Depression in ElderlyDepression in ElderlyKalpana P. Padala, MD, MSKalpana P. Padala, MD, MS

Research GeriatricianResearch GeriatricianAssistant ProfessorAssistant Professor

Dept. of Family MedicineDept. of Family MedicineUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center

Email: kpadala@unmc.eduEmail: kpadala@unmc.edu

DisclosuresDisclosures

NoneNone

Goals and ObjectivesGoals and Objectives

Identify the variation in presentation of Identify the variation in presentation of depression in various age groupsdepression in various age groups

Overview of assessment of depression Overview of assessment of depression along with use of common rating scalealong with use of common rating scale

Selection of antidepressants in Selection of antidepressants in management of depressionmanagement of depression

Special considerations with Special considerations with antidepressant use in elderlyantidepressant use in elderly

Overview of risk factors for Suicide Overview of risk factors for Suicide

EpidemiologyEpidemiology

Men: 5-12%Men: 5-12% Women: 10-25%Women: 10-25% Prevalence 1-2% in elderlyPrevalence 1-2% in elderly

– 6-10% in Primary Care setting6-10% in Primary Care setting– 12-20% in Nursing home setting12-20% in Nursing home setting– 11-45% in Inpatient setting11-45% in Inpatient setting– >40% of outpt. Psychiatry clinic and inpt. >40% of outpt. Psychiatry clinic and inpt.

psychiatrypsychiatry Peak age of onset 3rd decadePeak age of onset 3rd decade Late-life depression: secondary to vascular Late-life depression: secondary to vascular

etiologyetiology

Patho-physiologyPatho-physiology

Elevated stress levelsElevated stress levels Decreased levels or activity of Decreased levels or activity of

nor-epinephrine and/or serotoninnor-epinephrine and/or serotonin Decreased latency to 1Decreased latency to 1stst rapid eye rapid eye

movement sleep phase and movement sleep phase and hypoperfusion of the frontal lobeshypoperfusion of the frontal lobes

Cerebro-vascular diseaseCerebro-vascular disease Deep white matter hyperintensityDeep white matter hyperintensity

EtiologyEtiology

Biological factorsBiological factors Social factorsSocial factors Psychological factors Psychological factors

Biological factorsBiological factors

GeneticGenetic– High prevalence in first degree relativesHigh prevalence in first degree relatives– High concordance with monozygotic twinsHigh concordance with monozygotic twins– Short allele of serotonin transported geneShort allele of serotonin transported gene

Medical Illness: Medical Illness: – Parkinson's, Alzheimer's, cancer, diabetes or Parkinson's, Alzheimer's, cancer, diabetes or

strokestroke Vascular changes in the brain Vascular changes in the brain Chronic or severe painChronic or severe pain Previous history of depressionPrevious history of depression Substance abuseSubstance abuse

Social factorsSocial factors

Loneliness, isolation Loneliness, isolation Recent bereavement Recent bereavement Lack of a supportive social network Lack of a supportive social network Decreased mobility Decreased mobility

– Due to illness or loss of driving Due to illness or loss of driving privilegesprivileges

Psychological factorsPsychological factors

Traumatic experiencesTraumatic experiences– AbuseAbuse

Damage to body image Damage to body image Fear of death Fear of death Frustration with memory loss Frustration with memory loss Role transitionsRole transitions

Common precipitantsCommon precipitants Arguments with friends/relativesArguments with friends/relatives Rejection or abandonmentRejection or abandonment Death or major illness of loved oneDeath or major illness of loved one Loss of petLoss of pet Anniversary of a (-) eventAnniversary of a (-) event Major medical illness or age-related Major medical illness or age-related

deteriorationdeterioration Stressful event at work Stressful event at work Medication NoncomplianceMedication Noncompliance Substance useSubstance use

DefinitionDefinition

A syndrome complex A syndrome complex characterized by mood characterized by mood disturbance plus variety of disturbance plus variety of cognitive, psychological, and cognitive, psychological, and vegetative disturbancesvegetative disturbances

Clinical FeaturesClinical Features

DSM IV-TR criteriaDSM IV-TR criteria– 5/9 should be present for at least 5/9 should be present for at least

two weekstwo weeks– Must be a change from previous Must be a change from previous

functioning functioning – Presence of decreased interest or Presence of decreased interest or

low/depressed mood is must featurelow/depressed mood is must feature SIGECAPSSIGECAPS

