Download Depression in the Elderly

Depression in the Elderly Matthew J. Beelen, MD Geriatric Specialists Lancaster General Health June 18, 2014

What is depression…?

A Common Scenario… 

Before your office visit with your 82 year-old male patient, you receive the following message from his daughter:  “Over

the last few months Dad has been really irritable and gets angry with us when we try to talk about getting him more help. My siblings and I wonder if an antidepressant would help? Can you talk to him about this at your visit?”

Another scenario… 



You’re going to see a 78 year-old woman with moderate dementia who recently moved to skilled care from home after having a fall and suffering a spinal fracture. She is getting therapy and pain management. Staff is concerned because she is not motivated to leave her room, is resisting participation in therapy, and is only eating 25% of meals. She is often tearful and cries, “My kids put me away in a home!”

Objectives 

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Discuss diagnostic criteria for major depressive disorder and related conditions Assess depressive symptoms looking at the overall patient context List other medical conditions that can produce depressive symptoms or mimic depression Discuss non-medication strategies of treatment Discuss approaches to medical treatment

Epidemiology 

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5% of community dwelling older adults age 65 and older meet criteria for Major Depressive Disorder (MDD) “Clinically significant” depression is more common  

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Under-recognized and under-treated   

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10-15% of older adults in primary care 30-50% in institutional settings and long-term care

Stigma Symptoms may be considered part of normal aging Harder to diagnose in the setting of other medical problems and cognitive impairment

Normal emotions over-treated?

JAMA 2012;308:909-918.

Significance of Depression  

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Poor quality of life Difficulty with social, physical, and cognitive functioning Poor adherence to medical treatment Worsening of chronic medical problems Increased healthcare utilization Increased morbidity and mortality from suicide and other causes 

Estimated rate of suicide: 5-10% of depressed elderly

N Engl J Med 2007;357:2269-2276. Ann Clin Psychiatry 2007;19:221-238.

Spectrum of Mood Disorders    

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Major Depressive Disorder (MDD) Minor Depression Dysthymic Disorder Bereavement Adjustment Disorder Depression concurrent with Alzheimer’s disease

Bad Days… A word about checklists…

Diagnostic Criteria

Criteria for Major Depression  

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Depressed mood (core) Significant loss of interest or pleasure - anhedonia (core) Sleep disturbance Appetite Disturbance or significant weight gain/loss Persistent fatigue or loss of energy Difficulty with concentration or decisiveness Feelings of worthlessness or excessive guilt Psychomotor retardation or agitation Recurrent thoughts of death or suicidal thoughts

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1 core and at least 5 total - nearly every day for at least 2 weeks Other medical and psychiatric conditions ruled out Impaired function as a result of these symptoms

DSM IV

Late Onset Major Depression 

Late onset: (>age 60?) recurrent “young” onset  Less likely to have positive family history  More likely to have vascular risk factors  More likely to have cognitive impairment  Precursor to dementia?  vs



30% of MDD in older adults is late onset

Ann Clin Psychiatry 2007;19:221-238. Annu Rev Clin Psychol 2009;5:363-389.

Criteria for Minor Depression 

Periods of depression similar to Major Depression  Fewer

symptoms

 Still

require either sadness or anhedonia  2-4 symptoms total  Less

impairment

 Clinically

significant distress, or  Can have impaired function or near normal function with considerably increased effort  “Sub-syndromal DSM IV

depression”

Dysthymic Disorder 

Depressed mood most days for at least 2 years 

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No gap > 2 months without symptoms

At least 2 additional symptoms when depressed: Appetite disturbance  Sleep disturbance  Low energy  Low self-esteem  Poor concentration or decision-making ability  Feelings of hopelessness 

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Symptoms cause significant distress or impaired functioning

DSM IV

Bereavement

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In response to death of a loved one Many symptoms of Major Depression Consider Major Depression if symptoms persist beyond 2 months, or if there are severe symptoms

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What is normal bereavement?

