Beating the Blues: Depression in Older Patients Thomas Magnuson, M.D. Assistant Professor Division...

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Beating the Blues:Beating the Blues:Depression in Older Depression in Older

PatientsPatients

Thomas Magnuson, M.D.Thomas Magnuson, M.D.

Assistant ProfessorAssistant Professor

Division of Geriatric PsychiatryDivision of Geriatric Psychiatry

Department of PsychiatryDepartment of Psychiatry

UNMCUNMC

GoalsGoals

Discuss depressed mood as a problem in Discuss depressed mood as a problem in the nursing homethe nursing home

Discuss recognition of depressionDiscuss recognition of depression Discuss treatments of depression.Discuss treatments of depression.

Mood ProblemsMood Problems

Several diagnoses for depressed moodSeveral diagnoses for depressed mood Major depressive disorderMajor depressive disorder DysthymiaDysthymia Bipolar affective disorderBipolar affective disorder Mood disorder due to a general medical dxMood disorder due to a general medical dx Substance induced mood disorderSubstance induced mood disorder Adjustment disorder with depressionAdjustment disorder with depression Complicated bereavementComplicated bereavement Mood disorder not other wise specified (NOS)Mood disorder not other wise specified (NOS)

Major Depressive DisorderMajor Depressive Disorder

More intense than being blueMore intense than being blue Lasts for an extended time Lasts for an extended time DysfunctionDysfunction DSM IV criteria for Major Depressive DisorderDSM IV criteria for Major Depressive Disorder

Must have 1 of these 2Must have 1 of these 2• Depressed moodDepressed mood, more often than not, for 2W, more often than not, for 2W• Loss of interestLoss of interest

Plus these other symptoms to equal 5 totalPlus these other symptoms to equal 5 total• Sleep, energy, appetite, worthlessness,Sleep, energy, appetite, worthlessness, concentration, concentration,

suicidal ideation, suicidal ideation, helpless, hopeless, guilt, helpless, hopeless, guilt,

Epidemiology of Geriatric Epidemiology of Geriatric DepressionDepression

Of 35 million seniors in the USOf 35 million seniors in the US An estimated 2 million have a depressive illnessAn estimated 2 million have a depressive illness 5 million have subsyndromal depression 5 million have subsyndromal depression Less than 10% are treatedLess than 10% are treated 1 in 10 Americans over 65 will be depressed1 in 10 Americans over 65 will be depressed

19% of all suicides are by patients over 6519% of all suicides are by patients over 65 Seniors comprise 13% of the populationSeniors comprise 13% of the population The highest suicide rates in the U.S. are found in The highest suicide rates in the U.S. are found in

white men over age 85.white men over age 85. Seniors have 50% higher health care costs if Seniors have 50% higher health care costs if

depresseddepressed

www.efmoody.com/longterm/depression.html

Influence on general healthInfluence on general health CV disease, cancer, infection, fallsCV disease, cancer, infection, falls MortalityMortality

MDD in special populations of elderlyMDD in special populations of elderly Medical outpatient rate is 7-35%Medical outpatient rate is 7-35%

• 5x higher in the doctor’s office than in the 5x higher in the doctor’s office than in the communitycommunity

Medically hospitalized rate is 40%Medically hospitalized rate is 40%

Nursing Homes’ rate for MDD is 12.4-20%Nursing Homes’ rate for MDD is 12.4-20%• But 30-35% have other depressive disordersBut 30-35% have other depressive disorders

Dementia with depressionDementia with depression Adjustment disorder with depressed moodAdjustment disorder with depressed mood Complicated bereavementComplicated bereavement Depression due to GMC (Parkinson’s Disease, e.g.)Depression due to GMC (Parkinson’s Disease, e.g.)

Geriatric depression is associated with:Geriatric depression is associated with: Female gender Female gender

• Though this declines with ageThough this declines with age• Above age 80 gender differences rapidly fadeAbove age 80 gender differences rapidly fade

Low socio-economic levelLow socio-economic level Less social supportLess social support

• Especially those divorced or widowedEspecially those divorced or widowed Recent adverse life eventsRecent adverse life events

• Death and other lossesDeath and other losses Severe impairment in medical healthSevere impairment in medical health

• Especially neurological disorders, endocrine disorders, Especially neurological disorders, endocrine disorders, COPD, MI, cancersCOPD, MI, cancers

Underutilization of psychiatric servicesUnderutilization of psychiatric services Common in those over 65Common in those over 65

