Paula Bordelon, DO. Dr. Bordelon has no disclosures
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- Slide 1
- Paula Bordelon, DO
- Slide 2
- Dr. Bordelon has no disclosures.
- Slide 3
- Increased knowledge of comorbidities and risk factors
associated with depression in seniors Ability to recognize signs
and symptoms of depression in seniors Review of USPSTF
recommendation as it relates to screening adults for
depression
- Slide 4
- 15% of people age 65 and older suffer from depression Present
in 25% of those with chronic illness (e.g. CHF, DM) Increased risk
of mortality Costly, with direct and indirect costs totaling $43
billion/year Geriatric Mental Health Foundation;
http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.htm
l; last accessed 09/19/14 Geriatric Mental Health Foundation;
http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.htm
l
- Slide 5
- With less than 4000 geropsychiatrists in U.S., primary care
physicians treat 75% depressed elderly present to PCP, not
psychiatrists Increases functional decline Decreases quality of
life Increased mortality Extreme burden on family and
caregivers
- Slide 6
- Prior personal hx depression Female Increased stressors (e.g.
moved to assisted living) Lower socioeconomic Cognitive Impairment
Substance Use (e.g. alcohol) Bereavement
- Slide 7
- Depression lasting > 2 years considered chronic & has
poor prognosis Depressive symptoms or minor depression
Community8-15% Long-term care30-50% In-patient (OABH)60-70% Major
Depression Community 1 yr prev2.7% Primary Care5.6% Long-term
care6-25%
- Slide 8
- Unipolar Major Depression Dysthymia Depression NOS Bipolar I II
Cyclothymia Bipolar NOS
- Slide 9
- Must have depressed mood or anhedonia (without mania or
hypomania or substance use or another medical condition) PLUS: 4
other SIGECAPS Present at least 2 weeks Cause significant distress
Seniors are not always aware of their emotional feelings. May not
relay depression SIG E CAPS Sleep d/o Interest Guilt Energy
Concentration Appetite/weight Psychomotor agitation or retardation
Suicidal ideation
- Slide 10
- Experience anhedonia or depressive mood for at least 2 years
(think of it as long-lasting and not lifting) Plus at least 2
symptoms (not lifting > 2 mths): Poor appetite or overeating
Insomnia or hypersomnia Low energy Low self-esteem Poor
concentration Hopelessness
- Slide 11
- Rare in seniors to have its initial onset in late life
Dysthymia frequently persists from midlife to late life Do not give
this dx if senior ever met criteria for bipolar D/O or cyclothymic
D/O
- Slide 12
- Less frequent than nonpsychotic depression when considering all
age groups Psychotic depression much more common in elderly
Approximately 20 to 45% hospitalized depressed seniors suffer from
psychotic depression Symptoms associated with such include
hallucinations or delusions
- Slide 13
- Antidepressants alone not enough Warrants antidepressant and
antipsychotic or ECT considered first-line Effective in treatment
resistant patients
- Slide 14
- SymptomDescription Depressed mood or anhedoniaSenior wont state
I am depressed but exhibits loss of interest or anxiety Guilt, low
self-esteem, or worthlessnessNot common in seniors Somatic
ComplaintsAt risk of delayed diagnosis or misdiagnosed Psychomotor
changesElderly more likely to exhibit Insomnia or
hypersomniaHypersomnia much more common in younger adults Weight
loss, anorexiaVery common for seniors Suicidal ideationElderly make
fewer attempts; more likely to be successful
- Slide 15
- 68 year-old retired nurse with no past psychiatric or substance
abuse reports a 4-week hx of hearing the voice of her recently
deceased husband telling her that he misses her. Her husband
suffered an MI while the extended family was on a cruise
celebrating their 40 th wedding anniversary. The auditory
hallucinations occur at night. Ruth feels guilty, because as a RN,
she believes she should have seen this coming. She reports being
down, poor appetite and has lost 4 pounds over 45 days, difficulty
concentrating resulting in errors at work, insomnia, and
fatigue.
