Instructor: Sally Rigler, MD, MPH
Reviewed by: Doug Woolley, MD, MPH
Specific Learning Objectives
A. Introduction:
Before reviewing the learning objectives and content, please take the Pre-Test in Angel. You must do this before you can proceed with the module. The answers are given in the Post-Test that completes the module.
Please review the Objectives, Content material, and Cases before our class session.
B. Attitude:
C. Knowledge - Students will be able to:
D. Readings
Required Readings:
- Birrer RB, Vemuri SP. Depression in Later Life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69: 2375-82.
E. Skills - Students will come to class prepared to:
F. Cases
How common is depression?
- Community-dwelling older adults:
- 15% have depressive symptoms
- 3 to 5% have major depression
- Nursing Facilities:
- More than 10% of residents develop a new case of depression each year
- 20-50% prevalence of depression overall
- Depression is the 6th most common condition in long term care
What are the consequences of geriatric depression?
- Psychological suffering
- Increased mortality
- Suicide
- Excess functional disability
- Reduced well being and quality of life
- Excess cognitive difficulties
- Increased health care utilization and costs
Criteria for Major Depressive Disorder:
- Symptoms should be present for at least two weeks in a persistent fashion. Five symptoms are needed.
- At least one must be one of the two main features:
- Persistent sad mood (most of the day, on most days)
- Loss of interest or pleasure (anhedonia)
(Either by subjective report or observations of others)- The remainder can be from the following symptoms (on most days)
- Increase or decrease in appetite or weight
- Increase or decrease sleep
- Psychomotor agitation or retardation
- Fatigue
- Worthlessness or guilty feelings
- Difficulty concentrating or indecisiveness
- Recurrent thoughts of death or suicidal thoughts or plans
SIGECAPS mnemonic:
Sleep disorder (either increased or decreased sleep)
Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Energy deficit
Concentration deficit
Appetite disorder (either decreased or increased)
Psychomotor retardation or agitation
SuicidalityImportant notes about Diagnosis:
- Criteria can be met by subjective report or by observation by caregivers which is often necessary for persons with dementia.
- These symptoms must cause distress or impaired functioning .
- The symptoms are not due to a direct effect of a drug or medical condition
- History and physical exam, basic lab testing, and medication review are necessary
- However, treatment delay should be avoided if comorbid medical conditions are not reversible
- Significant ongoing depressive symptoms that are not severe enough to meet criteria for major depressive disorder may represent dysthymic disorder.
Geriatric Depression Scale (GDS, 15-item short-form)
You have seen this tool during the Skills Fair. It is the most commonly used clinical screening tool in older adults. It is well validated. However, in persons with more advanced dementia, the Cornell Scale for Depression in Dementia may be more suitable.
Today’s older adults may not report mood symptoms as readily. There may also be stigma about mental health issues. Some older adults may be reluctant to have a diagnosis of depression or to seek psychiatric care. These generalizations have to be made with caution, since these features are not true for all individuals. However, it does behoove providers to maintain a high index of suspicion of depression when caring for older adults.
- Older adults may be less likely to complain primarily of sad mood or demonstrate tearfulness.
- Anxiety, withdrawal, or anhedonia may be more prominent.
- Depressed older adults are more likely to present with cognitive and functional decline than younger adults. The older adult’s family may bring him or her to medical attention for these complaints.
- Somatic symptoms are prominent in depression in general; older adults may have more than their usual physical symptoms during depression. Assessment can be difficult because older adults as a group have more chronic comorbid conditions that can cause a variety of symptoms. Fatigue can be especially prominent.
- Psychotic features are more common in depressed older persons compared to younger.
- There is a higher risk of completed suicide.
Nonverbal cues of depression
- Flat affect; no smiles, no jokes
- Disinterest in encounter; lack of engagement
- Possible anger response if directly questioned about depression
- Avoidance of answering questions, or negotiates responses
Dementia increases the risk of depression. In addition, patients with more advanced dementia may be unable to report mood changes or other symptoms. Assessment sometimes has to rely more on observation than on subjective report. In nursing facilities, reports of family members and facility staff are important in identifying a new depressive episode and then monitoring whether treatment has been effective.
Psychotherapy
For mild depression, or in combination with antidepressants for moderate to severe depression. Patients should be cognitively capable of participation, and able to recall and discuss any stressors or life losses relevant to the depression.
Electroconvulsive Therapy
Provided by psychiatry colleagues for severe depression with extreme vegetative symptoms that are life-threatening, or for depression refractory to medications. Can be very effective and is usually well tolerated, although memory complaints may occur. Cardiorespiratory fitness for the procedure will be assessed, but most chronic stable diseases do not represent definite contraindications. ECT should be followed by medications to prevent relapse. Death rates during ECT are 1 or 2 per 100,00.
Pharmacotherapy:
General Concepts:
Medications take several weeks to see an effect. (Patient/family education is critical.)
- The first 6 to 8 weeks are focused on resolving symptoms and adjusting dose.
- Then, continuation phase lasts many months (6 to 12 months) to try to prevent relapse.
- Maintenance therapy indefinitely is appropriate for selected persons with recurrent depression.
Medication must be taken daily. (Explain this is not a prn drug)
For older adults, start at ½ the usual starting dose as a rule of thumb.
For some, lower doses will be effective, while others will need gradual increase to usual full doses.
Which agent to use as first-line therapy?
Must be individualized for tolerability concerns relevant to that particular patient’s comorbidities, cost concerns, potential drug interactions, and other issues.
Head to head trials comparing various competing antidepressants in current use do not include many older adults. Data are particularly sparse regarding frail older adults with medical and cognitive problems, such as those residing in nursing homes.
Many agents are now available in extended-release formulations.
Many current antidepressants are available in liquid or dissolvable table formulations for persons with physiologic or behavioral barriers to taking pills.
Tricyclic Antidepressants (TCAs):
- Generally not used for depression in older adults because side effects often hinder reaching an adequate dose for treatment of depression.
- Available as generics; older drugs are less expensive.
- Higher discontinuation rates than SSRI's due to side effects.
- Some common side effects:
- confusion
- orthostatic hypotension, tachycardia
- conduction defects (dangerous in overdose)
- anticholinergic effects
- urinary retention
- constipation
- dry mouth
- ocular dryness
- exacerbation of acute angle glaucoma
- sedation
- Nortriptyline (Pamelor) and desipramine are better tolerated, since they are less anticholinergic.
- Avoid amitriptyline (Elavil). This agent is the most heavily laden with problem side effects and should be avoided in older adults. Imipramine and doxepin are also not generally recommended in this group.
Selective Serotonin Reuptake Inhibitors (SSRIs):
- Newer agents; also have role in treatment of anxiety disorders
- Easier to dose; used once daily and generally better tolerated
- Possible side effects:
- gastrointestinal (nausea, diarrhea)—may improve over time with continued use. Less severe at outset if the starting dose is very small.
- sexual dysfunction
- tremor
- others (hyponatremia secondary to SIADH) less common
- Fluoxetine (Prozac) introduced first; very long half-life; now available in once-weekly form but often avoided in older adults because of long half-life.
- Sertraline (Zoloft)
- Paroxetine (Paxil) has mild anticholinergic effect, may be somewhat more sedating
- Citalopram (Celexa)
- Escitalopram (Lexapro)
Note: sertraline, citalopram, and escitalopram may have less potential for P450 - related drug interactions
Selective Serotonin & Norepinephrine Reuptake Inhibitors (SNRI)
- These agents can raise blood pressure at higher doses, and should be avoided in persons with difficult-to-control hypertension.
- Venlafaxine (Effexor)--used for treatment of depression and anxiety. Some speculation that it may have a somewhat more rapid onset of action than SSRIs because of the noradrenergic effects, but this is controversial.
- Duloxetine (Cymbalta)--a newer agent which is indicated for treatment of painful peripheral neuropathy in addition to depression. Data are limited in frail older adults with multiple other medications; has potential for drug interaction concerns.
Selected Other medications:
- Trazodone (Desyrel)
- less commonly used for depression now; often used for insomnia
- heterocyclic antidepressant, less anticholinergic than older tricyclics, but still sedating
- can still cause significant orthostasis
- Nefazodone (Serzone)
- Not often used anymore due to liver toxicity concerns. The trade-name agent was voluntarily pulled off the market in the US, but generic forms remain available.
- Bupropion (Wellbutrin)
- less sedating, less sexual dysfunction
- can lower seizure threshold; avoid in persons at risk for seizure
- same drug has been employed in smoking cessation
- Mirtazapine (Remeron)
- multiple chemical mechanisms of action
- given at night due to sedating effect
- an orally dissolving tablet is available for those who can't swallow
- purported to improve appetite
- MAO Inhibitors
- older class of drugs
- reserved for refractory depression in general
- effective but drug-food interactions are worrisome
- generally only prescribed by psychiatrists
This list is not all-inclusive. Some less-commonly prescribed drugs are not included, and new agents are becoming available at a rapid pace.
