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1 Presenter disclsures DEPRESSION IN THE ELDERLY Synergize March 3, 2016 Dallas Seitz, MD PhD FRCPC Department f Psychiatry, Queen s University Prvidence Care MHS Faculty: Dallas Seitz Relatinships with cmmercial interests: NONE Ptential fr cnflict(s) f interest: NONE Objectives 4 1. Review the epidemilgy f depressin in lder adults. 2. Describe the presentatin f depressin in lder adults. 3. Develp an apprach t the management f depressin in lder adults and review recent develpments in treatment ptins. OBJECTIVE 1: EPIDEMIOLOGY OF DEPRESSION IN OLDER ADULTS 1

2 Case presentatin Hw cmmn is depressin? Mrs. A presents t yur clinic tday with her daughter, wh is wrried her mther might be depressed: Mrs. A is 75 years ld Retired Nurse Lives independently at hme Mre details t cme Prevalence: Depressive symptms in cmmunity up t 28.7% Lifetime prevalence MDD in age > % 5-10% in primary care settings 12-45% within hspitals Up t 37% after hspitalizatin fr critical illness Up t 40% in LTC 5 Kessler 2005 Glasmaer 2011 Taylr 2014 Lyness 1999 Jacksn 2014 CCSMH Prevalence Risk factrs Depressin is under reprted Cnsidered a nrmal cnsequence f ageing Stigma Race Depressin is under diagnsed C-mrbid medical illness: symptm verlap Nt reprted Depressin is under treated Cnner 2010 Lyness Female gender Sleep disturbance Prir depressin Cgnitive impairment New medical Illness Pr self-rated health Disability Stressful life events Bereavement Alchl use 8 Cle 2003 Chang-Quan 2010 CCSMH guidelines 2

3 Medical cmrbidity and depressin Impact f depressin Medical cnditins assciated with MDD Ischemic Heart Disease Diabetes Arthritis/pain Strke Parkinsn s disease Dementia Hip fractures Respiratry disrders Patten Health related cnsequences: Increased perceived pr health Pr functin Nn-adherence t medical treatments Cgnitive decine Increased mrtality Health ecnmic cnsequences: Utilizatin f Medical Services Increased health care csts Beekman Mre n Mrs. A OBJECTIVE 2: PRESENTATION OF DEPRESSION IN OLDER ADULTS Her daughter tells yu Mrs. A is: Withdrawn and has stpped ging t church Spends much time in bed Has lst weight Has been mre frgetful Has been self-deprecating, and at times saying the wrld wuld be a better place withut me Her past medical histry is significant fr DM II, HTN, and she was recently diagnsed with CHF and mderately severe CKD She als suffers frm neurpathic pain 12 3

4 Differential? Differential Delirium (especially hypactive) Pain r discmfrt Other medical causes Envirnmental causes Apathy assciated with dementia 13 Sink, JAMA, 2005 Differential Screening tls Medicatin use ptentially related t depressin: Medical cnditins ptentially related t depressin: 16 Alexpuls, Lancet,

5 PHQ-9 GDS (SF) Crnell Scale fr Depressin in Dementia DSM-5 criteria fr MDD 5 f the fllwing symptms; same 2-week perid; represent a change frm previus functining; at least ne f the symptms is either (1) depressed md r (2) lss f interest r pleasure. Depressed md Markedly diminished interest r pleasure Significant weight lss r decrease r increase in appetite Insmnia r hypersmnia Psychmtr agitatin r retardatin Fatigue r lss f energy Feelings f wrthlessness r excessive r inapprpriate guilt Decreased cncentratin, r indecisiveness Recurrent thughts f death (nt just fear f dying) r suicidal ideatin 20 5

6 Features f late life depressin Depressin and cgnitin Depressed md may be less prminent Mre anxiety Mre likely t express smatic cmplaints 65% have hypchndriacal symptms Cgnitive impairment Psychsis mre cmmn Less likely t have family histry f depressin Alexpuls, Relatinship t dementia: each increases risk f the ther Cncept f vascular depressin Greater disability Mre cgnitive impairment Brain imaging: lateral ventricles mre enlarged Mre white matter intensities Tempral lbe atrphy Effect f depressin n cgnitin Memry, verbal learning Especially n tasks invlving fcused attentin, verbal learning, wrking memry Beekman 2013 Saczynski 2010 Bayer 2011 Olesen Mrs. A? OBJECTIVE 3: DEVELOP AN APPROACH TO MANAGEMENT Anything else yu want t knw? Any tests yu wuld rder? 6