- Slide 16
- Bereavement leads to adverse mental and physical outcomes
Associated increased mortality in the surviving conjugal partner
when compared to married persons of the same age Highest relative
risk of mortality occurred 7 12 months after spousal loss
- Slide 17
- Also associated with anxiety, substance use, suicide Symptoms
seen: Marked functional impairment Morbid preoccupation with
worthlessness Psychotic symptoms Psychomotor retardation Psychosis
Rosenzweig AS, Pasternak R, et al. Bereavement-Related Depression
in the Elderly. Is Drug Treatment Justified? Drug & Aging. 1996
May; 8 (5): 323-326.
- Slide 18
- Functional decline Increased use of non-mental health services
1 Increased medical mortality rate in those mood d/o Overall 2 :
> 4x rate of death over 15 months Cardiac 3 : 4x rate of death
within 4 mos after MI 1. Beekman et al. Psychol Med
19997;27:1397-1409. 2. Bruce and Leaf. Am J Public Health.
1989;79:727-730. 3. Romanelli e al. J Am Geriatr Soc
2002;50:817-822.
- Slide 19
- Is a state of chronic stress Risk factor for developing:
diabetes, cognitive impairment, coronary disease (CAD)
osteoporosis
- Slide 20
- Depression activates Hypothalamic Pituitary Axis (HPA)
Increased levels of cortisol Greater in those hospitalized vs
outpatient No differences between sexes HPA hyperactivity varies
but does increase risk of diseases, including diabetes by
increasing FBS and insulin levels Stetler C, Miller GE. Depression
and hypothalamic-pituitary adrenal activation: a quantitative
summary of four decades of research. Psychosom Med. 2011. Feb-Mar;
73(2): 14-26.
- Slide 21
- Depression is independent risk factor for CAD At increased risk
subclinical atherosclerosis Hospitalized depressed patients are at
increased risk of having a myocardial infarction (MI) Death from MI
Individuals suffering MI & depression are at increased risk of
another cardiac event
- Slide 22
- Neurodegeneration leads to depression Determine if it is
dementia syndrome of depression or depression causing cognitive
inabilities
- Slide 23
- Seniors represent 13% of the U.S. population but 18% of
suicides U.S. suicide rate 12.3/100,000 overall in 2011; Age 85+:
16.9/100,000 (41% higher) Among depressed elderly seen by PCP
during a 12 mth period, < 10% received tx for depression before
attempted suicide or suicide 70% of suicides occur within 1 month
of a visit to PCP American Foundation for Prevention of Suicide:
New Data Issued by CDC Releases 2011 Suicide Statistics.
- Slide 24
- Seniors have higher ratio of suicide completions to attempts
Higher rates of double suicides Higher use of firearms in seniors
as means to end life
- Slide 25
- White male Bereavement (e.g. Widow or Widower) Terminal or
chronic illness, including perceived ill health Poor sleep
Psychiatric Disorder Social isolation Hx prior suicide
attempt(s)
- Slide 26
- Less frequent in seniors Symptoms are not typically classic
(i.e. hyperactivity, decreased sleep, flight of ideas, grandiose
delusions, hypersexual) Several unusual presentations when we think
of what we learned in medical school Syndrome of reversible
cognitive impairment which is confused with Alzheimers is seen
- Slide 27
- Take a psychiatric history Speak to informant (esp. if
depressed male) Get past history (i.e. Is this the first episode of
depression?) Suicide attempt hx If prior hx of depression, obtain
previous tx successes and failures ASK ABOUT SUBSTANCE ABUSE! ASK
ABOUT FIREARMS! Investigate if hallucinations Never assume patient
is compliant with therapy
- Slide 28
- In fellowship, taught to use an objective depression scale
(there are quite a few Center for Epidemiologic Studies-Depression
Scale) is quantitative so can trend it Review PHQ-9, GDS,
Cornell
- Slide 29
- Have high degree of sensitivity and specificity USPSTF states
sufficiency in asking 2 simple questions: 1. Over the past 2 weeks,
have you felt down, depressed, or hopeless? 2. Over the past 2
weeks, have you felt little interst in doing things?
