1. Depression in Older Adults
University at Albany, SUNY
Gero Innovations Grant

2. Today’s presentation Overview of late life depression
Identify who is at risk
Recognize depressive symptoms
TOOLS: How to Screen / Assess
Manage suicidal behavior
When to refer older clients to a mental health professional
Information on antidepressant medications
Recognize EBP psychosocial treatments

3. Leads to physical mental & social disability
Depression Overview
 Leads to physical mental & social disability
Depression can be persistent, intermittent
Depression can increase levels of health service use and cost

4. Who’s at Risk? Generally Women
If you experienced a recent loss or severe stress
Fam. History of mental illness/suicidal behavior
Unexplained somatic symptoms
History of self-medicating
Chronic/major illness
Strokes heart disease, AIDS, cancer, diabetes, chronic pain

5. Late Life Depression
Depressive Disorders are very real & one of the most common mental health problems among older adults
Depression is also common with vision impairment, other medical conditions, and alcohol abuse
Among older adults, suicide risk is high

6. Suicide Rate Of Older Adults Higher Than Young Adults (15-24)
Source: Mortality Reports. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention.

7. Detection rates are poor
Reluctance of elderly to seek MH care
Lack of knowledge and/or reluctance of PCP / Human Services to detect or refer
Disguised presentation of depression or anxiety related to medical conditions
Why are older adults hesitant to seek MH care?
Cohort grew up when MH diagnosis meant really crazy/institutionalized
Tend to feel it is personal failing to not “pull self up by your bootstraps”
Re Disguised presentation of depression or anxiety – or pain, sleep disorder, GI issues, etc.

8. Prevalence of Major Depression in Later Life
More prevalent in women than men
Depressed mood is a risk factor-suicidal ideation

9. Prevalence of Subthreshold Depression in Later Life
High rates of depressive symptoms
More prevalent in women than men
Anhedonia is a risk factor-suicidal ideation

10. Disability & Depression in Later Life
Downward Spiral Theory
Depression is a risk factor for disability, and
Disability increases the risk of depression
Result: A high prevalence of depressive symptoms & disorders among disabled older adults.

11. Answers to commonly asked questions about depression, as they present in seniors.
I can’t do anything for myself
But I’m too old to be depressed
I’m not depressed. I just do not feel that my life is worth anything.
I’m in pain much of the time.
I’m of no use to anyone
I don’t see my friends anymore
I’m not interested in anything

12. Major Depression Episode 5 or more of the following symptoms during past two weeks:
Depressed mood most of the day, nearly every day (subjective/other report)
Decreased interest/pleasure in all activities
Significant weight loss (e.g. 5% body wght/1 month) or overeating
Insomnia or hypersomnia

13. Major Depressive Episode cont’d
Psychomotor agitation/retardation
fatigue or loss of energy
feelings of worthlessness
excessive guilt
unable to concentrate, indecisiveness
recurrent thoughts of death, recurrent suicidal ideation without a plan or
a suicide attempt or a specific plan

14. Major Depression Criteria
Presence of a single Major Depressive Episode
absence of psychosis, hallucinations, delusions
no manic, episode hx

15. Minor Depression
Older adult reports 2 to 4 symptoms for at least 2 weeks
One of the symptoms has to be:
Depressed mood or lack of pleasurable activities

16. Depressive Symptoms vs Clinical Depression
Many elderly may not be clinically depressed
Medical conditions, meds, family, financial or bereavement problems are some factors associated with symptoms of depression
Older person may be experiencing the “blues” of depressed mood

17. Why screen for late life depression?
Screening improve the accurate identification of depressed clients
Treatment of identified depressed adults decreases clinical morbidity.
Reduce potential suicidality
Also – they look better.
Depressed people can appear demented or those with mild cognitive decline can look very impaired.
When depression treated, they can follow up on other health maintenance strategies (such as med compliance, exercise, socialization) better.

18. Assessment of late life depression
Ask about family history
Assess for risk factors
Complete the screening with the client
Discern the type of depression
Most prevalent forms of depression
Major depression
Minor depression
Subthreshold depression

19. Assessment of late life depression
Ask about family history
Assess for risk factors
Complete the screening with the client
Discern the type of depression
Most prevalent forms of depression
Major depression
Minor depression
Subthreshold depression

20. Medical Conditions Associated with Depression
Cancer
Alcohol/drug abuse or withdrawal
Diabetes
HIV/AIDS
Hypothyroidism
Parkinson’s Disease
Stroke
Epilepsy
Vitamin deficiency (Folate and/or B12)

21. Physical appetite weight sleep change psychomotor changes fatigue
Depressive Symptoms
Psychological
depressed mood
feelings of worthlessness/guilt
loss of interest
decreased concentration/memory
suicidal ideation
Physical
appetite
weight
sleep change
psychomotor changes
fatigue

