Geriatric Depression

GERIATRIC GERIATRIC DEPRESSIONDEPRESSION

November 13, 2001November 13, 2001

Eric Troyer, M.D.Eric Troyer, M.D.

Swedish Family MedicineSwedish Family Medicine

Case 1Case 1

Eva is an 80 y.o. femaleEva is an 80 y.o. female– Complaints: Poor sleep, mild weight Complaints: Poor sleep, mild weight

loss due to poor appetite, slowing loss due to poor appetite, slowing down recently.down recently.

– History of incontinence, History of incontinence, cardiovascular disease, and diabetes.cardiovascular disease, and diabetes.

– How might you approach this How might you approach this patient’s problems?patient’s problems?

DSM-IV DIAGNOSTIC DSM-IV DIAGNOSTIC CRITERIACRITERIA

5 or more symptoms lasting >2 wk, 5 or more symptoms lasting >2 wk, change from previous functioning:change from previous functioning:– Depressed mood and/or loss of interestDepressed mood and/or loss of interest– Altered sleep, loss of energy, appetite Altered sleep, loss of energy, appetite

change or weight loss, feelings of change or weight loss, feelings of worthlessness/guilt, psychomotor worthlessness/guilt, psychomotor changes, loss of concentration and focus, changes, loss of concentration and focus, recurrent thoughts of deathrecurrent thoughts of death

SIG E CAPSSIG E CAPS

– SleepSleep– InterestInterest– Guilt (“Are you a burden to others?”)Guilt (“Are you a burden to others?”)– EnergyEnergy– ConcentrationConcentration– AppetiteAppetite– Psychomotor changesPsychomotor changes– Suicidality (“Do you wish you could Suicidality (“Do you wish you could

die?”)die?”)

Vegetative SymptomsVegetative Symptoms


die?”)die?”)

Vegetative SymptomsVegetative Symptoms

– These can often occur in other These can often occur in other medical illnessesmedical illnesses

– Not discriminating or sensitiveNot discriminating or sensitive

Psychological SymptomsPsychological Symptoms


die?”)die?”)

Psychological SymptomsPsychological Symptoms

– More reliable and are independent of More reliable and are independent of ageage

– But, elderly patients less willing to But, elderly patients less willing to talk about psychological problemstalk about psychological problems

– Pay attention to:Pay attention to: anxietyanxiety physical discomfortphysical discomfort adaptation to a new lifestyleadaptation to a new lifestyle

SIGNS AND SYMPTOMS IN SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSIONGERIATRIC DEPRESSION

SYMPTOMSSYMPTOMS

– MOODMOOD– COGNITIVECOGNITIVE– VEGETATIVEVEGETATIVE– VOLITIONALVOLITIONAL

SIGNSSIGNS

– APPEARANCEAPPEARANCE– BEHAVIORSBEHAVIORS– PSYCHOMOTOR PSYCHOMOTOR

RETARDATIONRETARDATION– PHYSCHOMOTOR PHYSCHOMOTOR

AGITATIONAGITATION

Case 1Case 1

SIG E CAPS & DM for Eva:SIG E CAPS & DM for Eva:– Positives: Sleep, Appetite, Positives: Sleep, Appetite,

Psychomotor retardationPsychomotor retardation– Negatives: Interests, Guilt, Energy, Negatives: Interests, Guilt, Energy,

Concentration, Suicidality, Depressed Concentration, Suicidality, Depressed moodmood

Case 1Case 1

– Poor sleep due to nocturia.Poor sleep due to nocturia.– Appetite changes due to decreased Appetite changes due to decreased

taste and smell.taste and smell.– Slowing down due to new Slowing down due to new

claudication.claudication.

Case 2Case 2

George is a 74 y.o. maleGeorge is a 74 y.o. male– Complaints: Sore muscles, dizziness, Complaints: Sore muscles, dizziness,

constipation. Repeated visits to doctor constipation. Repeated visits to doctor with vague symptoms.with vague symptoms.

– Daughter reports patient impossibly Daughter reports patient impossibly uncooperative and has angry outbursts.uncooperative and has angry outbursts.

– Wife died 2 years ago; he moved in with Wife died 2 years ago; he moved in with daughter 3 months ago after a fall.daughter 3 months ago after a fall.

INCIDENCE IN ELDERLYINCIDENCE IN ELDERLY

MAJOR DEPRESSIONMAJOR DEPRESSION– 3% community dwelling3% community dwelling– 14% two years after spouse dies14% two years after spouse dies– 15% medically ill15% medically ill– 25% long-term-care settings25% long-term-care settings

DEPRESSIVE SX’SDEPRESSIVE SX’S– 17-37% in primary care settings17-37% in primary care settings– 42% in long-term-care settings42% in long-term-care settings

How is Depression How is Depression Different in the Elderly?Different in the Elderly?

