Beating the Blues:

Depression in Older
Patients
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
UNMC
 Goals
 Discuss depressed mood as a problem in
the nursing home
 Discuss recognition of depression
 Discuss treatments of depression.
 Mood Problems
 Several diagnoses for depressed mood
 Major depressive disorder
 Dysthymia
 Bipolar affective disorder
 Mood disorder due to a general medical dx
 Substance induced mood disorder
 Adjustment disorder with depression
 Complicated bereavement
 Mood disorder not other wise specified (NOS)
 Major Depressive Disorder
 More intense than being blue
 Lasts for an extended time 2 wks

 Dysfunction
 DSM IV criteria for Major Depressive Disorder
 Must have 1 of these 2
• Depressed mood, more often than not, for 2W
• Loss of interest
 Plus these other symptoms to equal 5 total
• Sleep, energy, appetite, worthlessness, concentration,
suicidal ideation, helpless, hopeless, guilt,
 Epidemiology of Geriatric
Depression
 Of 35 million seniors in the US
 An estimated 2 million have a depressive illness
 5 million have subsyndromal depression
 Less than 10% are treated
 1 in 10 Americans over 65 will be depressed
 19% of all suicides are by patients over 65
 Seniors comprise 13% of the population
 The highest suicide rates in the U.S. are found in
white men over age 85.
 Seniors have 50% higher health care costs if
depressed
www.efmoody.com/longterm/depression.html
 Epidemiology of Geriatric
Depression
 Influence on general health
 CV disease, cancer, infection, falls
 Mortality
 Epidemiology of Geriatric
Depression
 MDD in special populations of elderly
 Medical outpatient rate is 7-35%
• 5x higher in the doctor’s office than in the
community
 Medically hospitalized rate is 40%
 Epidemiology of Geriatric
Depression
 Nursing Homes’ rate for MDD is 12.4-20%
• But 30-35% have other depressive disorders
 Dementia with depression
 Adjustment disorder with depressed mood
 Complicated bereavement
 Depression due to GMC (Parkinson’s Disease, e.g.)
 Epidemiology of Geriatric
Depression
 Geriatric depression is associated with:
 Female gender
• Though this declines with age
• Above age 80 gender differences rapidly fade
 Low socio-economic level
 Less social support
• Especially those divorced or widowed
 Recent adverse life events
• Death and other losses
 Severe impairment in medical health
• Especially neurological disorders, endocrine disorders,
COPD, MI, cancers
 Epidemiology of Geriatric
Depression
 Underutilization of psychiatric services
 Common in those over 65
• A matter of “will power”
• Cost of medicines, copays
• Depressed people went to the asylum
• Not socially acceptable to discuss one’s feelings
 Underutilization of psychiatric
services
 Contributes to the high suicide rate in this
group
• Over 65, white males have the highest rate of
completed suicide in the United States
 0.02%/yr for men, 0.005%/yr for women over 65
 Rate for white men over 85 is FIVE TIMES the national
rate
• 59 per 100,000 versus 10.6 per 100,000
MDS 3.0 criteria mood disorder
 Correspondsclosest to the diagnosis of
major depression.
 Major Depressive Disorder
 DSM IV criteria for Major Depressive
Disorder
 Must have 1 of these 2
• Depressed mood, more often than not, for 2W
• Loss of interest
 Plus these other symptoms to equal 5 total
• Sleep, energy, appetite, worthlessness,
concentration, suicidal ideation, helpless,
hopeless, guilt,
 MDS 3.0 Depression Definition
PHQ-9
2 or more sx occurring >= 50% time
 Over the last 2 wks have you been bothered by
any of the following problems?
 Little interest
 Feeling down
 Sleep
 Energy
 Appetite
 Feeling bad about yourself (worthlessness)
 Concentration
 Moving slowly (psychomotor retardation)
 Thoughts you would be better off dead
You suspect Depression
What next?
 Is it Medication?

 Pain medications
 codeine, darvon
 High blood pressure medications
• clonidine, reserpine
 Hormones
• estrogen, progesterone, prednisone
 Cardiac medications
• digitalis, propranolol
 Alcohol
 Is it medications?
 Anticancer agents
 cycloserine
 tamoxifen
 Nolvadex, Velban, Oncovin
 Parkinson’s disease medications
• L-dopa and bromocriptine
 Arthritis
 indomethacin
 Anti-anxiety drugs
 Valium and Halcion
 Is it a medical condition?
 Hypothyroidism
 Calcium
 B12
 Vitamin D deficiency
 Heart disease
 Neurological illnesses
 Cancer
 COPD
.
 Is it due to dementia?
Higher rate of depression than the general
population
• Varying intensity in 50%
• Alzheimer’s range 0-87%, mean 17-31%
 Mild to moderate stages report depression
• GDS
 Useful for mild to moderate dementia
 Patient answers 15 questions with yes or no
• Cornell Scale for Depression in Dementia
 Useful for moderate to severe dementia
 No self-report so rater must be well-trained
 Diagnosis of Geriatric
Depression in Dementia
 Confusion can often arise as to mood symptoms
in dementia
 Communication issues
• Patients with moderate to severe dementias do not verbally
communicate their mood
 Symptoms of other disorders can overlap with
depression
• Alzheimer’s patients have little appetite, lose concentration,
become isolative
• Parkinson’s patients lose affect, have slowed speech and
movements
• Frontal lobe injuries present with apathy, often misinterpreted
as depression, or frequent crying not related to mood
 Diagnosis of Geriatric
Depression in Dementia
 Useful to use:
 Frequent, dysfunctional sad, downcast mood
 New agitation and/or sudden loss of interest
 Psychic rather than vegetative features
• Vegetative features often are multifactoral
 i.e. poor sleep may have four or five causes
 Use caregiver reports from home or the NH
 The patient’s past medical and psychiatric history

