Download Depression in the Elderly

Depression in the Elderly
Laura Moyer MD
December 8, 2010
Objectives
Review criteria for the diagnosis of
depression and discuss several commonly
used screening instruments
Discuss risk factors for depression in the
elderly
Review treatment options for depression
DSM IV Criteria for Major Depressive
Episode
 Five or more of the following
symptoms have been present
during the same 2-wk period and
represent a change from previous
functioning. At least one of the
symptoms is either depressed
mood or loss of interest or
pleasure
 Depressed mood most of
the day, nearly every day
 Loss of interest or
pleasure in activities
 Significant wt loss or gain or
change in appetite
 Insomnia or hypersomnia
 Psychomotor agitation or
retardation
 Fatigue or loss of energy
 Feelings of worthlessness or
excessive or inappropriate guilt
 Decreased ability to
think/concentrate or indecisiveness
 Recurrent thoughts of death;
suicidal ideation
Other common mood disorders
 1. Mood disorder due to a general medical
condition
When depression appears to result directly from a specific
medical condition (ie hypothyroidism or pancreatic cancer)
In addition to treatment of the medical condition, treatment
of the mood disorder is also often needed
 2. Minor Depression
Also called sub-syndromal depression, mild depression,
and sub-clinical depression.
Defined as having 2-4 depressive symptoms as described
in DSM-IV criteria for MDD.
Is more common than late-life MDD.
15-50% of patients with minor depression develop MDD
within 2 years.
Prevalence of depression
Major depression
Clinically significant
depressive
symptoms
Acute care hospitals
Approx 11%
25%
Non-psychiatric
outpatient clinics
Approx 5%
10%
Long-term care
settings
Approx 12%
30%
Risk Factors for Late Life Depression
 Unlike depression in early life, genetic factors are less
important in depression that starts later in life.
 Late onset depression is associated with a higher
frequency of :
 Cognitive impairment
 Cerebral atrophy
 Deep white matter changes
 Patients at risk for cerebral vascular disease (ie HTN,
DM) are at greater risk for developing late life mood
disorders (including pts with small vessel vascular
disease.)
 Other risk factors include hx of depression, chronic
medical illness, female sex, being single or divorced,
alcohol abuse, stressful life events.
MEDICATIONS THAT MAY CAUSE
DEPRESSION Birrer and Vemuri (2004)
Cardiovascular drugs: Clonidine (Catapres) Digitalis Guanethidine (Ismelin) Hydralazine
(Apresoline) Methyldopa (Aldomet) Procainamide (Pronestyl) Propranolol (Inderal)
Reserpine (Serpasil) Thiazide diuretics
Antiparkinsonian drugs: Amantadine (Symmetrel) Bromocriptine (Parlodel) Levodopa
(Larodopa)
Antipsychotic drugs: Fluphenazine (Prolixin) Haloperidol (Haldol)
Sedatives and antianxiety drugs: Barbiturates Benzodiazepines Chloral hydrate Ethanol
Anticonvulsants: Carbamazepine (Tegretol) Ethosuximide (Zarontin) Phenobarbital
Phenytoin (Dilantin) Primidone (Mysoline)
Chemotherapeutics: 6-Azauridine Asparaginase (Elspar) Azathioprine (Imuran) Bleomycin
(Blenoxane) Cisplatin (Platinol) Cyclophosphamide (Cytoxan) Doxorubicin (Adriamycin)
Mithramycin (Mithracin) Vinblastine (Velban)
Hormones: Adrenocorticotropin Anabolic steroids Glucocorticoids Oral contraceptives
Other drugs: Choline Cimetidine (Tagamet) Disulfiram (Antabuse) Lecithin Methysergide
(Sansert) Phenylephrine (Neo-Synephrine) Physostigmine (Antilirium) Ranitidine
(Zantac)
Anti-inflammatory/anti-infective agents: Ampicillin Cycloserine (Seromycin) Dapsone
Ethambutol (Myambutol) Griseofulvin (Grisactin) Isoniazid (INH) Metoclopramide
(Reglan) Metronidazole (Flagyl) Nalidixic acid (NegGram) Nitrofurantoin (Furadantin)
Nonsteroidal anti-inflammatory agents Penicillin G procaine Streptomycin Sulfonamides
Tetracycline
Stimulants: Amphetamines (withdrawal) Caffeine Cocaine (withdrawal) Methylphenidate
(Ritalin)
Major Depression in Neurologic Disorders
Associated with Aging
Stroke 40-60%
Parkinson Disease 30-40%
Alzheimer’s Disease 20-40%
 Birrer and Vemuri (2004)
Suicide in the elderly
 14.3 of every 100,000 people age 65 and older
died by suicide in 2004, higher than the rate of
about 11 per 100,000 in the general population.