SIG(M)ECAPSSIG(M)ECAPS SSleep disturbance: decreased or leep disturbance: decreased or

increasedincreased IInterest or pleasure*: decreasednterest or pleasure*: decreased GGuilt or feeling worthless uilt or feeling worthless MMood* : sustained low or depressedood* : sustained low or depressed EEnergy loss or fatigue nergy loss or fatigue CConcentration problems or problems with oncentration problems or problems with

memory memory AAppetite disturbance, weight loss or gainppetite disturbance, weight loss or gain PPsychomotor agitation or retardationsychomotor agitation or retardation SSuicidal ideation, thoughts of deathuicidal ideation, thoughts of death

MINOR DepressionMINOR Depression Also known as Also known as

– subsyndromal subsyndromal depressiondepression

– subclinical subclinical depressiondepression

– mild depressionmild depression 2 - 4 times more 2 - 4 times more

common than common than major depressionmajor depression

Associated with:Associated with:– subsequent major subsequent major

depressiondepression– greater use of greater use of

health serviceshealth services– reduced physical, reduced physical,

social functioningsocial functioning– loss of quality of lifeloss of quality of life

Responds to same Responds to same treatments!treatments!

Atypical depressionAtypical depression

Somatic complaintsSomatic complaints Hyperphagia, Hyperphagia, Hypersomnia, Hypersomnia, Hypersensitivity to rejectionHypersensitivity to rejection ““Heavy” feeling in upper or lower Heavy” feeling in upper or lower

extremities (leaden paralysis)extremities (leaden paralysis)

Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

Depression – the physical Depression – the physical presentationpresentation

In primary care, physical symptoms are often the chief complaint in depressed patients

N = 1146 Primary care patients with major depression

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1

Dysthymia More chronic, low intensity mood disorder By definition, symp must be present > 2

yrs consecutively It is characterized by anhedonia, low self-

esteem, & low energy It may have a more psychologic than

biologic etiology It tends to respond to Rx & psychotherapy

equally Long-term psychotherapy is frequently

able to bring about lasting change in dysthymic individuals

Bipolar DisorderBipolar Disorder People with this type of illness People with this type of illness

change back and forth between change back and forth between periods of depression and periods of periods of depression and periods of mania (an extreme high). mania (an extreme high).

Symptoms of mania may include:Symptoms of mania may include:– Less need for sleepLess need for sleep– OverconfidenceOverconfidence– Racing thoughtsRacing thoughts– Reckless behaviorReckless behavior– Increased energyIncreased energy– Mood changes are usually gradual, but Mood changes are usually gradual, but

can be suddencan be sudden

Season Affective DisorderSeason Affective Disorder

Results from changes in the season. Results from changes in the season. Most cases begin in the fall or winter, Most cases begin in the fall or winter, or when there is a decrease in or when there is a decrease in sunlightsunlight

Pattern of onset at the same Pattern of onset at the same

time each yeartime each year Full remissions occur at a Full remissions occur at a

characteristic time of yearcharacteristic time of year

Pseudo-dementiaPseudo-dementia

A syndrome of cognitive impairment that mimics dementia but is actually depression

Poor attention and concentration Symptoms resolve as the depression is

treated effectively If considerable cognitive impairment

remains, an underlying dementia is suspected Even “completely recovered” patients have

higher rates of dementia (20% /year of f/u) This is 2.5 to 6 times higher than population

risk

Psychotic depressionPsychotic depression AAbnormal thought process – bnormal thought process –

psychotic thinking psychotic thinking Frank hallucinations and Frank hallucinations and

delusionsdelusions

Depression in ElderlyDepression in Elderly NOTNOT a normal part of aginga normal part of aging 2 million Americans over age 2 million Americans over age

65 have depressive illness65 have depressive illness Sub-syndromal depression Sub-syndromal depression

increases the risk of increases the risk of developing depressiondeveloping depression– Leads to early relapse and Leads to early relapse and

chronicitychronicity Often co-occurs with other Often co-occurs with other

serious illnessesserious illnesses Under-diagnosed and under-Under-diagnosed and under-

treatedtreated Suicide rates in the elderly Suicide rates in the elderly

are the highest of any age are the highest of any age group. group.