• A matter of “will power”A matter of “will power”• Cost of medicines, copaysCost of medicines, copays• Depressed people went to the asylumDepressed people went to the asylum• Not socially acceptable to discuss one’s feelingsNot socially acceptable to discuss one’s feelings

Underutilization of psychiatric Underutilization of psychiatric servicesservices

Contributes to the high suicide rate in this Contributes to the high suicide rate in this groupgroup• Over 65, white males have the highest rate of Over 65, white males have the highest rate of

completed suicide in the United Statescompleted suicide in the United States 0.02%/yr for men, 0.005%/yr for women over 650.02%/yr for men, 0.005%/yr for women over 65 Rate for white men over 85 is FIVE TIMES the national Rate for white men over 85 is FIVE TIMES the national

rate rate • 59 per 100,000 versus 10.6 per 100,00059 per 100,000 versus 10.6 per 100,000

MDS 3.0 criteria mood disorder MDS 3.0 criteria mood disorder

Corresponds closest to the diagnosis of Corresponds closest to the diagnosis of major depression.major depression.

Major Depressive DisorderMajor Depressive Disorder

DSM IV criteria for Major Depressive DSM IV criteria for Major Depressive DisorderDisorder Must have 1 of these 2Must have 1 of these 2

• Depressed moodDepressed mood, more often than not, for 2W, more often than not, for 2W• Loss of interestLoss of interest

Plus these other symptoms to equal 5 totalPlus these other symptoms to equal 5 total• Sleep, energy, appetite, worthlessness,Sleep, energy, appetite, worthlessness,

concentration, suicidal ideation, concentration, suicidal ideation, helpless, helpless, hopeless, guilt, hopeless, guilt,

MDS 3.0 Depression DefinitionMDS 3.0 Depression DefinitionPHQ-9PHQ-9

2 or more sx occurring >= 50% time2 or more sx occurring >= 50% time

Over the last 2 wks have you been bothered by Over the last 2 wks have you been bothered by any of the following problems?any of the following problems? Little interestLittle interest Feeling downFeeling down Sleep Sleep EnergyEnergy AppetiteAppetite Feeling bad about yourself (worthlessness)Feeling bad about yourself (worthlessness) ConcentrationConcentration Moving slowly (psychomotor retardation)Moving slowly (psychomotor retardation) Thoughts you would be better off deadThoughts you would be better off dead

You suspect DepressionYou suspect DepressionWhat next?What next?

Is it Medication?Is it Medication?

Pain medicationsPain medications codeine, darvoncodeine, darvon

High blood pressure medicationsHigh blood pressure medications• clonidine, reserpineclonidine, reserpine

HormonesHormones• estrogen, progesterone, prednisoneestrogen, progesterone, prednisone

Cardiac medicationsCardiac medications• digitalis, propranololdigitalis, propranolol

AlcoholAlcohol

Is it medications?Is it medications?

Anticancer agentsAnticancer agents cycloserinecycloserine tamoxifentamoxifen Nolvadex, Velban, OncovinNolvadex, Velban, Oncovin

Parkinson’s disease medicationsParkinson’s disease medications• L-dopa and bromocriptineL-dopa and bromocriptine

Arthritis Arthritis indomethacinindomethacin

Anti-anxiety drugsAnti-anxiety drugs Valium and HalcionValium and Halcion

Is it a medical condition?Is it a medical condition?

HypothyroidismHypothyroidism CalciumCalcium B12B12 Vitamin D deficiencyVitamin D deficiency Heart diseaseHeart disease Neurological illnessesNeurological illnesses CancerCancer COPDCOPD

Is it due to dementia?Is it due to dementia?

Higher rate of depression than the general Higher rate of depression than the general populationpopulation

• Varying intensity in 50%Varying intensity in 50%• Alzheimer’s range 0-87%, mean 17-31%Alzheimer’s range 0-87%, mean 17-31%

Mild to moderate stages report depressionMild to moderate stages report depression

• GDS GDS Useful for mild to moderate dementiaUseful for mild to moderate dementia Patient answers 15 questions with yes or noPatient answers 15 questions with yes or no

• Cornell Scale for Depression in Dementia Cornell Scale for Depression in Dementia Useful for moderate to severe dementiaUseful for moderate to severe dementia No self-report so rater must be well-trainedNo self-report so rater must be well-trained

Diagnosis of Geriatric Diagnosis of Geriatric Depression in DementiaDepression in Dementia

Confusion can often arise as to mood symptoms Confusion can often arise as to mood symptoms in dementiain dementia Communication issuesCommunication issues