 Non-Hispanic white men age 85 and older were
most likely to die by suicide. They had a rate of
49.8 suicide deaths per 100,000 persons in that
age group.
 Up to 75% of older adults who die by suicide
visited a physician within a month before death.
 www.cdc.gov/ncipc/wisqars
Mortality
Late life depression has been associated
with increased mortality apart from suicide
Murphy et al (1987) – 16 year prospective study
of a general population. Persons with reported
depression experienced 1.5x number of deaths
expected on the basis of rates for a large
reference population.
Challenges in diagnosing depression in
late life
 Clinicians and family may incorrectly attribute
depressive symptoms to aging process or result
of life stresses/losses (such as physical illness,
spousal death, financial stresses.)
 In older adults, patients may not report feeling
depressed, but may have anxiety, somatic
symptoms, irritability, and/or cognitive decline.
Agitation in patients with dementia can be a
symptom of depression.
 Patients may deny or under report symptoms
due to stigma/shame of psychiatric symptoms.
Undetected depression in older patients
 Licht-Strunk et al (2009) – Conducted a one year
follow-up study of GP pts >55y/o who were
diagnosed with depression using the GDS-15 and
PRIME-MD. GPs and pts were not informed of the
test results.
 67% of pts were not detected by GP as being
depressed – of these pts 33% had remitted after
one year
 33% of pts had depression detected by GP – of
these pts 37% had remitted after one year
 Other studies suggest that primary care
physicians may fail to recognize 30-50% of
patients with major depressive episodes - Thibault
and Steiner (2004)
Screening for Depression
 The USPSTF recommends screening adults for
depression when staff-assisted depression care
supports are in place to assure accurate
diagnosis, effective treatment, and follow-up.
Grade: B recommendation
 What if any screening instrument do you use?
Screening for Depression
 Patient Health Questionnaire (PHQ-9)
 This questionnaire consists of several statements. Read each
statement carefully, then pick the number that best describes the way
you have been feeling during the past two weeks, including today.
 Over the last 2 weeks, how often have you been bothered by any of
the following problems?

Not at all
Several Days More than half the days
0
1
2
Nearly every day
3
1) Little interest or pleasure in doing things?
2) Feeling down, depressed, or hopeless?
3) Trouble falling or staying asleep, or sleeping too much?
4) Feeling tired or having little energy?
5) Poor appetite or overeating?
6) Feeling bad about yourself -- or that you are a failure or have let
yourself or your family down?
 7) Trouble concentrating on things, such as reading the newspaper or
watching television?
 8) Moving or speaking so slowly that other people could have noticed?
Or the opposite — being so fidgety or restless that you have been
moving around a lot more than usual?
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 9)Thoughts that you would be better off dead or of hurting yourself?
Screening for Depression
 PHQ-2 is comprised of the first 2 questions of
the PHQ-9.
 Patients who score >= 3 on PHQ-2 should be
assessed with the remaining 7 questions of the
PHQ-9.
 PHQ-9 sensitivity 88%, specificity 88%. Positive
predictive value when used as a standardized
screening test is 56%, but when given to
selected patients suspected of having
depression it increases to 88% - Thibault and Steiner
(2004)
Indications to Start Antidepressant
Therapy Based on PHQ-9
PHQ-9 Depression
Score Severity
1-4
None
Clinician
Response
None
5-9
Mild-moderate
If not currently treated,
rescreen in 2wks. If on
treatment, optimize RX and
rescreen in 2wks.
