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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 • • • • • 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 • • • • • 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 - 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 • • • • • 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 • • • • • 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 • • • • • • 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.