GERIATRIC APPROACH TO DEPRESSION
JULY 11, 2000 Swedish Family Medicine Didactics PAT BORMAN, M.D.
CASES JT is an 80 year old white male who makes repeated visits to his doctor. Today’s complaints include bad taste in his mouth, sore muscles, dizziness and constipation. Last week his daughter reported he has been impossibly uncooperative at home with angry outbursts. JT's spouse died 3 years ago, 6 months ago he moved into his daughter's home. MG is a 78 year old white female with a pain, more of a sort of fullness of her left lower face. She complains bitterly of this to you, her family, her bridge partners. On her own she saw a neurologist, a rheumatologist, an ENT specialist, an accupuncturist, a massage therapist. Trials of NSAIDs, narcotics, neurontin, capsaicin, ice, heat and steroids offered no relief. AR is an 85 year old black female who suffered a large cerebral hemorrhage last year. She required nursing home placement and since moving in she acts withdrawn with no interest for activities available, she has made no friends, is eating poorly and loosing weight. She sleeps very little and worries that her son will not come to visit her. INCIDENCE 1-3 % of community dwelling elderly 14% two years after loss of spouse 15% in the medically ill 25% in long term care and acute care facilities 25-30% have depressive symptoms without full blown disease DIAGNOSTIC CRITERIA Five or more of the following symptoms present during the same 2 week period Representing a change from previous functioning At least one symptom is either depressed mood or loss of pleasure or interest: Depressed mood most of the day nearly every day Markedly diminished interest or ability to experience pleasure Significant weight loss without dieting Insomnia or hypersomnia Fatigue or loss of energy Feelings of worthlessness of excessive guilt Difficulty thinking, concentrating or remembering Recurrent thoughts of death
HOW IS DEPRESSION DIFFERENT IN THE OLDER PATIENT? Less verbalization of guilt Minimize or even deny their depressed mood, may not identify emotions Underestimate their abilities Preoccupied with somatic symptoms—More than 65 % have persistent attention to body: constipation, Pain complaints and other medical conditions, hypochondriacal Serious medical conditions can mask depression or cause depression *see table Concomitant anxiety, agitation, psychosis with delusions or nihilistic ideation Coexistent neurodegenerative disorders lead to complex neuropsychiatric syndromes Significant cognitive complaints “pseudodementia”
COMMON SIGNS AND SYMPTOMS IN GERIATRIC DEPRESSION
SYMPTOMS MOOD Decreased life satisfaction Loss of interest Inability to experience pleasure Dejection or persistent sadness Excessive worry or anxiety Helplessness and hopelessness COGNITIVE Self-blame and criticism Pessimism Negative ruminations Poor concentration/memory Suicidal thoughts Delusions Hallucinations Hypochondriasis VEGETATIVE Loss of appetite Fatigue Insomnia/hypersomnia Diminished libido Constipation Pain Complaints VOLITIONAL Loss of motivation Marked ambivalence Social withdrawal
SIGNS APPEARANCE Sad facies Stooped posture Withdrawn Neglected grooming Confused Tearful BEHAVIORS Uncooperative Angry outbursts Whining Negativistic Suicidal gestures, attempts Bizarre (psychotic depression)
PSYCHOMOTOR RETARDATION Slowed speech Slowed movements Bradyphrenia Slow shuffling gait Diminished gestures Inhibited blinking PSYCHOMOTOR AGITATION Continuous motor activity Hand wringing Pacing Picking at self
CULTURAL DIFFERENCES Mediteranean and Latin Chinese and Asian Native American Middle Eastern "nerves or headache" "imbalance, weak, tired" "heart, heartsick " heartbroken"
INTERVENTIONS Search of medical illness , medication side effects or cognitive disorders that contribute Medications can be helpful Consider altered pharmacokinetics, receptor site sensitivities, concomitant medications and diseases Role of non-psychiatric rehabilitation services (occupational therapy) to regain instrumental activities Counseling can be effective focus on role transitions, role disputes, interpersonal deficits, grief ECT Electro Convulsive Therapy Involve family and caretakers: Can help make the diagnosis They may be concomitantly depressed May need respite care Help reduce isolation SUICIDE RISK Suicide rate for depressed men over 65 is 5 times higher than younger patients 25% of completed suicides are in those aver age 65 Risk is greater if financial problems, physical illness, recent loss, or isolated Alcohol, Abuse, Suicides: 60% men succeed use guns or hanging Attempts: 75% are women 70% using drug overdose and 22% cut or slash
GERIATRIC PRESCRIBING PRINCIPLES C A R E Caution, Compliance Adjust dose for age Review Regimen Regularly, Remove and Reduce Educate, wallet cards, brown bag visits
START LOW AND GO SLOW Greater sensitivity to side effects Medically significant side effects Intercurrent Disease
1. 2. 3. 4.