10-14
MDD
Start antidepressant therapy
>=15
MDD
Start antidepressant
therapy; obtain psych
consult if suicidality or
psychosis is suspected.
Prescriber Response Guidelines at 4wks
Based on PHQ-9 and STAR*D Studies
PHQ-9 Score
or Change
No decrease or
increase
Decrease of 2-4
points
Decrease of
>=5 points
Score <5
Outcome
No response
Partial
response
Response
Remission
Clinician
Response
Switch
medication
Add medication
Maintain
medication
Maintain
medication
Geriatric Depression Scale (GDS, short
form)
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Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? Y/ N
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO

http://www.stanford.edu/~yesavage/GDS.english.short.html
Geriatric Depression Scale
 Although differing sensitivities and specificities
have been obtained across studies, for clinical
purposes a score > 5 points is suggestive of
depression and should warrant a follow-up
interview. Scores > 10 are almost always
depression.
 Wancata et al (2006) – Systematic review
looking at the screening accuracy of both
versions of the GDS. GDS-30 sen 0.753, spec
0.770, GDS-15 sen 0.805, spec 0.750
Evaluating patients with dementia for
depression
Neither PHQ-9 or GDS are reliable when
administered to pts with
moderate/severe dementia (but are valid
in pts with MMSE scores >=15) – Katz (1998)
Issues with applying DSM- IV criteria (For
example, cannot use “decreased ability to
think/concentrate” as a criteria for
diagnosis.) Ascertainment of symptoms
requires recall of recent experiences.
Evaluating patients with dementia for
depression
Hamilton Depression Rating Scale
(HDRS) – 21 questions asking about
symptoms such as insomnia, agitation,
anxiety, and somatic symptoms. Has been
used to demonstrate treatment responses
for depression in randomized clinical trials
in patients with dementia.
Another similar scale is the Cornell Scale
for Depression in Dementia (CS)
Evaluating patients with dementia for
depression
 There can be discrepancies between patient and
caregiver-derived information regarding presence
of depression.
 Based on patient interviews,14% of a sample of
pts with AD met DSM criteria for major
depression, but 50% did on the basis of info from
caregivers.
 Motivational disturbances increase with severity
of dementia (symptoms such as apathy, passivity,
and decreased initiative.) It has been suggested
that most apathy observed in AD is unrelated to
depression and that emphasizing
motivational/vegetative symptoms is likely to lead
to overdiagnosis.
 Katz (1998)
Evaluation and Treatment
 Evaluate medical status/thyroid/substance
abuse (ie sedatives and alcohol)
 Consider time course of medication use to
symptom onset
 When picking an antidepressant, ask about prior
antidepressant use and family hx of
antidepressant use
 Select antidepressant based on side effect
profile and ease of dosing
 Only 10-40% of depressed elderly are given
medication
 More than 1/3 of pts rely solely on their primary
care physician for treatment of psychiatric
conditions
 Birrer and Vemuri (2004); amednews.com (11/2010)
Treatment
 If patient has depression with psychotic features,
than treatment with combo of antidepressant and
antipsychotic or ECT or referral to psychiatrist
should be initiated.
(Psychotic symptoms are present in 20-45% of
hospitalized elderly pts with depression and
3.6% of community-dwelling pts with
depression.)
Compared with nonpsychotic depression, patients
with psychotic depression have recovery rates
that are reduced by ½ and relapse and disability
rates 2x greater.
Treatment
 Only 50% of pts with MDD fully respond to an
initial antidepressant treatment.
 An additional 1/3 recover when the
antidepressant is switched to another agent or
augmented with a 2nd antidepressant or
psychotherapy.
 Outcome studies indicate the recovery rate for
elderly depressed pts is similar to younger
depressed patients. Causes for poorer
outcomes include clinicians prescribing too low
doses for too short of time
Treatment
Data indicates that 4 wks is adequate to
identify pts who will be non-responders or
partial-responders at 12 wks.
