Depression in the Elderly

Noel H. Ponce, M.D.

Definition

• A disorder of mood, a syndrome that includes a cluster of sx

– Vegetative: sleep, appetite, wgt, sex– Cognitive: attention span, frustration

tolerance, memory, negative distortions

– Impulse: suicide, homicide – Behavior: motivation, pleasure, interest,

fatigability– Somatic: HA, abd’l pain, muscle tension

3 Major Clinical Presentations Associated with Depression in Older Patients

1. Community-dwelling persons who have recently experienced a significant loss. The initial presentation is one of

– depressed mood– loss of pleasure– vegetative sx

2. Those recently ill whose initial presentation is primarily a failure-to-thrive or vegetative state without clear sx of depressed mood.

Best identified by a decline in physical and cognitive function (out of proportion to or unexplained by recent episode of illness)

3. Recent onset of delusions, hallucinations or disruptive behavior might present an initial presentation of depressed mood and or a FTT syndrome

Epidemiology

• Prevalence of Major depressive disorder – Community: 3%– LTC facilities: 12%– Hospital: 11%

• Prevalence of Depressive symptoms– Community: 15%– Nursing home: 30%

Etiology

• Conglomeration of factors

– Biological • Family history / prior hx • in serotonin, dopamine and noradrenaline

– Physical • Chronic medical condition• Treatment

Etiology

– Psychological • Low self-esteem, memory loss, childhood sexual /

physical abuse

– Social • Losses of family and friends, isolation, lossof job and income

Neurological and Medical Causes • Parkinson’s disease• Alzheimer's disease• Cerebrovascular disease • Multiple sclerosis • Hypothyroidism• SLE• Rheumatoid arthritis • Carcinoma • Vitamin deficiencies

Pharmacologic causes

• Propanolol, Digitalis • Benzodiazepines • Corticosteroids • Phenytoin • Ibuprofen, indomethacin • Ampicillin, Tetracycline, Metronidazole • Meclizine • Pizotifen• Cimetidine

Significance in Medical Care

• Depression promotes loss of physical, cognitive, social function and prevents them from regaining function after tx of acute medical illness

• Despite appropriate tx of medical and surgical diseases, undiagnosed and or untreated depression leads to poor patient outcomes

Consequences of Failure in Recognition

• Social isolation • Reduced quality-of-life• Burden to family, society, economy• Increased M/M• Suicide risk

Symptoms• DSM-IV-TR lists the ffg sx as diagnostic criteria for

major depression in older persons 1. Depressed mood and or loss of interest or

pleasure PLUS 4 additional criteria2. Additional criteria

• Weight loss or weight gain• Insomnia or hypersomnia• Psychomotor retardation or agitation • Loss of energy• Feelings of worthlessness • Difficulty concentrating• Recurrent thoughts of death or suicide

Suicide

• More frequent in the elderly than in any other population

• Up to 70% of elderly who completed suicide visited their MD within the previous 4 weeks

• Suicidal attempts and ideation decrease with aging

Assessment

• History and PE including neurologic and mental status assessment

• Review of drug use• Rating scales

– Geriatric Depression Scale– Hamilton Rating Scale

• Laboratory tests

Geriatric Depression Scale

1. Are you basically satisfied with your life?2. Do you feel that your life is empty?3. Are you afraid that something bad is going to

happen to you? 4. Do you feel happy most of the time?

Answers: 1-N, 2-Y, 3-Y, 4-N0 - No depression 1 - Uncertain 2-4 - Probably depression present

Treatment

• Treatment Issues– Any loss incurred major depressive Disorder

– Unstable medical illness must be treated in parallel with the major depression for optimal outcome

– Exacerbation or relapse are typically resistant to Tx as a result of multiple co-morbid illness ergo maintenance therapy should be continued indefinitely

Treatment

• Treatment issues – Common mistakes made in pharmacotherapy

• Dose too low• Treatment too short • Settling for a partial response to tx instead of

complete remission of sx. Careful and frequent ff-up important

Treatment

• Non-pharmacologic– Social support to reduce isolation– Psychotherapy – Family counseling – Substance-abuse intervention as indicated– Bereavement counseling – Health promotion and maintenance

• Good nutrition • Light physical exercise • Attention to chronic medical conditions• Regular daily routine

Treatment

• Pharmacologic treatment– Antidepressant

• SSRI- Sertraline, Escitalopram, Paroxetine, Fluoxetine• SNRI- Venlafaxine, Duloxetine• NDRI- Bupropione• SSRI/ SNRI- Mirtazapine• TCA- Nortriptyline, Desipramine• SARI- Trazodone, Nefazodone

– Psychostimulants • Methyphenidate• Modafinil

Treatment

• Antipsychotics– Treats agitation, delirium, psychosis

• Haloperidol• Olanzapine• Quetiapine• Risperidone

Treatment

• Cognitive impairment – Cholinesterase inhibitors

• Donepezil• Galantamine• Rivastigmine

– NMDA receptor antagonist• Memantine

Electroconvulsive Therapy • Indications

– Severely depressed patients– Those who demonstrate significant

psychotic symptoms and self-destructive behavior

Those who do not tolerate or respond to antidepressants