Depression in Older Adults

Dr Baljeet Singh SalujaConsultant Psychiatrist-Older Adults

Lancashire Care NHS Foundation Trust

Classification Diagnostic Criteria-ICD-10

• Depressive Disorder Mild-F32.0 Moderate-F32.1 Severe without psychotic symptoms –F32.2 or with psychotic symptoms-F32.3 Presence or absence of Somatic Syndrome –F32.x1

• Recurrent Depressive Disorder-F33• Organic Depressive Disorder-F06.32• Dysthymia-F34.1• Mixed Anxiety and Depressive Disorder-F41.2• Adjustment Disorder with depressive reaction-F43.20

Classification DSM-V-Major Depressive Disorder• 2 weeks history-fulfilling diagnostic criteria 5 or more for depression-A• Fulfilling criteria B-D• Specifiers 1. Severity Mild Moderate Severe 2. Psychosis Delusions/hallucinations 3. Remission Partial/full 4. Mixed features manic criteria insufficient to diagnose manic episode 5. Anxious Distress Rating severity anxiety in depressive disorder suggestion of Suicidal Thinking, plans

Classification DSM-V-Major Depressive Disorder

• Dysthymic disorder removed from diagnostic criteria now included under Persistent Mood Disorder with chronic depression.

• Bereavement exclusion removed from Major Depressive Disorder-Criteria E

Depression in Old ageOther terminology used for depression • Bereavement• Minor depressive disorder• Depression without sadness• Mood disorder caused by a general medical condition• Subsyndromal or subthreshold depression• (Vascular) dementia with depressed mood• Depression–executive dysfunction syndrome-fronto-striatal

dysfunction• Substance- or medication-induced depression• Bipolar disorder, most recent episode depressed

Epidemiology

Systematic review on incidence of depressive disorders in late life• Systematic literature search-1985 and 2011 Inclusion criteria • Incidence -persons aged≥70 years at baseline• population-based sample or primary care sample.

(Buchtemann D et al-2011)

Epidemiology

• 20 studies reporting incidence -categorical (n=14) or dimensional diagnoses (n=6).

• Major Depression (MD) less often than Minor Depression (MinD), • Clinically relevant depressive symptoms as frequent as MinD. • Incidence rate of MD -0.2-14.1/100 person-years, • Incidence of clinically relevant depressive symptoms -6.8/100

person-years. • Female incidence mostly higher than male. • Associations between age and incidence -inconsistent between

studies.• Physical health and psychosocial influences -key variables in

depression prevention.(Buchtemann D et al-2011)

Epidemiology

24 studies analyzed age and gender-specific prevalence of depression • Prevalence of major depression -4.6% -9.3%• Prevalence of other Depressive disorders - 4.5% -37.4%. • Pooled prevalence • 7.2% (95% CI 4.4-10.6%) for major depression • 17.1% (95% CI 9.7-26.1%) for depressive disorders

(Luppa M et al 2012)

Prevalence and Risk Factors for Late Life DepressionLeipzig Longitudinal Study of the Aged –LEILA 75+

• Population-based sample -1,006 individuals • Aged 75 years and older

Prevalence

• 38.2% -Depressed

(Luppa M et al 2012)

Depression Older Adults- Prevalence rate - Population Groups • Hospitalized patients 11.5% of hospitalized elders meet the criteria for MDD and 23% have depressive symptoms.• Primary Care Settings Major depression affects 5% to 10% of older adults in primary care settings.• In long-term-care facilities MDD - 14.4%. Minor depression - 16.8%. The IOM's report - 49.6% nursing home residents aged 65 years and older had depression

Risk factors -Late life depression

• Divorced or widowed marital status, • Low educational level, • Poor self-rated health status, • Functional impairment, • Multi-domain MCI,• Stressful life events and poor social network

(Luppa M et al 2012)

Personality attributes in Late Life Depression• Robust personalities more prone to late life depression-

(Roth et al 1955) • Less premorbid personality dysfunction related to severe

depression ,Obsessional traits related to late life depression- (Post 1972)• Avoidant and dependent personalities more prone to

late life depression-(Abrams et al 1987)• Cluster C personalities(Avoidant/Dependent/Obsessional

Personalities) – experience more dysfunction and likely to respond to treatment in Late life Depression (Morse and Robins -2005)

Psychosocial Factors –contributing to Late Life Depression

• Life stressors• Stressful life events and daily hassles•  Medical illness and disability•  Low level of self-efficacy•  Poor functional status•  Trauma• Financial status•  Less education

(Arean and Reynolds 2005Averill and Beck 2000)

Psychosocial Factors

• Social stressors In Caring role –dementia/ physical illness-(Ballard etal -1996) Poor social support Loneliness/poor social contact Bereavement-(Green 1994, Clayton 2004)

• Cognitive distortions Maladaptive thoughts and behaviours Faulty information processing Learned helplessness