At 4 wks on treatment:
1/3 non-responders
1/3 partial-responders
1/3 full-responders
ACOVE Guidelines
 In an older adult, newly treated for depression, document
within 4 wks of treatment initiation:
 Degree of response to >= 2 of 9 DSM IV criteria
 Any medication adverse events
 If no meaningful response after 6 wks of Rx, then by the
8th week:
 Rx dose should be optimized or changed or refer to
psychiatrist
 If pt has only partial response after 12 wks of Rx, then by
the 16th week:
 Switch to a different med class or add 2nd med or add
psychotherapy or refer to psychiatrist
 PROSPECT (Prevention of Suicide in Primary Care
Elderly- Collaborative Trial) – published guidelines for
pharmacological treatment of late-life depression.
Augmentation vs Substitution
 STAR *D (Sequenced Treatment Alternatives to
Relieve Depression)- When pts did not achieve
remission with citalopram, augmentation with
bupropion or buspirone achieved remission in
1/3 of pts and was superior to switching to
another agent (remission achieved in ¼ of pts
who switched to venlafaxine, bupropion, or
sertraline.)
 PROSPECT: In partial responders, the algorithm
favors first a dosage increase up to the
maximum recommended dosage followed by
augmentation of current treatment.
Augmentation vs Substitution
 Factors favoring substitution:
Avoids potential drug-drug interactions
Simpler medication regimen and lower costs
Easier attribution and management of side effects
 Factors favoring augmentation:
Preserves improvement produced by current
antidepressant (in partial responders)
Prevents delay associated with discontinuation of
current med and titration of a new one
Combo of two different antidepressants affecting
different neurotransmitter systems may have synergistic
effect
ACOVE Guidelines
If patient has responded to Rx, then
continue on same dose for >= 6 mo
If patient has had >=3 episodes of
depression, than pt should receive
maintenance therapy with same dose for
>= 24 mo.
Recurrence risk after 1st episode of major
depression – 50%, after 2nd episode 70%,
after 3rd episode 90%
SSRIs
 SSRIs are recommended 1st line antidepressant. – often
initiate doses at half usual adult dosage and then titrate
slowly for a few weeks to optimal dose.
 More favorable safety and side effect profiles compared
with other antidepressants.
 Common side effects include GI symptoms– other
potential side effects include hyponatremia, sweating,
sexual dysfunction, insomnia, somnolence, tremor.
 SSRIs are weak inhibitors of cytochrome P450 system –
can affect pts taking drugs with dosage-dependent
enzyme inhibition interactions and a narrow therapeutic
index (ie TCAs, neuroleptics, anticonvulsants, warfarin.)
SSRIs
 Sertraline (Zoloft) – begin 25mg, move to 50mg
as indicated. Rarely need greater than 100mg in
elderly but can increase to 200mg
 Citalopram (Celexa) – begin 10mg; final dosage
20-40mg
 Escitalopram (Lexapro) – begin 5-10mg ; final
dosage 10-20mg
 Fluoxetine (Prozac) – long half life a
disadvantage – begin 5-10mg; final dosage 2040mg
 Paroxetine (Paxil) – May be sedating/cause
fatigue, withdrawal occurs – begin 10mg; final
dosage 20-40mg
Other Antidepressants
 Bupropion (Wellbutrin)– may be as effective as SSRIs and
TCAs in treatment of MDD – begin 75mg bid - lowers
seizure threshold, insomnia, no anxiolytic properties; final
dosage 150-300mg
 Trazodone – begin 25-50mg –sedation; final dosage 100400mg
 Mirtazapine (Remeron) – begin 7.5mg - sedation,
increased appetite; final dosage 15-45mg
 SNRIs
 Venlafaxine (Effexor) – option for treatment resistant
depression, rapid onset - begin 37.5 -75mg - HTN, anxiety,
GI symptoms; final dosage 75-300mg
 Duloxetine (Cymbalta) – begin 20mg – increased lfts –
approved for neuropathic pain treatment; final dosage 3060mg
Other Antidepressants
 ACOVE guidelines – If starting an antidepressant, then
the following medications should not be used as 1st or
2nd line therapy: tertiary amine tricyclics (amitriptyline,
doxepin,imipramine, clomipramine, trimipramine),
MAOIs; unless atypical depression is present, benzos, or
stimulants (except methylphenidate.)