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DSM IV

Adjustment Disorder 

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Emotional / behavioral symptoms (depression, anxiety, or conduct) in response to an identifiable stressor occurring within 3 months of the stressor Clinically significant symptoms Greater than expected distress  Symptoms lead to significant impairment in function 

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Not bereavement Symptoms do not last longer than 6 months after the stressor has terminated

DSM IV

Bipolar Disorders 

Evidence of Mania  Abnormally

and persistently elevated, expansive, or irritable mood  Examples – grandiosity, excessive spending or sexual activity, racing thoughts, excessive productivity 

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Usually psychiatrist input is helpful Not covered further in this talk

Perspective… 

Video Clip

The Elderly in Context 

Consideration of an older person’s life history along with recent and current circumstances can be helpful in evaluating symptoms of depression

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82 year-old man in the office…

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78 year-old woman in the nursing home…

Mental Health Context and Risk Factors 

Personal history  Mood

disorders  Anxiety  Life-long personality and coping styles 

Family history

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Substance use and abuse

Medical Context and Risk Factors 

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Prior stroke, myocardial infarction, vascular disease Parkinson’s Alzheimer’s Disease or other cognitive disorders Hypothyroidism Significant pain and pain medications

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Medications: sedatives, CNS acting meds Urinary incontinence Vision loss Sleep disorders Overall burden of medical illness

Social Context and Risk Factors      

Marriage Status Support network – family, friends, church, faith Functional Status and Independence Being a caregiver Lower socioeconomic status or lower education Recent Losses or Stressors Death of loved one  Move from long-time home / community  Retirement  Loss of driver’s license  Unable to continue hobbies  Financial stress 

Diagnostic Challenges 

Sadness/depression – reported less by elderly  Hopelessness,

irritability, anhedonia, anxiety, apathy may be more common  More common somatic symptoms    

Fatigue or low energy? Appetite and weight changes? Sleeping problems? Apathy?

Ann Clin Psychiatry 2007;19:221-238.

-

Mojtabai R. NEJM 2014;370:1180-82.

Is DSM wrong? Big Pharma impact? “Pills for Ills”? Doctors getting sloppy?

Diagnosis - PHQ  

Patient Health Questionnaire Covers the 9 Criteria of DSM for MDD 

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First 2 items are the core symptoms (PHQ-2)

Patient reported frequency of each symptom over the last 2 weeks “Not at all” = 0  “Several days” = 1  “More than half the days” = 2  “Nearly every day” = 3 

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Overall Score is totaled

Diagnosis - PHQ 

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Scores correlate with diagnosis, severity, and response to treatment PHQ-2 and PHQ-9 (used on MDS 3.0)  PHQ-2

(cut off of 3): 83-100% sensitivity, 77-92% specificity – if positive, a more in-depth evaluation should be done – a screening test  PHQ-9 (cut off of 10)  Sensitivity

of 88% for significant depression  Specificity of 88% N Engl J Med 2007;357:2269-2276. JAMA 2012;308:909-918.

Diagnosis – Geriatric Depression Scale  

GDS 5, 15, 30 item “Yes” and “No” questions based on common symptoms of depression  Does

not cover physical/somatic symptoms (e.g. sleep)

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In primary care elderly (15 item, cut-off of 6)  81%

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sensitive, 78% specific

Well validated in cognitively intact ECF patients

Arthritis Care and Research 2011;63:S454-S466.

PHQ and GDS Pitfalls 

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Completion by staff caregivers may not be as accurate Not accurate for patients with significant cognitive impairment or poor insight Numbers versus diagnoses  Consider

other contributing factors  Consider function

AMC Case

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78 year old woman, MOCA 19/30, mild to moderate mixed dementia (AD+microvascular) Recently paranoid, agitated, tearful, lonely. Per husband: “She doesn’t want to live this way, she hopes I pray that she will die…”

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PHQ-9 = 3 (normal)!

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What do we make of that?

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Depression and Cognitive Impairment 

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Between 30-50% of patients with Alzheimer’s may have significant depression Common underlying pathology?  Depression

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as a prodrome to dementia

One can cause the other Cognitive impairment can make evaluation of depression more difficult Unclear if treating depression in dementia helps

Nelson JC et al. J Am Geriatr Soc 2011;59:577-585.

2011 Meta-analysis looking at treating depression in dementia - 7 trials, 330 patients - “all trials significantly underpowered…inconclusive findings” Nelson JC et al. J Am Geriatr Soc 2011;59:577-585.

Evaluation of Depression in Dementia 

Cornell Scale for Depression in Dementia  Uses

report of informed caregiver with possible contribution of patient  19 questions looking at frequency of symptoms over the last week  Primarily a screening test  Scores correlate with major and minor depression  8-11:

minor depression  12 and greater: major depression  Limited

research in ECF settings

Dement Geriatr Cogn Disorders 2010;29(5):438-47

AMC case: Cornell Scale = 11

Evaluation of Depression in Dementia 

NIMH Provisional Criteria for Depression in AD (NIMH-dAD) 

3 of the following – present in the previous 2 weeks (at least 1 must be *) – caregiver and patient responses          

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Depressed mood* Anhedonia* Social isolation Concentration is not one of the criteria Poor appetite Poor sleep Psychomotor changes Irritability Fatigue and loss of energy Feelings of worthlessness, hopelessness, or excessive guilt Suicidal thoughts or recurrent thought of death

94% sensitive, 85% specific for major+minor depression 

Overdiagnosis?