Other Medication Options:
- Adjunctive Therapy
- Other medications (along with antidepressants) to enhance treatment benefit.
- Methylphenidate (Ritalin): works quickly; can be helpful in rehabilitation of depressed persons (e.g., might consider in hip fracture or stroke patient who is too depressed to participate in therapies and needs a rapid response. However, effectiveness data are limited; there is not clear consensus on the role of such treatment.)
- Psychotic depression often requires, at least initially, an antipsychotic agent to control paranoia, frightful delusions, or hallucinations. This agent can usually be weaned once the antidepressant effect is established. (ECT can also be considered for treatment of psychotic depression.)
Common at the time of nursing home admission.
Associated with reduced participation in rehabilitative efforts (e.g., after stroke or hip fracture) and thus worse outcomes.
In residents with more severe cognitive impairment, GDS may be less useful. The Cornell Scale for Depression in Dementia is then recommended. Staff and caregiver input is very important in assessment as subjective information becomes less accurate. Apathy is a hallmark of dementia, so it is not always easy to tell whether the observed signs are part of depression or dementia. Often it is likely that both are present concomitantly.
Ongoing depressive symptoms without depression treatment is a negative quality indicator that is posted for all nursing home residents. Rates of antidepressant use are now at an all-time high.
- 82 year old woman with major depression
- s/p large CVA with residual seizure disorder
- Hard-to-control hypertension
- 18 medications for multiple other comorbidities
Questions:
Top of page
- What general factors will you consider in selecting treatment for her?
- What medications would you be more likely and less likely to prescribe for her, and why?
Questions:
- A 75 year old woman is diagnosed with major depressive disorder, and agrees to start an antidepressant medication plus psychotherapy.
Top of page
- What points of patient education would you want to be sure she understands about depression and its treatment? What specifically will you tell her?
Questions:
- 85 year old man in nursing facility, with Alzheimer’s dementia and depression
- Sleeping poorly, appetite poor, weight low
- Orthostatic symptoms when he stands
Top of page
- What general factors will you consider in selecting treatment for him?
- What medications would you be more likely and less likely to prescribe for him, and why?
Questions:
- 90 year old woman with a new hip fracture, s/p surgical repair, admitted to a skilled nursing facility a few weeks ago.
- Today at a care plan meeting, the team is preparing to discharge her from skilled care due to lack of progress toward her therapy goals.
- The PT and OT say she has been withdrawn, disinterested, and irritable. When approached to go for PT or OT, she sends them away saying ‘Maybe I’ll go tomorrow, but not today. I’m too tired today.’
Top of page
- What other information would you want to know? How would you assess her clinical situation?
This is an 84 year old widowed man with CHF, CAD, COPD, OA, spinal stenosis and chronic back pain, and BPH. Over the last several years, he has been gradually less able to care for himself due to mobility problems and dyspnea. He is more and more deconditioned and weak. He has had several falls while trying to rush to get to the bathroom when experiencing urinary urgency.
He has difficulty adhering to his follow-up appointments, medication regimen and salt restriction, and has been hospitalized 4 times in the last year for CHF/COPD exacerbations. When asked, he reluctantly admits he often doesn’t take his diuretic because it worsens the urinary urgency, causes incontinence & makes him dizzy. He also relies heavily on frozen food because he is not able to shop or cook for himself.
After each hospitalization, he has been adamant to go home to his farm. He will agree (at discharge) to allow home health to come, but then once he is at home, he sends them away after their first or second visit, saying he is fine & doesn’t need any help. He tells his family and his doctor that his neighbors look in on him regularly and are help him with shopping and other chores, and that he is doing fine. However, that is not accurate. He is fiercely independent and has actually not been accepting of much help.
He is now hospitalized yet again. His adult daughter comes in from out of town to visit, and finds his home in poor repair, few groceries in the house, and she is worried. She thinks the time has come to discuss nursing home care with him. His response is simply “Never.” Further, his CHF and COPD are at the point where is going to require home oxygen. He is very discouraged by this change, and by the fact that he can only take a few steps by himself now & needs assistance with basic care.
Questions:
- What suicide risk factors does this patient have?
- What other information would you want to know? What would you ask, and how would you word it?
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The University of Kansas Medical Center