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Beating the Blues: Depression in Older Patients Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry Department of Psychiatry UNMC Goals Discuss depressed mood as a problem in the nursing home Discuss recognition of depression Discuss treatments of depression. Mood Problems Several diagnoses for depressed mood Major depressive disorder Dysthymia Bipolar affective disorder Mood disorder due to a general medical dx Substance induced mood disorder Adjustment disorder with depression Complicated bereavement Mood disorder not other wise specified (NOS) Major Depressive Disorder More intense than being blue 2 wks Lasts for an extended time Dysfunction DSM IV criteria for Major Depressive Disorder Must have 1 of these 2 • Depressed mood, more often than not, for 2W • Loss of interest Plus these other symptoms to equal 5 total • Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt, Epidemiology of Geriatric Depression Of 35 million seniors in the US 19% of all suicides are by patients over 65 An estimated 2 million have a depressive illness 5 million have subsyndromal depression Less than 10% are treated 1 in 10 Americans over 65 will be depressed Seniors comprise 13% of the population The highest suicide rates in the U.S. are found in white men over age 85. Seniors have 50% higher health care costs if depressed www.efmoody.com/longterm/depression.html Epidemiology of Geriatric Depression Influence on general health CV disease, cancer, infection, falls Mortality Epidemiology of Geriatric Depression MDD in special populations of elderly Medical outpatient rate is 7-35% • 5x higher in the doctor’s office than in the community Medically hospitalized rate is 40% Epidemiology of Geriatric Depression Nursing Homes’ rate for MDD is 12.4-20% • But 30-35% have other depressive disorders Dementia with depression Adjustment disorder with depressed mood Complicated bereavement Depression due to GMC (Parkinson’s Disease, e.g.) Epidemiology of Geriatric Depression Geriatric depression is associated with: Female gender • Though this declines with age • Above age 80 gender differences rapidly fade Low socio-economic level Less social support • Especially those divorced or widowed Recent adverse life events • Death and other losses Severe impairment in medical health • Especially neurological disorders, endocrine disorders, COPD, MI, cancers Epidemiology of Geriatric Depression Underutilization of psychiatric services Common in those over 65 • • • • A matter of “will power” Cost of medicines, copays Depressed people went to the asylum Not socially acceptable to discuss one’s feelings Underutilization of psychiatric services Contributes to the high suicide rate in this group • Over 65, white males have the highest rate of completed suicide in the United States 0.02%/yr for men, 0.005%/yr for women over 65 Rate for white men over 85 is FIVE TIMES the national rate • 59 per 100,000 versus 10.6 per 100,000 MDS 3.0 criteria mood disorder Corresponds closest to the diagnosis of major depression. Major Depressive Disorder DSM IV criteria for Major Depressive Disorder Must have 1 of these 2 • Depressed mood, more often than not, for 2W • Loss of interest Plus these other symptoms to equal 5 total • Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt, MDS 3.0 Depression Definition PHQ-9 2 or more sx occurring >= 50% time Over the last 2 wks have you been bothered by any of the following problems? Little interest Feeling down Sleep Energy Appetite Feeling bad about yourself (worthlessness) Concentration Moving slowly (psychomotor retardation) Thoughts you would be better off dead You suspect Depression What next? Is it Medication? Pain medications codeine, darvon High blood pressure medications • clonidine, reserpine Hormones • estrogen, progesterone, prednisone Cardiac medications • digitalis, propranolol Alcohol Is it medications? Anticancer agents cycloserine tamoxifen Nolvadex, Velban, Oncovin Parkinson’s disease medications • L-dopa and bromocriptine Arthritis indomethacin Anti-anxiety drugs Valium and Halcion Is it a medical condition? Hypothyroidism Calcium B12 Vitamin D deficiency Heart disease Neurological illnesses Cancer COPD . Is it due to dementia? Higher rate of depression than the general population • Varying intensity in 50% • Alzheimer’s range 0-87%, mean 17-31% Mild to moderate stages report depression • GDS Useful for mild to moderate dementia Patient answers 15 questions with yes or no • Cornell Scale for Depression in Dementia Useful for moderate to severe dementia No self-report so rater must be well-trained Diagnosis of Geriatric Depression in Dementia Confusion can often arise as to mood symptoms in dementia Communication issues • Patients with moderate to severe dementias do not verbally communicate their mood Symptoms of other disorders can overlap with depression • Alzheimer’s patients have little appetite, lose concentration, become isolative • Parkinson’s patients lose affect, have slowed speech and movements • Frontal lobe injuries present with apathy, often misinterpreted as depression, or frequent crying not related to mood Diagnosis of Geriatric Depression in Dementia Useful to use: Frequent, dysfunctional sad, downcast mood New agitation and/or sudden loss of interest Psychic rather than vegetative features • Vegetative features often are multifactoral i.e. poor sleep may have four or five causes Use caregiver reports from home or the NH The patient’s past medical and psychiatric history Diagnosis of Geriatric Depression in Dementia If unsure, TREAT FOR DEPRESSION Medications safer and more effective these days ECT a viable option Much worse to miss than overtreat Diagnosis of Geriatric Depression in Dementia Apathy is a common symptom in dementia Often mistaken for depression How to tell them apart? In apathy, no emotional changes or lasting emotional feelings. Treatment? (none with FDA approval) Amphetamine if pt sleeps too much-provigil Antidepressants Course of Geriatric Depression More chronic than early onset depression Adult rate for chronic depression is 20% Geriatric rate for chronic depression near 30% • 13-19% relapse at one year • Risks for relapse after age 65 Frequent episodes Late age at onset Dysthymia Medical illness High severity of first episode Hospitalization, suicide attempt Rationale for long term use of antidepressants in this population Psychotic depression Psychotic depression a problem in the elderly 20-45% of geriatric psychiatric inpatients 4% of depressed elders in the community Psychotic depression Presentation • Primarily delusions, hallucinations less so Guilt, hypochondriasis, nihilism, persecution, jealousy • Highly systematized, mood-congruent delusions Delusion often frightening or catastrophic • Needs treatment for depression and psychosis These patients require antipsychotic treatment • fluvoxamine (Luvox) may be useful alone Often require electroconvulsive therapy (ECT) • Especially when their condition compromises their physical health Medications to Treat Geriatric Depression SSRIs –most common Fluoxetine Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram SNRI’s Venlafaxine duloxetine Tricyclics MAOI Nortriptyline Selegeline patch Others mirtazepine bupropion trazodone Treatment for Depression Medications All have data or reports in use in elderly pts. All have some positive report in dementia pts. Depression harder to treat in older patients What should you expect from medication Treatment of Geriatric Depression? How 8 to 12 weeks in 30 year olds May stretch to 12-16 weeks in the elderly Can long does it take to work? you see changes earlier? Some yes. • Vegetative-sleep appetite energy • Good sign of response What should you expect from medication Treatment of Geriatric Depression? Are they dangerous? Not long-term Drug-drug interactions minimal in most cases Not addictive What should you expect from medication Treatment of Geriatric Depression? Do they have side effects? SSRI- GI, dec. sex drive, anxiety headache SNRI-HTN, anxiety TCAs-bladder, bowel, cardiac, confusion MAOI-Tyramine reaction Mirtazapine-sedation weight gain Buproprion-anxiety, HTN Trazodone-sedation, orthostatic BP Are Antidepressants used for other purposes? Anxiety/sleep- FDA approval for mirtazapine, nortriptyline Pain- duloxetine, venlafaxine, nortriptyline Appetite-mirtazapine, nortriptyline Are other medications used for depression? Methyphenidate No FDA approved, literature supports used in medically ill, apathetic, those with poor appetite Lamictal FDA approved for bipolar depression Treatment Psychotherapy Cognitive-behavioral and Interpersonal • Manual-driven • Easy to study • Effective in combination and alone Psychodynamic • Long-term issues; less studied Problem solving and Supportive • Mild-moderate dementia • Coping day-to-day Treatment ECT Works rapidly for those who can’t wait • Psychotic depression, especially Hospital venue • Anesthesia • 30-60 second seizure; 6-12 treatments Maintenance treatment Adverse effects minimal • Short-term memory loss; lasts less than 2 mos. • Mortality rate 0.01% Treatment ECT How does it work? Win the Nobel Prize in Medicine • Cerebrovascular contraction • Increased BBB permeability • Increased brain O2 concentration No absolute contraindications • Relative are brain tumor, MI in the last 3-6 mos. Response level is 90% • Trick is maintaining the response Goals Geriatric depression is common in NH Rates are different than the general population Various effective treatments do exist Visit our website and forum http://app1.unmc.edu/intmed/geriatrics/index.cfm?c onref=104 http://ltcmentalhealth.forumcircle.com/portal.php Post your cases here for education of others, or to ask for advise. Ask questions of faculty or group Review cases and our solutions Download tip sheets for each lecture Don’t forget to fill out the evaluation form —pay attention to the format.