7 Assessment Assessment Past psychiatric histry Depressin, biplar disrder (r histry f manic type episdes), anxiety, suicide attempts Histry f treatment respnse Past Medical Histry: Screen fr diseases that may increase risk f depressin (e.g. Parkinsn s disease, strke) r that may be affected by treatment Review medicatins fr ptential cntributing causes and ptential drug interactins if treatment is initiated Screen fr cgnitive impairment What type f prblems, if any? Clarify timeline In thery, cgnitive changes assciated with depressin are reversible but Obtain cllateral Labs Rutine, especially: TSH, B12: rule ut cntributing causes Cnsider ECG, lytes Nutritinal status BP Blazer, 2003 Management Management: what d guidelines say? Guidelines Nnpharmaclgical Pharmaclgical Nn-pharmaclgical Supprtive care shuld be ffered t all Psychtherapy is a first line ptin alne r in cmbinatin Based n type f depressin (and severity), cping style, cgnitin Pharmaclgical Mild-mderate: antidepressants, psychtherapy r cmb Severe: cmbinatin; cnsider ECT CCSMH,

8 Nn-pharmaclgical treatments Psychtherapy Strngest evidence fr Cgnitive Behaviural Therapy (CBT) and Prblem Slving Therapy (PST) Interpersnal Therapy (IPT) Usually weekly visits fr 8-12 weeks Access, presence f cgnitive impairment, patient mtivatin all ptential barriers Evidence fr PST PATH (prblem slving apprach + caregiver participatin) in lder adults with cgnitive impairment ranging frm mild deficits t mderate dementia 37.8% vs. 13.5% remissin rate cmpared t supprtive therapy in a RCT 66.7% vs. 32.3% respnse rate Dementia r depressin severity at baseline nt significant mderatrs Kisses, JAMA Psychiatry, 2015 Nn-pharmaclgical Treatments Pharmaclgical treatments Electrcnvulsive Therapy (ECT) Cnsider if: Medical refractry/resistant/intlerant Severe suicidal risk Fd/fluid refusal Psychtic depressin Depressin with mtr symptms (e.g. catatnia) Gd respnse rates in lder adults, as well tlerated as in yunger adults Transcranial Magnetic Stimulatin Cnflicting evidence re: age influence n respnse General principles: Start lwer (usually half f dse used in yunger adults) G slwer (but g!) Aim t reach target dse in ne mnth Use lwer max dse in mst cases Mnitr treatment respnse and d nt cntinue ineffective medicatins CCSMH,

9 Pharmaclgical Treatments Respnse rates First line: SSRIs Effective in sme but nt all trials Generally effective in larger trials Respnse rates 35-60% vs % with placeb Parxetine effective in trials but usually avided due t increased antichlinergic side effects Citalpram, escitalpram, sertraline generally used first due t tlerability Check sdium Secnd line: SNRIs Venlafaxine and dulxetine NEJM, 2014 Mulsant et al. Clin Geriatr Med, 2014 Remissin rates Pharmaclgical treatments Other ptins (3 rd line, r augmentatin) Buprpin XL Mirtazapine TCAs As effective as SSRIs, but mre side effects Nrtriptyline Mulsant et al. Clin Geriatr Med, 2014 NEJM 2014 Mulsant, Am J Geriatr Psychiatr,

10 Pharmaclgical treatments Other Atypical antipsychtics Augmentatin nt mntherapy Aripiprazle and quetiapine Stimulants Few high quality r large cntrlled trials Lithium Supprted by evidence in lder adults but can be difficult t initiate due t side effects and need fr mnitring Treatment: hw lng? Treatment: partial r n respnse? Guidelines: In remissin after first episde: treat minimum 1 and up t 2 years frm time f imprvement Recurrent episdes: indefinite maintenance treatment LTC:?, evaluate regularly Psychtherapy Nt clear Sme evidence t supprt decreased risk f relapse (check fr PST) Guidelines If n imprvement after 2 weeks at average dse, increase further until there is sme imprvement, max dse reached, r limited by side effects *Cntrversial* Change if, at max tlerated r recmmended dse: N imprvement at 4 weeks OR insufficient imprvement at 8 weeks In general: ptimize, augment r switch, augment r switch 10