- Slide 30
- Recommends screening adults for depression when staff-assisted
depression care supports are in place to assure accurate diagnosis,
treatment, and followup (Grade B recommendation) There may be
considerations supporting screening for depression in an individual
patient (Grade C recommendation) Positive screen should trigger
full diagnostic interview and examination
- Slide 31
- Cornell Scale for Depression in Dementia caretaker or family
member rates severity of symptoms: mood-related signs Behavioral
disturbances Physical signs Cyclic functions Ideational
disturbances Geriatric Depression Scale patient answers subjective
questions and validated in many studies Looks at attitudes and
cognition Less focus on vegetative symptoms
- Slide 32
- Depression is a prodrome Again: depression is linked to
cognitive impairment, especially if first episode of depression
ever Depression leads to disturbance in executive function; can
have pseudodementia Use MMSE or Montreal Cognitive assessment
(MOCA)
- Slide 33
- Take a Medical History Medication side-effects Drug or alcohol
abuse Infection Endocrinopathy (e.g. hypothyroidism) Malignancy
Nutritional disorders Sleep disorders (dont miss sleep apnea)
- Slide 34
- Acyclovir ACE-I B Blocker CCB Corticosteroids Digoxin
H2-receptor blockers Interferon alpha L-dopa Methyldopa and
clonidine Patten SB, Love EJ. Can Drugs Cause Depression: A review
of the evidence. J Psychiatr Neurosci. Vol 18. No. 3. 1993.
- Slide 35
- Study MRI Sleep Study (sleep apnea/MCI/Malaise) UA C&S
Chemistry LFTs Thyroid Fxn Tests Bun/Cr, GFR FBS Vitamin B-12 and
folate
- Slide 36
- Antidepressant medications are the foundation for treatment of
moderate and severe late life depression When considering an
antidepressant, is based on Efficacy Side effects Drug interactions
Cost
- Slide 37
- DiagnosisTreatment/therapy Nonpsychotic MDDSSRI (SNRI) or
venlafaxine XR + psychotherapy Psychotic MDDSSRI (SNRI) or
venlafaxine XR + Atypical Antipsychotic OR ECT DysthymiaSSRI (SNRI)
+ psychotherapy + tx concurrent medical conditions MDD +
insomniaSedating antidepressant Expert Consensus Guideline Series:
Pharmacotherapy of Depressive Disorders in Older Patients.
Postgrad. Med Sp Report 2001 (Oct.): 1-86. PMID: 17205639
- Slide 38
- FDA-indicated antidepressants are effective in treating
late-life depression; dont choose off label medication if
unnecessary Response rate (defined as 50% decrease in symptoms)
Remission rate (defined as > 90% symptom decrease) Typically
only achieved in 30 -40% with medication versus 15% for placebo NNT
for remission (drug vs placebo): 4
- Slide 39
- Avoid TCAs in seniors unless refractory depression because of
side effects Discontinuation 2d to SE is frequent in tx studies TCA
24% SSRI17% Side effectTCA (%)SSRI (%) Dry mouth287 N/V7.517
Drowsiness15.36.5 Vertigo12.27.8 Sleep disturbance42.6
- Slide 40
- SIADH most likely as result of SSRI Easy bruising SSRIs reduce
platelet aggregation GI bleed - Bowel Dysfunction (i.e.
