paula bordelon, do. dr. bordelon has no disclosures

Paula Bordelon, DO

Dr. Bordelon has no disclosures.

Increased knowledge of comorbidities and risk factors associated with depression in seniors Ability to recognize signs and symptoms of depression in seniors Review of USPSTF recommendation as it relates to screening adults for depression

15% of people age 65 and older suffer from depression Present in 25% of those with chronic illness (e.g. CHF, DM) Increased risk of mortality Costly, with direct and indirect costs totaling $43 billion/year Geriatric Mental Health Foundation; http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.htm l; last accessed 09/19/14 Geriatric Mental Health Foundation; http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.htm l

With less than 4000 geropsychiatrists in U.S., primary care physicians treat 75% depressed elderly present to PCP, not psychiatrists Increases functional decline Decreases quality of life Increased mortality Extreme burden on family and caregivers

Prior personal hx depression Female Increased stressors (e.g. moved to assisted living) Lower socioeconomic Cognitive Impairment Substance Use (e.g. alcohol) Bereavement

Depression lasting > 2 years considered chronic & has poor prognosis Depressive symptoms or minor depression Community8-15% Long-term care30-50% In-patient (OABH)60-70% Major Depression Community 1 yr prev2.7% Primary Care5.6% Long-term care6-25%

Unipolar Major Depression Dysthymia Depression NOS Bipolar I II Cyclothymia Bipolar NOS

Must have depressed mood or anhedonia (without mania or hypomania or substance use or another medical condition) PLUS: 4 other SIGECAPS Present at least 2 weeks Cause significant distress Seniors are not always aware of their emotional feelings. May not relay depression SIG E CAPS Sleep d/o Interest Guilt Energy Concentration Appetite/weight Psychomotor agitation or retardation Suicidal ideation

Experience anhedonia or depressive mood for at least 2 years (think of it as long-lasting and not lifting) Plus at least 2 symptoms (not lifting > 2 mths): Poor appetite or overeating Insomnia or hypersomnia Low energy Low self-esteem Poor concentration Hopelessness

Rare in seniors to have its initial onset in late life Dysthymia frequently persists from midlife to late life Do not give this dx if senior ever met criteria for bipolar D/O or cyclothymic D/O

Less frequent than nonpsychotic depression when considering all age groups Psychotic depression much more common in elderly Approximately 20 to 45% hospitalized depressed seniors suffer from psychotic depression Symptoms associated with such include hallucinations or delusions

Antidepressants alone not enough Warrants antidepressant and antipsychotic or ECT considered first-line Effective in treatment resistant patients

SymptomDescription Depressed mood or anhedoniaSenior wont state I am depressed but exhibits loss of interest or anxiety Guilt, low self-esteem, or worthlessnessNot common in seniors Somatic ComplaintsAt risk of delayed diagnosis or misdiagnosed Psychomotor changesElderly more likely to exhibit Insomnia or hypersomniaHypersomnia much more common in younger adults Weight loss, anorexiaVery common for seniors Suicidal ideationElderly make fewer attempts; more likely to be successful

68 year-old retired nurse with no past psychiatric or substance abuse reports a 4-week hx of hearing the voice of her recently deceased husband telling her that he misses her. Her husband suffered an MI while the extended family was on a cruise celebrating their 40 th wedding anniversary. The auditory hallucinations occur at night. Ruth feels guilty, because as a RN, she believes she should have seen this coming. She reports being down, poor appetite and has lost 4 pounds over 45 days, difficulty concentrating resulting in errors at work, insomnia, and fatigue.

Bereavement leads to adverse mental and physical outcomes Associated increased mortality in the surviving conjugal partner when compared to married persons of the same age Highest relative risk of mortality occurred 7 12 months after spousal loss

Also associated with anxiety, substance use, suicide Symptoms seen: Marked functional impairment Morbid preoccupation with worthlessness Psychotic symptoms Psychomotor retardation Psychosis Rosenzweig AS, Pasternak R, et al. Bereavement-Related Depression in the Elderly. Is Drug Treatment Justified? Drug & Aging. 1996 May; 8 (5): 323-326.

Functional decline Increased use of non-mental health services 1 Increased medical mortality rate in those mood d/o Overall 2 : > 4x rate of death over 15 months Cardiac 3 : 4x rate of death within 4 mos after MI 1. Beekman et al. Psychol Med 19997;27:1397-1409. 2. Bruce and Leaf. Am J Public Health. 1989;79:727-730. 3. Romanelli e al. J Am Geriatr Soc 2002;50:817-822.

