 Review the diagnostic criteria for depression
 Increase awareness of the prevalence and consequences of untreated depression in the older adult

 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

 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

 DSM-IV-TR (“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

 DSM-IV-TR
 Loss of energy or fatigue
 Feelings of worthlessness or excessive guilt
 Difficulty with thinking, concentration, or decision making
 Recurrent thoughts of death or suicide

 Depression without sadness
 Lack of feeling or emotion
 Prominent cognitive compliants
 prominent somatic compliants
 Multiple primary care visits without resolution of problem
 Social withdrawal,avoidance of social intraction

 For Major Depression, these symptoms
 Produce social impairment
 Are not related to substance abuse
 Are not related to bereavement

 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

 Minor depression is common
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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

 Classical major depression is less frequent:
 M.d.d about 1-2%
 Dysthymic disorder 2%
 Depressive symptoms 15-25%

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Medically ill
Disabled and institutionalized elderly
Spousal death
Older adult with malignancies,neurologic and endocrine: one half of post strok,onefourth of cancer inpatients, one third of MI
 -

 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

 Medical diagnosis or diagnoses associated with a high risk of depression
 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

CO MORBID CONDITIONS TO CONCIDER IN LATE LIFE
DEP.
 Substance,dementia,chronic pain
 Metabolic disease,malnutrition,endocrine dysfunction
 Cerebral disorder
 Cardiovascular disorder,hypotensive episodes
 CHF
 Pulmonary disease
 Cancer
 Physical abuse or emotional abuse by caregivers/relative

?

 Anabolic steroids
 Anti-arrhythmic medications
 Anticonvulsant medications
 Barbiturates
 Benzodiazepines
 Carbidopa or levodopa
 Certain beta-adrenergic antagonists (i.e. propranol)

 Clonidine
 Digitalis preparations
 Glucocorticoids (prednisone)
 H2 blockers
 Metoclopramide
 Opioids

 , BUN, creat, Ca ++ , glucose)
 CBC
 Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline
 Thyroid function (T3, T4, TSH)
 EKG

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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

 DEPRESSION  DEMENTIA
Subacute onset
Family recognition early
Rapid progression
Insidious onset
Delayed family recognition
Slow progression
; slow, gradual decline
Appears depressed
Anhedonia
Abstract thought usually normal
“I don’t know” response to questions
Pt often unconcerned
Pt denies/unaware of deficits
Not depressed
Can experience pleasure
Abstract thought impaired
Near miss answers
Pt tries to cover up

 Mood Symptoms?
 Cognitive symptoms?
 Behavioral symptoms?

 onset?
 Stressor?
 New medical illness?
 New events?
 Motor sign?
 Cognitive signe?

 Cognitive evaluation
 (acute change? Incidious? )
 Psychosis
 Mood

 acute? : Dlirium(retard psychomotor-agitation)
 Chronic :dementia evaluation
 Focal sign?
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 Psychiatric disorders:
 Medical illness especial neurological disease
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 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.

 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

 Pharmacotherapy
 Psychotherapy
 Electroconvulsive therapy (ECT)

 Patients should be monitored for response to treatment by:
 Observation for resolution of signs and symptoms of depression
 Also monitor patients carefully for side effects and interactions with other medications

 50-60% improve with antidepressants
 Age related change influence pharmakietic:
 Longer time for response
 More side effects

 Depends :
 Psychiatric co morbidity
 Medical illness
 But , drug of choice
 SSRIS

 Sertraline:25-50mg daily
 Fluoxetine:10 mg
 Citalopram :10mg
 Less intraction :sertraline and citalopram
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Fluoxetine increase nortriptyline,verapamil,B blokers
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
 ,

 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

 TCA : nortriptyline.desipramine
 Caution: cardiac .prostatic,glaucoma,cognitive,falling risk
 10-25mg
 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

 SNRI: Velnafaxin 37/5mg_75mg up 112.5-225mg
 Caution :hypertention
 Side effects:nausea,(slow titration)
 special for chronic pain

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Cognitive-behavioral
Interpersonal
Short-term psychodynamic
Life review, reminisce
Problem solving
Supportive
Bereavement therapy
Behavioral
Dialectical-behavioral therapy

 Risk factors for suicide:
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 depression older age
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 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.

 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

 Suicide is a serious concern in depressed older patients, particularly older white males
 Treatment (acute & preventive) should be individualized and may include:
 Pharmacotherapy
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Psychotherapy
ECT
 Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions