Download Assessment of late life depression

Depression in Older
Adults
University at Albany, SUNY
Gero Innovations Grant
Today’s presentation

Overview of late life depression

Identify who is at risk

Recognize depressive symptoms

TOOLS: How to Screen / Assess

Manage suicidal behavior

When to refer older clients to a mental health
professional

Information on antidepressant medications

Recognize EBP psychosocial treatments
Depression Overview
• Leads to physical mental & social disability
• Depression can be persistent, intermittent
• Depression can increase levels of health
service use and cost
Who’s at Risk?

Generally Women

If you experienced a recent loss or severe stress

Fam. History of mental illness/suicidal behavior

Unexplained somatic symptoms

History of self-medicating

Chronic/major illness

Strokes heart disease, AIDS, cancer, diabetes, chronic
pain
Late Life Depression

Depressive Disorders are
very real & one of the
most common mental
health problems among
older adults

Depression is also
common with vision
impairment, other medical
conditions, and alcohol
abuse

Among older adults,
suicide risk is high
Suicide Rate Of Older Adults
Higher Than Young Adults (15-24)
Source: Mortality Reports. National Center for Injury Prevention and Control. Centers for
Disease Control and Prevention.
http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html
Detection rates are poor
 Reluctance of elderly to seek MH care
 Lack of knowledge and/or reluctance of
PCP / Human Services to detect or
refer
 Disguised presentation of depression or
anxiety related to medical conditions
Prevalence of Major Depression
in Later Life
30
25
20
15
10
5
0
30
1
3
5
9
13
12
Community Primary C Homecare Nursing H

More prevalent in women than men

Depressed mood is a risk factor-suicidal ideation
Low
High
Prevalence of Subthreshold
Depression in Later Life
40
36
30
27.5
20
10
0
16
15
20
Low
High
8
Community Primary C
Homecare
Nhome
High rates of depressive symptoms
More prevalent in women than men
Anhedonia is a risk factor-suicidal ideation
Disability & Depression in
Later Life
 Downward Spiral Theory

Depression is a risk factor for disability, and

Disability increases the risk of depression
 Result: A high prevalence of depressive
symptoms & disorders among disabled
older adults.
Answers to commonly asked questions
about depression, as they present in
seniors.
 I can’t do anything for myself
 But I’m too old to be
depressed
 I’m not depressed. I just do
not feel that my life is worth
anything.
I’m in pain much of the time.
I’m of no use to anyone
I don’t see my friends anymore
I’m not interested in anything
Major Depression Episode
5 or more of the following symptoms during past
two weeks:
 Depressed mood most of the day, nearly
every day (subjective/other report)
 Decreased interest/pleasure in all
activities
 Significant weight loss (e.g. 5% body
wght/1 month) or overeating
 Insomnia or hypersomnia
Major Depressive Episode
cont’d
 Psychomotor agitation/retardation
 fatigue or loss of energy
 feelings of worthlessness
 excessive guilt
 unable to concentrate, indecisiveness
 recurrent thoughts of death, recurrent suicidal
ideation without a plan or
 a suicide attempt or a specific plan
Major Depression Criteria
Presence of a single Major Depressive
Episode
absence of psychosis, hallucinations,
delusions
no manic, episode hx
Minor Depression
Older adult reports 2 to 4 symptoms for at
least 2 weeks
One of the symptoms has to be:
Depressed mood or lack of pleasurable
activities
Depressive Symptoms vs
Clinical Depression
 Many elderly may not be clinically
depressed
 Medical conditions, meds, family,
financial or bereavement problems are
some factors associated with
symptoms of depression
 Older person may be experiencing the
“blues” of depressed mood
Why screen for late life
depression?
 Screening improve the accurate
identification of depressed clients
 Treatment of identified depressed
adults decreases clinical morbidity.
 Reduce potential suicidality
Assessment of late life
depression
Ask about family history
Assess for risk factors
Complete the screening with the client
Discern the type of depression
Most prevalent forms of depression
Major depression
Minor depression
Subthreshold depression
Assessment of late life
depression

