DEPRESSION

IN THE
ELDERLY
Module developed by
James T. Birch, Jr., MD, MSPH
Assistant Clinical Professor
Dept. of Family Medicine, Division of Geriatric Medicine
Landon Center on Aging
University of Kansas Medical Center
Objectives
 Review the diagnostic criteria for
depression
 Increase awareness of the prevalence and
consequences of untreated depression in
the older adult
 Discuss screening, treatment, and follow-up
for those who have depression
Content
 1. Define depression
 2. Review the epidemiology of depression in the
elderly.
 3. Risk Factors
 4. Recognition of signs and symptoms
 5. Differential Diagnosis
 6. Screening Tools
 7. Treatment
 8. Review the consequences/complications of
inadequately treated depression.
 9. ACOVE – 3 Indicators
Introduction
 Depression is under-recognized and
undertreated in the older adult
 Many older adults who die by suicide (up to
75%) suffer with depression and most visited a
physician within a month before death
 Untreated depression can delay recovery or
worsen the outcome of other medical illnesses
via increased morbidity or mortality
 Depression is NOT a part of normal aging
What is Depression?
 DSM-IV-TR Definition
 Five or more of the following must have been
present during the same 2-week interval and
represent a change from baseline functioning
 One(1) of the symptoms must be depressed
mood or loss of interest or pleasure

Geriatric Nursing (26)3;2005

What is Depression?
 DSM-IV-TR (a.k.a. “core symptoms”; occur
most of the day nearly every day)
 Depressed mood
 Loss of interest in all or almost all
activities or pleasure (anhedonia)
 Appetite change or weight loss
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
What is Depression?
 DSM-IV-TR (cont.)
 Loss of energy or fatigue
 Feelings of worthlessness or excessive guilt
 Difficulty with thinking, concentration, or
decision making
 Recurrent thoughts of death or suicide
 Preoccupation with somatic symptoms, health
status, or physical limitations
What is Depression?
 For Major Depression, these symptoms
 Produce social impairment
 Are not related to substance abuse
 Are not related to bereavement
What is Depression?
 Types of Depressive Disorders (DSM-IV)
 Mild episode of major depression
 Moderate episode of major depression
 Severe episode of major depression
 Severe episode of major depression with
psychotic features

AMDA Clinical Practice Guideline

What is Depression?
 Minor depression is common
 15% of older persons
 Causes  use of health services, excess disability,
poor health outcomes, including  mortality

 Major depression is not common

 1%–2% of physically healthy community dwellers
 Elders less likely to recognize or endorse depressed
mood
What is Depression
 “Late-life” depression (a geriatric syndrome)
 is a recurrence of depressive symptoms that
initially occurred during early adulthood.
 there is no known or identifiable precipitating
factor.
 patients usually have no family history of
depression. Depressed mood is not required to
meet criteria for major depressive disorder.
Epidemiology (of major depression)
 Community-  Primary Care
Dwelling 1 - 9 % Settings 10 – 12 %