constipation) Weight Gain (e.g. with TCAs) Decreased libido (not
unique to elderly)
- Slide 41
- Polypharmacy: avg adult > age 65 is on 5 or more medications
Age exacerbates potential for side effects Renal elimination of
drugs decreases Hepatic inactivation of drugs decreases
Anticholinergic vunerability increases
- Slide 42
- Careful treatment initiation can reduce side effects and
PREMATURE withdrawal! Dosing initiation rule: adult dose Start low
and go slow Treatment takes more time: Acute treatment:8 weeks
Increase dose:after 6 weeks Remission:Months Continuation:6-12
Months Maintenance:1-5 years vs lifetime
- Slide 43
- Even with maintenance, there is a high recurrence rate
Maintenance pharmacotherapy reduces recurrence risk (Maintenance
means beyond 12 months) Slower initial responders may do better
with combined therapy in maintenance 1 1. Dew et al. J Affect
Disord 2001;65:155-166
- Slide 44
- Psychotherapy is under-prescribed (avoid in the demented
because of lack of efficacy) Effective for non-psychotic MDD and in
dysthymia Several approaches are evidence-based Cognitive Behavior
Therapy (CBT) Problem Solving Therapy (PST) Interpersonal Therapy
(IPT)
- Slide 45
- Adequacy of treatment Duration of treatment Dosage of
medication Solo therapy versus dual therapy Behavioral factors
Personality disorder Psychosocial stressors Compliance Education
provided Diagnosis Missed medical conditions
- Slide 46
- Nonadherence (33-81%) facilitated by: Preference for different
treatment (e.g. no medications) Complexity of medication regimen
Cost (e.g. too expensive so skip doses) Side effects (e.g. too
severe) Cognitive impairment (i.e. noncompliance) Patterns:
underuse, overuse, altered use
- Slide 47
- Recognition and treatment is poor-missed in 50% of the
ambulatory population Among those treated, treated inappropriately:
Inappropriate use of medications Too low doses for fear of side
effects Too short duration Inadequate followup (dont see often
enough)
- Slide 48
- Delusional depression is more prevalent in older depressives vs
younger depressives Associated with: Hypochondriasis Delusional
relapses Worse response to monotherapy Longer hospitalizations
Higher relapse rates
- Slide 49
- Optimize current therapy Switch therapy to new agent Augment
with additional medication or co- prescribe ECT
- Slide 50
- Switch Slower Simpler, less costly Avoids drug-drug interaction
Reduces SE Introduce different mechanism Quicker More complex,
costly Risks drug-drug interaction Can increase SE Avoids loss of
earlier partial response Augmentation
- Slide 51
- Venlafaxine when ANXIETY is prominent Bupropion when APATHY is
prominent Mirtazapine when INSOMNIA/ANXIETY are prominent
Aripiprazole is atypical antipsychotic approved for major
depressive disorder and bipolar disorder
- Slide 52
- Challenging in treating depressed older adults who have not
responded to multiple trials of antidepressant medications Elderly
with psychotic symptoms who failed antidepressant therapy often do
respond to ECT Some studies suggest that ECT is in fact the
SUPERIOR treatment in late life compared to midlife
- Slide 53
- Underused! Some indications: Antidepressant intolerance and/or
nonresponse Prior positive response to ECT Psychosis Catatonia
Mania Profound weight loss
- Slide 54
- Relative contraindications: Cardiac: Recent MI, unstable
angina, uncompensated CHF, arrhythmias, severe valvular disease
Neurologic: intracranial lesions increase risk, recent CVA
- Slide 55
- Major concern of patients (transient retrograde amnesia) ECT
may improve depression-impaired cognition but exacerbate impaired
cognition of dementia Preparation: Education Pre-screen to
establish baseline Monitor memory throughout treatment Decrease
treatment frequency when pronounced
- Slide 56
- The diagnosis of late-life depression is as valid as any other
significant medical disorder. MDD in seniors is associated with
psychiatric and medical morbidity, increased utilization of health
care, and increased mortality. Late-life depression is treatable
but may be refractory to a single intervention. Late-life
depression often coexists with cognitive impairment.