Is a state of chronic stress Risk factor for developing: diabetes, cognitive impairment, coronary disease (CAD) osteoporosis

Depression activates Hypothalamic Pituitary Axis (HPA) Increased levels of cortisol Greater in those hospitalized vs outpatient No differences between sexes HPA hyperactivity varies but does increase risk of diseases, including diabetes by increasing FBS and insulin levels Stetler C, Miller GE. Depression and hypothalamic-pituitary adrenal activation: a quantitative summary of four decades of research. Psychosom Med. 2011. Feb-Mar; 73(2): 14-26.

Depression is independent risk factor for CAD At increased risk subclinical atherosclerosis Hospitalized depressed patients are at increased risk of having a myocardial infarction (MI) Death from MI Individuals suffering MI & depression are at increased risk of another cardiac event

Neurodegeneration leads to depression Determine if it is dementia syndrome of depression or depression causing cognitive inabilities

Seniors represent 13% of the U.S. population but 18% of suicides U.S. suicide rate 12.3/100,000 overall in 2011; Age 85+: 16.9/100,000 (41% higher) Among depressed elderly seen by PCP during a 12 mth period, < 10% received tx for depression before attempted suicide or suicide 70% of suicides occur within 1 month of a visit to PCP American Foundation for Prevention of Suicide: New Data Issued by CDC Releases 2011 Suicide Statistics.

Seniors have higher ratio of suicide completions to attempts Higher rates of double suicides Higher use of firearms in seniors as means to end life

White male Bereavement (e.g. Widow or Widower) Terminal or chronic illness, including perceived ill health Poor sleep Psychiatric Disorder Social isolation Hx prior suicide attempt(s)

Less frequent in seniors Symptoms are not typically classic (i.e. hyperactivity, decreased sleep, flight of ideas, grandiose delusions, hypersexual) Several unusual presentations when we think of what we learned in medical school Syndrome of reversible cognitive impairment which is confused with Alzheimers is seen

Take a psychiatric history Speak to informant (esp. if depressed male) Get past history (i.e. Is this the first episode of depression?) Suicide attempt hx If prior hx of depression, obtain previous tx successes and failures ASK ABOUT SUBSTANCE ABUSE! ASK ABOUT FIREARMS! Investigate if hallucinations Never assume patient is compliant with therapy

In fellowship, taught to use an objective depression scale (there are quite a few Center for Epidemiologic Studies-Depression Scale) is quantitative so can trend it Review PHQ-9, GDS, Cornell

Have high degree of sensitivity and specificity USPSTF states sufficiency in asking 2 simple questions: 1. Over the past 2 weeks, have you felt down, depressed, or hopeless? 2. Over the past 2 weeks, have you felt little interst in doing things?

Recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, treatment, and followup (Grade B recommendation) There may be considerations supporting screening for depression in an individual patient (Grade C recommendation) Positive screen should trigger full diagnostic interview and examination

Cornell Scale for Depression in Dementia caretaker or family member rates severity of symptoms: mood-related signs Behavioral disturbances Physical signs Cyclic functions Ideational disturbances Geriatric Depression Scale patient answers subjective questions and validated in many studies Looks at attitudes and cognition Less focus on vegetative symptoms

Depression is a prodrome Again: depression is linked to cognitive impairment, especially if first episode of depression ever Depression leads to disturbance in executive function; can have pseudodementia Use MMSE or Montreal Cognitive assessment (MOCA)

Take a Medical History Medication side-effects Drug or alcohol abuse Infection Endocrinopathy (e.g. hypothyroidism) Malignancy Nutritional disorders Sleep disorders (dont miss sleep apnea)

Acyclovir ACE-I B Blocker CCB Corticosteroids Digoxin H2-receptor blockers Interferon alpha L-dopa Methyldopa and clonidine Patten SB, Love EJ. Can Drugs Cause Depression: A review of the evidence. J Psychiatr Neurosci. Vol 18. No. 3. 1993.

Study MRI Sleep Study (sleep apnea/MCI/Malaise) UA C&S Chemistry LFTs Thyroid Fxn Tests Bun/Cr, GFR FBS Vitamin B-12 and folate

Antidepressant medications are the foundation for treatment of moderate and severe late life depression When considering an antidepressant, is based on Efficacy Side effects Drug interactions Cost

DiagnosisTreatment/therapy Nonpsychotic MDDSSRI (SNRI) or venlafaxine XR + psychotherapy Psychotic MDDSSRI (SNRI) or venlafaxine XR + Atypical Antipsychotic OR ECT DysthymiaSSRI (SNRI) + psychotherapy + tx concurrent medical conditions MDD + insomniaSedating antidepressant Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Patients. Postgrad. Med Sp Report 2001 (Oct.): 1-86. PMID: 17205639