 Nursing Home
 Hospitalized 10-26%
11 – 45 % Permanent
Placement Up to
43%
Risk Factors
 Alcohol or substance abuse
 Current use of a medication associated with
a high risk of depression
 Hearing or vision impairment severe
enough to affect function
 History of attempted suicide
 History of psychiatric hospitalization
Risk factors
 Medical diagnosis or diagnoses associated
with a high risk of depression
 New admission or change of environment
 New stressful losses (loss of autonomy,
privacy, functional status, body part, family
member or friend)
 Personal or family history of depression or
mood disorder
What medications do YOU
prescribe for older adults that
might place them at risk for
DEPRESSION ?
Medications that may cause symptoms
of Depression
 Anabolic steroids
 Anti-arrhythmic medications (amiodarone,
mexilitine)
 Anticonvulsant medications
 Barbiturates
 Benzodiazepines
 Carbidopa or levodopa
 Certain beta-adrenergic antagonists (i.e.
propranol)
Medications that may cause symptoms
of Depression
 Clonidine
 Cytokines (specifically IL-2)
 Digitalis preparations
 Glucocorticoids (prednisone)
 H2 blockers
 Metoclopramide
 Opioids
Laboratory Tests for Evaluation
 CMP (lytes, BUN, creat, Ca++, glucose)
 CBC
 Serum levels of anticonvulsant drugs, TCAs,
digoxin, theophylline
 Thyroid function (T3, T4, TSH)
 EKG
 Folate level
 UA
 Vitamin B12
Differential Diagnosis
 Thyroid disorders (hypo- and hyper-thyroidism)
 Dementia (or mild cognitive impairment)
 Bereavement
 Anxiety Disorder
 Substance Abuse Disorder
 Personality Disorder
 Diabetes mellitus
 Underlying malignancy
 Anemia
 Medication side effects
Differential Diagnosis
 DEPRESSION
Subacute onset
Family recognition early
Rapid progression
Impairment inconsistent over time
Pt admits deficits
Appears depressed
Anhedonia
Abstract thought usually normal
“I don’t know” response to
questions
Pt often unconcerned
 DEMENTIA
Insidious onset
Delayed family recognition
Slow progression
Impairment consistent; slow,
gradual decline
Pt denies/unaware of deficits
Not depressed
Can experience pleasure
Abstract thought impaired
Near miss answers
Pt tries to cover up
What is the most commonly used
and validated screening tool for
diagnosis of Depression in the
elderly patient?
The Geriatric Depression Scale
Screening Tools
 Geriatric Depression Scale (GDS; validated) 15
item scale ( > 5 points or positive responses is
diagnostic)
 Cornell Scale for Depression in Dementia (scoring
system: >12 means probable depression)
 Center for Epidemiologic Studies of Depression
Scale (CES-D)
 Patient Health Questionnaire 9 (9 item self-rating
scale)
AMDA Clinical Practice Guideline
Screening Tools
 Two – item scale (PHQ-2):
During the previous 2 weeks……..
1. Have you often been bothered by feeling
down, depressed or hopeless?
2. Have you often been bothered by having
little interest or pleasure in doing things?
(“Yes” answer to either is considered positive)
 Sensitivity: 100%; Specificity:77%; PPV: 14%
NEJM: 357:22; 11/29/07
Treatment
 The consequences of depression in the
elderly require serious attention because of
the disproportionately high risk of suicide
 For the year 2000, 13% of the U.S.
population was 65 and older, and the
suicide rate accounted for 18% of all
suicides
Geriatric Nursing (26)3: 2005
http://www.cdc.gov/ncipc/wisqars/default.htm
Treatment
 Goals of therapy: improve mood, function, and
quality of life
 Goals of treatment of an acute depressive
episode are to achieve recovery and prevent
future episodes of depression
 The intended outcome should be complete
resolution of symptoms, not simply a reduction in
depressive symptoms.
 Three phases of treatment are generally required
to achieve these goals.
Treatment
 Acute Phase (reverse current episode)
 Duration: about 3 months: Goal is complete recovery from
signs and sx of acute episode
 Continuation Phase (prevent a relapse)
 Duration: 4-6 months: Goal is to prevent relapse as sx
continue to decline and functionality improves
 Maintenance Phase (prevent future recurrence)
 Duration: 3 months or longer: Goal is to prevent
recurrence of a new depressive episode
Treatment
 Pharmacotherapy

