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Depression in the Elderly
Steven W. Clay, DO
Assistant Professor of
Family Medicine
OUCOM
Objectives
• Describe Common Psychological
Characteristics Of The Elderly.
• Describe Common Depressive
Disorders And Their Treatment In
The Elderly.
Objectives
• Differentiate Bereavement From
Psychiatric Disorders In The
Elderly.
Outline
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1. Psychological Issues.
2. Bereavement
3. Common Mood Disorders.
4. Pseudodementia
5. Depression With Psychotic
Symptoms.
1. Psychological Issues
 Elders deal with many losses.
 Mostly widowed women.
 Self-esteem correlates with age.
 The elderly think more
concretely, giving the false
impression of inflexibility.
Psychological Issues
 Life Satisfaction Is
Stable With Age.
 Coping With Stress Improves
With Age, As The Elderly See
Stressors As Less Important.
 Sense Of Control Vs. Learned
Helplessness.
Centenarian Characteristics
Moderation (Food, Drink, Activity)
Forgiveness Of Others And Self.
Positive Thinking And Optimism.
Constant Phys. / Mental Activity.
Integrity And A Desire To Do Good.
Independence And Interaction.
How Would You Feel If This Year?
Your Spouse Died.
Two Of Your Best Friends Died.
Your Child Was Diagnosed With
Terminal Cancer.
You Broke Your Hip And Now
Live In A Nursing Home.
2. Bereavement
Response To Death Of A Loved One.
Patient Considers It Appropriate.
Not A Disorder, Function Maintained.
Duration Varies Widely.
May Have Non-distressing And
Transient Hallucinations.
Mrs. B. Still Feels Mr. B There.
• 77 Year Old Female Comes To
The Office After Mr. B Recently
Died At Home From Lung CA.
• She Not Sewing As Much But
“I’m Ok,” Her Family Agrees.
• At Times She Still Hears His
Voice And Feels Him Next To Her
In Bed.
Mrs. B.
• Are Hearing The Voice Of Her
Deceased Husband And Feeling
Him Next To Her In Bed
Hallucinations?
• Is This A Disorder Or Is She Still
Functioning Fairly Well?
3. Some Mood Disorders
• Not From The Aging Process!!!
--Major Depression
--Dysthymia
--Adjustment With
Depressed Mood /
Mixed Emotions
• Bipolar Disorders Unusual
Depression in Elders
35
31
29
30
major dep.
26
minor dep.
25
20
18
14
15
10
4
5
0
comun. hosp.
nurs.
hm.
Depression & Other Disease
Hypo- / Hyperthyroidism
Cushings / Addisons
Hyperparathyroidism
Cancers, esp. Pancreatic / CNS
Infection, Uremia
B-12 or Folate Deficiency
Depression & CNS Disease
Stroke
Dementia
Parkinson’s
30-50%
20-30%
20-30%
Meds & Depression:
• Antihypertensives:
B Blockers, Methyldopa (Aldomet)
• Steroids: Corticosteroids, Estrogens,
Progesterones)
• Benzodiazepines
• Anti-Psychotics
• Polypharmacy
Depression & Addiction
 >5% Community Elderly
 10% Elderly Medical Outpatients
 Alcoholism: Men > Women
 Prescribed Drugs: Women > Men
Assessment
• Obtain H+P Information From
Family / Caregivers / Records.
• Any Hx. Of Alcohol / Drug Use ?
• Labs: CBC, TSH, T4, Chem-20,
UA, CXR, EKG and as Indicated.
• MMSE, GDS
Depression - Symptoms
• Depressed Mood (Hopeless, Sad,
Empty, Tearful, Irritable)
• Apathy (No Interest In Activities)
• Weight Loss / Gain
• Insomnia / Hypersomnia
• Guilt / Worthlessness
Depression - Symptoms
• Psychomotor Agitation /
Retardation
• Fatigue, No Energy
• Inability To Think Or Concentrate
• Recurrent Thoughts Of Death Or
Suicide
• Ask About Suicidal Thoughts!!
Depression Presentation
Older Adults Present Differently.
Somatic Complaints Predominate
Depression Often Denied
Common Apathy And Withdrawal
Common Loss Of Self-Esteem
GDS -The Geriatric
Depression Scale
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Tool Specific For The Elderly.
15 Questions Short Form
30 Questions Long Form
May Suggest Depression
Must Be Used In Conjunction
With A Full Patient Assessment
Tired & Apathetic Mr. L.
• 65 YO White Male Comes To
Office Complaining Of “ I Just
Want To Sleep And Do Nothing, I
Don’t Care What Happens
Anymore.”
