DEPRESSION IN ELDERLY WOMEN

Dr Doha Rasheedy
Assistant professor of geriatric
medicine
Geriatric medicine department
Ain Shams University
Is depression a normal
response to the aging
process?
NO
EPIDEMIOLOGY
over 65
▫ 1.4% ♀ major depression
▫ 2% dysthymia
▫ 15% depressive symptoms
▫ Higher in institutional setting: Up to
25-40% in a general hospital setting
and in long term care
Effects of depression:
 Depression is associated with poorer self-care and slower recovery after
acute medical illnesses.
 It can accelerate cognitive and physical decline and leads to an increased
use and cost of health care services.
 Less effective rehabilitation
 Lower quality of life, higher level of chronic pain, and increased disability
(is the fourth leading cause of disability in the United States).
 The mortality rate coincided with the level of depression even when
controlling for other factors.
DSM-IV DIAGNOSTIC CRITERIA FOR MAJOR
DEPRESSION
•Gateway symptoms (must have 1)
• Depressed mood
• Loss of interest or pleasure (anhedonia)
•Other symptoms
• Appetite change or weight loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Loss of energy
• Feelings of worthlessness or guilt
• Difficulty concentrating, making decisions
• Recurrent thoughts of suicide or death
SYMPTOM DESCRIPTION
1) Depressed mood and/or lack of interest or pleasure in usual activities
• The older adults may be more likely to express a loss of pleasure than to
specifically complain of depression
2) Feelings of worthlessness or inappropriate guilt
• Less common in older adults than in younger adults
3) Diminished ability to concentrate or make decisions
• Often manifested as a complaint of memory problems—adults of all ages
with moderate-to-severe depression complain of problems with
concentration and memory, but depressed elders, in contrast to younger
adults, exhibit impairment on psychological testing even when they do not
have a comorbid dementing disorder
4) Fatigue Common regardless of age
5) Psychomotor agitation or retardation
• Older persons may exhibit either of these symptoms
6) Insomnia or hypersomnia Older persons rarely, if ever, exhibit
hypersomnia—a symptom that is much more common in adolescence and
young adults
7) Significant decrease or increase in weight or appetite
• Older adults rarely gain weight or experience an increase in appetite during
a depressive episode
8) Recurrent thoughts of death or suicidal ideation
• Although thoughts of death are not uncommon in older adults, suicidal
ideation among depressed elders is less frequent than among the depressed
who are younger but more risky.
Types of depression
• older adult should exhibit most of the time for at least 2
weeks one or both of two core symptoms—depressed
mood and/or lack of interest or pleasure in usual
activities—along with four or more of the other
symptoms (major depression)
• subjects must experience one of the core symptoms for
major depression plus one to three additional
symptoms (minor depression)
• Primary depression is not triggered by any other
psychological or medical cause. Rather, this type of
depression is triggered by psychological instability,
genetic predisposition.
• Secondary depression is caused by one or more negative
life events such as illness, this kind of depression is
triggered by a medical condition as thyroid gland
disorder and by a psychiatric illness as schizophrenia.
Depression is under-reported: WHY?
• Communication issues (eg. hearing
impairment)
• Presence of dementia
▫ Symptom overlap
• Stigma of aging
▫ Depression is “normal”
• Symptoms “masked” by co-morbid illness

THEREFORE YOU MUST SCREEN IN

THOSE AT HIGHER RISK!
Geriatric Depression Rating Scale:

• This is a screening tool for depression, but

it does not diagnosis depression. It is a 30
item form with a rating score of 10 –19
points indicating mild case and > 20
points indicating a severe case.
• A short form of 15 questions is also used.
What are risk factors for depression
in the elderly?
• Recently bereaved
• Female gender
• Single/widowed (recently)
• Stressful life events (eg. prolonged
hospitalization, recent move to nursing home)
• Social isolation
• Persistent complaints of memory difficulties,
diagnosis of dementia
• Chronic disabling illness or recent major
physical illness (eg. Parkinson’s disease,
stroke), medications
• Chronic sleep problems or anxiety
• Genetics
 Does depression look different in
the elderly?
• “Depressed mood” may be less prominent
• More anxiety
• More likely to express somatic complaints
▫ 65% have hypochondriacal symptoms
• Less likely to report guilt feelings
• Cognitive impairment more common
• Psychosis more common
▫ Typical delusions – more common
 Somatic, persecution, nihilism, poverty
DIAGNOSIS IN OLDER PATIENTS IS DIFFICULT
BECAUSE THEY
1. More often report somatic symptoms

2. Less often report depressed mood, guilt

3. May present with “masked” depression cloaked

(coated) in preoccupation with physical concerns
and complicated by overlap of physical and
emotional symptoms
 Physical Disorders Associated with Depression
Addison’s disease hyperparathyroidism
Acquired immunodeficiency Influenza
syndrome Intracranial tumors (malignant or
Angina benign)
Cancer (particularly of the Multiple sclerosis
pancreas, ovary) Myocardial infarction
Cerebral arteriosclerosis, cerebral Parkinson’s disease
infarction Pernicious anemia
Cushing’s disease Porphyria
Diabetes Renal disease
Electrolyte abnormalities (e.g., Rheumatoid arthritis
hypernatremia, hypercalcemia, Senile dementia
hypokalemia, hyperkalemia) Syphilis
Folate and thiamine deficiencies Systemic lupus erythematosus
Hepatitis Temporal arteritis
Hypoglycemia Temporal lobe epilepsy
Hypothyroidism, Viral pneumonia
hyperthyroidism,