 Psychotherapy

 Electroconvulsive
therapy (ECT)
Treatment
 Patients should be monitored for response to
treatment by:
 Observation for resolution of signs and symptoms of
depression
 Documenting improvement in scores on screening tools
 Improvement in attendance at and participation in usual
activities
 Improvement in sleep pattern
 Also monitor patients carefully for side effects and
interactions with other medications
Treatment : Pharmacotherapy
 Antidepressants
 SSRI’s
 Celexa (citalopram) 20-40mg/day
 Lexapro (ecitalopram) 10-20mg/day
 Prozac (fluoxetine) 20-40mg q am
 Paxil (paroxetine) 10-40mg q am or q hs
 Zoloft (sertraline) 50-200mg q am
 Better tolerated than tricyclics
 SIADH at high doses and sexual side effects
 Interact with CYP-450 isoenzymes by inhibition
 Can increase the anticoagulant effect of warfarin
 Do not discontinue abruptly; taper the dose
Treatment : Pharmacotherapy
 Antidepressants (SSRIs continued)
 Nausea and diarrhea might occur
 Fluoxetine is not a preferred drug for use in the elderly
due to a prolonged half life (4-6 days; metabolite 9.3
days) and potential for many drug interactions. It might
also induce anxiety, sleep disturbance, and/or agitation
 Paroxetine is also not favored due to anti-cholinergic
properties and other effects noted with fluoxetine
Treatment : Pharmacotherapy
 Antidepressants
 Tricyclics (secondary amines)
 Norpramin (desipramine) 20-150 qd / q hs
 Pamelor, Aventyl (nortriptyline) 20 – 100 mg q hs
 Potential for anticholinergic and sedative effects
 Avoid in pts. who are prone to constipation, orthostatic
hypotension, glaucoma, or who have BPH
 May cause ventricular conduction delays and heart block
 May be fatal in overdose
Treatment : Pharmacotherapy
 Antidepressants
 Bicyclics
 Effexor (venlafaxine) 75 mg BID
 Effexor XR 75 – 100mg qd
 Fewer drug interactions
 Can cause or aggravate hypertension
 Pts. are at risk for withdrawal syndrome
Treatment : Pharmacotherapy
 Antidepressants
 SNRI and SSRI
 Cymbalta (duloxetine) 30-60 mg/day
 Norepinephrine, 5HT2 and 5HT3 antagonist
 Remeron (mirtazapine) 15-45 mg q hs
 Can cause serotonin syndrome when given with
other SSRI’s
Treatment : Pharmacotherapy
 Antidepressants
 Norepinephrine-dopamine reuptake inhibitor
 Wellbutrin (bupropion) 100 mg TID
 Wellbutrin SR 150 mg BID
 Serotonin antagonist and reuptake inhibitor
 Serzone (nefazodone) 150mg BID
 Desyrel (trazodone) 50 – 200mg q hs
Treatment : Pharmacotherapy
 Antidepressants
 Stimulants
 Ritalin (methylphenidate) 20mg BID
 Provigil (modafinil) 400mg q am
 Dexedrine (dextroamphetamine)
2.5-5mg
7am and
noon
Treatment : Pharmacotherapy
 Antidepressants
 Monoamine Oxidase Inhibitors (MAOIs)
 Marplan (isocarboxazid) 30 mg/day
 Nardil (phenelzine) 30–45 mg/day
 Parnate (tranylcypromine) 30–40 mg/day
 Orthostatic hypotension, falls
 Life-threatening hypertensive crisis if taken with tyramine-
rich foods, cold remedies (pressor amine)
 Fatal serotonin syndrome possible if taken with SSRI,
meperidine
Treatment
Should the elderly patient experiencing
bereavement be treated for Depression?
NO!
However, if symptoms of MAJOR
DEPRESSION persist for more than 2
months after the loss, treatment for
depression should be strongly
considered.
Unutzer, J. NEJM, Nov. 29, 2007
Treatment : Psychotherapy
 Cognitive-behavioral
 Interpersonal
 Short-term
psychodynamic
 Life review, reminisce
 Problem solving
 Supportive
 Bereavement therapy
 Behavioral
 Dialectical-behavioral
therapy
Treatment : Psychotherapy
 Individualize standard approaches
 Cognitive-behavioral therapy
 Interpersonal psychotherapy
 Problem-solving therapy

