Vilben Michael De Guzman, MSN, APRN,NP-C

Objective:

-Identifying depression in older adults

-Symptoms of depression

-Types of Depression

-Risk factor and prevalence

-Treatment modalities

-Research

INTRODUCTION:

The Older Adult Population is Growing:

According to the US Census Bureau, ages 65 and older make up more than 12% of the US population and will grow to 1/5 of American population by 2030

Rapid growth in the older adult population requires attention and demand for mental health services is likely to increase.

Older adult population also is expected to become increasingly diverse. ( 8% AA, 6% Latino, 3% asian,<1% american indian). More than 26% will be members of racial or ethnic minority groups in 2030. Latinos will nearly double at 10.5. Why is it important?

Increase racial and diversity will affect the

following:

- Access and barriers to depression treatment

- Language barrier

- Stigma

- Older adults and care provider dynamics

- Cultural differences in the perception of depression,

treatment preferences and response to treatment

Risk factors:

Nursing home residence. 54% diagnosed within 1st year(

Hoover, Segel and Kalay, 2010)

Female gender. Higher prevalence across all age group

Changes in physical health or functioning/General medical

illness

Changes in mental health

Changes in circumstances or social support. Widowhood &

social isolation

Depressed mood most of the time

Loss of interest or pleasure in activities

Disturbed sleep( too much or too little)

Weight loss or gain( changes in appetite)

Fatigue or lack of energy

Feelings of worthlessness or extreme guilt

Difficulties with concentration or decision making

Noticeable restlessness( agitation) or slow movement

Frequent thoughts of suicide, or an attempt of suicide

Adapted from: American Psychiatric Assosciation. Diagnostic and Statistical Manual of Mental Disorders(DSM-V).

Symptoms of depression

Classification of Depression

Major depression

- Includes a combination of 5 or more following symptoms that are present

nearly everyday for at least a 2-week period. At least one complaint must be

either depressed mood or loss of interest in activities.

Minor depression

- Includes at least 2-4 depression symptoms which MUST include ether

depressed mood or loss of interest or pleasure that occur at least 2 weeks but

not more than 2 years.

Dysthymia

-Includes 2-4 symptoms of depression that occur most of the day almost

everyday for at least 2 years. Characterized by long-term, chronic

symptoms.Often times described as having a depressive personality that is

marked by a persistent negative perspective and low mood.

Psychotic depression/ Vascular depression/ Alzheimer disease and other

dementias

Diagnosis

Depression diagnosis with medical comorbidity

- Mood or somatic symptoms out of proportion to what is

expected

- Poor response to standard medical treatment

- Poor motivation to participate in treatment

- Lack of engagement with care providers

Depression diagnosis in the frail elderly

-should emphasize a change in mood or interest with at least 2

weeks duration, non-physical symptoms, social regression or

incapacity.

Screening instruments/Tools:

Screening instruments/ tools:

Two question screener-

“ During the past month, have you been bothered by feeling down, depressed or

hopeless?”

“ during the past month, have you been bothered by little interest or pleasure in

doing things?

Geriatric Depression Scale: Five item self-report instrument

- Are you basically satisfied with your life?

- Do you often get bored?

- Do you often feel helpless?

- Do you prefer to stay at home rather than going out and doing new things?

- Do you feel pretty worthless the way you are now?

PHQ-9: Developed specifically for use in primary care setting.

88% sensitivity and specificty.Useful in monitoring response to

treatment. Score >10 likely major depression(Score 0-27)

Cornell Scale for Depression in Dementia. Interviews primary

caregiver and patient. Score of >12 indicate probable

depression.

Treatment modalities

Psychotherapy interventions:

-Cognitive behavioral therapy- education; relaxation exercises,

coping skills training, stress management or assertiveness

-Behavioral therapy- mindfulness,

-Problem-solving treatment

-Interpersonal psychotherapy-address interpersonal difficulties

that lead to psychological problems.Focuses on 4 problem areas: grief

and loss; interpersonal dispute; role translation; and interpersonal skill

-Reminiscence therapy- oral or visual stimuli that bring good

memories

-Cognitive bibliotherapy- expressive therapy that involves the

reading of specific books with the purpose of healing

Pharmacotherapy: Antidepressant medications

Multidisciplinary geriatric mental health outreach services

Pharmacotherapy:

Selective serotonin reuptake inhibitors(SSRIs)

-first line of treatment due to tolerability, ease of use, general safety

especially in overdose. (e.g. Escitalopram, Citalopram, Sertraline,

Fluoxetine, Parozetine).

