Depression in the Older Adults. Summary

Transcription

1 Depressin in the Older Adults Summary Majr depressive disrder (MDD) is the leading cause f disability accrding t the Wrld Health Organizatin. Cmmn clinical cnditins and previus research has shwn that the wrldwide prevalence is apprximately 15% in cmmunity-dwelling individuals. Significant depressive symptms are present in nearly 15% f lder adults living in the cmmunity, especially in thse lder adults wh have chrnic illness and pain. Depressin in later life is assciated with greater risk f suicide, ischemic heart disease, heart failure, steprsis and pr cgnitive and scial functining. Physilgically it is assciated with changes such as hypercrtislemia, visceral adipsity, and higher risk f hypertensin and diabetes mellitus. Depressin in the lder adult Key Pints amplifies disability/pain lessens quality f life and increases mrtality results in increasing ffice and emergency department visits results in mre prescriptin and OTC medicatin use leads t increased alchl and drug use increases length f hspital stay Eighty percent (80%) f mental health treatment fr depressed lder adults is delivered in the primary care setting. It is estimated that percent f lder adults with intact cgnitive functining have depressin. Health care prviders shuld screen all geriatric patients fr depressin. Greater than 50% f nursing hme residents are depressed. Dementia syndrme f depressin is defined as a cgnitive impairment present in an elderly patient with majr depressin that may have cgnitive deficits that develp after the nset f md symptm.

2 Female sex Previus depressive episde Inadequate emtinal supprt Impaired memry Living alne Mild cgnitive impairment Smatfrm disrders Risk Factrs fr depressin in lder adults Assessment Atypical presentatin f depressin in lder adults may include: Mre sleep disturbance, Fatigue Psychmtr retardatin Memry impairment Slwer cgnitive perceptin Assessment f the lder adult suspected f being depressed includes: A cmplete and thrugh medical and psychiatric histry Presence f suicidal ideatin and plan (lethality, intent, and means). Acute suicidal ideatin requires urgent psychiatric referral. Unlike the yunger ppulatin, elderly attempt suicide less ften, but are usually mre successful. Review f system - ask specifically abut hpelessness, insmnia, and psychtic symptms. Cnduct a cmplete medicatin review (prescribed, OTC, and hmepathic) evaluating ptential side effects that may cause depressin. Assess ptential drug-drug interactins with substances such as alchl, piates, benzdiazepines, and ther CNS depressants. Utilize a standardized, reliable and valid geriatric screening tl such as the Geriatric Depressin Scale. This scale has a 5, 15 r 30 questin scale available fr clinicians. See the 5 questin scale belw:

3 Use the Geriatric Depressin Scale (GDS) t screen fr depressin (Hyt et al., 1999): Are yu basically satisfied with yur life? Yes N D yu ften get bred? Yes N D yu ften feel helpless? Yes N D yu prefer t stay at hme, rather than ging ut and ding new things? Yes N D yu feel pretty wrthless the way yu are nw? Yes N Tw ut f five depressive respnses ("n" t questin 1 r "yes" t questins 2 thrugh 5) suggests the diagnsis f depressin. Interventins An interprfessinal team apprach is imprtant t prvide supprt t yur patient and their family. Include family members wherever pssible in diagnsis and treatment. Utilize Chaplain Services, Scial Wrk, Psychiatry and Psychlgy t assist with nn-pharmaclgic services. Psychtherapy and pharmactherapy may be used as mntherapy r in cmbinatin. Elder adults respnd well t psychtherapy, althugh pharmactherapy r a cmbinatin f pharmactherapy and psychtherapy is recmmended fr mderate t severe depressin. Fr depressed patients with chrnic and r life-threatening illness, use a cmbinatin f supprtive psychtherapy, cgnitive appraches, behaviral techniques, and antidepressant medicatin. Medicare cvers therapy services. Exercise may be effective in the treatment f minr r majr depressin in the elderly. Patients with majr depressin, hwever, may be difficult t engage in an exercise prgram and wuld likely benefit frm cncmitant pharmactherapy r psychtherapy. Imprtant pharmaclgic treatment cnsideratins in the elderly are: Initial medicatin dsage shuld be lw and then adjusted fr the elder adult; typically starting half the usual starting dse fr patients (hwever, full therapeutic dses are ften required t achieve the desired respnses). Typically take tw t fur weeks t shw efficacy; in lder patients a full antidepressant respnse may nt ccur until 6 t 8 weeks f therapy. Life-lng treatment may be necessary t prevent recurrence. All patients shuld be fllwed up within tw weeks f initiating medicatin t discuss tlerance, assess respnse, mnitr fr adverse events and adjust dse as indicated. First line: SSRIs are first-line antidepressants because f safety and tlerability. Secnd line: venlafaxine, dulxetine, mirtazapine, r buprpin.