 Combination with an antidepressant has been

shown to extend remission after recovery
 Watch for depressive syndromes in caregivers,
who might benefit from therapy
Treatment : Psychotherapy
 Individualize choice of drug on basis of:
 Patient’s comorbidities
 Drug’s side-effect profile
 Patient’s sensitivity to these effects
 Drug’s potential for interacting with other
medications
Treatment : ECT
 For depression with
pronounced psychotic
features and resistance to
standard medical therapy

 Effective for treatment of

major depression & mania;
response rates exceed 70%
in older adults
Treatment : ECT
 First-line treatment for patients at serious
risk for suicide, life-threatening poor intake

 Standard for psychotic depression in older

adults; response rates 80%
Treatment : ECT
 Side Effects
 Anterograde amnesia improves rapidly after treatment
 Retrograde amnesia is more persistent; recall of events
just before treatment may be lost permanently

 Lasting effects not shown in longitudinal studies

 Right unilateral treatment: fewer side effects but less
effective than bilateral
Treatment : ECT
 Contraindications
 Increased intracranial pressure
 Recent MI or CVA and unstable CAD increase
risk of complications

 Continue pharmacotherapy following

completion of ECT treatment

 May use maintenance ECT to prevent relapse

 Treatment Response
Responsive to initial
 40% of cases of major
Monotherapy pharmacotherapy
depression respond to fails 35-45%
initial 40%
pharmacotherapy
within 6 weeks
 Additional 15% to
25% achieve
remission with
continued treatment
for 6 weeks
Responsive to continued
treatment
GRS, 2006 15-25%
Treatment Response
 The most common prescribing error is failure to increase
the dose to the recommended level within the first 2
weeks of treatment
 When monotherapy fails:
 Consider switch to another drug class
 Combine lithium carbonate, methylphenidate, or
triiodothyronine with secondary amine TCA
 Add psychotherapy
 Consult a geriatric psychiatrist
Treatment Response
 Reasons for partial response or treatment
failure
 Dementia that is confused with or accompanied
by late life depression
 Concurrent psychosis (interferes with diagnosis
and treatment of depression)
 Compliance is difficult when patients are
depressed

www.medscape.com/viewarticle/41887
Consequences and Complications of
Inadequately Treated Depression
 Recurrence, partial recovery, and chronicity . . .
  disability

