CASE #1
PRACTICAL MANAGEMENT OF DEPRESSION IN OLDER ADULTS Lee A. Jennings, MD MSHS Assistant Professor Division of Geriatrics, UCLA
OBJECTIVES Epidemiology Presentation in older adults Assessment Treatment options
EPIDEMIOLOGY DEPRESSION IS COMMON Healthy, independent community-dwelling older adults have lower prevalence than general adult population Higher prevalence of depression in nursing home and hospital settings The breakdown: 6-10% primary care clinics 12-50% nursing home 30-45% inpatients Most depression treatment for older adults happens in primary care (>80%) Patients may misperceive as normal consequence of aging Depression vs. Grief
CONSEQUENCES OF DEPRESSION Depression associated with: Increased use of health care (ED, office visits, drugs, longer length of stay, cost of care) Excess disability Poor health outcomes Higher mortality Increased risk of developing dementia (AD, vascular)
SUICIDE RISK Attempt less, but complete more often ~25% of all completions Highest risk: white men age 85 or older For most, was 1 st episode of depression & had seen a doctor in last month Risk factors Hopelessness Insomnia Psychosis ETOH use Poorly controlled pain Worsening comorbid illness Social isolation, widowed Prior attempt Ask about guns
HOW DOES DEPRESSION LOOK DIFFERENT IN OLDER PATIENTS? More somatic symptoms; less depressed mood/guilt Patients with advanced physical illness may be pre-occupied with thoughts of death & worthlessness Depression in late life is more likely to become chronic with frequent relapses Extensive comorbidity increases risk of relapse Comorbid anxiety common Watch for comorbid substance use ETOH, pain meds, sleep aidesà falls, cognitive impairment, accidents Men vs. women Men: anger, irritability, apathy, ETOH abuse, less sadness Vascular depression in men
OTHER DIAGNOSES TO CONSIDER Persistent depressive disorder (dysthymia) Depressive sx on majority of days for 2 yrs, at risk for MDD Subsyndromal depression/minor depression Depressive sx but don t meet other DX criteria Common in older adults Associated with poorer outcomes, responds to treatment Vascular depression Following CVA or with chronic CNS ischemic changes, Increased risk of vascular dementia Anhedonia, apathy, executive function impairment, slowing, parkinsonism Dementia syndrome of depression Onset of cognitive sx after onset of mood sx Cognitive sx improve with mood improvement Increased risk of developing dementia
OTHER DIAGNOSES TO CONSIDER MDD with psychotic features (hallucinations, delusions) Bipolar disorder with mixed features (mania)
DEPRESSION SCREENING TOOLS 2-item screen GDS (5-item) PHQ-9 (9-item) Cornell (19-item) Sensitivity (%) Specificity (%) Inpatient Outpatient Physically ill Cognitively impaired 97 67 Unknown Yes Unknown No 94 81 Yes Yes Yes Unknown 88 88 Unknown Yes Yes Unknown 90 75 Yes Yes Unknown Yes 1) During the past month, have you been bothered by feeling down, depressed or hopeless? 2) During the past month, have you been bothered by little interest or pleasure in doing things?"
Covers the 9 DSM-V criteria for MDD Can be used to establish a diagnosis Can be used to monitor treatment response Developed for outpatient setting
GERIATRIC DEPRESSION SCALE (GDS) Yes/no format may be easier No somatic or sleep questions No question on suicidal ideation Not useful for assessing treatment response Studied in multiple settings (including inpatient) 5-item version: (2/5=positive screen) Are you basically satisfied with your life? Do you often get bored? Do you often feel helpless? Do you prefer to stay at home rather than going out and doing new things? Do you feel pretty worthless the way you are now?
OTHER ASSESSMENTS Functional assessment Social support Cognitive assessment
PRINCIPLES OF TREATMENT: MEDS VS. THERAPY Antidepressant medications and structured psychotherapies are equally effective Pharmacotherapy (alone or in combination) is recommended for moderate/severe depression Combination therapy recommended for chronic depression Late-Life Depression NEJM 2007; 357:2269-76.