4 Third line: Cnsider augmentatin f first-r secnd line antidepressants with aripiprazle r quetiapine, r SSRI with buspirne r buprpin. Alternatively, cnsider switching t a different classificatin f medicatin. Older adults shuld be assessed fr relapse. The table belw prvides basic infrmatin regarding medicatins fr the treatment f depressin: Class Medicatin Initial Dsage Usual Dsage Frmulatin Cmments SSRIs Class Adverse Events: EPS, hypnatremia, increased risk f upper GI bleeding, suicide (early in treatment), lwer BMD and fragility fractures, risk f txicity if methylene bile r linezlid c administratin. Avid if histry f falls r fractures; cautin if histry f SIADH Citalpram (Celera) mg p 20 T: 20,40,60 S: 5mg/10ml 20 is max dse in age >60; cncerns abut dsedependent QT interval prlngatin that can lead t arrhythmias Escitalpram (Lexapr) 10 mg p 10 T: 10,20 10 is max dse in age>60 Fluxetine (Przac) 5 mg p 5-60 T: 10 C: 10,20, 40; C SR90 S: 20mg/5ml Lng half-lives f parent and active metablite; may cause mre insmnia than ther SSRI T: 10,20,30,40 Parxetine (Paxil) 5 mg p CR: 12.5mg p CR: CR: T: ER 12.5, 25, 37.5 CR: S: 10mg/ml CR: Increase by 12.5 mg n faster than nce/week Helpful with anxiety symptms; increased risk fr withdrawal symptms (dizziness); antichlinergic events SNRIs Cautin with histry SIADH. Mst cmmn adverse events: nausea, dry muth, cnstipatin, diarrhea, urinary hesitance;

5 Dulxetine (Cymbalta) Venlafaxine (Effexr) Desvenlafaxine (Pristiq) TCAs Desipramine (Nrpramin) Nrtriptyline Additinal Optins Buprprin (Wellbutrin) Wellbutrin SR (Zyban) 20 mg p, then 20 mg p mg p XR: 75 mg p 60 mg p mg p qhs mg p qhs mg p SR: 100 mg p r q24h mg q24h r 30 mg in divided dses XR: mg mg C: 20,30,60 T: 25, 37.5, 50, 75, 100 XR: 37.5, 75, 150 SR T: 50,100 T: 10,25,50,75, 100, 125 C: 10,25,50,75, 100,150 S: 10mg/5ml T: 75,100 T: 100,150,200 Wellbutrin XL 150 mg 300 T: 150,300 reduce dsage if CrCl ml/min; cntraindicated if CrCl < 30 ml/min Useful in patients with depressin and neurpathic pain Lw antichlinergic activity; minimal sedatin and hyptensin; may increase BP and QTC; may be useful when smatic pain present; EPS, withdrawal symptms, hypnatremia Active metablite f venlafaxine; adjust fr CrCl <30ml/min Cautin in the elderly due t significant arrhythmic side effects, antichlinergic effects causing urinary retentin, rthstasis, and pssible exacerbatin f dementia. Therapeutic serum level >115 ng/ml Therapeutic windw ng/ml Cnsider fr SSRI, TCA nnrespnders; safe in HR; may be stimulating; can lwer seizure threshld.

6 p q day Methylphenidate (Ritalin) mg p q7am and q12pm 5-10 mg at 7am and 12p T: 5,10,20 Shrt term treatment f depressin r apathy in physically ill lder adults; avid if insmnia; used as adjunct Mirtazapine (Remern) 15 mg p qhs T: 15,30,45; ODT (SlTab available) Useful fr patients with insmnia, agitatin, restlessness, r anrexia and weight lss; sedating ECT may be effective fr the lder patient wh is unable t tlerate medicatins r wh is nt respnding t medicatins. ECT causes transient memry lss. References Alexpuls, G. (2005). Depressin in the Elderly. The Lancet; 365: Areán, P.A., & Ck, B.L. (2002) Psychtherapy and cmbined psychtherapy/pharmactherapy fr late life depressin. Bilgical Psychiatry; 52:293. Ba, Y., Pst, E.P., Ten, T.R., et al. (2009). Achieving effective antidepressant pharmactherapy in primary care: the rle f depressin care management in treating latelife depressin. Jurnal f the American Geriatric Sciety; 57:895 Beyer J. (2007). Managing Depressin in Geriatric Ppulatins. Annals f Clinical Psychiatry; 19(4): Bruce, M.L., Ten Have, T.R., Reynlds, C.F. et al. (2004). Reducing suicidal ideatin and depressive symptms in depressed lder primary care patients: A randmized cntrlled trial. Jurnal f the American Medical Assciatin; 291:1081. Delgad-Guay, M., Parsns, H., Li, Z., et al. (2009). The assciatin between anxiety, depressin, and physical symptms in patients with advanced cancer. Supprt Care Cancer; 17: Hyl, M.T., Alessi, C.A., Harker, J.O., et al. (1999). Develpment and testing f a five-item versin f the Geriatric Depressin Scale. Jurnal f the American Geriatric Sciety; 47:873. Licht-Strunk, E., Van Marwijk, H.W., Hekstra, T., et al. (2009). Outcme f depressin in later life in primary care: Lngitudinal chrt study with three years' fllw-up. British Medical Jurnal; 338:a3079.

7 Llyd-Williams, M., Dennis, M., & Taylr, F. (2004). A prspective study t determine the assciatin between physical symptms and depressin in patients with advanced cancer. Palliative Medicine; 18: Pinquart, M., Duberstein, P.R., & Lyness, J.M. (2006). Treatments fr later-life depressive cnditins: a meta-analytic cmparisn f pharmactherapy and psychtherapy. American Jurnal f Psychiatry; 163:1493. Sjösten, N., Kivelä, S.L. (2006). The effects f physical exercise n depressive symptms amng the aged: a systematic review. Internatinal Jurnal f Geriatric Psychiatry; 21:410. Thielke, S.M., Fan, M.Y., Sullivan, M., & Unützer, J. (2007). Pain limits the effectiveness f cllabrative care fr depressin. American Jurnal f Geriatric Psychiatry; 15:699. Vignarli, E., Pace, E., Willey, J., et al. (2006). The Edmntn Symptm Assessment as a Screening Tl fr Depressin and Anxiety. Jurnal f Palliative Medicine; 9: