DEPRESSION IN OLD AGE(FOR PRIMARY HEALTHCARE ENCOUNTER)

AHMED EID ELAGHOURY, MDEGYPTIAN AND ARAB BOARD-CERTIFIED IN PSYCHIATRY

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Old Man in Sorrow (On the Threshold of Eternity)

 is an oil painting by Vincent van Gogh, 1890

Feb 2017

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BACKGROUND

• DEPRESSION IS NOT A NORMAL CONSEQUENCE OF AGING

• DEPRESSION OFTEN GOES UNDIAGNOSED IN PRIMARY CARE

• DEPRESSION AMONG MEDICAL OUTPATIENTS ABOVE AGE 65 YRS: 7% - 36% • FHX OF DEPRESSION: 2X ↑ RISK, LONGER EPISODE, MORE FREQUENT, MORE SUICIDAL • LATE LIFE DEPRESSION MAY BE: A PRODROMAL STAGE OF DEMENTIA OR AN INDEPENDENT

RISK FACTOR FOR DEMENTIA.

• THERAPEUTIC NIHILISM: PATIENT, FAMILY, OR PROVIDER ARE NOT ENCOURAGED TO START RX

UpToDate: Jul, 2016BMJ Best Practice: Dec,2016

Feb 2017Taif, SA

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RISK FACTORS FOR LATE-LIFE DEPRESSION

• FEMALE SEX

• SOCIAL ISOLATION

• WIDOWED, DIVORCED, OR SEPARATED MARITAL STATUS

• LOWER SOCIOECONOMIC STATUS

• COMORBID GENERAL MEDICAL CONDITIONS

• UNCONTROLLED PAIN

• INSOMNIA

• FUNCTIONAL IMPAIRMENT

• COGNITIVE IMPAIRMENT

UpToDate: Jul, 2016Feb 2017

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MAJOR DEPRESSIVE EPISODE, MDE

• COURSE: SINGLE EPISODE/RECURRENT EPISODE [2-M APART]• REMISSION: IN PARTIAL REMISSION/IN FULL REMISSION• LATE ONSET PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA): CHRONIC

EPISODE FOR AT LEAST 2 YRS

DSM5, 2013Feb 2017

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OTHER DIFFERENT PRESENTATIONS1. MDE WITH ANXIOUS DISTRESS: ANXIETY, FEARFULNESS. RISK FOR:

SUICIDE, RX NON-RESPONSE, LONGER EPISODES2. MDE WITH MIXED FEATURES: SUBSYNDROMAL HYPOMANIA; IRRITABLE

DEPRESSION. RISK FOR: BIPOLAR DS, SRI NON-RESPONSE OR SRI WORSENING

3. MDE WITH MELANCHOLIC FEATURES: SOMATIC/BIOLOGIC SYNDROME. RISK FOR: SRI NON-RESPONSE, PSYCHOTIC SX

4. MDE WITH PSYCHOTIC FEATURES: MOOD-CONGRUENT/MOOD-INCONGRUENT. E.G. COTARD SYNDROME

5. MDE WITH CATATONIA: DEPRESSIVE STUPOR

DSM5, 2013

Feb 2017

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DEPRESSIVE DS DUE TO ANOTHER MEDICAL CONDITION, AMC

• DUE TO THE DIRECT PATHOPHYSIOLOGICAL CONSEQUENCE OF AMC• THERE IS AN EVIDENCE FROM HX, PE / LAB, IMAGING • W/O DELIRIUM• CAN BE: WITH DEPRESSIVE FEATURES, WITH MDE-LIKE FEATURES / WITH MIXED

FEATURES• COMMON EXAMPLES: HYPOTHYROIDISM,OBESITY, DM, IHD, VIT D ↓, CANCER• POST-STROKE (VASCULAR) DEPRESSION: FIRST 2 YRS AFTER A STROKE, ESP LT

BRAIN (COMMON IN 3-6 MS AFTER), RISK FACTOR FOR VASCULAR DEMENTIA

DSM5, 2013Feb 2017

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MEDICATION-INDUCED DEPRESSIVE DS

• AFTER EXPOSURE TO A MEDICATION• DURING/SOON AFTER SUBSTANCE INTOXICATION/WITHDRAWAL• NO EVIDENCE OF AN INDEPENDENT DEPRESSIVE DS: E.G. PRIOR HX,

PROTRACTED SX• COMMON WITH: STEROIDS, INF, PROPRANOLOL

DSM5, 2013UpToDate: Jul, 2016

Feb 2017

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SCREENING THROUGH PHQ-2: TWO QS

• Q1: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT DOWN, DEPRESSED, HOPELESS?' [DEPRESSED MOOD] 

• Q2: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT LITTLE INTEREST OR PLEASURE IN DOING THINGS?' [ANHEDONIA]

• A POSITIVE RESPONSE TO EITHER QUESTION (SN= 97%, SP= 67%): ASSESS FOR A DEPRESSIVE DS

• ALSO: GERIATRIC DEPRESSION SCALE, GDS (>5 SUGGESTS DEPRESSION) AVAILABLE AS A FREE APP

PHQ: patient health questionaireBMJ Best Practice: Dec,2016

Feb 2017

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WORKUP: DON'T MISS

• TSH• VIT D3• VIT B12• FOLATE

Feb 2017

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MANAGEMENT

• CONSIDER: COMORBID CONDITIONS AND DRUG INTERACTIONS• ANTICHOLINERGIC LOAD: BEERS CRITERIA (POTENTIALLY INAPPROPRIATE PRESCRIBING)• COMBINED: PSYCHOTHERAPY + SOMATIC THERAPY ---- PHYSICAL EXERCISE• SOMATIC THERAPY: DRUGS + BRAIN STIMULATION• DRUGS: CITALOPRAM, S-CITALOPRAM, SERTRALINE, MIRTAZAPINE, TRAZODONE ---- LONGER DURATIONS• ALSO: ANALGESICS, FOLIC ACID, VIT D, VIT B12, L-THYROXIN, ARIPIPRAZOLE, METHYLPHENIDATE,

LITHIUM• AVOID: TCA, PAROXETINE, BZD• BRAINS STIMULATION: ECT, TMS

Feb 2017

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