Treating Depression in the Elderly A Multi-disciplinary Approach 12/11/2003

12/04/2003Psychopathology2 Who are the elderly? Over 65 years old, but less than 75: “young elderly”—often still active and independent Over 75 “Frail elderly”: many living in institutions with multiple chronic conditions

12/04/2003Psychopathology3 Major Depression Episode At least 2 weeks of sustained symptoms Feelings of sadness or loss of interest PLUS at least four other symptoms: Agitation or Fatigue Loss or increase in appetite Insomnia or hypersomnia Feelings of worthlessness, hopelessness, powerlessness Inability to concentrate, memory problems, and distractability

12/04/2003Psychopathology4 Rule Out: Caused by medical condition such as hypothyroidism, hormonal imbalance, metabolic disorder, anemia, stroke etc Caused by substance such as alcohol, prescription medication, drugs or toxin exposure Other mood disorders Dementia

12/04/2003Psychopathology5 Manifestations in the Elderly Present with somatic complaints rather than mood dysfunction Loss of function, ability to get things done Irritability or anxiety Social withdrawal Changes in hygiene or grooming Feelings of uselessness and loneliness

12/04/2003Psychopathology6 Manifestations in Elderly Cognitive function impairment Confusion Disorientation Memory impairment Lack of concentration

12/04/2003Psychopathology7 Risk Factors Significant loss(es), sometimes concurrent Spouse due to death Friends and other family Mobility and/or stamina Hearing and vision General health Income Sense of identity Independence Home and/or neighborhood due to relocation

12/04/2003Psychopathology8 Risk Factors Chronic medical conditions Arthritis Anemia Stroke Metabolic disorders Hormonal imbalances Parkinson’s disease Cardiac conditions Hypertension Glaucoma or cataracts

12/04/2003Psychopathology9 Risk Factors Female Lack of social supports Family or personal history of depression Alcohol or substance abuse Family conflict

12/04/2003Psychopathology10 Special Concerns Depression is undiagnosed or misdiagnosed in elderly Can exacerbate existing medical conditions due to degeneration of self care, poor eating habits, and increased perception of pain Social withdrawal and increasing isolation compound feelings of loneliness Increases dependence

12/04/2003Psychopathology11 Special Concerns Increased risk for falls and injury, infections, and poor nutrition Increased risk for premature admission to a nursing facility Can lead to a downward spiral in general health and functioning Economic problems Reduced mobility

12/04/2003Psychopathology12 Assessment Critical Make sure medical issues, including drug side effects and interactions, have been ruled out. Because the elderly tend to have multiple issues occurring simultaneously, it is important to do a thorough evaluation to determine all the factors involved in the situation. May need to use a modified version of Beck depression assessment tool, the Geriatric Depression Scale, developed particularly for elderly.

12/04/2003Psychopathology13 Treatment Options Drug Therapy Only Psychotherapy Only Combination of Psychotherapy and Drug Therapy Electroconvulsive Therapy (ECT)

12/04/2003Psychopathology14 Treatment Phases Acute or Initial Phase 6 to 8 weeks, longer for psychotherapy alone (16 – 20 weeks) Fully resolve depressive symptoms Phase 2, Continuation of Treatment Maintenance Phase Can be a year or more, depending on history

12/04/2003Psychopathology15 Medication Types of medication used to treat depression: Cyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Lithium salts Serotonin reuptake inhibitors (SSRIs) Each medication has its own side effects and dosage requirements

12/04/2003Psychopathology16 Psychotherapy Options Interpersonal Cognitive Behavioral Cognitive-Behavioral (CBT) Reminiscence or Life Review Family Therapy

12/04/2003Psychopathology17 Combination Therapy Use medication to reduce acute symptoms of depression Type of medication depends on evaluation Follow with psychotherapy Type of therapy depends on evaluation, however, CBT is shown to be effective Monitor for adverse reactions to medication and compliance Address psychosocial stressors

12/04/2003Psychopathology18 Treatment Issues If dementia is present, effectiveness of treatment is affected for psychotherapy as well as drug therapy Side effects of medications can lead to non-compliance In psychotherapy, inconvenience, conflict, and resistance may lead to lack of attendance to sessions

12/04/2003Psychopathology19 Summary Depression is not an inevitable part of aging Depression is highly treatable through different approaches Once acute symptoms are reduced through drug therapy, some form of psychotherapy can help person address other factors that are contributing to the situation