Biological FactorsVascular

• Myocardial infarction• Coronary heart disease• Cerebrovascular accident• Silent cerebral infarction and white matter hyper intensities

Biological Factors• Genetic polymorphisms/mutations CADASIL-cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy MTHFR-methyltetrahydrofolate reductase deficiency CBS-cystathionine beta-synthetase deficiency• Dementia Alzheimer disease/Vascular dementia• Diabetes mellitus• Parkinsons disease

Biological Factors

• Endocrine/Metabolic Disorders Thyroid dysfunction/ Cushings Disease, calcium dysregulation, pernicious anaemia• Occult Carcinoma-Pancreas, Lung• Chronic infections AIDS,Neurocysticercosis,encephalomyelitis, neurosyphillis,brucellosis

Biological Factors

Medication• Beta blockers• Steroids• Opioid analgesics• Anti-Parkinsonian medication-

Levodopa,Amantadine,Tetrabenazine• Psychotropics-neuroleptics, benzodiazepines• Alcohol

Late Life Depression- Pathophysiology

• Biogenic Amines hypothesis• Dopamine pathways• CRF,TRH, GHRH, HPA Axis. abnormalities• Immune and inflammatory responses-prolonged exposure to

glucocorticoids.• Structural brain changes- cortical atrophy-frontal lobe atrophy.

Vascular Depression

Vascular depression hypothesis(Alexopoulos 1997)

• Depression,vascular disease,vascular risk factors, ischemic lesions in pre –frontal cortex

Presentation• Psychomotor retardation• less guilt • poorer insight• limited depressive symptoms • More cognitive impairment and disability• Fluency and naming impaired

Vascular Depression

• Homocysteine depression hypothesis. • Elevated levels of homocysteine lead to cerebral vascular

disease and neurotransmitter deficiency, which then cause depressed mood

• Levels of homocysteine may increase in Deficiency of B12, folate, and B6

Genetic variation of enzymes, such as methyl-tetrahydrofolate reductase (MHFR)and cystathionine beta-synthetase (CBS)-essential for the metabolism of homocysteine.

Vascular Depression

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) • stroke or a migraine; • 6% -present initially with depression. • Depression, adjustment disorder, and subcortical dementia, -

30% cases• High rates of cerebrovascular disease and white matter

hyperintensities (WMH) on MRIs in depressed elderly patients.

Vascular Depression-Neuroimaging

• Areas of the brain implicated in late-life depression. Anterior cingulate cortex (ACC) Orbitofrontal cortex (OFC) Hippocampus.

• Depressed individuals -smaller ACC volumes.• OFC - includes the hippocampus, amygdala, and basal ganglia-

smaller OFC volumes related to late life depression• Reduction in hippocampal volume found in the depressed

elderly population

• Severity of White matter hyperintensities - more in Late Onset Depression compared

to Early onset depression suggesting different aetiological basis

Vascular Depression

Functional neuroimaging • Dorsal cingulate gyrus, middle and dorsolateral prefrontal cortex

(DLPFC), insula, and superior temporal gyrus Hypoactive at rest during negative mood states Activity increases with SSRI treatment.• Cortical-limbic network-the medial and inferior frontal cortex and

basal ganglia Overactive at rest and during induction of negative mood states. Activity reduces with antidepressant treatment.

Management

• Good clinical assessment including cognitive assessment and assessment of risk.

• Good collateral history from a reliable informant.• Capacity assessment .• Physical examination in all cases.• Laboratory investigation to rule out reversible causes for

depression.• EEG if indicated from clinical assessment to rule out organic

brain syndrome.• Neuroimaging – if evidence of neurological changes, vascular

history or in resistance cases.

Management of late life depression

• Multidisciplinary team approach• Patient centred approach.• Well informed patient - wishes and choices about treatment

considered at all stages. • Reviewing medication and physical illnesses contributing to

presentation.• Explaining treatment modalities in detail.• Comprehensive Care plan Provided to patients and Carers

Aim of treatment• Minimise risks.• Achieve remission in acute phase• Assist in functioning to pre-morbid level• Treatment of co-morbid physical health issues.• Maintain remission and prevent future relapses

Pharmacological Intervention

• Consideration to be given to current physical health issues which can affect pharmaco-kinetic response

• Ensuring safe prescribing-noting drug interactions.• Minimising multiple drug treatments.• Monitor risk of delirium with medication .

Treatment phases

• Acute phase-initial phase with signs of improvement and remission –usually weeks

• Continuation phase-second phase to prevent relapse-usually months.

• Maintenance Treatment-prevention of future episodes –usually years.