• Patients with moderate to severe dementias do not verbally Patients with moderate to severe dementias do not verbally communicate their moodcommunicate their mood

Symptoms of other disorders can overlap with Symptoms of other disorders can overlap with depressiondepression

• Alzheimer’s patients have little appetite, lose concentration, Alzheimer’s patients have little appetite, lose concentration, become isolativebecome isolative

• Parkinson’s patients lose affect, have slowed speech and Parkinson’s patients lose affect, have slowed speech and movementsmovements

• Frontal lobe injuries present with apathy, often misinterpreted Frontal lobe injuries present with apathy, often misinterpreted as depression, or frequent crying not related to moodas depression, or frequent crying not related to mood

Diagnosis of Geriatric Diagnosis of Geriatric Depression in DementiaDepression in Dementia

Useful to use:Useful to use: Frequent, dysfunctional sad, downcast mood Frequent, dysfunctional sad, downcast mood New agitation and/or sudden loss of interestNew agitation and/or sudden loss of interest Psychic rather than vegetative featuresPsychic rather than vegetative features

• Vegetative features often are multifactoralVegetative features often are multifactoral i.e. poor sleep may have four or five causesi.e. poor sleep may have four or five causes

Use caregiver reports from home or the NHUse caregiver reports from home or the NH The patient’s past medical and psychiatric historyThe patient’s past medical and psychiatric history

Diagnosis of Geriatric Depression Diagnosis of Geriatric Depression in Dementiain Dementia

If unsure, TREAT FOR DEPRESSIONIf unsure, TREAT FOR DEPRESSION Medications safer and more effective these Medications safer and more effective these

daysdays ECT a viable optionECT a viable option Much worse to miss than overtreatMuch worse to miss than overtreat

Diagnosis of Geriatric Depression Diagnosis of Geriatric Depression in Dementiain Dementia

Apathy is a common symptom in dementiaApathy is a common symptom in dementia Often mistaken for depression-Often mistaken for depression- How to tell them apart?How to tell them apart?

In apathy, no emotional changes or lasting In apathy, no emotional changes or lasting emotional feelings.emotional feelings.

Treatment? (none with FDA approval)Treatment? (none with FDA approval) Amphetamine if pt sleeps too much-provigilAmphetamine if pt sleeps too much-provigil Antidepressants Antidepressants

Course of Geriatric DepressionCourse of Geriatric Depression

More chronic than early onset depressionMore chronic than early onset depression Adult rate for chronic depression is 20%Adult rate for chronic depression is 20% Geriatric rate for chronic depression near 30%Geriatric rate for chronic depression near 30%

• 13-19% relapse at one year13-19% relapse at one year• Risks for relapse after age 65Risks for relapse after age 65

Frequent episodesFrequent episodes Late age at onsetLate age at onset DysthymiaDysthymia Medical illnessMedical illness High severity of first episodeHigh severity of first episode Hospitalization, suicide attemptHospitalization, suicide attempt

Rationale for long term use of antidepressants in this Rationale for long term use of antidepressants in this populationpopulation

Psychotic depressionPsychotic depression

Psychotic depression a problem in the elderlyPsychotic depression a problem in the elderly 20-45% of geriatric psychiatric inpatients20-45% of geriatric psychiatric inpatients 4% of depressed elders in the community4% of depressed elders in the community

Psychotic depressionPsychotic depression

PresentationPresentation• Primarily delusions, hallucinations less soPrimarily delusions, hallucinations less so

Guilt, hypochondriasis, nihilism, persecution, jealousyGuilt, hypochondriasis, nihilism, persecution, jealousy

• Highly systematized, mood-congruent delusionsHighly systematized, mood-congruent delusions Delusion often frightening or catastrophicDelusion often frightening or catastrophic

• Needs treatment for depression and psychosisNeeds treatment for depression and psychosis These patients require antipsychotic treatmentThese patients require antipsychotic treatment

• fluvoxamine (Luvox) may be useful alonefluvoxamine (Luvox) may be useful alone Often require electroconvulsive therapy (ECT)Often require electroconvulsive therapy (ECT)

• Especially when their condition compromises their Especially when their condition compromises their physical healthphysical health

Medications to Treat Geriatric Medications to Treat Geriatric DepressionDepression

SSRIs –most commonSSRIs –most common FluoxetineFluoxetine SertralineSertraline ParoxetineParoxetine FluvoxamineFluvoxamine CitalopramCitalopram EscitalopramEscitalopram

SNRI’sSNRI’s VenlafaxineVenlafaxine duloxetineduloxetine

Tricyclics Tricyclics NortriptylineNortriptyline

MAOIMAOI Selegeline patchSelegeline patch

OthersOthers mirtazepine mirtazepine bupropion bupropion trazodonetrazodone

Treatment for DepressionTreatment for Depression

MedicationsMedications All have data or reports in use in elderly pts.All have data or reports in use in elderly pts. All have some positive report in dementia pts.All have some positive report in dementia pts. Depression harder to treat in older patientsDepression harder to treat in older patients

What should you expect from What should you expect from medication Treatment of Geriatric medication Treatment of Geriatric

Depression?Depression? How long does it take to work?How long does it take to work?

