Elderly Depression. Malakouti.S.K. MD Psychiatric ward, Rasool Hospital. malakouti SK., Rasool Hosp., psychiatric ward

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1 Elderly Depression Malakouti.S.K. MD Psychiatric ward, Rasool Hospital

2 Depressive Syndromes Sub-clinical GDS>10, not fulfilled the DSM criteria Minor depressive disorder Major depressive disorder

3 Minor depressive disorder Minor depression, defined as two to 4 depressive symptoms lasting for 2 consecutive weeks 10% to 25% develop major depression within the next year

4 Depressive disorders prevalence (Care settings) Primary care setting Minor DD/Major DD: 4/1 Nursing home 6% to 26% for major depression 11% to 50% for minor depression 30% to 48% for depressive symptoms,

5 Barriers to proper diagnosis and treatment of depression in elderly Attributing depressive symptoms to "normal" aging, physical illness Masking the effects of coexisting medical problems, Self-medication (e.g. alcohol use) Stigma Poverty, low socioeconomic status Bereavement Social isolation Lack of family support Misdiagnosis of depression as dementia, hypochondriasis, somatization, anxiety disorders

6 Explanations of somatization in Asian population containment of emotion suppress expression of emotions Stigma Pain and distress are viewed as a normal Physical illnesses are socially acceptable

8 سوالهای اضطراب در فرم 28 سوالی در سالمندان ازيك ماه گذشته تا به امروز در مورد سالمتي خود چه احساسي داشته ايد )عاليم جسمانی( آيا از يك ماه گذشته تا به امروز اتفاق افتاده كه بر اثر نگراني دچار بي خوابي شده باشيد آيا از يك ماه گذشته تا به امروز شب ها وسط خواب بيدار مي شويد آيا از يك ماه گذشته تا کنون احساس کرده ايد که دائما تحت فشار هستيد آيا از يك ماه گذشته تا به امروز عصباني و بدخلق شده ايد يا از يك ماه گذشته تا به امروز بدون هيچ دليل قانع كنندهاي هراسان و يا وحشتزده شدهايد آيا ا ز يك ماه گذشته تاامروز احساس كرده ايد كه در تمامي مدت عصباني هستيد و دلشوره داريد آيا از يك ماه گذشته تا به امروز اتفاق افتاده كه براي انجام كارهايتان بيشتر از حد معمول وقت صرف نماييد )عملکرد اجتماعی( آيا از يك ماه گذشته تا به امروز اين فكر به ذهنتان رسيده است كه بخواهيد به زندگيتان خاتمه دهيد )افسردگی(

9 عالیم افسردگی در پرسشنامه 28 سوالی سالمندی 20 آيا از يك ماه گذشته تا به امروز احساس ضعف و سستي كرده ايد 21 آيا از يك ماه گذشته تا به امروز احساس كرده ايد كه بيمار هستيد 22 آيا از يك ماه گذشته تا به امروز توانايي تصميم گيري درباره مسائل را داشتهايد )عملکرد( ) سوماتيک( )سوماتيک( 23 آيا از يك ماه گذشته تا به امروز فكر كرده ايد كه شخص بي ارزشي هستيد 24 آيا از يك ماه گذشته تا به امروز احساس كرده ايد كه زندگي كامال نااميد كننده است 25 آيا از يك ماه گذشته تا به امروز احساس كرده ايد كه زندگي ارزش زنده بودن را ندارد 26 آيا از يك ماه گذشته تا به امروز به اين مسئله فكر كرده ايد كه ممكن است دست به خودكشي بزنيد 27 آيا از يك ماه گذشته تا به امروز احساس كرده ايد كه چون اعصابتان خراب است نمي توانيد كاري انجام دهيد 28 آيا از يك ماه گذشته تا به امروز Hosp., به اين Rasool نتيجه SK., رسيدهايد malakouti كه كاش مرده بوديد و كال از شر زندگي خالص ميشديد

10 Diagnosis key of depression in elderly Look carefully for symptoms of depression rather than relying on the patient to report mood changes

11 Risk factors for MDD Pain Functional limitations Visual impairment Stroke Loneliness (OR=3.3) Lack of social support Negative life events Perceived inadequacy of care Urban residence>rural area (OR=3.8) Assistance in IADLs (OR=1.2).