 TCAs with fewer anticholinergic side effects include
nortriptyline (secondary tricyclics.) TCAs can cause
sedation, cardiac effects, orthostatic hypotension, and
lower seizure threshold.
 Hypo/hypertension and food-drug interactions are most
likely problems with MAOI use.
Augmentation strategies
Buproprion to SSRIs or Venlafaxine
Mirtazapine
ECT
Patients intolerant to treatment
 Depressed elderly with somatic symptoms may mistake
somatic symptoms early in treatment for side effects,
leading to premature discontinuation of antidepressant
medication.
 In PROSPECT, somatic symptoms are assessed at
baseline and at f/u. If side effects occur, dosage or time
of administration can be adjusted, or symptomatic
treatment instituted (ie stool softeners).
 Pts unable to tolerate citalopram 10mg/day are treated
with bupropion SR. If unable to tolerate it, they are
switched to nefazodone. “Citalopram, bupriopion, and
nefazodone affect different neurotransmitter systems and
have distinct side effect profiles. Thus, it is unlikely that a
patient would not be able to take any of these
medications.”
Psychotherapeutic interventions
 Can include cognitive-behavior therapy,
supportive psychotherapy, problem-solving
therapy, and interpersonal therapy.
 Can be beneficial alone, or in conjunction with
medication therapy.
 A combo of psychotherapeutic interventions and
medication therapy has better results than either
form of treatment alone for mod/severe
depression.
 Older adults often have better treatment
compliance, lower dropout rates, and more
positive responses to psychotherapy than
younger patients.
ECT (Electroconvulsive therapy)
Effective for depression complicated by
psychosis or poor response to medication
therapy
First-line treatment for patients at serious
risk of suicide
Remission
Better rates of remission – pts with good
social support, better medical health, early
and aggressive treatment with
antidepressants, and use of ECT when
indicated.
References
 Birrer RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic
challenge. Am Fam Physician. 2004;69(10):2375-82.
 Center for Disease Control and Prevention. Accessed online November, 2010 at:
www.cdc.gov/ncipc/wisqars.
 Geriatric Depression Scale. Acessed online November, 2010 at:
http://www.stanford.edu/~yesavage/GDS.english.short.html.
 Katz IR. Diagnosis and treatment of depression in patients with Alzheimer’s
disease and other dementias. J Clin Psychiatry. 1998;59 Suppl 9:38-44.
 Lapid MI, Rummans TA. Evaluation and management of geriatric depression in
primary care. Mayo Clin Proc. 2003;78(11):1423-9.
 Licht-Strunk E et al. The prognosis of undetected depression in older general
practice patients. A one year follow-up study. J Affect Disord. 2009;114(1-3):3105.
 Moyer, CS. Primary care doctors carrying heavier mental health load. Accessed
online November, 2010 at: http://www.amaassn.org/amednews/2010/10/25/prl21025.htm.
 Mulsant BH et al. Pharmacological treatment of depression in older primary care
patients: the PROSPECT algorithm. Int J Geriatr Psychiatry. 2001;16(6):585-92.
References
 Murphy et al. Affective disorders and mortality. A general population study.
Arch Gen Psychiatry. 1987;44(5):473-80.
 Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum
in Geriatric Medicine. 7th ed. New York: American Geriatrics Society; 2010.
 Sinyor M, Schaffer A, Levitt A. The Sequenced Treatment Alternatives to
Relieve Depression (STAR*D) Trial: A review. Can J Psychiatry.
2010;55(3):126-35.
 Thibault JM, Steiner RW. Efficient identification of adults with depression
and dementia. Am Fam Physician. 2004;70(6):1101-10.
 U.S. Preventative Services Task Force. Screening for depression in adults.
Acessed online November, 2010 at:
http:///www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm.
 Wancata J et al. The criterion validity of the Geriatric Depression Scale: a
systematic review. Acta Psychiatr Scand. 2006;114(6):398-410.