FDA-indicated antidepressants are effective in treating late-life depression; dont choose off label medication if unnecessary Response rate (defined as 50% decrease in symptoms) Remission rate (defined as > 90% symptom decrease) Typically only achieved in 30 -40% with medication versus 15% for placebo NNT for remission (drug vs placebo): 4

Avoid TCAs in seniors unless refractory depression because of side effects Discontinuation 2d to SE is frequent in tx studies TCA 24% SSRI17% Side effectTCA (%)SSRI (%) Dry mouth287 N/V7.517 Drowsiness15.36.5 Vertigo12.27.8 Sleep disturbance42.6

SIADH most likely as result of SSRI Easy bruising SSRIs reduce platelet aggregation GI bleed - Bowel Dysfunction (i.e. constipation) Weight Gain (e.g. with TCAs) Decreased libido (not unique to elderly)

Polypharmacy: avg adult > age 65 is on 5 or more medications Age exacerbates potential for side effects Renal elimination of drugs decreases Hepatic inactivation of drugs decreases Anticholinergic vunerability increases

Careful treatment initiation can reduce side effects and PREMATURE withdrawal! Dosing initiation rule: adult dose Start low and go slow Treatment takes more time: Acute treatment:8 weeks Increase dose:after 6 weeks Remission:Months Continuation:6-12 Months Maintenance:1-5 years vs lifetime

Even with maintenance, there is a high recurrence rate Maintenance pharmacotherapy reduces recurrence risk (Maintenance means beyond 12 months) Slower initial responders may do better with combined therapy in maintenance 1 1. Dew et al. J Affect Disord 2001;65:155-166

Psychotherapy is under-prescribed (avoid in the demented because of lack of efficacy) Effective for non-psychotic MDD and in dysthymia Several approaches are evidence-based Cognitive Behavior Therapy (CBT) Problem Solving Therapy (PST) Interpersonal Therapy (IPT)

Adequacy of treatment Duration of treatment Dosage of medication Solo therapy versus dual therapy Behavioral factors Personality disorder Psychosocial stressors Compliance Education provided Diagnosis Missed medical conditions

Nonadherence (33-81%) facilitated by: Preference for different treatment (e.g. no medications) Complexity of medication regimen Cost (e.g. too expensive so skip doses) Side effects (e.g. too severe) Cognitive impairment (i.e. noncompliance) Patterns: underuse, overuse, altered use

Recognition and treatment is poor-missed in 50% of the ambulatory population Among those treated, treated inappropriately: Inappropriate use of medications Too low doses for fear of side effects Too short duration Inadequate followup (dont see often enough)

Delusional depression is more prevalent in older depressives vs younger depressives Associated with: Hypochondriasis Delusional relapses Worse response to monotherapy Longer hospitalizations Higher relapse rates

Optimize current therapy Switch therapy to new agent Augment with additional medication or co- prescribe ECT

Switch Slower Simpler, less costly Avoids drug-drug interaction Reduces SE Introduce different mechanism Quicker More complex, costly Risks drug-drug interaction Can increase SE Avoids loss of earlier partial response Augmentation

Venlafaxine when ANXIETY is prominent Bupropion when APATHY is prominent Mirtazapine when INSOMNIA/ANXIETY are prominent Aripiprazole is atypical antipsychotic approved for major depressive disorder and bipolar disorder

Challenging in treating depressed older adults who have not responded to multiple trials of antidepressant medications Elderly with psychotic symptoms who failed antidepressant therapy often do respond to ECT Some studies suggest that ECT is in fact the SUPERIOR treatment in late life compared to midlife

Underused! Some indications: Antidepressant intolerance and/or nonresponse Prior positive response to ECT Psychosis Catatonia Mania Profound weight loss

Relative contraindications: Cardiac: Recent MI, unstable angina, uncompensated CHF, arrhythmias, severe valvular disease Neurologic: intracranial lesions increase risk, recent CVA

Major concern of patients (transient retrograde amnesia) ECT may improve depression-impaired cognition but exacerbate impaired cognition of dementia Preparation: Education Pre-screen to establish baseline Monitor memory throughout treatment Decrease treatment frequency when pronounced

The diagnosis of late-life depression is as valid as any other significant medical disorder. MDD in seniors is associated with psychiatric and medical morbidity, increased utilization of health care, and increased mortality. Late-life depression is treatable but may be refractory to a single intervention. Late-life depression often coexists with cognitive impairment.

paula bordelon, do. dr. bordelon has no disclosures

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