• H & P: No Recent Losses, No
Suicidal Ideation, Low Affect,
Mr. L.
• Takes Lopressor 100 Mg Qd For
Hypertension.
• Mr. L. Was Switched To An ACE
Inhibitor For Hypertension.
• Mr. L. Returned In Two Weeks
With No Complaints “You’ve
Turned My Life Around.”
A. Major Depression
Overwhelming Depression For
At Least 2 Weeks.
Completely Unable To Cope.
Function Is Usually Greatly
Impaired.
May Be High Risk For Suicide.
DSM-IV Major Depression
• A. Five (Or More) Of The Following
Symptoms
– Present During a 2-week Period
– Represent A Change From Previous
Functioning;
• At Least One Of The Symptoms Is
Either (1) Depressed Mood Or (2)
Loss Of Interest Or Pleasure.
Major Depression
• (1) Depressed Mood Most Of The Day,
Nearly Every Day
• (2) Markedly Diminished Interest Or
Pleasure In All, Or Almost All, Activities
Most Of The Day, Nearly Every Day
• (3) Significant Weight Loss When Not
Dieting Or Weight Gain, Or Decrease Or
Increase In Appetite Nearly Every Day.
Major Depression
• (4) Insomnia Or Hypersomnia Nearly Every
Day
• (5) Psychomotor Agitation Or Retardation
Nearly Every Day (Observable By Others,)
• (6) Fatigue Or Loss Of Energy Nearly Every
Day
• (7) Feelings Of Worthlessness Or Excessive
Or Inappropriate Guilt (Which May Be
Delusional) Nearly Every Day
Major Depression
• (8) Diminished Ability To Think Or
Concentrate, Or Indecisiveness, Nearly
Every Day
• (9) Recurrent Thoughts Of Death,
Recurrent Suicidal Ideation Without or
With A Specific Plan, Or A Suicide
Attempt
Major Depression
• B. The Symptoms Do Not Meet Criteria
For A Mixed Episode.
• C. The Symptoms Cause Clinically
Significant Distress Or Impairment
• D. The Symptoms Are Not Due To The
Direct Physiological Effects Of A
Substance Or A General Medical
Condition
• E. The Symptoms Are Not Better
Accounted For By Bereavement
Suicide in elderly
Highest Risk Of All Of Society
White, Elderly, Males
Multiple Losses
25% Of All Suicides
Attempts To Success Ratio:
Young Adult 10
Elderly
1
Retired, Widowed Mr. S
• 68 YO White Dairy Farmer
Recently Lost His Wife, Can’t
Run The Farm By Himself, Plans
To Sell And Complains Only Of A
Backache.
• Denies Depression, Refuses All
Medication And Counseling, “I’ll
Just Deal With Things Myself.”
Mr. S.
• White Male With Many Losses:
-His Wife
-Close To Losing His Farm
-No Family Helping On Farm
• High Risk For Suicide.
• Mr. S Was Found Behind The
Barn With A Bullet In His Head.
B. Dysthymia
Milder Depression
Lasting At Least Two Years
Almost A Way Of Life
Very Responsive To Medical And
Counseling Treatments.
DSM-IV Dysthymia
• Depressed Mood For Most Of The
Day, For More Days Than Not, For
At Least 2 Years.
• During The 2-year Period The
Person Has Never Been Without
The Symptoms For More Than 2
Months At A Time.
DSM-IV Dysthymia
• While depressed, of two (or more)
of the following:
– poor appetite or overeating
– insomnia or hypersomnia
– low energy or fatigue
– low self-esteem
– poor concentration or difficulty
making decisions
– feelings of hopelessness
Mrs. D. Still Complains
• 77 Year Old Female With Multiple
Complaints: Arthritis, Not Sleeping
Well, “My Nerves,” Etc.
• Denies Depression, “I’m Just Me.”
• Mod-low Affect, Slight Apathy No
Suicidal Ideation
Mrs. D.
• Daughter Says “She Has Always
Been This Way As Far Back As I
Can Remember.”
• Low Dose SSRI Zoloft
(Sertraline) 25mg A Day And
Counseling Started.
Mrs. D.
• Mrs. D. Returned In Two Weeks
Much Happier, Able To Deal With
Her Arthritis
• She Says “I Never Realized I Was
Depressed, I Just Thought Life
Was Like That.”
C. Adjustment Disorders
Response to Stress
Last 3 months
A disorder because of:
loss of function
symptoms >>> stressor
Very common in the elderly
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Adjustment Disorder:
With Depression
With Anxiety
With Mixed emotions.
Mr. A & Mrs. A’s COPD
• 78 Yo Female COPD Patient
Says: “My Breathing Is Horrible
And My Chest Hurts So Bad I
Want To Die.”
