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Depression in the Elderly
Matthew J. Beelen, MDGeriatric SpecialistsLancaster 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
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
5% of community dwelling older adults age 65 and older meet criteria for Major Depressive Disorder (MDD)
“Clinically significant” depression is more common 10-15% of older adults in primary care 30-50% in institutional settings and long-term care
Under-recognized and under-treated 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
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
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
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
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?) vs 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? 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 depression”
DSM IV
Dysthymic Disorder
Depressed mood most days for at least 2 years 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
Symptoms cause significant distress or impaired functioning
DSM IV
Bereavement
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
What is normal bereavement?
DSM IV
Adjustment Disorder
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
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
Usually psychiatrist input is helpful Not covered further in this talk
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
82 year-old man in the office…
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
Substance use and abuse
Medical Context and Risk Factors
Prior stroke, myocardial infarction, vascular disease
Parkinson’s Alzheimer’s Disease
or other cognitive disorders
Hypothyroidism Significant pain and
pain medications
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.
- Is DSM wrong?- Big Pharma impact?- “Pills for Ills”?- Doctors getting sloppy?
Mojtabai R. NEJM 2014;370:1180-82.
Diagnosis - PHQ
Patient Health Questionnaire Covers the 9 Criteria of DSM for MDD
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
Overall Score is totaled
Diagnosis - PHQ
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) In primary care elderly (15 item, cut-off of 6)
81% sensitive, 78% specific Well validated in cognitively intact ECF
patients
Arthritis Care and Research 2011;63:S454-S466.
PHQ and GDS Pitfalls
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
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…”
PHQ-9 = 3 (normal)!
What do we make of that?
Depression and Cognitive Impairment
Between 30-50% of patients with Alzheimer’s may have significant depression
Common underlying pathology? Depression 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 Depressed mood* Anhedonia* Social isolation 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.
Concentration is not one of the criteria
Treatment of Depression
Treatment of Depression
Most of the studies on treatment have been done on people who meet the criteria for major depression
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:
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
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
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
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
“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
SSRISNRI (lower dose)mirtazapine(TCA)
mirtazapine (high dose)SNRI (higher dose)bupropionTCA
bupropion (high dose)sertraline
Selective Serotonin Reuptake Inhibitors
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
Citalopram (Celexa) Escitalopram (Lexapro) Sertraline (Zoloft) Fluoxetine (Prozac)
More drug interactions Very long acting
Paroxetine (Paxil) More drug interactions More anticholinergic and short acting
Harv Rev Psychiatry 2009;17:242-253.
Better choices in the elderly
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)
Mechanism – norepinephrine and dopamine reuptake inhibition
Associated with Activation – jitteriness and insomnia No sexual side effects Increased risk of seizures, headaches
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
Less desirable options in elderly Amitriptyline Imipramine
Medication Monitoring
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
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 Risk of harm (severe weight loss, malnutrition, food refusal, suicidal)
Usually started in inpatient unit: 6-12 treatments over 2-4 weeks Common side effects/risks
Nausea, HA, jaw pain, muscle aches, increased risk of falls, memory loss
Risk of serious morbidity/mortality less than 1% Contraindications
Unstable cardiopulmonary disease Recent intracranial surgery Intracranial mass with increased ICP Recent ICH or CVA
JAMA 2012;308:909-918.
What if patient is not improving?
Considerations in Non-Responders
Wrong diagnosis? Comorbid psychiatric
disorder? Chronic pain? Sleep disorder? ETOH or drug
misuse? Medical problems or
medications that can worsen depression?
Severe psychological or social stressors
Adherence problems?
Insufficient med trial? Adverse effects? Initial treatment
appropriate but just not effective?
Depression: Step-Wise Approach1. 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 Approach3. 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
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