Ask about family history

Assess for risk factors

Complete the screening with the client

Discern the type of depression

Most prevalent forms of depression

Major depression

Minor depression

Subthreshold depression
Medical Conditions
Associated with Depression
Cancer
Alcohol/drug abuse or withdrawal
Diabetes
HIV/AIDS
Hypothyroidism
Parkinson’s Disease
Stroke
Epilepsy
Vitamin deficiency (Folate and/or B12)
Depressive Symptoms
Physical
Psychological
appetite
depressed mood
weight
feelings of
worthlessness/guilt
sleep change
psychomotor
changes
fatigue
loss of interest
decreased
concentration/memory
suicidal ideation
Elderly may show signs and
symptoms
D
Dysphoria
E
Eating behavior
P
Physical Complaints
R
Rumination
E
Energy loss
S
Suicidal thoughts and plans
S
Poor sleep or too much sleep
I
Isolation (Lack of Social Support)
O
Omission of pleasurable activities
N
Negativity in relation to self, others, future
Depression Screening Tools
Rapid Rating Scales
PHQ-9
Geriatric Depression Scale
CES-D Scale
BDI
HAM-D
Case: Mrs. D
76 yr old female
Frequently contacts primary care physician about her
health
When seen, she expresses numerous worries about
other areas of her life
She relates that she has always been a “worry wart”
and this has made her life difficult
She has difficulty concentrating, making decisions
She reports feeling restless, difficulty going to sleep
because of excessive rumination
She worries that others avoid her because she is no fun
to be around
She lives alone
She states that she doesn’t feel like doing anything
Suicidality Components
Thoughts of death
Intent
Plan
Means
Prior suicidal history or behavior
Interventions for Suicidal
Management
Listen for clues in what they say:
‘No one left”, “I can’t go on”, What’s
the use?, I gave some things away”
ASK the client
INFORM them that you are concerned
for their wellbeing
Interventions for Suicidal
Management
Most people who are thinking about suicide
will communicate their intent through clues
Myth-asking someone about Suicide will
encourage it
Refer to mental health/psychiatry
Interventions for Approaching
the Topic of late Life Depression
How are things at home?
Have you had any stress lately?
How are you handling it?
How have you been coping?
Interventions for Approaching
the Topic of Late Life Depression
•Discuss your concerns with client
•You can say:
“It is very common…”
“It is a medical condition”
“It is treatable”
Guidelines for Making a
Referral to Mental Health
If the older client has a psychiatric history
If there is suicidal ideation
Client safety, risk of suicide
Hospitalization
Client needs medication
Client needs ongoing psychotherapy
Evidence-Based Interventions
(1) Cognitive Behavioral Therapy has
been well-validated in controlled efficacy
trials in community & primary care
settings
Sessions range (8-20)
Evidence-Based Interventions
(2) Problem Solving Therapy has been wellvalidated in controlled efficacy trials in
community & primary care settings
Sessions (range 6 – 12)
RCT of brief PST intervention with
homebound older adults (Gellis, 2007)
Evidence-Based Interventions
(3) Interpersonal Therapy has been
validated in controlled efficacy trials in mental
health, outpatient, & primary care settings
IPT focuses on interpersonal events such as
interpersonal disputes / conflicts, interpersonal
role transitions, complicated grief related to
onset and / or maintenance of depression.
Evidence-Based Interventions
(4) Relaxation training has shown effects for
depression & generalized anxiety
(5) Adjunct written educational materials for clients
& family members have been shown to improve
medication adherence & clinical outcomes
(6) Pharmacologic Treatments
70-80% of depressed pts will respond to meds
alone
-most pts respond within 4-6 weeks
-”Start Low and Go Slow”
Antidepressants
SSRIs – 1st line of treatment
SNRIs
TCA - e.g. imipramine
MAOI - Restriction in diet (no cheese or
smoked food) and no antihistamines
Serotonin Selective Reuptake
Inhibitors
Fluoxetine (Prozac), 20-80 mg/d
Initiate with 5-10 mg/d
Sertraline (Zoloft), 50-200 mg/d
Initiate with 25-50 mg/d
Paroxetine (Paxil), 20-50 mg/d
Initiate with 10mg/d
Fluvoxamine (Luvox), 50-300 mg/d
Initiate with 25 mg/d
Citalopram (Celexa)

- Initiate with 10-20 mg/d
 Start low- -Go Slow
Serotonin-Norepinephrine
Reuptake Inhibitor (SNRI)
Venlafaxine-XR (Effexor-XR) 75-300 mg/d
Cymbalta
Typical side effects
GI distress, jitteriness, headaches, sexual
disturbance
And Remember….
Depression in older adults is real if
the symptoms are:
excessive, uncontrollable, create
distress, and interfere with daily
living
Summary
Depression is prevalent in aging but is not a part
of aging
Comorbid with other medical illnesses
Most forms of depression are easily diagnosed
and treatable
Depression requires training for careful screening
and follow-up
Early screening and intervention is critical
Appropriate asmt. And tx can improve the QoL
for depressed older persons
Depression in Older Adults
2007
University at Albany, SUNY