Less verbalization of emotions or guiltLess verbalization of emotions or guilt Minimize or deny depressed mood Minimize or deny depressed mood

(“masked depression”)(“masked depression”) Preoccupied with somatic symptomsPreoccupied with somatic symptoms

– 65% have hypochondriacal symptoms65% have hypochondriacal symptoms Cognitive impairment can be markedCognitive impairment can be marked Hopelessness appears to be Hopelessness appears to be

persistentpersistent


Depressive ideation, anxiety, Depressive ideation, anxiety, psychomotor retardation, and weight psychomotor retardation, and weight loss have high assoc. with disabilityloss have high assoc. with disability

More anxiety, agitation and psychosisMore anxiety, agitation and psychosis– esp. delusions with themes of guilt, esp. delusions with themes of guilt,

nihilism, persecution, jealousy nihilism, persecution, jealousy Medical Conditions can mask or cause Medical Conditions can mask or cause

depressiondepression


Subsyndromal depression is more Subsyndromal depression is more common and presents as:common and presents as:– new medical complaintsnew medical complaints– exacerbation of GI sx’s or arthritic painexacerbation of GI sx’s or arthritic pain– cardiovascular sx’scardiovascular sx’s– preoccupation with healthpreoccupation with health– diminished interest, fatigue, poor diminished interest, fatigue, poor

concentrationconcentration

Case 3Case 3

Francine is a 67 y.o. femaleFrancine is a 67 y.o. female– Complaints: Sad, decreased interests, Complaints: Sad, decreased interests,

shaky, “falling apart.”shaky, “falling apart.”– Your nurse mentions that she took a Your nurse mentions that she took a

while to bring back, esp. out in the while to bring back, esp. out in the lobby.lobby.

– Your exam shows tremor and Your exam shows tremor and cogwheel rigidity.cogwheel rigidity.

Medical Conditions Medical Conditions Mask or Cause DepressionMask or Cause Depression

AutoimmuneAutoimmune Cerebrovascular Cerebrovascular Chronic painChronic pain Degenerative Degenerative

DiseaseDisease EndocrineEndocrine MetabolicMetabolic NeoplasmsNeoplasms InfectionsInfections

DRUGSDRUGS– PropranololPropranolol– CimetidineCimetidine– ClonidineClonidine– BenzodiazepinesBenzodiazepines– SteroidsSteroids– TamoxifenTamoxifen– Many more...Many more...

Parkinson’s DiseaseParkinson’s Disease

About 50% of patients develop About 50% of patients develop depressiondepression

Useful treatment includes TCA’sUseful treatment includes TCA’s ECT helps depression and PD sx’s:ECT helps depression and PD sx’s:

– tremors, rigidity, & bradykinesia tremors, rigidity, & bradykinesia improved with 3-4 sessionsimproved with 3-4 sessions

– depression improved after 7-9 depression improved after 7-9 sessionssessions

Early Alzheimer’s DzEarly Alzheimer’s Dz

Presents with:Presents with:– insomniainsomnia– fatiguefatigue– agitationagitation– psychomotor retardationpsychomotor retardation– decreased interest & energydecreased interest & energy– concentration problemsconcentration problems

50% of AD pt’s have depressive sx’s 50% of AD pt’s have depressive sx’s (15-20% with major depression)(15-20% with major depression)

Vascular DepressionVascular Depression

Cerebrovascular disease can precipitate Cerebrovascular disease can precipitate or perpetuate depressionor perpetuate depression

Caused by ischemia (“silent strokes”) in Caused by ischemia (“silent strokes”) in prefrontal cortex and basal ganglia; prefrontal cortex and basal ganglia; motor & sensory deficits usu. not found.motor & sensory deficits usu. not found.

Apathy, psychomotor retardation, Apathy, psychomotor retardation, cognitive declinecognitive decline

May explain incr. depression s/p CABGMay explain incr. depression s/p CABG

PseudodementiaPseudodementia

aka “dementia of depression”aka “dementia of depression” cognitive decline that clears if cognitive decline that clears if

depression is treateddepression is treated however, dementia rate in these however, dementia rate in these

patients is still 20%/year even patients is still 20%/year even after full recovery of intellectual after full recovery of intellectual functionfunction

WorkupWorkup

It might include:It might include:– H & PH & P– CBC, TSH, testosteroneCBC, TSH, testosterone– ESR, renal/liver functionESR, renal/liver function– U/AU/A– EKGEKG– brain imaging if tumor or vascular brain imaging if tumor or vascular

disease suspecteddisease suspected

Case 4Case 4

Eugene is a 70 y.o. maleEugene is a 70 y.o. male– Dx’d with bladder cancer, had Dx’d with bladder cancer, had

cystectomy and now with Indiana pouch. cystectomy and now with Indiana pouch. Needs to cath through umbilicus q4hr. Needs to cath through umbilicus q4hr. His wife recently dx’d with breast His wife recently dx’d with breast cancer.cancer.

– Pt. has single episode of major Pt. has single episode of major depression 25 years ago following tough depression 25 years ago following tough work situation and increased EtOH use.work situation and increased EtOH use.

Case 4 (cont’d)Case 4 (cont’d)

– Symptoms: Withdrawn, no interest in Symptoms: Withdrawn, no interest in activities (not even Mariners games), activities (not even Mariners games), sleeping excessively, lost 10#, sleeping excessively, lost 10#, constant worry about cath procedure, constant worry about cath procedure, belief he is burden to family.belief he is burden to family.

