take drugs not currently prescribed
40% stop drugs too soon
Depression of the Elderly - - Jackie
L. Neel, D.O.
Principles of Pharmacologic
Treatment
• Use medications with minimal
Anticholinergic, cardiovascular and
orthostatic effects
• Begin with low dose
• Monitor compliance
• Monitor side effects
• Increase dose slowly, but use adequate
amounts
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First
• Selective Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine (Prozac)
Fluvoxetine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopvam (Lexapro)
10-80 mg/d
25-250 mg/d
10-60 mg/d
25-200 mg/d
25-200 mg/d
10-20 mg/d
– Safe, effective
– Side effects--Activation,GI, headache,
enzyme inhibition (Cyt P450)
Depression of the Elderly - - Jackie
L. Neel, D.O.
sexual,
Use the More Selective Drugs
with Less Side Effects First, cont.
• Serotonin Syndrome
– Myoclonus, hyperreflexia, tremor
– Confusion, agitation, hypomania
– Fever, sweating, shivering
– Diarrhea
• Stop or reduce drug
• Propranolol, clonazepam
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Venlafaxine (Effexor)
– 12.5mg BID-350 mg/d, XR 37.5,75,150
mg/d
– Reuptake inhibition of serotonin and
norepinephrine
– May be more efficacious in refractory
cases and vegetative depression
– Side effects--nausea, activation,
serotonin syndrome, htn, tremor
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Nefazodone (Serzone)
– 50-600 mg divided or HS q Day
– Safe, anxiolytic, increases sleep, less
sexual side effects
– Side effects--dizziness,sedation, GI,
CytoP450 inhibition
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Bupropion (Wellbutron)
– 75-150 mg TID, SR 100-150 mg BID
– Safe, effective, no sexual side effects,
activation
– Side effects--activation, GI, HA, Seizures
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Mirtazapine (Remeron)
– 7.5-60 mg (sedating at the lower doses)
– Safe, antidepressant, anti-anxiety, 1X/d
– Helps sleep and appetite in elderly at low
dose
– Side effects--constipation, dizziness, dry
mouth, somnolence
– Agranulocytosis or neutropenia (rare)
Depression of the Elderly - - Jackie
L. Neel, D.O.
Tricyclic Antidepressants
• Effective antidepressants BUT avoid due to:
– Orthostatic hypotension
– Slow cardiac conduction
– Increase HR
– Decreased heart rate variability
– Sedation
Depression of the Elderly - - Jackie
L. Neel, D.O.
Tricyclic Antidepressants,
cont.
• Effective antidepressants BUT avoid due to:
– Sexual
– Dry mouth
– Constipation
– Urinary retention
Depression of the Elderly - - Jackie
L. Neel, D.O.
If other types of antidepressants
fail:
• Nortriptyline and desiprimine
– Starting at low doses
– Monitoring blood levels can be used
• Trazodone (Desyrel)
– Use for sleep in low doses--very high doses
may be necessary for antidepressant effect
– May lead to orthostasis
– Less anticholinergic side effects.
Depression of the Elderly - - Jackie
L. Neel, D.O.
If other types of antidepressants
fail, cont.
• Psychostimulants
– Ritalin--5mg q am-5-10 mg tid
– Watch BP and HR
– May cause psychosis
– May mobilize the vegetatively depressed
and medically ill
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features:
• Low doses of higher potency
antipsychotics
– .5 - 2 mg haloperidol (Haldol) will often
suffice
– 2.5 - 5 mg olanzepine (Zyprexa)
– 25 mg quetiapine (Seroquel)
– .25 - .5 mg risperidone (Risperdal)
– May go higher if tolerated and no
response at lower doses
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features, cont.
• Mood Stabilizers
– Lithium
– Valproate (Depakote)
– Carbemazepine (Tegretol)
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Monitor blood levels
Liver enzymes for Depakote and Tegretol
CBC for Tegretol
TSH, Cr for Lithium
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features, cont.
• For agitation:
– Lorazepam (Ativan) .5-1 mg TID PO or IM
or IV
• Increased risk for falls with use
Depression of the Elderly - - Jackie
L. Neel, D.O.
Electroconvulsive Therapy
• For depression which is:
– Unresponsive to medication
– With psychotic features
– Putting the patient at risk due to poor oral
intake or suicidality
• More cardiac risks in the elderly, but can
be performed safely
Depression of the Elderly - - Jackie
L. Neel, D.O.
Psychotherapy
• Problem Solving
• Supportive
• Cognitive
Behavioral
• Reminiscent
• Pets
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Touching
Education
Family
Groups
Psychosocial
Intervention
Depression of the Elderly - - Jackie
L. Neel, D.O.
Erikson’s Final Stage of
Development
• Integrity Versus Despair and Isolation
• Feeling life has been worthwhile and
accepting your place in the life cycle
• “Healthy children will not fear life if their
parents have integrity enough not to fear
death.”
Depression of the Elderly - - Jackie
L. Neel, D.O.
References
• Zisook, S, M.D., and Downs, N. S., M.D., Diagnosis and
Treatment of Depression in Late Life, Journal of Psychiatry
1998;59 (suppl 4), pg. 80-91.
• Medical Advances -- Health in Mind and Body, Vol. 2, No. 1
Depression of the Elderly - - Jackie
L. Neel, D.O.