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS Effective psychotherapy options include: Cognitive behavior therapy (focuses on correcting negative thought associated with depression) Problem-solving therapy (helps patients learn strategies for solving everyday problems associated with depression) Interpersonal psychotherapy (focus on interpersonal causes of depression) CBT best if have comorbid anxiety (GAD) Aerobic exercise (e.g., 12-week, group-based) 45-65% reduction in sx, benefits persist if you keep exercising Bright light (1hr early-morning BLT x 3 wks) Other social interventions (church or community groups)
COLLABORATIVE CARE FOR DEPRESSION Emphasize patient/caregiver education Non-MD mental health professionals or depression care managers Integrated psychiatric and primary care Improves outcomes Depressive sx, suicidality, physical function, quality of life, mortality for severe depression Benefits sustained at a year IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) Program
PRINCIPLES OF TREATMENT: MEDICATIONS Medication monotherapy is preferred in older adults to minimize side effects and drug interactions Start with half the dose, but usually requires titrating to full dosage to see response Treatment duration: 4-6 weeks to see response, may take 8-16 weeks Follow-up at 2 weeks to check drug tolerance Continuation of treatment to prevent relapse For 6-12 months past full remission Maintenance treatment to prevent recurrence Duration varies depending on severity Chronic therapy if 3+ episodes of depression
EFFICACY OF TREATMENT Only 50% of patients with major depressive fully respond to initial antidepressant therapy An additional 1/3 recover when Antidepressant is switched to another agent or Augmented with psychotherapy or Augmented with second agent For those who recover, 40-60% will experience a recurrence
FIRST WEEKS OF TREATMENT More depression, slower response 4 weeks is a good predictor of success of treatment at 12 weeks 1/3 non-responders 1/3 partial responders 1/3 full responders
PHARMACOLOGIC THERAPY SSRIs are first-line No more effective than TCAs but better tolerated SNRIs (venlafaxine, duloxetine) Useful if co-existing neuropathic pain Diastolic HTN Mirtazapine Good if insomnia, agitation/restlessness, anorexia/weight loss Give low dose at night, higher doses in the morning Buproprion Sustained release (Q12H) is preferred (3 different formulations) Seizure (rare, associated with IR formulation), diastolic HTN Activating, good for patients with lethargy, insomnia at high doses TCAs and MAO Inhibitors: 3 rd line, significant side-effects, used for resistant sx, best managed by psych
PHARMACOLOGICAL THERAPY Trazodone Soporific at low doses Anti-depressant at higher doses but also more anticholinergic SEs & sedation Atypical antipsychotics Adjunctive treatment for MDD that does not respond to monotherapy Not recommended as monotherapy to due increased side-effects Methylphenidate used as adjunctive therapy w/ SSRI, but increase risk of CV events
SSRIS Most drug interactions: fluoxetine, fluvoxamine, paroxetine Potent inhibitors of CYP P450 enzymes Fluoxetine Longest half-life; anorexia, nausea, agitation Paroxetine Most anticholinergic, shortest halflife (most likely to cause withdrawal syndrome) Side effects Serotonin syndrome Hyponatremia (SIADH) Sweating Sexual dysfunction Weight gain GI upset, diarrhea, anorexia CNS effects (insomnia or sedation may occur) Akathisia Enhanced physiologic tremor Long QT (citalopram 20mg) Hiemke C, et al. Pharmacology & Therapeutics. 2000;85:11-28.
SSRIS SSRI discontinuation syndrome Taper over 2-4 weeks to minimize withdrawal sx Exception: fluoxetine does not need to be tapered (long half-life) Drug-Induced Serotonin Syndrome Confusion, hyperactivity, delirium, muscle twitching, excessive sweating, diarrhea, fever risk: any combination of SSRI, SNRI, MAOI, TCA, trazodone, bupropion, mirtazapine, tramadol Linezolid (MAOI property)
PRINCIPLES OF TREATMENT: ECT ECT is an alternative for older adults who cannot tolerate medications Are not responding Have severe symptoms affecting function ECT is generally well-tolerated in older adults
ECT Highly effective treatment for MDD and mania May be first-line therapy for patients with High suicide risk Life-threatening symptoms (refusal to eat/drink) Severe sx affecting function Typically no lasting cognitive deficits Causes transient memory loss Typically 2-3 treatments/wk for 6-12 treatments Maintenance ECT for some patients
PRE-ECT RISK ASSESSMENT Low risk procedure per ACC-AHA guidelines If no major risk factors (recent MI, unstable angina, uncompensated HF, severe valvular disease, serious arrhythmia) then no testing Contraindications Intracranial masses/increased pressure Recent stroke (within 1 month) Evaluation: H&P, BMP, EKG Medical Evaluation of Patient Undergoing ECT NEJM 2009; 360:1437.
ECT COMPLICATIONS Hypertension (expected for 20-30 min post ECT) Asystole or bradycardia Myocardial ischemia (rare) Headache Transient memory loss/delirium (retrograde or anterograde) More likely with advanced age 25-50% persist > 6 mo Falls Medical Evaluation of Patient Undergoing ECT NEJM 2009; 360:1437.
PSYCHOTIC DEPRESSION Study of Pharmacotherapy of Psychotic Depression (STOP-PD) STOP-PD found 60% remission in patients who took sertraline & olanzapine over 12 weeks Combination of antidepressant + antipsychotic agent can be effective initial strategy Electroconvulsive therapy (ECT) is also effective but typically not first-line Referral to a psychiatrist