– Statements like, “I wish I was dead,” Statements like, “I wish I was dead,” and, “my problem will affect this and, “my problem will affect this entire hospital.”entire hospital.”

Case 4Case 4

SIG E CAPS & DM for Eugene:SIG E CAPS & DM for Eugene:– Positives: Sleep, Interests, Positives: Sleep, Interests,

Guilt/Burden, Energy, Concentration, Guilt/Burden, Energy, Concentration, Appetite, Psychomotor retardation, Appetite, Psychomotor retardation, Suicidal (passive), Depressed moodSuicidal (passive), Depressed mood

– Additional findings: Nihilistic, Additional findings: Nihilistic, DelusionalDelusional

SUICIDE IS A REAL RISKSUICIDE IS A REAL RISK

25% of all completed suicides are > 6525% of all completed suicides are > 65 Suicide rate for depressed men over 65 Suicide rate for depressed men over 65

is 5 times higher than for younger menis 5 times higher than for younger men 20% of older people who committed 20% of older people who committed

suicide saw a physician that daysuicide saw a physician that day Increased risk: financial problems, Increased risk: financial problems,

physical illness, recent loss, EtOH, physical illness, recent loss, EtOH, abuse, isolationabuse, isolation

INTERVENTIONSINTERVENTIONS

Seek out medical illnessSeek out medical illness Recognize medical side effectsRecognize medical side effects Rehab services to maximize remaining Rehab services to maximize remaining

function and retrain impaired iADL’sfunction and retrain impaired iADL’s Involve family and caretakers Involve family and caretakers Counsel re: role transitions, grief, Counsel re: role transitions, grief,

dependencydependency Medications / ECTMedications / ECT

GERIATRIC PRESCRIBING GERIATRIC PRESCRIBING PRINCIPLESPRINCIPLES

CC Caution, ComplianceCaution, Compliance AA Adjust dose for AgeAdjust dose for Age RR Review, Remove, ReduceReview, Remove, Reduce EE Educate Educate

START LOW & GO SLOWSTART LOW & GO SLOW

MEDICAL THERAPY IN MEDICAL THERAPY IN GERIATRIC DEPRESSIONGERIATRIC DEPRESSION

Select based on symptoms, prior Select based on symptoms, prior response, concurrent illness, side response, concurrent illness, side effect profileeffect profile

Reassess after 4-6 weeks:Reassess after 4-6 weeks:– Increase dose, augment with second Increase dose, augment with second

agent, add psychotherapyagent, add psychotherapy– Consider psychiatric consult/referralConsider psychiatric consult/referral

PREFERRED PREFERRED ANTIDEPRESSANTSANTIDEPRESSANTS

SSRI’sSSRI’s– Celexa, PaxilCelexa, Paxil– Zoloft, ProzacZoloft, Prozac

TCATCA– NortriptylineNortriptyline

OthersOthers– WellbutrinWellbutrin– SerzoneSerzone– RemeronRemeron

fewer side effectsfewer side effects– good safety recordgood safety record– more expensivemore expensive

least expensive least expensive

activation, tremoractivation, tremor anxiolytic, somaticanxiolytic, somatic sleep, appetitesleep, appetite

ACCEPTABLE ACCEPTABLE ANTIDEPRESSANTSANTIDEPRESSANTS

TCATCA– DesipramineDesipramine

HCAHCA– TrazodoneTrazodone

SNRISNRI– EffexorEffexor

Sedation, Sedation, hypotensionhypotension

cognitive slowingcognitive slowing

Dizzy, anorexia, Dizzy, anorexia, nausea, BP nausea, BP increaseincrease

ANTIDEPRESSANTS TO ANTIDEPRESSANTS TO AVIOD IN THE ELDERLYAVIOD IN THE ELDERLY

Too many side effects: Too many side effects: Older TCA’s:Older TCA’s:

– amitriptyline, clomipramine, doxepin, amitriptyline, clomipramine, doxepin, imipramine, protriptyline, imipramine, protriptyline, trimipraminetrimipramine

MAOI’s:MAOI’s:– phenelzine, tranylcyprominephenelzine, tranylcypromine

Other DrugsOther Drugs

Newer atypical anti-psychotics:Newer atypical anti-psychotics:– for “jump start” or behavior issuesfor “jump start” or behavior issues– Risperdal (risperidone), Seroquel Risperdal (risperidone), Seroquel

(quetiapine), Zyprexa (olanzapine)(quetiapine), Zyprexa (olanzapine) PsychostimulantsPsychostimulants

– for “jump start” or for severe apathyfor “jump start” or for severe apathy

Electroconvulsive Therapy Electroconvulsive Therapy (ECT)(ECT)

Works well for psychotic Works well for psychotic depression, high suicide risk, depression, high suicide risk, Parkinson’s-related depression, Parkinson’s-related depression, failed drug treatmentfailed drug treatment

Very effective short term, but with Very effective short term, but with high relapse rates over next 6-12 high relapse rates over next 6-12 months.months.

Drug therapy can reduce relapseDrug therapy can reduce relapse

Health & Medicine

Geriatric Depression