8 to 12 weeks in 30 year olds8 to 12 weeks in 30 year olds May stretch to 12-16 weeks in the elderlyMay stretch to 12-16 weeks in the elderly

Can you see changes earlier?Can you see changes earlier? Some yes.Some yes.

• Vegetative-sleep appetite energyVegetative-sleep appetite energy• Good sign of responseGood sign of response

Depression?Depression? Are they dangerous?Are they dangerous?

Not long-termNot long-term Drug-drug interactions minimal in most casesDrug-drug interactions minimal in most cases Not addictiveNot addictive

Depression?Depression? Do they have side effects?Do they have side effects? SSRI- SSRI- GI, dec. sex drive, anxiety headacheGI, dec. sex drive, anxiety headache SNRI-HTN, anxietySNRI-HTN, anxiety TCAs-bladder, bowel, cardiac, confusionTCAs-bladder, bowel, cardiac, confusion MAOI-Tyramine reactionMAOI-Tyramine reaction Mirtazapine-sedation weight gainMirtazapine-sedation weight gain Buproprion-anxiety, HTNBuproprion-anxiety, HTN Trazodone-sedation, orthostatic BPTrazodone-sedation, orthostatic BP

Are Antidepressants used for other Are Antidepressants used for other purposes?purposes?

Anxiety/sleep- FDA approval for Anxiety/sleep- FDA approval for mirtazapine, nortriptylinemirtazapine, nortriptyline

Pain- duloxetine, venlafaxine, nortriptylinePain- duloxetine, venlafaxine, nortriptyline Appetite-mirtazapine, nortriptylineAppetite-mirtazapine, nortriptyline

Are other medications used for Are other medications used for depression?depression?

MethyphenidateMethyphenidate No FDA approved, literature supports used in No FDA approved, literature supports used in

medically ill, apathetic, those with poor medically ill, apathetic, those with poor appetiteappetite

Lamictal- Lamictal- FDA approved for bipolar depressionFDA approved for bipolar depression

TreatmentTreatment

PsychotherapyPsychotherapy Cognitive-behavioral and InterpersonalCognitive-behavioral and Interpersonal

• Manual-drivenManual-driven• Easy to studyEasy to study• Effective in combination and aloneEffective in combination and alone

PsychodynamicPsychodynamic• Long-term issues; less studied Long-term issues; less studied

Problem solving and SupportiveProblem solving and Supportive• Mild-moderate dementiaMild-moderate dementia• Coping day-to-dayCoping day-to-day

TreatmentTreatment

ECTECT Works rapidly for those who can’t waitWorks rapidly for those who can’t wait

• Psychotic depression, especiallyPsychotic depression, especially Hospital venueHospital venue

• Anesthesia Anesthesia • 30-60 second seizure; 6-12 treatments30-60 second seizure; 6-12 treatments

Maintenance treatmentMaintenance treatment Adverse effects minimalAdverse effects minimal

• Short-term memory loss; lasts less than 2 mos.Short-term memory loss; lasts less than 2 mos.• Mortality rate 0.01%Mortality rate 0.01%

TreatmentTreatment

ECTECT How does it work?How does it work?

Win the Nobel Prize in MedicineWin the Nobel Prize in Medicine• Cerebrovascular contractionCerebrovascular contraction• Increased BBB permeabilityIncreased BBB permeability• Increased brain O2 concentrationIncreased brain O2 concentration

No absolute contraindicationsNo absolute contraindications• Relative are brain tumor, MI in the last 3-6 mos.Relative are brain tumor, MI in the last 3-6 mos.

Response level is 90% Response level is 90% • Trick is maintaining the responseTrick is maintaining the response

GoalsGoals

Geriatric depression is common in NHGeriatric depression is common in NH Rates are different than the general Rates are different than the general

populationpopulation Various effective treatments do existVarious effective treatments do exist

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Beating the Blues: Depression in Older Patients Thomas Magnuson, M.D. Assistant Professor Division...

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