• On Questioning She Is Upset
Because Her Husband Died
Several Months Ago And:
Mrs. A.
• Yesterday Her Daughter
Attempted Suicide Because Of A
Separation.
• Pe Unchanged, But Sad And
Crying.
• Pulse Oximitry 92%
Mrs. A.
• CXR With COPD, No Infiltrates
• EKG With Sinus Tachycardia.
• Short Term Counseling And Low
Dose Antidepressants Helped Her.
• These Were Discontinued A Few
Weeks Later.
“Pseudodementia”
Depression That Appears Like
Dementia --A Treatable “Dementia”
Must Distinguish From True
Dementia
Depression Superimposed Onto True
Dementia Is Much More Common,
With Tx. Pseudodementia Clears.
Pseudodementia And
True Dementia Compared
onset
duration
mood
cognition
disabilities
answers
DEMENTIA
insidious
long
variable
consistant
concealed
near miss
PSEUDO-D
rapid
short
constant
inconsistant
highlighted
“I don’t
know”
Mrs. Y. Is Declining
• 68 YO Female Son Asks: “Does
She Have Old-timers Disease?
• She Has No Memory, She Just
Sits, Sleeps Poorly And Has Lost
Weight.
• She Has Been Down For Years”
Mrs. Y.
• “But Over The Last Month She Acts
Like She Doesn’t Even Know Me.”
• H&P: Unremarkable Except Low Affect,
Doesn’t Try On MMSE Unless
Encouraged, “I Don’t Know” Answers.
• She Denies Depression And Suicidal
Ideation “I’m Tired, Leave Me Alone.”
Mrs. Y.
• MMSE: 14 / 30 with 12 “I don’t
Know” Answers.
• S-GDS: 10 / 15
• After Treatment For Depression
One Month Later MMSE Results
27 / 30
Depression Tx: Choices
• Depressed With:
• 1. Anxiety, Panic, Obsessing– Consider SSRI
• 2. Withdrawing, Psychomotor
Retardation, Not Eating– Consider NE Agent
– TCAD, SNRI
Depression Tx: SSRI
• Effective In 2/3 Of Patients
• May Stimulate Activity If
Withdrawn
• Side Effects: GI Upset / Diarrhea
Anxiety, Insomnia, Serotonin
Syndrome
SSRI’s QD Dosing
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Fluoxetine (Prozac) 10-20 mg
Sertraline (Zoloft) 25-50 mg
Paroxetine (Paxil) 10-20 mg
Citalopram (Celexa) 10-20 mg
Escitalopram (Lexapro) 5-10 mg
Depression Tx: TCAD
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Effective In 2/3 Of Patients
May Help Appetite And Insomnia.
Cardiac Arrhythmias, Confusion
Nortriptyline (Pamelor) 25mg hs.
Desipramine (Norpramin) 25mg Hs
Depression Tx: SNRI
• Duloxetine (Cymbalta) 30-60 mg
–Headache, Rare Hepatotoxicity
• Venlafaxine (Effexor) 37.5 -75 mg
–Need 150mg for NE Effects
–Some Dopamine Effect
Psychotic Symptoms
Hallucinations:
Sensory Perceptions Without
Any Stimuli.
Visual -Especially With
Physical Problems.
Auditory-Especially With
Psych. Problems.
Psychotic Symptoms
• Delusions
--Firmly Held False Beliefs
--Despite Contrary Evidence
--Commonly Paranoia In
Elders
• --”You’re All Out To Steal My
Money!”, Etc.
B. Depression With
Psychotic Features
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Mood Changes Prominent
Usually A Major Depression
Delusions Not Bizarre
Previous Psych. History Common.
Quit Eating, Refuse Treatment, Etc.
Can Have Rapid Decline
Delusional Dep. -Tx.
• Antidepressant of Choice
• Atypical Antipsychotic In Low Dose
–Risperidone (Risperdal)
–Quetiapine (Seroquel)
• Sedating, Less Parkinsonian
• Occasionally ECT Required.
– Safe and Very Effective
Mrs. N. Won’t Eat.
• 84 YO Female At The Nursing Home
Tells Everyone “Get Out Of My
Room, Leave Me Alone, You All Just
Want Me Dead Anyway.”
• She Won’t Eat Or Take Her
Medication Swings At Nurses, And
Throws Her Dinner Tray At You.
Mrs. N.
• Low Dose Risperidone (Risperdal)
And Zoloft 25mg Started.
• After A Few Days Risperidone
Stopped and Antidepressant
Continued.
• 1-2 Weeks Later Eating Better, Out
For Meals And Joked With Staff.