Depression in the ElderlyDepression in the Elderly

Steven W. Clay, DOSteven W. Clay, DO

Assistant Professor of Assistant Professor of

Family MedicineFamily Medicine

OUCOMOUCOM

ObjectivesObjectives

• Describe Common Psychological Characteristics Of The Elderly.

• Describe Common Depressive Disorders And Their Treatment In The Elderly.

ObjectivesObjectives

• Differentiate Bereavement From Psychiatric Disorders In The Elderly.

OutlineOutline

• 1. Psychological Issues.

• 2. Bereavement

• 3. Common Mood Disorders.

• 4. Pseudodementia

• 5. Depression With Psychotic Symptoms.

1. Psychological Issues 1. Psychological Issues

Elders deal with many losses. Mostly widowed women. Self-esteem correlates with age. The elderly think more

concretely, giving the false impression of inflexibility.

Psychological IssuesPsychological Issues

Life Satisfaction Is Stable With Age.

Coping With Stress Improves With Age, As The Elderly See Stressors As Less Important.

Sense Of Control Vs. Learned Helplessness.

Centenarian CharacteristicsCentenarian Characteristics

Moderation (Food, Drink, Activity)Forgiveness Of Others And Self.Positive Thinking And Optimism.Constant Phys. / Mental Activity.Integrity And A Desire To Do Good.Independence And Interaction.

How Would You Feel If This Year?How Would You Feel If This Year?

Your Spouse Died.Two Of Your Best Friends Died.Your Child Was Diagnosed With

Terminal Cancer.You Broke Your Hip And Now

Live In A Nursing Home.

2. Bereavement2. Bereavement

Response To Death Of A Loved One.Patient Considers It Appropriate.Not A Disorder, Function Maintained.Duration Varies Widely.May Have Non-distressing And

Transient Hallucinations.

Mrs. B. Still Feels Mr. B There.Mrs. B. Still Feels Mr. B There.

• 77 Year Old Female Comes To The Office After Mr. B Recently Died At Home From Lung CA.

• She Not Sewing As Much But “I’m Ok,” Her Family Agrees.

• At Times She Still Hears His Voice And Feels Him Next To Her In Bed.

Mrs. B.Mrs. B.

• Are Hearing The Voice Of Her Deceased Husband And Feeling Him Next To Her In Bed Hallucinations?

• Is This A Disorder Or Is She Still Functioning Fairly Well?

3. Some Mood Disorders3. Some Mood Disorders

• Not From The Aging Process!!! --Major Depression--Dysthymia--Adjustment With

Depressed Mood / Mixed Emotions

• Bipolar Disorders Unusual

Depression in EldersDepression in Elders

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comun. hosp. nurs.hm.

major dep.

minor dep.

Depression & Other DiseaseDepression & Other DiseaseHypo- / HyperthyroidismCushings / AddisonsHyperparathyroidismCancers, esp. Pancreatic / CNSInfection, UremiaB-12 or Folate Deficiency

Depression & CNS DiseaseDepression & CNS Disease

Stroke 30-50% Dementia 20-30% Parkinson’s 20-30%

Meds & Depression:Meds & Depression:

• Antihypertensives: B Blockers, Methyldopa (Aldomet)

• Steroids: Corticosteroids, Estrogens, Progesterones)

• Benzodiazepines• Anti-Psychotics • Polypharmacy

Depression & AddictionDepression & Addiction

>5% Community Elderly 10% Elderly Medical Outpatients Alcoholism: Men > Women

Prescribed Drugs: Women > Men

Assessment Assessment

• Obtain H+P Information From Family / Caregivers / Records.

• Any Hx. Of Alcohol / Drug Use ?

• Labs: CBC, TSH, T4, Chem-20, UA, CXR, EKG and as Indicated.

• MMSE, GDS

Depression - SymptomsDepression - Symptoms

• Depressed Mood (Hopeless, Sad, Empty, Tearful, Irritable)

• Apathy (No Interest In Activities)

• Weight Loss / Gain

• Insomnia / Hypersomnia

• Guilt / Worthlessness

Depression - SymptomsDepression - Symptoms

• Psychomotor Agitation / Retardation

• Fatigue, No Energy• Inability To Think Or Concentrate• Recurrent Thoughts Of Death Or

Suicide• Ask About Suicidal Thoughts!!

Depression PresentationDepression Presentation

Older Adults Present Differently.Somatic Complaints PredominateDepression Often DeniedCommon Apathy And WithdrawalCommon Loss Of Self-Esteem

GDS -The Geriatric GDS -The Geriatric Depression ScaleDepression Scale

• Tool Specific For The Elderly.

• 15 Questions Short Form

• 30 Questions Long Form

• May Suggest Depression

• Must Be Used In Conjunction With A Full Patient Assessment

Tired & Apathetic Mr. L.Tired & Apathetic Mr. L.

• 65 YO White Male Comes To Office Complaining Of “ I Just Want To Sleep And Do Nothing, I Don’t Care What Happens Anymore.”