Pharmacodynamics: increase serotogenic activity.

Serotonin( 5-hydroxytryptamine or 5-HT) is an indoleamine

neurotransmitter released in the brain from neurons originating in

brainstem raphe nuclei. Serotonergic neurotransmission in the brain

involves at least 14 different types of pre- and post-synaptic serotonin

receptors. All SSRIs potentially decrease the presynaptic serotonin

reuptake pump by 60-80%. This increases the length of time that

serotonin is available in the synapse and increase postsynaptic serotonin

receptor occupancy( Zahajszky, Rosenbaum, 2009)

Dosing: 20-40mg daily. Max 40mg daily. Older adults half the adult dose upon

initiation of treatment

Medical tests, plasma levels, and monitoring: NA

SE: Sexual dysfunction(17%); Drowsiness(17%); Weight gain(12%);

Insomnia(11%);Anxiety(11%); Headache(10%); dry mouth(7%); blurred

vision(6%); nausea(6%); QTc prolongation (Beach, Kostis, Celano,2014)

Serotonin-norepinephrine reuptake inhibitors( SNRIs)

-second line agent for treatment failure with SSRIs, ( Venlafaxine and

Cymbalta)

Pharmacodynamics: initially blocks presynaptic serotonin an norepinephrine

transporter proteins. This inhibits reuptake of these neurotransmitters, which

changes various homeostatic mechanisms, and ultimately increasing stimulation

of postsynaptic receptors.

SE: Nausea; Dizziness; Diaphoresis

Atypical antidepressants- e.g. Buproprion/Wellbutrin, Mirtazapine/Remeron

- First line treatment if the drug has desirable characteristic( eg sexual side

effects and weight gain occur less often with Buproprion than SSRIs)

SE: dry mouth(21%); Nausea(13%); Insomnia(12%);Increased appetite(11%)

Dizziness(10%); Anxiety(6%).

OD: May cause seizures, hypertension, tachycardia and death

Tricyclic and tetracyclic antidepressants

-useful for treatment failure with other antidepressants. Tend to have dose-

related SE at therapeutic doses. Considered “ Broad spectrum” as it interacts

with many neurotransmitter system. Blocks Muscarinic M1; histamin H1, alpha-

adrenergic receptors and commonly cause cardiac effects, anticholinergic

effects, antihistaminic effects, sexual dysfunction, decrease seizure threshold.

Monoamine oxidase inhibitors(MAOIs)

-rarely used except when previously initiated and tolerated.Affect wide range

of neurotransmitter systems and cause many undesirable side effects.

Choice of treatment ?

-Dependent on the severity and duration of depression

-Older adults clinical presentation

-Older adults prior history of response to treatments

-Presence of other health conditions or medications

-Tolerability of treatments with respect to side effects

-Older adult’s treatment preferences

Summary and recommendations:

Late-life depression often goes undetected

Depression is not a normal consequence of ageing

Suicide rates are almost twice as high in the elderly

Depression in the elderly can be challenging to diagnose

Psychotherapy is effective in older adults, although for moderate to

severe depression, pharmacotherapy or a combination of

pharmacotherapy and psychotherapy is recommended

Medication monotherapy is preferred in the elderly to minimize drug

side effects and drug-drug interactions. Initial medication dosage

should be adjusted for the older adult

All medications typically take 4-6 weeks to show efficacy; in elderly

patients a full antidepressant response may not occur until 8 to 12 or

even 16 weeks of therapy.

Patients should be contacted or seen within 2 weeks of initiating

medication to discuss tolerance and adjust dose as indicated and should

have an office visit 2-4 weeks of treatment to assess response, monitor

side effects and address complication or deterioration

SSRIs first line antidepressants because of safety and tolerability

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Thank you