TREATMENT OF DEPRESSION IN THE ELDERLY Jackie L. Neel, D.O.
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Transcript TREATMENT OF DEPRESSION IN THE ELDERLY Jackie L. Neel, D.O.
TREATMENT OF DEPRESSION
IN THE ELDERLY
Jackie L. Neel, D.O.
OSU Center for Health Sciences
College of Osteopathic Medicine
(Revised 9/2002)
“It is not enough for a great
nation merely to have added
new years to life--our objective
must also be to add new life to
those years.”
---John F. Kennedy
Depression of the Elderly - - Jackie
L. Neel, D.O.
Our population is Aging!
• 2/3 of all the people in the history of the
world who have reached age 65 are alive
today!
• 1/2 the women who are 65 today will
survive to age 85.
• 1980-1990 population over 85 increased
by 40%; centenarians doubled.
• Avg. lifespan in 1900=47, today=75
Depression of the Elderly - - Jackie
L. Neel, D.O.
Healthy functioning older adults
are at no greater risk for
depression than younger adults
Depression of the Elderly - - Jackie
L. Neel, D.O.
Risk Factors
• Depression increases in the elderly due to:
– Multiple losses
– Medical illness
– Cognitive dysfunction
• The greatest risk factor for depression in
the elderly is history of previous
depression
Depression of the Elderly - - Jackie
L. Neel, D.O.
Compounding of Adverse Life
Events in Aging
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Jobs
Money
Homes
Friends
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Abilities
Health
Hopes
Bereavement
Depression of the Elderly - - Jackie
L. Neel, D.O.
Prevalence of Depression in
Medical Illness
Stroke
Cancer
Myocardial infarct
Rheumatoid Arthritis
Parkinson’s Disease
Diabetes
26-61%
18-39%
15-19%
13%
10-37%
5-11%
Depression of the Elderly - - Jackie
L. Neel, D.O.
Categories of Medical Problems
in elderly inpatients with Major
Depression
Circulatory
69%
Digestive
61%
Endocrine, metabolic
45%
Other
25%
Genitourinary
24%
Mean # of medical problems = 5
Depression of the Elderly - - Jackie
L. Neel, D.O.
Common Secondary Causes of
Depression in the Elderly
• Alzheimer’s
• Vascular and other
dementia
• Common infections
(i.e. pneumonia or
UTI)
• Substance abuse
• Endocrine disorders
• Electrolyte
imbalance
• Tumor
• Endocrine
• Prescription
meds
Depression of the Elderly - - Jackie
L. Neel, D.O.
Dementia and Depression
• Alzheimer’s - 20-40%
• Similar rates with other dementia's
– Vascular
– Parkinson’s
– Huntington’s
– Brain injury
– B12,folate
• Depression may precede other symptoms
Depression of the Elderly - - Jackie
L. Neel, D.O.
Having a mental disorder in late
life increases mortality
by 1.6 - 2.5 times
Depression of the Elderly - - Jackie
L. Neel, D.O.
Rates of MI are 4.5 times
greater in patients with history
of major depression
Depression of the Elderly - - Jackie
L. Neel, D.O.
Suicide
• 15% of severely depressed persons
commit suicide
• Elderly white males are at greatest risk
• 80% consult physician in the month before
death
• Elderly are less likely to have had previous
attempts or to complain of suicidal
thoughts--more likely to complete it.
Depression of the Elderly - - Jackie
L. Neel, D.O.
Suicide,
cont.
• 10 years after stroke
– Mortality for non-depressed is 40%
– Mortality for depressed is 70%
Depression of the Elderly - - Jackie
L. Neel, D.O.
Diagnosing Depression in the
Elderly
• DSM-IV criteria may not be met
– Deny most mood symptoms, but may
appear fearful or sad
– Loss of interest in usual activities
– Irritable, brooding
– Somatic
Depression of the Elderly - - Jackie
L. Neel, D.O.
Diagnosing Depression in the
Elderly, cont.