Facts in ElderlyFacts in Elderly

Only 11 percent : in community Only 11 percent : in community receive adequate antidepressant receive adequate antidepressant treatment treatment

The direct and indirect costs – The direct and indirect costs – $43 billion each year$43 billion each year

Late life depression is particularly Late life depression is particularly costly because of the excess costly because of the excess disability that it causes and its disability that it causes and its deleterious interaction with deleterious interaction with physical healthphysical health

Depression in ElderlyDepression in Elderly Difficult to diagnoseDifficult to diagnose Low/depressed mood need not be presentLow/depressed mood need not be present Persistent loss of pleasure and interest in Persistent loss of pleasure and interest in

previously enjoyable activities (anhedonia) previously enjoyable activities (anhedonia) must be presentmust be present

Reject diagnosis of depressionReject diagnosis of depression Masked depression or depression without Masked depression or depression without

sadness- mainly somatic complaintssadness- mainly somatic complaints

Depression in ElderlyDepression in Elderly Symptoms of minor depression Symptoms of minor depression Somatic complaints: Persistent, vague, Somatic complaints: Persistent, vague,

unexplained physical complaintsunexplained physical complaints Agitation, anxietyAgitation, anxiety Memory problems, difficulty Memory problems, difficulty

concentratingconcentrating Social withdrawalSocial withdrawal A high degree of suspicion and specific A high degree of suspicion and specific

inquiry is necessary for its detection inquiry is necessary for its detection and treatmentand treatment

Differential diagnosis in Differential diagnosis in ElderlyElderly

Differentiation from medical illness:Differentiation from medical illness:– HyperthyroidismHyperthyroidism– Parkinson’s diseaseParkinson’s disease– Carcinoma of the pancreasCarcinoma of the pancreas– Dementia Dementia

Bereavement:Bereavement:– Time limited resolves within few monthsTime limited resolves within few months– 14% develop depression within 2 yrs of 14% develop depression within 2 yrs of

lossloss– Look for functional impairmentLook for functional impairment

Depression associated with Depression associated with Structural Brain DiseaseStructural Brain Disease

Alzheimers disease:Alzheimers disease:– 20% of subjects with early AD have depression20% of subjects with early AD have depression

CerebroVascular disease: Vascular CerebroVascular disease: Vascular depression:depression:– Anhedonia, executive dysfunction and absence Anhedonia, executive dysfunction and absence

of guilt preoccupations of guilt preoccupations – Late age of onsetLate age of onset– Risk factors for vascular diseaseRisk factors for vascular disease– Prefrontal or subcortical white matter Prefrontal or subcortical white matter

hyperintensities on T2 weighted MRIhyperintensities on T2 weighted MRI– Non-amnestic neuropsychologic deficits in tasks Non-amnestic neuropsychologic deficits in tasks

req’ initiation, persistence and self monitoringreq’ initiation, persistence and self monitoring

AssessmentAssessment

Geriatric Depression ScaleGeriatric Depression ScaleChoose the best answer for how you have felt over the past week:Choose the best answer for how you have felt over the past week:1. Are you basically satisfied with your life1. Are you basically satisfied with your life? ? YESYES // NONO2. Have you dropped many of your activities and interests? 2. Have you dropped many of your activities and interests? YESYES / NO / NO3. Do you feel that your life is empty3. Do you feel that your life is empty? ? YES YES / NO/ NO4. Do you often get bored? 4. Do you often get bored? YESYES / NO/ NO5. Are you in good spirits most of the time? YES / 5. Are you in good spirits most of the time? YES / NONO6. Are you afraid that something bad is going to happen to you?6. Are you afraid that something bad is going to happen to you? YES YES / /

NONO7. Do you feel happy most of the time?7. Do you feel happy most of the time? YESYES // NONO8. Do you often feel helpless? 8. Do you often feel helpless? YESYES / NO/ NO9. Do you prefer to stay home, rather than going out, doing new 9. Do you prefer to stay home, rather than going out, doing new

things? things? YES YES // NONO10. Do you feel you have more problems with memory than most? 10. Do you feel you have more problems with memory than most?