12 Depression side effects are Diminished quality of life Increased risk of suicide Elevated health care expenditures

13 Factors contributed to response to treatment recurrent depression (EOD) intact cognition Presence of WMHIs areas Rate of CVRF Late Onset Depression (LOD) Presence of Vascular Depression feature

14 Does depression in elderly responds to treatment? Response rate of 67% (vs placebo 38%) 75% remission rate in primary care is quite comparable with the 78% rate in a mental health setting Cumulative probability of remaining well without recurrence is 70%. Longer time to respond and higher anxiety predicted shorter time to recurrence

15 Response rate Recovery rate: 54% - 90% Relapse rate: 12% - 30% 50% for Ads and ECT in the first 18 month Remain ill or disabled: 4% - 30%

16 Why LOD accompany cognitive impairment? 1. Cerebral atrophy 2. White matter hyperintensities (Alexopoulos-2001) 1. disruption of fronto-striatal pathways 2. executive dysfunction 3. Hippocampal damage, perhaps due to hypercortisolemia (Sheline-1998) 1. Co-morbid e.g dementing illness (van Reekum)

17 WMHIs Unidentified Bright Objects (UBOs) Leukoencephalopathy (Coffey et al., 1988) Leuko-araïosis (Hachinski et al., 1987) Subcortical encephalomalacia

WMHIs in depression longitudinal study-taylor WD, 2003 WMHIs 10-15 mm, above the AC-PC line is associated with a lower rate of remission of LOD after treatment with citalopram The

18 WMHIs in depression longitudinal study-taylor WD, 2003 WMHIs mm, above the AC-PC line is associated with a lower rate of remission of LOD after treatment with citalopram The depressed subgroup that achieved remission had 11.5% WMHIs, compated with group did not (31.6%)(p<0.05) every 1% increase in WMH volume carried with it a 7% increased risk of poor outcome

19 Mechanisms of an association between vascular disease and geriatric depression The disruption of striato-pallido-thalamo-cortical pathways (Krishnan) elevated blood levels of ischemia-induced inflammatory markers cause elevation of central monoamin system this stimulation could lead to monoamine neuronal toxicity and decreased monoamine function (Connor and Leonard, 1998).

20 LOD and striatum Decreased Lt caudate volume versus early onset depression Increased left periamygdala Decreased left DLPFC, Decreased left striatal (caudate head)

21 LOD and Hippocamp Hippocampal volume correlate negatively with age, depression, cognitive impairment patients who responded to treatment had greater right hippocampal volume

22 LOD features Apathy (ACA) Limited depressive ideation Less guilt Excessive cognitive impairment Greater impairment in motivation, attention, and decision making (OFC) Psychomotor retardation(aca) Poor insight Greater disability Absence of family history High levels of WMHIs Poorer response to ADs

23 LOD criteria Cardinal features of "vascular depression" 1. Clinical and/or laboratory evidence of vascular disease or vascular risk factors 2. Depression onset after 65 years of age, or change in the course of depression after the onset of vascular disease Secondary features (consequence of "the microvascular frontal subcortical syndrome of aging ) that might be present in most but not all patients 1. cognitive impairment 2. psychomotor retardation 3. limited depressive ideation 4. poor insight 5. disability 6. absence of family history of mood disorders) 7. gait disorders, falls 8. urinary dysfunction

24 2 types of depression in the elderly Early-onset (EOD) first episodes during adulthood recurrence in old age associated with bereavement with personality disorders, neuroticism, greater medical morbidity Late-onset (LOD) Associated with cognitive impairment Increased ventricular-tobrain ratio WMHIs in neuroimaging, Poorer outcome Evolution towards dementia Resistance to drug treatment

25 Emery and Oxman proposed: late-life mood disorders and cognitive abnormalities may exist on a continuum

26 Other risk factors for lateonset depression Hypothyroidism (50%) Myocardial infarction (45%) Macular degeneration (33%) Diabetes (8% to 28%) Cancer (24%) Coronary artery disease (20%)

27 Chronic disease and depression Severe or chronic diseases associated with high rates of depression include Stroke (30 to 60 percent), Coronary heart disease (8 to 44 percent), Cancer (1 to 40 percent), Parkinson's disease (40 percent), Alzheimer's disease (20 to 40 percent), Dementia (17 to 31 percent). Multiple sclerosis (27% to 54%) Huntington's disease (9% to 44%) Microvascular ischemic disease of the brain (20%)

28 Cancer and depression pancreatic cancer has the highest risk (50%), cancer of the oropharynx (22% to 40%), colon cancer (26%), breast cancer (13% to 26%), gynecologic cancers (23%), lymphoma (17%), gastric cancer (11%). acute leukemia has the lowest risk (1.5%).

29 Infarction and depression In the first 10 days after infarction minor depression 27% major depression 18%, By the third month 33%,

30 Differentiation between depression and dementia Depression Dementia Onset abrupt, rapid slow, insidious Sleep problems Early awakening No specific pattern Diurnal variation Worse morning Sundowning present Electroencephalogram Normal Abnormal DST NEG normal Thyrotropin-releasing Blunting Normal hormone test Antidepressant trial Response No response

31 از توجه شما متشکرم

9/24/2012. Amer M Burhan, MBChB, FRCP(C)

9/24/2012. Amer M Burhan, MBChB, FRCP(C) Depression and Dementia Amer M Burhan MBChB, FRCPC Head of CAMH Memory Clinic, Toronto Geriatric Neuropsychiatrist Assistant Prof Psychiatry at U of T Objectives Discuss the prevalence and impact of depression