  use of health care resources

  morbidity and mortality

 Suicide (one fourth of

all suicides occur in

persons  65)
Consequences and Complications of
Inadequately Treated Depression
Which demographic in the elderly
population has the highest risk
and incidence of suicide?
Highest: white males age 80 & older
Next highest: white males between 65
and 80
AMDA Guidelines
Consequences and Complications of
Inadequately Treated Depression
 Suicide:
Ask the patients about
thoughts of hurting
themselves; if YES, ask
whether they have a plan;
if YES, ask what it is; then
ask about stockpiled
medications or weapons in
the home. Patients with a
plan require emergent
psychiatric evaluation in
ER or local crisis unit.
Consequences and Complications of
Inadequately Treated Depression
 Risk factors for suicide:
 depression
 older age
 physical illness
 living alone (single, divorced, or separated and without
children)
 male gender
 drug abuse or alcoholism
 having a personal or family history of suicide attempt
 severe anxiety or stress
 specific plan with access to firearms or other means.
Consequences and Complications of
Inadequately Treated Depression
 Violent suicides (e.g. firearms, hanging) are
more common than non-violent methods
among older adults, despite the potential
for drug overdosing
ACOVE – 3 Quality Indicators
 Total of #20 IF-THEN-BECAUSE directives for
care of Depression; they include:
 Screening for and Recognizing Depression
 Documenting Depression Symptoms
 Suicidal Ideation
 Evaluate for Comorbid condition
 Initiating Depression Treatment
 Antidepressant Choice
ACOVE – 3 Quality Indicators
 Psychotic Depression
 Electrocardiogram for Tricyclic Use
 Interactions with MAOIs
 Depression Follow-Up
 The First 12 Weeks of Depression
Treatment
 Continuing Depression Therapy
ACOVE – 3 Quality Indicators
Indicators #4 thru #7 were selected
for review
ACOVE – 3 Quality Indicators
 Indicator #4 : IF a VE receives a diagnosis
of a new depression episode, THEN the
medical record should document at least
three of the nine DSM-IV target symptoms
for major depression within 2 weeks of
diagnosis, BECAUSE monitoring
depression treatment requires identification
and reevalution of the presenting
depression symptoms.
ACOVE – 3 Quality Indicators
 Indicator #5: IF a VE receives a diagnosis of a
new depression episode, THEN the medical
record should document on the day of diagnosis
the presence or absence of suicidal ideation
and psychosis, BECAUSE suicidal patients may
require hospitalization, and patients with
psychotic depression may need antipsychotic
medication or ECT and referral to a psychiatrist.
ACOVE – 3 Quality Indicators
 Indicator #6: IF a VE has thoughts of
suicide, THEN the medical record should
document, on the same date, that the
patient has no immediate plan for suicide or
was referred for evaluation for psychiatric
hospitalization AND…..
ACOVE – 3 Quality Indicators
 Indicator #7: IF a VE has thoughts of
suicide, THEN the medical record should
document on the same date, that the
patient was asked about access to
firearms, BECAUSE the likelihood of
suicide increases if the patient has a
specific plan to commit suicide and access
to firearms, and it decreases if the patient is
hospitalized to receive psychiatric care.
Summary
 All health care workers should maintain a high
index of suspicion for the presence of depression
or depressive symptoms in their patients.
 Screen older
adults for
depression
at the initial
visit
Summary
 In older adults, depression is:
 Common (especially “minor” depression)

 Associated with morbidity

 Difficult to diagnose because of atypical

presentation, more somatic concerns, overlap

with symptoms of other illnesses
 Differential diagnoses include other medical
illnesses, dementia, bereavement
Summary
 Suicide is a serious concern in depressed older
patients, particularly older white males
 Treatment (acute & preventive) should be
individualized and may include:
 Pharmacotherapy
 Psychotherapy
 ECT
 Choice of antidepressant should be based on
comorbidities, side-effect profiles, patient
sensitivity, potential drug interactions
Final thought:
On the Threshold of Eternity.
In 1890, Vincent van Gogh
painted this picture seen
by some as symbolizing
the despair and
hopelessness felt in
depression. Van Gogh
himself suffered from
depression and committed
suicide later that same
year.
References
 Geriatrics Review Syllabus, 6th Edition; American Geriatrics Society, 2006, Chap. 35, pp. 269-79
 Nakajima, G.A., Wenger, N.S. Quality Indicators for the Care of Depression in Vulnerable
Elders; JAGS: (55)S2:S302-11; Oct. 2007
 Current Geriatric Diagnosis and Treatment; Landefeld, C.S., et al; McGraw-Hill Co., 2004.
Chap. 14, pp. 100-107
 Depression: Clinical Practice Guideline; American Medical Directors Association
 Buffum, M.D., et al; Treating Depression in the Elderly: An Update on Antidepressants; Geriatric
Nursing 26(3): 138-142
 Kotylar, M. Update on Drug-Induced Depression in the Elderly; Am J of Geriatric
Pharmacotherapy 3(4):Dec. 2005; 288-300
 http://www.medscape.com/viewarticle/41887
Update on Depression in the Elderly
Retrieved 02/19/2009
 National Institute of Mental Health; Older Adults: Depression and Suicide Facts;
http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-
sheet/index
 Unutzer, J. Late-Life Depression; NEJM 357(22): Nov. 29, 2007; pp2269-76