1. Depression and Aging Aging Q 3 William P. Moran, MD, MS Medical University of South Carolina October 31, 2012

2. Key Messages Major depression kills (suicide risk) Risk factors: comorbid conditions Use PHQ to screen, diagnose and monitor Treatment goals is REMISSION, not response – Choice of first agent, augment – Duration 9-12 months Recurrence may mean lifetime treatment

3. Epidemiology and diagnosis Late-life depression often goes undetected and has a significant adverse impact on quality of life, outcomes of medical disease, healthcare utilization, and morbidity and mortality. – The overwhelming majority of older adults with depression initially present to primary care, often with somatic complaints. Depression is not a normal consequence of aging. – Healthy independent elders have a lower prevalence rate of major depression than the general population. – Rates increase greatly with medical illness, particularly cancer, MI, and neurological disorders such as stroke and Parkinson disease. UpToDate, 2012

4. Epidemiology and diagnosis Suicide rates are almost twice as high in the elderly, with the rate highest for white men over 85 years of age. Most older adults who commit suicide had seen a clinician within the previous month. UpToDate, 2012

5. Epidemiology and diagnosis "Minor" or "subsyndromal" depression in late life is more prevalent than major depression, has significant health consequences, and responds to antidepressant medication or psychotherapy. Delusional (psychotic) depression is a very severe illness and can be lethal. – Cognitive deficits may be pronounced and similar to dementia. – Both depressive symptoms and cognitive impairment respond to treatment with antidepressants, distinguishing these patients from those with Alzheimer disease and secondary depression. UpToDate, 2012

6. Epidemiology and diagnosis Depression associated with cerebrovascular disease is characterized by psychomotor retardation, anhedonia, greater frontal executive dysfunction, and poor insight. Depression in the elderly can be challenging to diagnose. UpToDate, 2012

7. Risk Factors for Depression in Older Adults Risk factors of depression include specific diagnoses of MI, CVA, or malignancy. Suicide is a significant risk in older adults, men more than women. Risk factors for suicide: living alone, male, alcoholism, comorbid physical illnesses. Older men are at highest risk for completed suicide (15% of population, 25% of suicides). 50% of patients who commit suicide were seen by a provider in the preceding 30 days. Older individuals are more susceptible to medication toxicity such as serotonin syndrome. Early dementia may co-occur with late onset depression.

8. MEDICATIONS ASSOCIATED WITH DEPRESSION Varenicline Benzodiazepines & other sedative hypnotics Opiates Isotretinoin Finasteride (high dose) Leukotriene antagonists Anti-hypertensives – (weak association)

9. Compared against DSM-IV criteria for major depression, the PHQ-2 had a sensitivity of 100 percent and specificity of 77 percent in this population; specificity increased with age, male gender, and varied with racial and ethnic groups. Screening Instruments UpToDate, 2012

10. Compared against DSM-IV criteria for major depression, the PHQ-2 had a sensitivity of 100 percent and specificity of 77 percent in this population; specificity increased with age, male gender, and varied with racial and ethnic groups. Screening Instruments UpToDate, 2012

11. Initial evaluation Assess for suicidality, including ideation and plan Assess for psychotic symptoms, hopelessness, insomnia, and malnutrition. UpToDate, 2012

12. Initial evaluation Determine whether the patient is using medication(s) with depressant side effects (benzodiazepines, CNS depressants, opiates, other pain medications) or is abusing alcohol. Consider other medical conditions commonly associated with depressive symptoms, particularly unrecognized thyroid disease, or diabetes. Pain syndromes can be a barrier to treatment response in depression and should be treated along with the depression. UpToDate, 2012

13. Initial evaluation Determine history of prior depressive episodes – age of depression onset – prior drug therapy and outcome – length of prior remission if achieved. Determine family history of depression and family response to medication. – Older patients with mild depressive symptoms and first degree relatives with confirmed depression diagnosis have a 1.5 to 3 times greater risk for depression than the general population. UpToDate, 2012

15. Treatment: Use an adequate trial of an antidepressant, consisting of BOTH an adequate dose and duration. The goal of treatment is remission, not just response. The PHQ-9 can be used to assess response to treatment and monitor disease An adequate treatment trial is a period of 6 to 8 weeks, including a minimum of 6 weeks at a maximum tolerated dose. Patient education is critical to adherence and treatment success.