Am J Geriatr Psychiatry 2008;16:469-47.

Treatment of Depression

Treatment of Depression 

Most of the studies on treatment have been done on people who meet the criteria for major depression

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The best approach is unclear for people who do not meet full criteria  Watchful

waiting with close monitoring may be appropriate in milder cases

Non-pharmacologic Treatment   

Psychotherapy Exercise Community Resources

Psychotherapy  

Many patients may prefer this over medications Main Types:  

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Cognitive-behavioral therapy – to correct negative thoughts Interpersonal therapy – focuses on interpersonal causes of depression Problem-solving treatment – learning new strategies for solving everyday problems associated with depression Shorter types: activity scheduling, behavioral activation

Work with patient preferences Establish relationship with local mental health specialists who can provide this therapy

JAMA 2012;308:909-918

Psychotherapy - Efficacy  

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May be as effective as medications 45-70% have significant improvement, compared to 25-35% of controls Combined therapy with medications may be better than either therapy alone

N Engl J Med 2007;357:2269-2276.

Exercise and Physical Activity 

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Mode, duration, and intensity varies among studies Any amount may help – tailor to person’s abilities and interests Better for mild-moderate depression in those motivated to do it May be hard for older, more frail patients or those with severe depression

JAMA 2012;308:909-918

Other Options    

Community Crisis Phone Lines Insurance Company Mental Health Support Pastoral Support Support groups  Bereavement  Caregiver  Widow

/ widower  Condition specific (e.g. cancer, Parkinson’s)

Medications…

Treatment - Medications 

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Relatively few placebo-controlled studies examining efficacy in late-life depression Much of the information we have is from studies in younger patients with few numbers of elderly, with the results extrapolated to the elderly Some studies do not show benefit in late life depression Generalizing from studies to our individual patients can be hard as the studies often exclude patients with multiple comorbidities or cognitive impairments

Ann Clin Psychiatry 2007;19:221-238.

Moderators of Therapy 

Which elderly respond best? (Meta-analysis, 7 studies, 2300 patients) – Better response when:  Longer

duration of depression (> 10 years)  More severe depression   

Older brains may respond less well to medication Longer duration of treatment may be needed Augmentation with second medication may be needed

Nelson JC et al. Am J Psychiatry 2013;170:651-659.

Medical Treatment     

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“Start low, go slow” Titrate to full adult doses Titrate off rather than stopping abruptly Elderly are more prone to side effects All classes of antidepressants have similar efficacy in the elderly Best choice depends on side effect profile, prior treatment history, treatment history of close family members

Ann Clin Psychiatry 2007;19:221-238.

A Proper Medication Trial 

Right drug, right dose, right duration  Trials

should last at least 4-6 weeks  If some response by 4 weeks, usually full response can be expected  If no response by 4 weeks, unlikely to get adequate response  Often 12 weeks needed to see full response 

Close follow up by phone or in person is helpful during initiation phase

Neurotransmitters in Depression mirtazapine (high dose) SNRI (higher dose) bupropion TCA

SSRI SNRI (lower dose) mirtazapine (TCA)

bupropion (high dose) sertraline

Selective Serotonin Reuptake Inhibitors  

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SSRI - Usually first line agents in the elderly GI side effects (nausea or dyspepsia) most common – usually resolve in 7-10 days. Other side effects Sweating  Weight loss  Sexual dysfunction  Sedation or restlessness  Low sodium  Risk of falls 

Harv Rev Psychiatry 2009;17:242-253.

SSRI Choices   

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Citalopram (Celexa) Escitalopram (Lexapro) Sertraline (Zoloft) Fluoxetine (Prozac)

Better choices in the elderly

 More

drug interactions  Very long acting 

Paroxetine (Paxil)  More

drug interactions  More anticholinergic and short acting Harv Rev Psychiatry 2009;17:242-253.