No single antidepressant agent is clearly more effective than another No single agent results in remission for all patients Choice based on adverse effects, prior response, concurrent illness, concomitant medications Assess after 4 - 6 weeks of low dose therapy if no or only partial response: Continue current medication with dosage increase Switch to a different agent Augment with second agent Add psychotherapy Obtain psychiatric consultation/referral
AGENTS FOR GERIATRIC DEPRESSION
Generic/Brand
Class
Dosage Range
Cost/ month
Advantage/Disadvantage
PREFERRED Nortriptyline/ Pamelor Citalopram/ Celexa Bupropin/ Wellbutrin Nefazodone/ Serzone Paroxetine/ Paxil Sertraline/ Zoloft Fluoxetine/ Paxil TCA 10-100mg/d 15-80 low cost, least sedating and anticholinergic TCA, toxic overdose nausea, dry mouth, diarrhea, somnolence
SSRI
20mg/d
50-60
HCA
50-300mg/d
60-100 Activation, restlessness, tremor, insomnia, nausea, seizures 60-180 Nausea, dry mouth, dizziness, constipation, asthenia, anxiolytic 50-150 dry moth, constipation, urinary retention liquid form 50-150 SIADH, hyponatremia
HCA
100-400mg/d
SSRI
10-40mg/d
SSRI
25-200mg/d
SSRI
5-40mg/d
30-95
SIADH, hyponatremia, liquid form
ACCEPTABLE Desipramine Trazodone Mirtazapine/ Remeron TCA HCA HCA 10-100mg/d 25-150mg/d 15-30mg/d 15-65 5-20 Sedation, hypotension Sedation, cognitive slowing, hypotension,
85-100 Somnolence, dry mouth, increased appetite weight gain, constipation, dizziness 60-120 Nausea, somnolence, nervousness, dry mouth, dizziness, Increased blood pressure anorexia
Venlafaxine XR/ SNRI Effexor XR
75-225mg/d
UNACCEPTABLE Amitriptyline, Amozapine, Doxepine, Protriplyline, Trimipramine TCA Sedation, anticholinergic, orthostatic hypotension, Extrapyramidal, increased risk of ataxia and falls,
Phenalzine, Trancypromine MAOI
Increased risk of side effects and interactions
GERIATRIC DEPRESSION PRETEST ANSWER TRUE FALSE _____ _____ 1. Geriatric patients have greater sensitivity to side effects of antidepressant medications than younger patients. 2. Two years after the death of a spouse 30% of elderly have depression. 3. Geriatric men complete suicides five times more frequently than younger men. 4. 5% of all completed suicides occur in men over age 65. 5. Nortriptyline is the least sedating and most often used tricyclic antidepressant for depression in the elderly. 6. Only 30% of confirmed cases of depression are treated with antidepressants in the nursing home population. 7. The disease most commonly confused for Alzheimer's Dementia is depression. 8. The diagnostic criteria for geriatric depression differ from those for younger patients.
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