Are All Older Adults Depressed? Common Mental Health Disorders in Older Adults Cherie Simpson, PhD, APRN, CNS-BC Myth vs Fact All old people get depressed. Depression in late life is more enduring and difficult to treat than depression at younger ages. Depression in late life is typically due to psychological factors. If an older person does not look depressed, he/she does not feel depressed. If an older person looks depressed, he or she must feel depressed. 1
Objectives Gain knowledge: of the common mental health disorders in the older adult on how mental health disorders impact the older adult. on common pharmacological approaches and not so common non-pharmacological treatments on the challenges in treatment of mental health disorders in older adults Significance of Mental Health Disorders in the Aging Adult 2
Significance: Mental Health Problems in Aging Adults 1 out of 5 people age 55 years or older experience some type of mental health concern Mood disorders (such as depression and bipolar) are among the most common conditions Depression is the most prevalent mental health condition among older adults More than 50% of nursing home residents have some form of cognitive impairment Impact of Mental Health Disorders Mental health issues (particularly depression) are a risk factor for suicide Older men have the highest suicide rate of any group Men > 85 years have a suicide rate of 45.23 per 100,000 vs. overall rate of 11.01 per 100,000 Untreated or undertreated mental health problems adversely affect physical health and ability to function 3
Depression in the Older Adult Not normal aging! * DSM 5 = Diagnostic and Statistical Manual for Mental Disorders 5th Edition DSM 5: Major Depressive Disorder (Depression) A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 3. Significant unintentional weight loss/ gain, or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. 4
Depression in the Elderly Hypochondria features, agitation, suspiciousness or frank paranoia Elderly less likely to report being sad 9 Young Depression in Young vs. Old Adults Emotional sx Hopelessness, uselessness and helplessness Negative toward self Insomnia Eating disorders Verbal expression of SI Passive means of suicide (Miller, 2009) Elderly Cognitive & physical sx Apathy, exaggeration of helplessness Emptiness, loss of interest, social withdrawal Hypersomnia, early AM wakening Anorexia, wt loss Less talk of SI > more successful and violent means 10 5
Differentiating Depression, Delirium, & Dementia Onset Duration/ Attention Psychomot Mood Psychotic Course Span or activity features Depression gradual Persistent, normal decreased depressed rarely improves with treatment Delirium sudden short decreased Increased Normal to hallucinatio or anxious ns decreased Dementia insidio Slowly normal Normal to Normal, Paranoid us progressive decreased apathy delusions common Treatments for Depression First line: SSRI (Selective Serotonin Reuptake Inhibitor) Examples are Prozac, Zoloft, Celexa, Lexapro, Viibryd SNRI (Serotonin-norepinephrine reuptake inhibitors) Examples are Cymbalta and Effexor Remeron Wellbutrin (increases norepinephrine) 6
Treatment of Depression Non medication interventions New ideas Psychotherapy: Transcranial magnetic important even with stimulation medication!! Genetic testing Exercise and diet L-methylfolate Increased socialization Education about depression Anxiety Common symptoms Fearfulness Difficulty thinking, speaking, forming thoughts Persistent, excessive, and unrealistic worry May have physical problems such as dizziness, weakness, poor appetite, excessive appetite, restlessness May have panic attacks 7
Non Pharmocological Treatment for Anxiety Talk therapy Cognitive-behavior therapy: helps to identify and challenge the negative thinking patterns Exposure therapy: Confront fears in a safe, controlled environment Treatment for Anxiety Antidepressants: SSRI, Remeron, SNRI Benzodiazepines: Ativan, Xanax are short acting Clonazepam and Valium are longer acting In seniors watch for gait disturbance, delirium, psychosis, increased depressive symptoms. Cannot be stopped. Must be tapered to prevent discontinuation syndrome Buspar: Sometimes it works, sometimes it doesn t. May take a few weeks to be effective. 8
Benzodiazipines Use initially until antidepressant works Choose shorter acting lorazepm Alprazolam most abused Watch for paradoxical effect DSM 5: Bipolar I Disorder Characterized by a MANIC episode Abnormally/persistently elevated, expansive or irritable mood, increased goal-directed activity or energy 3 or more Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility Increase in goal directed activity Excessive involvement in activities that have high potential for painful consequence Marked impairment in social or occupational function 9
DSM 5: Bipolar II Disorder Hypomanic same characteristics as manic episode except: Period is 4 days versus a week Episode is an unequivocal change in functioning but not to the level of causing marked impairment (mania) Observable by others If psychotic features are present by definition mania DEPRESSION: occurs in both but not required for diagnosis of Bipolar I but required for Bipolar II Texas Medical Algorithm (2007) Mania or Hypomania Depression 10
DSM 5: Schizophrenia and Schizoaffective Disorder Schizophrenia - 2 or more for a month Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms (diminished emotional expression, avolition Must have ruled out schizoaffective disorder Schizoaffective disorder Uninterrupted period of illness with a major mood episode of either depression or mania with Concurrent with Criteria A of schizophrenia Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness. Proper Use of Antipsychotics FDA Approved Uses of Antipsychotics Schizophrenia Schizoaffective disorder Delusional Disorder Mood disorder (depression or mania) with psychotic features Acute Psychotic Episodes An appropriate indication for use A specific and documented goal of therapy Ongoing monitoring of the effectiveness, achievement of goal and adverse side effects Use only for the duration needed and at the lowest effective dose. CMS Schizophrenia Huntington s Disease Tourette's Syndrome 11
????? 12