YESYES / NO / NO11. Do you think it is wonderful to be alive now? YES / 11. Do you think it is wonderful to be alive now? YES / NONO12. Do you feel pretty worthless the way you are now? 12. Do you feel pretty worthless the way you are now? YESYES / NO / NO13. Do you feel full of energy? YES / 13. Do you feel full of energy? YES / NONO14. Do you feel that your situation is hopeless? 14. Do you feel that your situation is hopeless? YESYES / NO / NO15. Do you think that most people are better off than you are? 15. Do you think that most people are better off than you are? YES YES / /

NONO*Underlined items constitute the four item scale*Underlined items constitute the four item scale

Labs:Labs:

CBCCBC CMPCMP TSHTSH Dementia workupDementia workup Cognitive testingCognitive testing EKGEKG

Professional treatment Professional treatment must for depressionmust for depression

Why treatWhy treat

Substantially the likelihood of death Substantially the likelihood of death from physical illnesses from physical illnesses

impairment from a medical disorder and impairment from a medical disorder and impedes its improvement impedes its improvement

When untreated - interferes with a patient's When untreated - interferes with a patient's ability to follow the necessary treatment ability to follow the necessary treatment regimen regimen

Healthcare costs of elderly people: 50% Healthcare costs of elderly people: 50% higher than those of non-depressed higher than those of non-depressed seniors. seniors.

Lasts longer in the elderly.Lasts longer in the elderly.

TreatmentTreatment

Non-medical Non-medical MedicalMedical

Non-Medical interventionsNon-Medical interventions Balanced dietBalanced diet FluidsFluids ExerciseExercise Avoid alcoholAvoid alcohol Family support/social Family support/social

supportsupport Focus on positivesFocus on positives Promote autonomyPromote autonomy Promote creativityPromote creativity Alternate therapy: Pet Alternate therapy: Pet

therapy, horticulture therapy, horticulture therapytherapy

Pace appropriatelyPace appropriately

Inform about Inform about depressiondepression

Avoid stressorsAvoid stressors

Medical InterventionsMedical Interventions

MedicationsMedications PsychotherapyPsychotherapy Electro-convulsive therapyElectro-convulsive therapy Vagal Nerve stimulationVagal Nerve stimulation Combination therapyCombination therapy

MedicationsMedications

SerotonergicSerotonergic– SSRIs: Citalopram, Escitalopram, SSRIs: Citalopram, Escitalopram,

Sertraline, Paroxetine, FluoxetineSertraline, Paroxetine, Fluoxetine NoradrenergicNoradrenergic

– TCAsTCAs DopaminergicDopaminergic

– BupropionBupropion Dual mechanismDual mechanism

– Venlafaxine, Mirtazapine, Duloxetine, Venlafaxine, Mirtazapine, Duloxetine, SSRIs + BuproprionSSRIs + Buproprion

Treatment selectionTreatment selection

SerotonergicSerotonergic– Anxious, agitated, hostile, Anxious, agitated, hostile, – hypochondriachypochondriac

NoradrenergicNoradrenergic– Avoid use in elderlyAvoid use in elderly

DopaminergicDopaminergic– Psychomotor retarded, blunted, apatheticPsychomotor retarded, blunted, apathetic

Dual mechanism Dual mechanism – Melancholic, atypical, treatment resistantMelancholic, atypical, treatment resistant

Medication Starting Dose (mg/day) Therapeutic Dose (mg/day)

TCAsAmitryptylineNortriptylineImipramine

25-502525-50

100-30050-200100-300

SSRIsCitalopramFluoxetineSertralineParoxetineEscitalopram

10-2010-2025-5010-2010

20-6020-80100-20020-5020

MAOIsPhenelzineTranylcypromine

4520

18030-60

Mixed antidepressantsMirtazapineVenlafaxine XRBupropion SRDuloxetine

7.5-1537.5100-15020-30

15-4575-22530060

Special considerations in Special considerations in elderlyelderly

Start low and go slowStart low and go slow Dose adjustment based on renal clearance: Dose adjustment based on renal clearance:

30% reduction of mirtazapine clearance 30% reduction of mirtazapine clearance with creatinine clearance : 11-15with creatinine clearance : 11-15

SSRIs are used at the same dose as adultsSSRIs are used at the same dose as adults Response time is longer in elderly >6-12 Response time is longer in elderly >6-12

weeksweeks Because of higher risk of relapse in elderly, Because of higher risk of relapse in elderly,

continue antidepressants for > 2 years after continue antidepressants for > 2 years after remission of major depressive disorderremission of major depressive disorder

Special considerations in Special considerations in elderlyelderly

All antidepressants are equally efficaciousAll antidepressants are equally efficacious SSRIs are better tolerated than TCAsSSRIs are better tolerated than TCAs Escitalopram, citalopram, sertraline, Escitalopram, citalopram, sertraline,

venlafaxine and mirtazapine may have venlafaxine and mirtazapine may have fewer drug interactionsfewer drug interactions