22. Elderly may show signs and symptoms
D Dysphoria
E Eating behavior
P Physical Complaints
R Rumination
E Energy loss
S Suicidal thoughts and plans
S Poor sleep or too much sleep
I Isolation (Lack of Social Support)
O Omission of pleasurable activities
N Negativity in relation to self, others, future

23. Depression Screening Tools
Rapid Rating Scales
PHQ-9
Geriatric Depression Scale
CES-D Scale
BDI
HAM-D
Give students one of the above tools to try out with one another. How is this screening different than with younger adults? (greater variety of ways to ask about depressive symptoms without using the word depression)

24. Case: Mrs. D 76 yr old female
Frequently contacts primary care physician about her health
When seen, she expresses numerous worries about other areas of her life
She relates that she has always been a “worry wart” and this has made her life difficult
She has difficulty concentrating, making decisions
She reports feeling restless, difficulty going to sleep because of excessive rumination
She worries that others avoid her because she is no fun to be around
She lives alone
She states that she doesn’t feel like doing anything
Ask students for differential diagnosis
Criteria for Major Depression – 5 symptoms
Decreased pleasure (9)
Insomnia (6) or psychomotor agitation
Unable to concentrate (5)
Excessive guilt (4)
Consider how long? Risk of suicide? Other anxiety disorder?

25. Suicidality Components
Thoughts of death
Intent
Plan
Means
Prior suicidal history or behavior

26. Interventions for Suicidal Management
Listen for clues in what they say:
‘No one left”, “I can’t go on”, What’s the use?, I gave some things away”
ASK the client
INFORM them that you are concerned for their wellbeing

27. Interventions for Suicidal Management
Most people who are thinking about suicide will communicate their intent through clues
Myth-asking someone about Suicide will encourage it
Refer to mental health/psychiatry

28. Interventions for Approaching the Topic of late Life Depression
How are things at home?
Have you had any stress lately?
How are you handling it?
How have you been coping?

29. Interventions for Approaching the Topic of Late Life Depression
Discuss your concerns with client
You can say:
“It is very common…”
“It is a medical condition”
“It is treatable”

30. Guidelines for Making a Referral to Mental Health
If the older client has a psychiatric history
If there is suicidal ideation
Client safety, risk of suicide
Hospitalization
Client needs medication
Client needs ongoing psychotherapy

31. Evidence-Based Interventions
(1) Cognitive Behavioral Therapy has been well-validated in controlled efficacy trials in community & primary care settings
Sessions range (8-20)

32. Evidence-Based Interventions
(2) Problem Solving Therapy has been well- validated in controlled efficacy trials in community & primary care settings
Sessions (range 6 – 12)
RCT of brief PST intervention with
homebound older adults (Gellis, 2007)

33. Evidence-Based Interventions
(3) Interpersonal Therapy has been validated in controlled efficacy trials in mental health, outpatient, & primary care settings
IPT focuses on interpersonal events such as interpersonal disputes / conflicts, interpersonal role transitions, complicated grief related to onset and / or maintenance of depression.

34. Evidence-Based Interventions
(4) Relaxation training has shown effects for depression & generalized anxiety
(5) Adjunct written educational materials for clients & family members have been shown to improve medication adherence & clinical outcomes
(6) Pharmacologic Treatments
70-80% of depressed pts will respond to meds alone
-most pts respond within 4-6 weeks
-”Start Low and Go Slow”
Related interventions not specifically for depression: Caregiver interventions

35. Antidepressants SSRIs – 1st line of treatment SNRIs
TCA - e.g. imipramine
MAOI - Restriction in diet (no cheese or smoked food) and no antihistamines

36. Serotonin Selective Reuptake Inhibitors
Fluoxetine (Prozac), mg/d
Initiate with 5-10 mg/d
Sertraline (Zoloft), mg/d
Initiate with mg/d
Paroxetine (Paxil), mg/d
Initiate with 10mg/d
Fluvoxamine (Luvox), mg/d
Initiate with 25 mg/d
Citalopram (Celexa)
- Initiate with mg/d
Start low- -Go Slow

37. Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Venlafaxine-XR (Effexor-XR) mg/d
Cymbalta
Typical side effects
GI distress, jitteriness, headaches, sexual disturbance

38. And Remember…. Depression in older adults is real if the symptoms are:
excessive, uncontrollable, create distress, and interfere with daily living

39. Summary Depression is prevalent in aging but is not a part of aging
Comorbid with other medical illnesses
Most forms of depression are easily diagnosed and treatable
Depression requires training for careful screening and follow-up
Early screening and intervention is critical
Appropriate asmt. And tx can improve the QoL for depressed older persons

40. Depression in Older Adults 2007
University at Albany, SUNY