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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

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Goals Discuss depressed mood as a problem in the nursing home Discuss recognition of depression Discuss treatments of depression.

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Mood Problems Several diagnoses for depressed mood Major depressive disorder Major depressive disorder Dysthymia Dysthymia Bipolar affective disorder Bipolar affective disorder Mood disorder due to a general medical dx Mood disorder due to a general medical dx Substance induced mood disorder Substance induced mood disorder Adjustment disorder with depression Adjustment disorder with depression Complicated bereavement Complicated bereavement Mood disorder not other wise specified (NOS) Mood disorder not other wise specified (NOS)

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Major Depressive Disorder More intense than being blue Lasts for an extended time Dysfunction DSM IV criteria for Major Depressive Disorder Must have 1 of these 2 Must have 1 of these 2 Depressed mood, more often than not, for 2WDepressed mood, more often than not, for 2W Loss of interestLoss of interest Plus these other symptoms to equal 5 total Plus these other symptoms to equal 5 total Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt,Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt, 2 wks

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Epidemiology of Geriatric Depression Of 35 million seniors in the US An estimated 2 million have a depressive illness An estimated 2 million have a depressive illness 5 million have subsyndromal depression 5 million have subsyndromal depression Less than 10% are treated Less than 10% are treated 1 in 10 Americans over 65 will be depressed 1 in 10 Americans over 65 will be depressed 19% of all suicides are by patients over 65 Seniors comprise 13% of the population Seniors comprise 13% of the population The highest suicide rates in the U.S. are found in white men over age 85. 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

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www.efmoody.com/longterm/depression.html

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Epidemiology of Geriatric Depression Influence on general health CV disease, cancer, infection, falls Mortality

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Epidemiology of Geriatric Depression MDD in special populations of elderly Medical outpatient rate is 7-35% Medical outpatient rate is 7-35% 5x higher in the doctors office than in the community5x higher in the doctors office than in the community Medically hospitalized rate is 40% Medically hospitalized rate is 40%

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Epidemiology of Geriatric Depression 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 depression Dementia with depression Adjustment disorder with depressed mood Adjustment disorder with depressed mood Complicated bereavement Complicated bereavement Depression due to GMC (Parkinsons Disease, e.g.) Depression due to GMC (Parkinsons Disease, e.g.)

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Epidemiology of Geriatric Depression 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 level Low socio-economic level Less social support Less social support Especially those divorced or widowedEspecially those divorced or widowed Recent adverse life events Recent adverse life events Death and other lossesDeath and other losses Severe impairment in medical health Severe impairment in medical health Especially neurological disorders, endocrine disorders, COPD, MI, cancersEspecially neurological disorders, endocrine disorders, COPD, MI, cancers

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Epidemiology of Geriatric Depression Underutilization of psychiatric services Common in those over 65 Common in those over 65 A matter of will powerA 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 ones feelingsNot socially acceptable to discuss ones feelings

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Underutilization of psychiatric services Contributes to the high suicide rate in this group Contributes to the high suicide rate in this group Over 65, white males have the highest rate of completed suicide in the United StatesOver 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 0.02%/yr for men, 0.005%/yr for women over 65 Rate for white men over 85 is FIVE TIMES the national rate Rate for white men over 85 is FIVE TIMES the national rate 59 per 100,000 versus 10.6 per 100,00059 per 100,000 versus 10.6 per 100,000

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MDS 3.0 criteria mood disorder Corresponds closest to the diagnosis of major depression.

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Major Depressive Disorder DSM IV criteria for Major Depressive Disorder Must have 1 of these 2 Must have 1 of these 2 Depressed mood, more often than not, for 2WDepressed mood, more often than not, for 2W Loss of interestLoss of interest Plus these other symptoms to equal 5 total Plus these other symptoms to equal 5 total Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt,Sleep, energy, appetite, worthlessness, concentration, suicidal ideation, helpless, hopeless, guilt,

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MDS 3.0 Depression Definition PHQ-9 2 or more sx occurring >= 50% time 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 Little interest Feeling down Feeling down Sleep Sleep Energy Energy Appetite Appetite Feeling bad about yourself (worthlessness) Feeling bad about yourself (worthlessness) Concentration Concentration Moving slowly (psychomotor retardation) Moving slowly (psychomotor retardation) Thoughts you would be better off dead Thoughts you would be better off dead

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You suspect Depression What next?

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Is it Medication? Pain medications Pain medications codeine, darvon codeine, darvon High blood pressure medications High blood pressure medications clonidine, reserpineclonidine, reserpine Hormones Hormones estrogen, progesterone, prednisoneestrogen, progesterone, prednisone Cardiac medications Cardiac medications digitalis, propranololdigitalis, propranolol Alcohol Alcohol

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Is it medications? Anticancer agents Anticancer agents cycloserine cycloserine tamoxifen tamoxifen Nolvadex, Velban, Oncovin Nolvadex, Velban, Oncovin Parkinsons disease medications Parkinsons disease medications L-dopa and bromocriptineL-dopa and bromocriptine Arthritis Arthritis indomethacin indomethacin Anti-anxiety drugs Anti-anxiety drugs Valium and Halcion Valium and Halcion

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Is it a medical condition? Hypothyroidism Calcium B12 Vitamin D deficiency Heart disease Neurological illnesses Cancer COPD.