Acute Phase treatment

• Establish diagnosis• Start treatment-monitor side effects /response for initial 4-

6weeks .• if partial response wait for another 4-6 weeks, increase dose

if necessary.• Monitor and review regularly.• If no response then switch -only switch if no clear benefit

(STAR-D study)

• If no change then consider augmentation.• Consider ECT if indicated

Anti-depressants• Tricyclics-Trazodone, Lofepramine, Nortriptyline • SSRI’sCitalopram, Escitalopram Sertraline-shown to be efficacious and well tolerated,Risk of hyponatraemia and QT prolongation with SSRI.• MAO inhibitors-Phenelzine• RIMA-Moclobemide• SNRI’s-Venlafaxine • NARI-Reboxetine• NAASa-Mirtazapine, Duloxetine

Late Life Depression-Antidepressants

• Sertraline- Best Tolerated• Effective- Mirtazapine, Escitalopram, Venlafaxine, Sertraline• Less Effective- Duloxetine, Fluoxetine, Fluvoxamine, Paroxetine

(Cipriani et al 2009)

Augmentation strategies • SSRI with Lithium • SSRI with Mirtazapine• SSRI with Venlafaxine • SSRI with TCA• Mirtazapine with Venlafaxine • Antidepressants with antipsychotics- in case of psychotic

depression ,anxious agitated state• Acetylcholine-esterase inhibitors- not shown to be efficacious

in combination with anti-depressants. (McDermott C.L.2012)• Lithium augmentation shown to be the most useful in

systematic review in refractory depression.(Cooper etal 2011)

ECTSafe and Effective treatment• Effective in acute phase with high risk• Rapidly acting to achieve remission (H. P. Spaans et al. (2015)• Bilateral ECT more effective than unilateral treatment(Bjolseth

T.M. 2015)• More cognitive impairment evident with bilateral.• Prone to high relapse rate after initial remission.• Continued use of antidepressant recommended to achieve long

term remission. • M-ECT is probably as effective as continuation medication in

severely depressed elderly patients after a successful course of ECT and is generally well tolerated( Van Schaik A.M.,2012)

• ECT remains a standard and vital treatment for their most seriously ill in the geriatric age group-(Kellner etal 2015)

Psychological Treatment

Cognitive behavioural therapy• Evidence indicates that cognitive behavioral therapies are

likely to be efficacious and cost effective in older people when compared with treatment as usual. (Jayasekara R. 2015), (Titov N. 2015), (Simon et al 2015)

• preliminary support for entirely self-guided iCBT for older adults with anxiety and depression-(Dear B.F. ,2015)

PATH-Problem Adaptation Therapy More efficacious than supportive therapy in cognitively impaired geriatric patients (Kiosses D.N 2015).

Social interventions • Psychosocial interventions have a small but statistically

significant effect in reducing depressive symptoms among older adults (Forsman AK 2011)

• A three-month outdoor activity intervention shown to improve mood among older people with severe mobility limitations .(Rantakokko etal 2015)

• Physical activity with antidepressants -more efficacious for MD compared to medication alone.(Mura G.2013),(Pereira D.S. 2013),(Tony G. 2013),

• Exercise shown to help with depression in long term care. (OPERA TRIAL-Underwood M 2011)

• Listening to music can help older people to reduce their depression level.(Chan M.F. 2012)

Home treatment-Late Life Depression

• Shown to reduce symptom severity, improve functioning and reduce hospital admission

(Klug etal 2010)

Prognosis• Greater risk of relapse compared to young population.Poor prognosis indicated by • Slow initial recovery• Chronic depression• Medical comorbidity• Cerebrovascular disease• Dementia • Poor social support

Suicide Risk - Late Life Depression

• Among those who attempt suicide, elderly are the most likely to die.

• In adolescence, risk of attempted to completed suicides 200:1,

• Risk for the general population -from 8:1 to 33:1.• Risk for elderly 4:1• 4 times increased risk of self harm controlling for age, sex, and

physical health than controls• Higher score on Geriatric Depression Scale indicates early

death by suicide

Suicide and late life depression• Increased suicide risk and non-suicide mortality. • Elderly with suicidal thoughts -more likely to act on them and

successfully commit suicide than their younger counterparts.• Older age -significantly associated with more determined and

planned self-destructive acts and with fewer warnings of suicidal intent.

Suicide-Elderly

Most common methods• firearms,• hanging, • self-poisoning, • falls from height

Late Life Depression-Mortality

Depression increases likelihood of dying from other causes

• Non adherence to their medication regimen• Unable to maintain their cognitive and physical functioning

capabilities,• likely to alienate their social network • less likely to seek out preventive and curative health care

treatments.• increased mortality in those with cardiovascular disease.

Late Life Depression-Mortality

• Older adults with major depression -intensively managed with regards to depression had a mortality risk lower than that observed in usual care and similar to older adults without depression

PROSPECT STUDY(Gallo J.J. 2013)

Prevention • Aimed at identifying high risk groups• Early identification of depressive symptoms and management.• Few studies focussing on Older Adults groups.• More research needed due to high risk group.

(Cuijpers etal 2015)