Serotonin-Norepinephrine Reuptake Inhibitors 

SNRI’s  May

be more activating (agitation, insomnia, high blood pressure)  Short half life, may work more quickly  May give more side effects compared to SSRI 

Roles  If

co-existing chronic pain (neuropathic)  If “activation” is desired  First or second line agent

SNRI Medications   

Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta)

Mirtazapine (Remeron)  

Primarily increases serotonin levels Associated with  Sedation

(antihistamine effect)  Increased appetite  Weight gain  No sexual side effects 

Potential Roles  First

or second line (may be combined with SNRI)  When also treating low appetite, insomnia  If sexual side effects are a concern

Bupropion (Wellbutrin) 

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Mechanism – norepinephrine and dopamine reuptake inhibition Associated with – jitteriness and insomnia  No sexual side effects  Increased risk of seizures, headaches  Activation

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Potential Roles  Second

line agent (can be combined with SSRI)  If activation desired  If sexual side effects are a concern

Tricyclic Antidepressants – TCA’s    

More anticholinergic effects than SSRI, SNRI Risk of cardiac toxicity – arrhythmia More side effects than other classes Potential Roles  Third

line?  Intolerant of other drugs  Previously successful treatment or long-term use  When there is no concern for cognitive impairment

TCA Medications 

Better options in elderly (less anticholinergic)  Desipramine  Nortriptyline

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Less desirable options in elderly  Amitriptyline  Imipramine

Medication Monitoring  

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Monitor for relapse May need treatment for 2 years to prevent relapse When stopping, taper slowly If high risk patients or with recurrent depression, consider lifetime of treatment

NEJM 2006;354:1130-1138

Medication Reduction 

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F-329: Federal regulation for skilled nursing facilities requiring gradual dose reductions for psychotropic medications A good general principle for all elderly Patient circumstances change Patient physiology changes

Other options for treatment…

Other Options – Psychiatrist 

Consider consultation especially if:  Suicidal

ideation  Psychosis  Active bipolar disorder  Concurrent substance use problems  Non-response to reasonable trials of treatment  A patient is an immediate danger to themselves or others and may need inpatient treatment

Electroconvulsive Therapy: ECT 

Consider if 

Severe, persistent depression not responding to treatment

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Risk of harm (severe weight loss, malnutrition, food refusal, suicidal)

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Usually started in inpatient unit: 6-12 treatments over 2-4 weeks

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Common side effects/risks 

Nausea, HA, jaw pain, muscle aches, increased risk of falls, memory loss

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Risk of serious morbidity/mortality less than 1%

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Contraindications 

Unstable cardiopulmonary disease

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Recent intracranial surgery

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Intracranial mass with increased ICP

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Recent ICH or CVA

JAMA 2012;308:909-918.

What if patient is not improving?

Considerations in Non-Responders  

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Wrong diagnosis? Comorbid psychiatric disorder? Chronic pain? Sleep disorder? ETOH or drug misuse? Medical problems or medications that can worsen depression?

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Severe psychological or social stressors Adherence problems? Insufficient med trial? Adverse effects? Initial treatment appropriate but just not effective?

Depression: Step-Wise Approach 1. Assessment, support, psychoeducation for patients suspected of depression - Use screening tools - look at associated factors

2. Active monitoring, support, “low-intensity psychosocial interventions,” and exercise for those with recent onset or mild symptoms - individual guided self help - basic cognitive-behavioral therapy

Depression: Step-Wise Approach 3. Persistent, moderate symptoms not responding to step 2, or with significant PMH of depression: - medications (for at least 6 months) and/or - high-intensity psychosocial interventions 4. Mental health referral for severe or resistant symptoms

2009 UK NICE Guidelines

A Common Scenario… 

Before your office visit with your 82 year-old male patient, you receive the following message from his daughter:  “Over

the last few months Dad has been really irritable and gets angry with us when we try to talk about getting him more help. My siblings and I wonder if an antidepressant would help? Can you talk to him about this at your visit?”

Another scenario… 



You’re going to see a 78 year-old woman with moderate dementia who recently moved to skilled care from home after having a fall and suffering a spinal fracture. She is getting therapy and pain management. Staff is concerned because she is not motivated to leave her room, is resisting participation in therapy, and is only eating 25% of meals. She is often tearful and cries, “My kids put me away in a home!”

Questions 

Handout

Summary 

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Significant depression in the elderly is relatively common, likely underdiagnosed, and often undertreated Mood symptoms have a variety of causes Consider whole-patient context when assessing for depression and planning treatment Medications are not always needed Consider non-drug treatment approaches

Closing Thought… “He who is of calm and happy nature will hardly feel the pressure of age, but to him who is of an opposite disposition youth and age are equally a burden” Plato (427-347 BC), The Republic