A Basic Approach to Mood and Anxiety Disorders in the Elderly November 1 2013 Sarah Colman MD FRCPC Clinical Fellow, Geriatric Psychiatry Mount Sinai Hospital, University of Toronto
Disclosure No conflict of interest or commercial affiliations to declare
Objectives Appreciate the differences in symptom presentation between mood and anxiety disorders in the elderly versus younger adults Develop a framework for knowing how and when to treat and when to refer anxious or depressed patients to a specialist
Major Depressive Disorder Prevalence 14 percentage in age 65 and older 12 10 8 6 4 2 0 community nursing homes
Major Depressive Disorder Risk Factors
MCQ Clinical features of depression that are more often seen in older vs younger patients are: A) psychotic symptoms that include auditory hallucinations and persecutory delusions B) Increased interpersonal sensitivity C) Mood that is worse in the morning and improves throughout the day D) Increased sleep
Major Depressive Disorder Clinical Characteristics Melancholic features: anhedonia lack of mood reactivity severe weight loss or loss of appetite psychomotor agitation or retardation early morning awakening excessive guilt diurnal variation
Major Depressive Disorder Clinical Characteristics somatic complaints anxiety functional decline resistance to care rumination
Major Depressive Disorder Psychotic Symptoms Mood congruent delusions poverty guilt somatic
Major Depressive Disorder Psychotic Symptoms Do you feel there is something horribly wrong with you? How is your financial situation? Have you done something that you regret?
Major Depressive Disorder Suicide Rate of suicide, all Canadians, average over 2000-2007, according to age at death Age-standardized mortality rate per 100,000 population
Major Depressive Disorder Treatment Biopsychosocial approach In mild-moderate depression, psychotherapy is as effective as pharmachotherapy Combined psychotherapy and pharmacotherapy may be required Psychotherapy includes supportive stance, behavioural activation Good evidence for Cognitive Behavioural Therapy, Interpersonal Therapy, Problem Solving Therapy
Major Depressive Disorder Treatment Kok RM, Nolen WA, Heeran TJ 2012
Medication SSRIs citalopram/ escitalopram Major Depressive Disorder Side effects specific to older patients hyponatremia Treatment Specific indications Dose range prolonged QT C: start 5-10, max 20 E: start 5, max 10. sertraline GI effects good first choice start 25, max 200 mirtazapine venlafaxine duloxetine buproprion generally use SR or XL noradrenergic at higher doses noradrenergic at higher doses activating, can increase agitation weight loss, poor sleep agitated depression (anecdotal) pain often used as an augmenting agent fewer sexual side effects start 7.5, max 45 start 37.5, max 300 start 20-40mg, max 120mg start 100/150mg, max 200bid (SR) or 450mg od (XL) TCAs and MAOIs work, but a psychiatrist should be involved when they are prescribed.
Major Depressive Disorder Treatment Start low, go slow, AIM HIGH. Good trial = therapeutic dose for at least 8 weeks. Maintenance > 6 months. Stanton and Kohn 2012
MCQ The following would be acceptable treatment for depression with psychotic features, EXCEPT: a) adequate dose of SSRI + 50mg quetiapine B) adequate dose of SNRI + 1.5mg risperidone C) adequate dose of TCA + 15mg olanzapine D) ECT
Major Depressive Disorder Treatment psychosis Medication Quetiapine Olanzapine Risperidone Aripirazole/ Asenapine Typical Antipsychotics (haloperidol) Side effects specific to older patients At antipsychotic doses, orthostatic hypotension, sedation, anticholinergic Metabolic side effects, anticholinergic Extrapyramidal effects Specific indications insomnia, parkinsonian features Can be given IM Can be given as a depot Purportedly less SEs Newer, so less evidence Depending on potency, EPS vs. anticholinergic Can be given IM Dose range start: 12.5-25mg. max: 400mg- 1200mg for antipsychotic effect start: 5 mg Max: 20mg start: 0.5 mg, max: 2-4 mg H: start: 0.5mg max 10mg
Major Depressive Disorder Treatment - psychosis ECT consider early! better tolerated than medications fast acting Side effects of ECT Short term memory loss Headache Risk of general anesthesia Side effects of antipsychotics falls, stroke, sudden death EPS dystonia, parkinsonism, TD Metabolic derangement Polypharmacy
Bipolar Disorder Prevalence
Bipolar Disorder Clinical Characteristics May have longer episode durations, more frequent episodes Less likely to have a family history of bipolar disorder Often have had previous depressive episodes, often with long latency period before first mania
Bipolar Disorder Clinical Characteristics New onset mania in older person: neurologic trauma right sided brain lesion in basal ganglia, thalamus, limbic aspects of frontal and temporal lobes. decreased cognitive function medication effects
MCQ The correct blood level of Li in a patient over 65 is: A) 0.8-1.2 B) 1.2-3.0 C) 0.5-0.8 D) Lithium is unsafe in the geriatric population and should be discontinued.
Bipolar Disorder Treatment* More likely to develop cognitive side effects to lithium [Li] 0.5-0.8 = dose of Li (150mg-600mg per day) Take a trough level 12 hours after last dose. More likely to develop extrapyramidal side effects, orthostatic hypotension and falls If treating depression with an antidepressant, there should be concurrent treatment with a mood stabilizer. *REFER!
Anxiety Disorders Prevalence 3.2-14.2% prevalence as age
Anxiety Risk Factors
MCQ Panic attacks in older patients: A) are more common than in younger patients B) are often secondary to medical problems C) are often in the context of a major depressive episode D) B and C E) all of the above.
Anxiety Clinical Characteristics Physical autonomic response panic attacks Psychological worries about family and finances worries about physical problems hoarding fear of falling Terminology somatic words
Anxiety Medical Comorbidities GI, hyperthyroidism, diabetes, Parkinson s Mortality after heart surgery Panic attacks associated with increased cardiovascular morbid and mortality Cardiac problems, respiratory conditions, vestibular problems secondary and cyclical anxiety
Anxiety Disorders Treatment How they are being treated: 25.3% prescribed benzodiazepines vs. 3.8% prescribed antidepressant. If using a benzodiazepine, regular dosing and LOT
Anxiety Disorders Treatment How they should be treated: Antidepressants: citalopram/escitalopram (QT issue), sertraline, venlafaxine. CBT
Take Home Points! Lower prevalence of mood and anxiety disorders in the elderly Depression often has melancholic features Mood congruent psychosis Ask high yield questions, refer, think about ECT Screen for suicidality in your older, depressed, medically ill male patients. Antidepressants start low, go slow but AIM THERAPEUTIC DOSE New onset mania likely a brain injury of some kind Lower dose and level of Li and other mood stabilizers. Anxiety prescribe antidepressants, not benzodiazepines. If new onset anxiety in older person, rule out medical conditions AND treat the anxiety.