SSRI related side effects seen in elderlySSRI related side effects seen in elderly– Extrapyramidal side effectsExtrapyramidal side effects– ApathyApathy– AnorexiaAnorexia– SIADHSIADH– Upper GI bleedingUpper GI bleeding

PsychotherapyPsychotherapy Very helpful in mild to moderate depressionVery helpful in mild to moderate depression Response time slowerResponse time slower Relapse less frequentRelapse less frequent CBTCBT

– As effective as antidepressantsAs effective as antidepressants IPTIPT

more effective than antidepressantsmore effective than antidepressantsin treating mood suicidal ideations,in treating mood suicidal ideations,and lack of interest, whereas and lack of interest, whereas antidepressants are more antidepressants are more effective for appetite and effective for appetite and sleep disturbancessleep disturbances

Electro-convulsive TherapyElectro-convulsive Therapy Indications:Indications:

– Failure of antidepressant trialsFailure of antidepressant trials– Severe depression with catatonic or psychotic Severe depression with catatonic or psychotic

featuresfeatures– High risk of suicideHigh risk of suicide– Poor tolerability of oral medsPoor tolerability of oral meds

Response rates from 70-90%Response rates from 70-90% Most efficacious antidepressantMost efficacious antidepressant Contraindication: ICP, intracranial tumorsContraindication: ICP, intracranial tumors 3x/wk with avg number of treatments 3x/wk with avg number of treatments 8-12, may need maintenance therapy8-12, may need maintenance therapy Side effects: Short term memory lossSide effects: Short term memory loss

Vagal Nerve StimulationVagal Nerve Stimulation

Electrical pulses applied to the left vagus Electrical pulses applied to the left vagus nerve in the neck for transmission to the nerve in the neck for transmission to the brainbrain

Intermittent stimulationIntermittent stimulation– 30 sec on/5 min off30 sec on/5 min off

Implanted in over 11,500 patients Implanted in over 11,500 patients Battery life of 8-12years, weighs 38 gms, Battery life of 8-12years, weighs 38 gms,

10.3 mm thick10.3 mm thick Side effects: Side effects:

– hoarse voice, pain or tingling in the throat or hoarse voice, pain or tingling in the throat or neck, cough, headache and ear pain, difficulty neck, cough, headache and ear pain, difficulty sleeping, shortness of breath, vomiting sleeping, shortness of breath, vomiting

Vagal Nerve Stimulator Vagal Nerve Stimulator (VNS)(VNS)

SUICIDE: DON’T FORGETSUICIDE: DON’T FORGET

Ask about Ask about

–suicidal ideation suicidal ideation –intentintent

Suicide risk in elderlySuicide risk in elderly

Very Important, Easy to missVery Important, Easy to miss Always ask Always ask Firearms at homeFirearms at home Many older adults who commit suicide Many older adults who commit suicide

have visited a primary care physician have visited a primary care physician very close to the time of the suicidevery close to the time of the suicide– 20 percent on the same day20 percent on the same day– 40 percent within one week – of the 40 percent within one week – of the

suicidesuicide

Suicide risk in elderlySuicide risk in elderly

Suicides twice as common as homicides 12% of the population is elderly, they

account for 20% of the 30,000 suicides/yr

Older patients make 2 to 4 attempts per completed suicide, younger patients make 100 to 200 attempts per completion

When they decide - they are serious

Assessment tool for suicide Assessment tool for suicide risk:risk:

SS- Male Sex- Male SexAA- Age (young/elderly)- Age (young/elderly)DD- Depression- DepressionPP- Previous attempts- Previous attemptsEE- ETOH- ETOHRR- Reality testing - Reality testing

(Impaired)(Impaired)SS- Social support- Social support

(lack of)(lack of)OO- Organized plan- Organized planNN- No spouse- No spouseSS- Sickness- Sickness

Suicide RiskSuicide Risk

Paradoxically Paradoxically ↑ ↑ as patient begins to as patient begins to respond to treatmentrespond to treatment

Somatic or “vegetative” symptoms Somatic or “vegetative” symptoms (sleep, appetite, energy) are usually (sleep, appetite, energy) are usually the first symptoms to improve the first symptoms to improve

““Cognitive” symptoms of depression Cognitive” symptoms of depression (low self-esteem, guilt, suicidal (low self-esteem, guilt, suicidal thoughts) tend to improve more thoughts) tend to improve more slowlyslowly

QuestionsQuestions