• DSM-IV criteria may not be met
– Sleep and appetite changes
– Fatigue
– Less suicidal complaints, but highest rate
in elderly males
– Social withdrawal
Depression of the Elderly - - Jackie
L. Neel, D.O.
The Diagnosis of Depression in
the Elderly is Often Missed
• Sx of medical illness may be the same as
depression
– low energy
– loss of interest
– anorexia
– fatigue
Depression of the Elderly - - Jackie
L. Neel, D.O.
The Diagnosis of Depression in
the Elderly is Often Missed, cont.
• Study at Duke University
– Assessment given to elderly medical
admits
– Of those meeting criteria for depression,
only 40.5% received an anti-depressant
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pseudodementia
• Cognitive problems related to depression
• Higher incidence of development of
dementia
• Past hx of mood disorder
• Depressive sx precede cognitive sx
• Acute onset
• Increase in dependency
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pseudodementia,
cont.
• Slow psychomotor response,low
motivation and social interaction
• Improve with antidepressant
• Better to risk over-diagnosis and treat for
depression
• Use clinical judgement based on patient
history and function
Depression of the Elderly - - Jackie
L. Neel, D.O.
Treatment of Depression in the
Elderly
• Treat co-morbid conditions and etiologies
of secondary depression
• Choose appropriate level of care
• Keep in mind that suicide occurs more in
elderly than in any other age group
• Choose therapies appropriate to age and
cognitive functioning
• Psychosocial interventions
Depression of the Elderly - - Jackie
L. Neel, D.O.
Watch for Signs of Elder Abuse
and Neglect
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Malnutrition and dehydration
Bruises, fractures, burns
Mental abuse
Neglected medical care
Sexually transmitted diseases
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacology
START LOW -- GO SLOW
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacologic Complications in
the Elderly
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Pharmacokinetics
Pharmacodynamics
End-organ physiological change
Medical illness
Cognitive decline
Polypharmacy
Compliance
Life adversity
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacokinetics and the
Elderly
• Gastric motility and pH
– Causes absorption
• Fat/lean body ratio
– Causes volume of distribution and
half-life
• Hepatic blood flow
– Causes breakdown
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacokinetics and the
Elderly, cont.
• Activity of some catabolic enzymes
– Causes plasma levels and half-life
• GFR
– Causes clearance and accumulation
Depression of the Elderly - - Jackie
L. Neel, D.O.
Pharmacodynamics and the
Elderly
• Increased sensitivity to:
– Sedation
– Cardiovascular effects
– Anticholinergic effects
Depression of the Elderly - - Jackie
L. Neel, D.O.
Noncompliance in the Elderly
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40-70% noncompliance
10% take drugs prescribed for others
20% take drugs not currently prescribed
40% stop drugs too soon
Depression of the Elderly - - Jackie
L. Neel, D.O.
Principles of Pharmacologic
Treatment
• Use medications with minimal
Anticholinergic, cardiovascular and
orthostatic effects
• Begin with low dose
• Monitor compliance
• Monitor side effects
• Increase dose slowly, but use adequate
amounts
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First
• Selective Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine (Prozac)
Fluvoxetine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopvam (Lexapro)
10-80 mg/d
25-250 mg/d
10-60 mg/d
25-200 mg/d
25-200 mg/d
10-20 mg/d
– Safe, effective
– Side effects--Activation,GI, headache,
enzyme inhibition (Cyt P450)
Depression of the Elderly - - Jackie
L. Neel, D.O.
sexual,
Use the More Selective Drugs
with Less Side Effects First, cont.
• Serotonin Syndrome
– Myoclonus, hyperreflexia, tremor
– Confusion, agitation, hypomania
– Fever, sweating, shivering
– Diarrhea
• Stop or reduce drug
• Propranolol, clonazepam
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Venlafaxine (Effexor)
– 12.5mg BID-350 mg/d, XR 37.5,75,150
mg/d
– Reuptake inhibition of serotonin and
norepinephrine
– May be more efficacious in refractory
cases and vegetative depression
– Side effects--nausea, activation,
serotonin syndrome, htn, tremor
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Nefazodone (Serzone)
– 50-600 mg divided or HS q Day
– Safe, anxiolytic, increases sleep, less
sexual side effects
– Side effects--dizziness,sedation, GI,
CytoP450 inhibition
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Bupropion (Wellbutron)
– 75-150 mg TID, SR 100-150 mg BID
– Safe, effective, no sexual side effects,
activation
– Side effects--activation, GI, HA, Seizures
Depression of the Elderly - - Jackie
L. Neel, D.O.
Use the More Selective Drugs
with Less Side Effects First, cont.