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Is it due to dementia? Higher rate of depression than the general population Varying intensity in 50%Varying intensity in 50% Alzheimers range 0-87%, mean 17-31%Alzheimers range 0-87%, mean 17-31% Mild to moderate stages report depression Mild to moderate stages report depression GDSGDS Useful for mild to moderate dementia Useful for mild to moderate dementia Patient answers 15 questions with yes or no Patient answers 15 questions with yes or no Cornell Scale for Depression in DementiaCornell Scale for Depression in Dementia Useful for moderate to severe dementia Useful for moderate to severe dementia No self-report so rater must be well-trained No self-report so rater must be well-trained

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Diagnosis of Geriatric Depression in Dementia Confusion can often arise as to mood symptoms in dementia Communication issues Communication issues Patients with moderate to severe dementias do not verbally communicate their moodPatients with moderate to severe dementias do not verbally communicate their mood Symptoms of other disorders can overlap with depression Symptoms of other disorders can overlap with depression Alzheimers patients have little appetite, lose concentration, become isolativeAlzheimers patients have little appetite, lose concentration, become isolative Parkinsons patients lose affect, have slowed speech and movementsParkinsons patients lose affect, have slowed speech and movements Frontal lobe injuries present with apathy, often misinterpreted as depression, or frequent crying not related to moodFrontal lobe injuries present with apathy, often misinterpreted as depression, or frequent crying not related to mood

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Diagnosis of Geriatric Depression in Dementia Useful to use: Frequent, dysfunctional sad, downcast mood Frequent, dysfunctional sad, downcast mood New agitation and/or sudden loss of interest New agitation and/or sudden loss of interest Psychic rather than vegetative features Psychic rather than vegetative features Vegetative features often are multifactoralVegetative features often are multifactoral i.e. poor sleep may have four or five causes i.e. poor sleep may have four or five causes Use caregiver reports from home or the NH Use caregiver reports from home or the NH The patients past medical and psychiatric history The patients past medical and psychiatric history

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Diagnosis of Geriatric Depression in Dementia If unsure, TREAT FOR DEPRESSION Medications safer and more effective these days Medications safer and more effective these days ECT a viable option ECT a viable option Much worse to miss than overtreat Much worse to miss than overtreat

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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. In apathy, no emotional changes or lasting emotional feelings. Treatment? (none with FDA approval) Amphetamine if pt sleeps too much-provigil Amphetamine if pt sleeps too much-provigil Antidepressants Antidepressants

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Course of Geriatric Depression More 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 episodes Frequent episodes Late age at onset Late age at onset Dysthymia Dysthymia Medical illness Medical illness High severity of first episode High severity of first episode Hospitalization, suicide attempt Hospitalization, suicide attempt Rationale for long term use of antidepressants in this population Rationale for long term use of antidepressants in this population

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

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Psychotic depression Presentation Presentation Primarily delusions, hallucinations less soPrimarily delusions, hallucinations less so Guilt, hypochondriasis, nihilism, persecution, jealousy Guilt, hypochondriasis, nihilism, persecution, jealousy Highly systematized, mood-congruent delusionsHighly systematized, mood-congruent delusions Delusion often frightening or catastrophic Delusion often frightening or catastrophic Needs treatment for depression and psychosisNeeds treatment for depression and psychosis These patients require antipsychotic treatment These 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 physical healthEspecially when their condition compromises their physical health

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Medications to Treat Geriatric Depression SSRIs most common Fluoxetine Fluoxetine Sertraline Sertraline Paroxetine Paroxetine Fluvoxamine Fluvoxamine Citalopram Citalopram Escitalopram Escitalopram SNRIs Venlafaxine Venlafaxine duloxetine duloxetine Tricyclics Nortriptyline MAOI Selegeline patch Others mirtazepine bupropion trazodone

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Treatment for Depression Medications 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 patients Depression harder to treat in older patients

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What should you expect from medication Treatment of Geriatric Depression? How long does it take to work? 8 to 12 weeks in 30 year olds 8 to 12 weeks in 30 year olds May stretch to 12-16 weeks in the elderly May stretch to 12-16 weeks in the elderly Can you see changes earlier? Some yes. Some yes. Vegetative-sleep appetite energyVegetative-sleep appetite energy Good sign of responseGood sign of response

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What should you expect from medication Treatment of Geriatric Depression? Are they dangerous? Not long-term Not long-term Drug-drug interactions minimal in most cases Drug-drug interactions minimal in most cases Not addictive Not addictive

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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

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Are Antidepressants used for other purposes? Anxiety/sleep- FDA approval for mirtazapine, nortriptyline Pain- duloxetine, venlafaxine, nortriptyline Appetite-mirtazapine, nortriptyline

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Are other medications used for depression? Methyphenidate No FDA approved, literature supports used in medically ill, apathetic, those with poor appetite No FDA approved, literature supports used in medically ill, apathetic, those with poor appetite Lamictal- FDA approved for bipolar depression FDA approved for bipolar depression

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Treatment Psychotherapy Cognitive-behavioral and Interpersonal Cognitive-behavioral and Interpersonal Manual-drivenManual-driven Easy to studyEasy to study Effective in combination and aloneEffective in combination and alone Psychodynamic Psychodynamic Long-term issues; less studiedLong-term issues; less studied Problem solving and Supportive Problem solving and Supportive Mild-moderate dementiaMild-moderate dementia Coping day-to-dayCoping day-to-day

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Treatment ECT Works rapidly for those who cant wait Works rapidly for those who cant wait Psychotic depression, especiallyPsychotic depression, especially Hospital venue Hospital venue AnesthesiaAnesthesia 30-60 second seizure; 6-12 treatments30-60 second seizure; 6-12 treatments Maintenance treatment Maintenance treatment Adverse effects minimal Adverse 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%

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Treatment ECT How does it work? Win the Nobel Prize in Medicine Win the Nobel Prize in Medicine Cerebrovascular contractionCerebrovascular contraction Increased BBB permeabilityIncreased BBB permeability Increased brain O2 concentrationIncreased brain O2 concentration No absolute contraindications No 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

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Goals Geriatric depression is common in NH Rates are different than the general population Various effective treatments do exist

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