16. Pearls for SSRIs: Sertraline is the preferred SSRI in patients with CAD/CVD. Fluoxetine has a very long half-life; avoid in patients who have had ADRs to previous SSRIs. Hyponatremia – Risk with SSRIs, SNRIs; increased risk in elderly, women and patients on thiazides. Sexual Dysfunction – Sexual dysfunction can be seen when treating depression with pharmacologic therapies. Of the treatment options, mirtazapine and buproprion have the lowest incidence of sexual dysfunction.

17. Pearls for SNRIs and Others Mirtazapine – Good in patients with decreased appetite and insomnia. Avoid SNRIs in patients with uncontrolled hypertension (or those on >2 anti- hypertensives). Duloxetine – Potential complications include abnormal bleeding and hepatic failure.

21. SSRIs Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline SNRIs Duloxetine Venlafaxine Other Mirtazapine Buproprion EPIDEMIOLOGY OF DEPRESSION A diagnosis of depression is associated with increased length of hospitalization, increased medical costs, and a higher rate of readmission. Risk factors of depression include specific diagnoses of MI, CVA, or malignancy. 50% of patients who commit suicide were seen by a provider in the preceding 30 days. Risk factors for suicide: living alone, male, alcoholism, comorbid physical illnesses. Suicide is a significant risk in older adults, men more than women. Older men are at highest risk for completed suicide (15% of population, 25% of suicides). Older individuals are more susceptible to medication toxicity such as serotonin syndrome. Early dementia may co-occur with late onset depression. CBT (Cognitive Behavioral therapy) is an option before starting or in combination with pharmacotherapy at any stage in the algorithm. Depression in Older Adults Depression is common in older adults, and especially prevalent in older adults with chronic illnesses Reference: UpToDate TREATMENT OF NON-PSYCHOTIC MAJOR DEPRESSIVE DISORDER IN PRIMARY CARE Funded by D.W. Reynolds Foundation PEARLS OF WISDOM Pearls for SSRIs: Sertraline is the preferred SSRI in patients with CAD/CVD. Fluoxetine has a very long half-life; avoid in patients who have had ADRs to previous SSRIs. Hyponatremia – Risk with SSRIs, SNRIs; increased risk in elderly, women and patients on thiazides. Sexual Dysfunction – Sexual dysfunction can be seen when treating depression with pharmacologic therapies. Of the treatment options, mirtazapine and buproprion have the lowest incidence of sexual dysfunction. Pearls for SNRIs and Other: Mirtazapine – Good in patients with decreased appetite and insomnia. Avoid SNRIs in patients with uncontrolled hypertension (or those on >2 antihypertensives). Duloxetine – Potential complications include abnormal bleeding and hepatic failure. Key: BUP = bupropion SR/XL BUS = buspirone CBT = cognitive behavior therapy MRT = mirtazapine SNRI = serotonin-noreprinephrine reuptake inhibitor SSRI = selective serontonin reuptake inhibitor No response Partial Response No response Partial Response No response MEDICATIONS ASSOCIATED WITH DEPRESSION Varenicline Benzodiazepines & other sedative hypnotics Opiates Isotretinoin Finasteride (high dose) Leukotriene antagonists Anti-hypertensives – (Weak Association)

22. Key Messages Major depression kills (suicide risk) Risk factors: comorbid conditions Use PHQ to screen, diagnose and monitor Treatment goals is REMISSION, not response – Choice of first agent, augment – Duration 9-12 months Recurrence may mean lifetime treatment