• Mirtazapine (Remeron)
– 7.5-60 mg (sedating at the lower doses)
– Safe, antidepressant, anti-anxiety, 1X/d
– Helps sleep and appetite in elderly at low
dose
– Side effects--constipation, dizziness, dry
mouth, somnolence
– Agranulocytosis or neutropenia (rare)
Depression of the Elderly - - Jackie
L. Neel, D.O.
Tricyclic Antidepressants
• Effective antidepressants BUT avoid due to:
– Orthostatic hypotension
– Slow cardiac conduction
– Increase HR
– Decreased heart rate variability
– Sedation
Depression of the Elderly - - Jackie
L. Neel, D.O.
Tricyclic Antidepressants,
cont.
• Effective antidepressants BUT avoid due to:
– Sexual
– Dry mouth
– Constipation
– Urinary retention
Depression of the Elderly - - Jackie
L. Neel, D.O.
If other types of antidepressants
fail:
• Nortriptyline and desiprimine
– Starting at low doses
– Monitoring blood levels can be used
• Trazodone (Desyrel)
– Use for sleep in low doses--very high doses
may be necessary for antidepressant effect
– May lead to orthostasis
– Less anticholinergic side effects.
Depression of the Elderly - - Jackie
L. Neel, D.O.
If other types of antidepressants
fail, cont.
• Psychostimulants
– Ritalin--5mg q am-5-10 mg tid
– Watch BP and HR
– May cause psychosis
– May mobilize the vegetatively depressed
and medically ill
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features:
• Low doses of higher potency
antipsychotics
– .5 - 2 mg haloperidol (Haldol) will often
suffice
– 2.5 - 5 mg olanzepine (Zyprexa)
– 25 mg quetiapine (Seroquel)
– .25 - .5 mg risperidone (Risperdal)
– May go higher if tolerated and no
response at lower doses
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features, cont.
• Mood Stabilizers
– Lithium
– Valproate (Depakote)
– Carbemazepine (Tegretol)
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Monitor blood levels
Liver enzymes for Depakote and Tegretol
CBC for Tegretol
TSH, Cr for Lithium
Depression of the Elderly - - Jackie
L. Neel, D.O.
For depression with psychotic
features, cont.
• For agitation:
– Lorazepam (Ativan) .5-1 mg TID PO or IM
or IV
• Increased risk for falls with use
Depression of the Elderly - - Jackie
L. Neel, D.O.
Electroconvulsive Therapy
• For depression which is:
– Unresponsive to medication
– With psychotic features
– Putting the patient at risk due to poor oral
intake or suicidality
• More cardiac risks in the elderly, but can
be performed safely
Depression of the Elderly - - Jackie
L. Neel, D.O.
Psychotherapy
• Problem Solving
• Supportive
• Cognitive
Behavioral
• Reminiscent
• Pets
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Touching
Education
Family
Groups
Psychosocial
Intervention
Depression of the Elderly - - Jackie
L. Neel, D.O.
Erikson’s Final Stage of
Development
• Integrity Versus Despair and Isolation
• Feeling life has been worthwhile and
accepting your place in the life cycle
• “Healthy children will not fear life if their
parents have integrity enough not to fear
death.”
Depression of the Elderly - - Jackie
L. Neel, D.O.
References
• Zisook, S, M.D., and Downs, N. S., M.D., Diagnosis and
Treatment of Depression in Late Life, Journal of Psychiatry
1998;59 (suppl 4), pg. 80-91.
• Medical Advances -- Health in Mind and Body, Vol. 2, No. 1
Depression of the Elderly - - Jackie
L. Neel, D.O.