 Diagnosis of Geriatric Depression
in Dementia
 If unsure, TREAT FOR DEPRESSION
 Medications safer and more effective these
days
 ECT a viable option
 Much worse to miss than overtreat
 Diagnosis of Geriatric Depression
in Dementia
 Apathy is a common symptom in dementia
 Often mistaken for depression-
 How to tell them apart?
 In apathy, no emotional changes or lasting
emotional feelings.
 Treatment? (none with FDA approval)
 Amphetamine if pt sleeps too much-provigil
 Antidepressants
Course of Geriatric Depression
 More chronic than early onset depression
 Adult rate for chronic depression is 20%
 Geriatric rate for chronic depression near 30%
• 13-19% relapse at one year
• Risks for relapse after age 65
 Frequent episodes
 Late age at onset
 Dysthymia
 Medical illness
 High severity of first episode
 Hospitalization, suicide attempt
 Rationale for long term use of antidepressants in this
population
 Psychotic depression
 Psychotic depression a problem in the elderly
 20-45% of geriatric psychiatric inpatients
 4% of depressed elders in the community
 Psychotic depression
 Presentation
• Primarily delusions, hallucinations less so
 Guilt, hypochondriasis, nihilism, persecution, jealousy
• Highly systematized, mood-congruent delusions
 Delusion often frightening or catastrophic
• Needs treatment for depression and psychosis
 These patients require antipsychotic treatment
• fluvoxamine (Luvox) may be useful alone
 Often require electroconvulsive therapy (ECT)
• Especially when their condition compromises their
physical health
 Medications to Treat Geriatric
Depression
 SSRIs –most common  Tricyclics
 Fluoxetine  Nortriptyline
 Sertraline
 Paroxetine  MAOI
 Fluvoxamine  Selegeline patch
 Citalopram  Others
 Escitalopram
 mirtazepine
 SNRI’s
 bupropion
 Venlafaxine
 duloxetine  trazodone
 Treatment for Depression
 Medications
 All have data or reports in use in elderly pts.
 All have some positive report in dementia pts.
 Depression harder to treat in older patients
 What should you expect from
medication Treatment of Geriatric
Depression?
 How long does it take to work?
 8 to 12 weeks in 30 year olds
 May stretch to 12-16 weeks in the elderly
 Can you see changes earlier?
 Some yes.
• Vegetative-sleep appetite energy
• Good sign of response
 What should you expect from
medication Treatment of Geriatric
Depression?
 Are they dangerous?
 Not long-term
 Drug-drug interactions minimal in most cases
 Not addictive
 What should you expect from
medication Treatment of Geriatric
Depression?
 Dothey have side effects?
 SSRI- GI, dec. sex drive, anxiety headache
 SNRI-HTN, anxiety
 TCAs-bladder, bowel, cardiac, confusion
 MAOI-Tyramine reaction
 Mirtazapine-sedation weight gain
 Buproprion-anxiety, HTN
 Trazodone-sedation, orthostatic BP
 Are Antidepressants used for other
purposes?
 Anxiety/sleep- FDA approval for
mirtazapine, nortriptyline
 Pain- duloxetine, venlafaxine, nortriptyline
 Appetite-mirtazapine, nortriptyline
 Are other medications used for
depression?
 Methyphenidate
 No FDA approved, literature supports used in
medically ill, apathetic, those with poor
appetite
 Lamictal-
 FDA approved for bipolar depression
 Treatment
 Psychotherapy
 Cognitive-behavioral and Interpersonal
• Manual-driven
• Easy to study
• Effective in combination and alone
 Psychodynamic
• Long-term issues; less studied
 Problem solving and Supportive
• Mild-moderate dementia
• Coping day-to-day
 Treatment
 ECT
 Works rapidly for those who can’t wait
• Psychotic depression, especially
 Hospital venue
• Anesthesia
• 30-60 second seizure; 6-12 treatments
 Maintenance treatment
 Adverse effects minimal
• Short-term memory loss; lasts less than 2 mos.
• Mortality rate 0.01%
 Treatment
 ECT
 How does it work?
 Win the Nobel Prize in Medicine
• Cerebrovascular contraction
• Increased BBB permeability
• Increased brain O2 concentration
 No absolute contraindications
• Relative are brain tumor, MI in the last 3-6 mos.
 Response level is 90%
• Trick is maintaining the response
 Goals
 Geriatricdepression is common in NH
 Rates are different than the general
population
 Various effective treatments do exist
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