1. LOUIS A. CANCELLARO, PhD, MD, EFAC Psych Professor Emeritus and Interim Chair ETSU Department of Psychiatry & Behavioral Sciences Depression in the Elderly: Recognition, Diagnosis, and Treatment

2. Diagnosis Diagnosing depression in elderly Use family + patient for history Report >2 weeks history of (one or more): Loss of energy, loss of interests Increase in somatic symptoms w/o adequate physical explanation Behavioral and/or personality change Suicidal tendencies Delusions

3. MDD The symptoms cannot be the result of a medical illness, alcohol or drug usage, medications, or other psychiatric disorder.

4. Atypical Presentation of the Geriatric Patient Older patients are more likely to report somatic complaints and less depressed mood than younger adults. Older depressed patients may present with a “masked presentation,” i.e., the patient reports physical rather than mood complaints such as back pain or constipation.

5. Predisposing Factors Prior history of depression Women with prior history are more likely than men to have recurrent episodes Prior suicidal attempts/family history of depression/suicide History of substance or alcohol abuse Lack of social support Males living alone/loss of spouse Medical illness/disability Cognitive impairment/dementia

6. Barriers to Recognition of MDD Medical Illness Most geriatric patients suffer from several chronic illnesses, particularly cardiac disease, Type 2 diabetes, hypertension, arthritis, COPD, malignancies and G I disorders MDD in older medically ill patients is 10 times more frequent than in community dwelling older individuals MDD is diagnosed in 25% to 50% of geriatric inpatients referred for psychiatric consultation

7. Barriers to Recognition of MDD Primary Care Clinicians May not be aware of the MDD diagnostic criteria May attribute depressive symptoms to: The aging process Functional decline Personal loss

8. Barriers to Recognition of MDD Primary Care Clinicians May not routinely screen for depression May believe treatments are marginally effective May inadequately treat patients with depression

9. Cognitive Decline and Depressive Symptoms Depressed patients tend to exaggerate the degree of their cognitive dysfunction as well as emphasizing their disabilities; while downplaying their depressive symptoms. Hence the term “pseudo dementia depressive syndrome”. Following charts will assist the clinician in distinguishing the difference between depression and dementia; and depression and grief.

10. FeaturesDementiaDepression Onset Vague, insidious, no clear cut time frame. Several months to years Clear, recent, rapid onset with episodic course ProgressionRelatively steady decline Uneven, often no progression AffectBland, labile fluctuating from laughter to tears, not consistent or sustained. Influenced easily by suggestion. Environmentally responsive Marked disturbance, feelings of despair, hopelessness which are pervasive and persistent. Not influenced by suggestion

11. FeaturesDementiaDepression Memory Short term Long Term Impaired for recent events Unimpaired early in Disease, later confabulation and/or perseveration Minimal impairment as determined by objective testing OrientationVarying levels of awareness as disease progresses. May exhibit disorientation to time and place Basically unaffected

12. FeaturesDementiaDepression Insight Lacking, minimal appreciation for illness particularly in later stages. Not distressed. Nearly always aware of defects and can be quite distressed. IntellectGrossly impaired on testing. May appear impaired clinically but performs well on formal testing. Psychotic symptoms Mainly visual hallucinations and/or delusions of paranoid type Auditory hallucinations and delusions may occur in psychotic depression

13. FeaturesDementiaDepression Physical complaints Vague complaints of aches and pains in head/back. Fatigue and feelings of malaise Vegetative signs of depression are present Neurological signs Global amnesia, anomia, aphasia, apraxia None present Test performance Good cooperation and effort. Near miss responses. Little test anxiety Poor cooperation and effort. Variable achievement. Considerable anxiety. I don’t know answers are typical.

14. Grief vs Depression GriefDepression Functional impairment <2moImpairment>2mo Fluctuating anhedoniaRelatively fixed anhedonia Self-esteem preservedSelf-esteem decreased Functioning: “muddles through” Functioning severely impaired Guilt not generalized: Focused on better care of the deceased Generalized guilt Passively suicidal or not at allOften actively suicidal

15. Aids to Recognition of Depression Ask the patient about depressive feelings – “Do you often feel sad or depressed?” “Lose interest or pleasure?” Patients with unexplained complaints Failure to thrive Making a slower than expected recovery from a medical illness; older patients are less likely to be spontaneous in reporting depressive symptoms Inquire about recent loss of any kind. Losses equate to increased risk.

16. Aids to Recognition of Depression Ask directly about suicidal thoughts or morbid preoccupation with death For all patients 65 years of age <65; rate is 50% higher. Lethality is 1 out of 2 attempts vs 1 out of 8 in younger. Suicide is highest in elderly white, depressed, drinking males with medical problems who live alone. Use of firearms are the most common completion method in elderly, both men and women.

17. Aids to Recognition of Depression Use screening instruments, simple scales can serve clinicians such as Brief Geriatric Depression Scale

18. Treatment Use pharmacological and non- pharmacological modalities Some patients are reluctant to take medication, therefore it is necessary to educate the patient and significant family members as to choice rationale Become familiar with several antidepressants from different classes

19. Choice of Antidepressant Previous history of response Side effect profile Safety profile Pharmacokinetic profile Potential for drug/drug interactions Cost Medical condition/age

20. Duration of Treatment 30% -40% of geriatric MDD are chronic with recurrence rates greater than 30% 3-6 years after resolution of initial depression Recommend maintenance indefinitely

21. Pharmacotherapy Selective Serotonin Reuptake Inhibitors (SSRIs) Generally considered first line of choice Well tolerated in the elderly-no cognitive impairment-1/4 to ½ normal starting dose Favorable side effect profile Common GI complaints; nausea and appetite loss may diminish if taken with meals and full glass of water Low toxicity

22. Pharmacotherapy Withdrawal symptoms may occur if stopped abruptly-flu-like symptoms, dizziness, and agitation Shorter acting drugs are preferred; paroxetine and sertraline. Sexual dysfunction may occur with usage May inhibit P450-2D6 system, thus requires lower dose or a lower dose of other drugs given in concert. Sertraline is least interactive.

23. Treatment of Comorbid Anxiety and Depression in Elderly Patients Risk of chronic benzodiazepine use increases with advancing age. Often one sees both an anti- depressant and benzodiazepine used in combination Benzodiazepine use should be avoided. Use occurs 3-10 times more frequently than antidepressants Venlafaxine XR and SSRIs are useful for both anxiety and depression

24. Reasons for Treatment Failure Inadequate trial Inadequate dosage Poor compliance

25. Noncompliance Lack of knowledge about the illness Lack of knowledge about drug side effects Cost-can’t afford to purchase Can’t read the label Can’t access the drug-safety caps Polypharmacy-too many drugs taken

26. When do you Refer to a Psychiatrist Presence of a comorbid psychiatric disorder Presence of comorbid medical and neurological conditions Drug resistant depression Presence of psychosis (hallucinations/delusions) Need for electroconvulsive therapy Need for psychotherapy

27. Remember: Clinical Responsibilities Foster a clinical/patient relationship Understand patient stressors Educate patient and care providers Correct prejudices Simplify drug regimen Convey confidence Know medication cost