11 Flwchart Summary Treatment ften guided by practices in yunger ppulatins Limited data n efficacy and safety in lder adults Little data n lng-term treatment r maintenance strategies Little evidence t supprt practice f individualizing treatment/matching side effect prfile t symptms Cmparable efficacy f all antidepressants acrss the lifespan Apprach with therapeutic ptimism Blazer, 2004 CCSMH, 2006 Mulsant, 2014 Update n recent evidence Stepped care apprach vs. usual care IMPACT Antidepressant r PST switch cmbine antidepressant and PST PROSPECT Optimize dse switch t citalpram augment with buprprin switch t venlafaxine augment with mirtazapine, nrtriptyline, *same eligibility criteria in study and usual care grups 1. Gldwasser, Int J Aging Hum Dev, Buettner L, Am J Alz Dis Other Dement, Buettner L, Am J Alz Dis, week RCT in 143 geriatric utpatients with majr depressin (N = 143) 3 treatment grups: Citalpram 20-60mg Methylphenidate 5-40mg Methylphenidate + citalpram Depressin significantly imprved in all grups Greater and faster imprvement in cmbinatin grup N differences in cgnitive utcmes Am J Psychiatry,

12 Depressin in Dementia (DpD) 12- week RCT f aripiprazle augmentatin f venlafaxine in depressed adults >60 years ld (N = 181) Pre-trial treatment (N = 468) with at least 12 weeks f venlafaxine ( mg/day) Patients wh did nt achieve remissin randmized t aripiprazle (10-15mg/day) r placeb Greater prprtin achieved remissin in aripiprazle grup 44% vs. 29% (p=0.03) Akathisia (26%) and Parkinsnism (17%) mst cmmn side effects Lancet, September 2015 (nline) NIMH prvisinal criteria Tw week perid f three r mre symptms: Depressed md Decreased psitive affect r pleasure in respnse t scial cntacts and usual activities Disruptin f sleep and/r appetite Psychmtr changes Irritability Fatigue r lss f energy Feelings f wrthlessness, hpelessness, r excessive guilt Recurrent thughts f death, suicidal ideatin r plan Psychlgical Treatments fr DpD 6 randmized cntrlled trials 1 Based n varius mdels (CBT, IPT, cunseling) N effect n secndary utcmes, such as ADLs, quality f life, cgnitin, r caregiver depressin 1. Ortega, B J Psych, 2015 Antidepressants fr DpD 2 meta-analyses f antidepressants fr depressin in dementia failed t find statistically significant benefits ver placeb: Nelsn et al (N=7 studies): Respnse OR: 2.12 ( ) Remissin OR: 1.97 ( ) Adverse event rates relatively lw: 9% vs. 6% with placeb Bains et al 2 (N=4 studies) Weak supprt fr efficacy f antidepressants 11RCTs 5 psitive, 6 negative studies Nelsn, J Am Geriatr Sc, 2011 Bains et al., Cchrane Syst Rev, 2002 Enach, Curr Op in Psych,

13 Challenges: DpD Thanks Can be difficult t assess and diagnse Overlap between symptms f dementia and depressin Limited rle fr psychlgical therapies in individuals with cgnitive impairment Incnsistent evidence fr pharmaclgical treatments seitzd@prvidencecare.ca References Selected references: Taylr, W. D. (2014). Depressin in the elderly. N Engl J Med, 371(13), Alexpuls, G. S. (2005). Depressin in the elderly. The lancet, 365(9475), Blazer, D.G. (2003). J Gerntl A Bil Sci Med Sci, 58(3): CCSMH Natinal Guidelines fr Senirs Mental Health: Assessment and Treatment f Depressin, May 2006 (available at ccsmh.ca) 13