• H & P: No Recent Losses, No Suicidal Ideation, Low Affect,

Mr. L.Mr. L.

• Takes Lopressor 100 Mg Qd For Hypertension.

• Mr. L. Was Switched To An ACE Inhibitor For Hypertension.

• Mr. L. Returned In Two Weeks With No Complaints “You’ve Turned My Life Around.”

A. Major DepressionA. Major Depression

Overwhelming Depression ForAt Least 2 Weeks.

Completely Unable To Cope.Function Is Usually Greatly

Impaired.May Be High Risk For Suicide.

DSM-IV Major DepressionDSM-IV Major Depression

• A. Five (Or More) Of The Following Symptoms – Present During a 2-week Period– Represent A Change From Previous

Functioning;

• At Least One Of The Symptoms Is Either (1) Depressed Mood Or (2) Loss Of Interest Or Pleasure.

Major DepressionMajor Depression

• (1) Depressed Mood Most Of The Day, Nearly Every Day

• (2) Markedly Diminished Interest Or Pleasure In All, Or Almost All, Activities Most Of The Day, Nearly Every Day

• (3) Significant Weight Loss When Not Dieting Or Weight Gain, Or Decrease Or Increase In Appetite Nearly Every Day.

Major DepressionMajor Depression

• (4) Insomnia Or Hypersomnia Nearly Every Day

• (5) Psychomotor Agitation Or Retardation Nearly Every Day (Observable By Others,)

• (6) Fatigue Or Loss Of Energy Nearly Every Day

• (7) Feelings Of Worthlessness Or Excessive Or Inappropriate Guilt (Which May Be Delusional) Nearly Every Day

Major DepressionMajor Depression

• (8) Diminished Ability To Think Or Concentrate, Or Indecisiveness, Nearly Every Day

• (9) Recurrent Thoughts Of Death, Recurrent Suicidal Ideation Without or With A Specific Plan, Or A Suicide Attempt

Major DepressionMajor Depression

• B. The Symptoms Do Not Meet Criteria For A Mixed Episode.

• C. The Symptoms Cause Clinically Significant Distress Or Impairment

• D. The Symptoms Are Not Due To The Direct Physiological Effects Of A Substance Or A General Medical Condition

• E. The Symptoms Are Not Better Accounted For By Bereavement

Suicide in elderlySuicide in elderlyHighest Risk Of All Of Society

White, Elderly, Males Multiple Losses 25% Of All Suicides

Attempts To Success Ratio: Young Adult 10Elderly 1

Retired, Widowed Mr. SRetired, Widowed Mr. S • 68 YO White Dairy Farmer Recently

Lost His Wife, Can’t Run The Farm By Himself, Plans To Sell And Complains Only Of A Backache.

• Denies Depression, Refuses All Medication And Counseling, “I’ll Just Deal With Things Myself.”

Mr. S.Mr. S.

• White Male With Many Losses:-His Wife -Close

To Losing His Farm -No Family Helping On Farm

• High Risk For Suicide.• Mr. S Was Found Behind The

Barn With A Bullet In His Head.

B. DysthymiaB. Dysthymia

Milder DepressionLasting At Least Two YearsAlmost A Way Of Life Very Responsive To Medical

And Counseling Treatments.

DSM-IV DysthymiaDSM-IV Dysthymia

• Depressed Mood For Most Of The Day, For More Days Than Not, For At Least 2 Years.

• During The 2-year Period The Person Has Never Been Without The Symptoms For More Than 2 Months At A Time.

DSM-IV DysthymiaDSM-IV Dysthymia• While depressed, of two (or more) of

the following: – poor appetite or overeating – insomnia or hypersomnia – low energy or fatigue – low self-esteem – poor concentration or difficulty

making decisions – feelings of hopelessness

Mrs. D. Still ComplainsMrs. D. Still Complains

• 77 Year Old Female With Multiple Complaints: Arthritis, Not Sleeping Well, “My Nerves,” Etc.

• Denies Depression, “I’m Just Me.”

• Mod-low Affect, Slight Apathy No Suicidal Ideation

Mrs. D.Mrs. D.

• Daughter Says “She Has Always Been This Way As Far Back As I Can Remember.”

• Low Dose SSRI Zoloft (Sertraline) 25mg A Day And Counseling Started.

Mrs. D.Mrs. D.

• Mrs. D. Returned In Two Weeks Much Happier, Able To Deal With Her Arthritis

• She Says “I Never Realized I Was Depressed, I Just Thought Life Was Like That.”

C. Adjustment DisordersC. Adjustment DisordersResponse to Stress Last 3 monthsA disorder because of:

-loss of function -symptoms >>> stressor

Very common in the elderly

Adjustment Disorder:Adjustment Disorder:

With DepressionWith AnxietyWith Mixed emotions.

Mr. A & Mrs. A’s COPDMr. A & Mrs. A’s COPD

• 78 Yo Female COPD Patient Says: “My Breathing Is Horrible And My Chest Hurts So Bad I Want To Die.”

• On Questioning She Is Upset Because Her Husband Died Several Months Ago And:

Mrs. A.Mrs. A.

• Yesterday Her Daughter Attempted Suicide Because Of A Separation.

• Pe Unchanged, But Sad And Crying.

• Pulse Oximitry 92%

Mrs. A.Mrs. A.

• CXR With COPD, No Infiltrates

• EKG With Sinus Tachycardia.

• Short Term Counseling And Low Dose Antidepressants Helped Her.

• These Were Discontinued A Few Weeks Later.

““Pseudodementia”Pseudodementia”Depression That Appears Like

Dementia --A Treatable “Dementia”Must Distinguish From True

DementiaDepression Superimposed Onto True

Dementia Is Much More Common,With Tx. Pseudodementia Clears.

Pseudodementia And Pseudodementia And True Dementia ComparedTrue Dementia Compared

DEMENTIA PSEUDO-Donset insidious rapidduration long shortmood variable constantcognition consistant inconsistantdisabilities concealed highlightedanswers near miss “I don’t

know”

Mrs. Y. Is DecliningMrs. Y. Is Declining

• 68 YO Female Son Asks: “Does She Have Old-timers Disease?

• She Has No Memory, She Just Sits, Sleeps Poorly And Has Lost Weight.

• She Has Been Down For Years”

Mrs. Y.Mrs. Y.

• “But Over The Last Month She Acts Like She Doesn’t Even Know Me.”

• H&P: Unremarkable Except Low Affect, Doesn’t Try On MMSE Unless Encouraged, “I Don’t Know” Answers.

• She Denies Depression And Suicidal Ideation “I’m Tired, Leave Me Alone.”

Mrs. Y.Mrs. Y.

• MMSE: 14 / 30 with 12 “I don’t Know” Answers.

• S-GDS: 10 / 15

• After Treatment For Depression One Month Later MMSE Results 27 / 30

Depression Tx: ChoicesDepression Tx: Choices

• Depressed With:

• 1. Anxiety, Panic, Obsessing-– Consider SSRI

• 2. Withdrawing, Psychomotor Retardation, Not Eating-– Consider NE Agent

– TCAD, SNRI

Depression Tx: SSRIDepression Tx: SSRI

• Effective In 2/3 Of Patients

• May Stimulate Activity If Withdrawn

• Side Effects: GI Upset / Diarrhea Anxiety, Insomnia, Serotonin Syndrome

SSRI’s QD DosingSSRI’s QD Dosing

• Fluoxetine (Prozac) 10-20 mg

• Sertraline (Zoloft) 25-50 mg

• Paroxetine (Paxil) 10-20 mg

• Citalopram (Celexa) 10-20 mg

• Escitalopram (Lexapro) 5-10 mg

Depression Tx: Depression Tx: TCADTCAD

• Effective In 2/3 Of Patients

• May Help Appetite And Insomnia.

• Cardiac Arrhythmias, Confusion

• Nortriptyline (Pamelor) 25mg hs.

• Desipramine (Norpramin) 25mg Hs

Depression Tx: SNRIDepression Tx: SNRI

• Duloxetine (Cymbalta) 30-60 mg

–Headache, Rare Hepatotoxicity

• Venlafaxine (Effexor) 37.5 -75 mg

–Need 150mg for NE Effects

–Some Dopamine Effect

Psychotic SymptomsPsychotic Symptoms Hallucinations:

Sensory Perceptions Without Any Stimuli.

Visual -Especially With Physical Problems.

Auditory-Especially With Psych. Problems.

Psychotic SymptomsPsychotic Symptoms

• Delusions--Firmly Held False Beliefs--Despite Contrary Evidence--Commonly Paranoia In

Elders• --”You’re All Out To Steal My

Money!”, Etc.

B. Depression With B. Depression With Psychotic FeaturesPsychotic Features

• Mood Changes Prominent

• Usually A Major Depression

• Delusions Not Bizarre

• Previous Psych. History Common.

• Quit Eating, Refuse Treatment, Etc.

• Can Have Rapid Decline

Delusional Dep. -Tx.Delusional Dep. -Tx.

• Antidepressant of Choice• Atypical Antipsychotic In Low Dose

–Risperidone (Risperdal)–Quetiapine (Seroquel)

• Sedating, Less Parkinsonian

• Occasionally ECT Required.– Safe and Very Effective

Mrs. N. Won’t EatMrs. N. Won’t Eat..

• 84 YO Female At The Nursing Home Tells Everyone “Get Out Of My Room, Leave Me Alone, You All Just Want Me Dead Anyway.”

• She Won’t Eat Or Take Her Medication Swings At Nurses, And Throws Her Dinner Tray At You.

Mrs. N.Mrs. N.

• Low Dose Risperidone (Risperdal) And Zoloft 25mg Started.

• After A Few Days Risperidone Stopped and Antidepressant Continued.

• 1-2 Weeks Later Eating Better, Out For Meals And Joked With Staff.