Cardiovascular drugs
Clonidine (Catapres)
Digitalis
Hydralazine (Apresoline)
Methyldopa (Aldomet)
Procainamide (Pronestyl)
Propranolol (Inderal)
Reserpine (Serpasil)
Thiazide diuretics
Chemotherapeutics
6-Azauridine
Azathioprine (Imuran)
Bleomycin (Blenoxane)
Cisplatin (Platinol)
Cyclophosphamide (Cytoxan)
Doxorubicin (Adriamycin)
Mithramycin (Mithracin)
Vinblastine (Velban)
Vincristine
Hormones
Adrenocorticotropin
Anabolic steroids
Glucocorticoids
Oral contraceptives
Medications That May Cause Depression
Antiparkinsonian drugs Anti-inflammatory/
Amantadine (Symmetrel) anti-infective agents
Bromocriptine (Parlodel) Ampicillin
Levodopa (Larodopa) Cycloserine (Seromycin)
Antipsychotic drugs Dapsone
Fluphenazine (Prolixin) Ethambutol (Myambutol)
Haloperidol (Haldol) Griseofulvin (Grisactin)
Sedatives and antianxiety drugs Isoniazid (INH)
Barbiturates Metronidazole (Flagyl)
Benzodiazepines Nalidixic acid (NegGram)
Chloral hydrate Nitrofurantoin (Furadantin)
Ethanol Nonsteroidal anti-inflammatory
Anticonvulsants agents
Carbamazepine (Tegretol) Penicillin G procaine
Ethosuximide (Zarontin) Streptomycin
Phenobarbital Sulfonamides
Phenytoin (Dilantin) Tetracycline
Primidone (Mysoline) Stimulants
Other drugs Amphetamines (withdrawal)
Cimetidine (Tagamet) Caffeine
Disulfiram (Antabuse) Cocaine (withdrawal)
Methysergide (Sansert) Methylphenidate (Ritalin)
Phenylephrine (Neo-Synephrine)
Physostigmine (Antilirium)
Ranitidine (Zantac)
Metoclopramide (Reglan)
Medical Conditions Mask or Cause
Depression
• Autoimmune
• DRUGS
• Cerebrovascular
▫ Propranolol
• Chronic pain
▫ Cimetidine
• Degenerative
▫ Clonidine
Disease
▫ Benzodiazepines
• Endocrine
▫ Steroids
• Metabolic
▫ Tamoxifen
• Neoplasms
▫ Many more...
• Infections
DIFFERENTIAL DIAGNOSIS
•Medical illness can mimic depression
• Thyroid disease, conditions that promote apathy
•Dementia has overlapping symptoms
Bereavement is different because:
• Most disturbing symptoms resolve in 2 months
• Not associated with marked functional impairment
• Delirium (hypoactive type)
• Other comorbid psychiatric illnesses must also be considered, such as
anxiety disorder, substance abuse disorder, or personality disorders
• Chronic fatigue syndrome
• Substance-Induced Depression
 • Is it Depression or Dementia?
Symptoms of Symptoms of Dementia
Depression
• Mental decline is rapid
Knows the correct time, date
Difficulty concentrating
Language and motor skills are slow,
but normal
Notices or worries about memory
problems
*Mental decline happens slowly
Confused and disoriented; becomes lost in
familiar locations
• Difficulty with short-term memory
• Writing, speaking, motor skills are
impaired
Doesn’t notice memory problems or seem to
care
Pseudodementia
“dementia of depression”
• cognitive decline that clears if depression is
treated
• however, dementia rate in these patients is still
20%/year even after full recovery of intellectual
function.
ASSESSMENT
1-History:
• Medical disorders
• medications
• psychiatric diseases, alcohol, substance abuse
• cognitive impairment
• social factors, stressful life events
• symptoms suggesting depression. asking about a history of
mania, suicide
• Obtaining a corroborating history from confidants or family
members is highly recommended
• Functional ability/level of care Any recent changes in ADL’s /
IADL’s
ASSESSMENT
• Social history/ Personal history(include interests
and hobbies)
• Any stressors (past/new)
2-Screening tool:
• Geriatric Depression Rating Scale
• Mini- Mental Status Exam
3-medical work-up (includes blood work,
urines, CT Scan, X-Rays etc..)
INTERVENTIONS
• Seek out medical illness
• Recognize medical side effects
• Rehab services to maximize remaining function
and retrain impaired iADL’s
• Involve family and caretakers
• Counselling: role transitions, grief, dependency
• Medications / ECT
TYPES OF THERAPY FOR DEPRESSION
• Psychotherapy

• Pharmacotherapy

• Electroconvulsive therapy (ECT)

MEDICAL THERAPY IN GERIATRIC
DEPRESSION
• Select based on symptoms, prior response,
concurrent illness, side effect profile
• Reassess after 4-6 weeks:
▫ Increase dose, augment with second agent, add
psychotherapy
▫ Consider psychiatric consult/referral
STEPS IN TREATING DEPRESSION
• Acute — reverse current episode

• Continuation — prevent a relapse

 Continue for 6 months

• Maintenance — prevent recurrence

 Continue for 12–18 months or indefinitely if
hospitalization was required or suicidality or psychosis
was present
 Guidelines for Switching Antidepressants:
Change if:
• No improvement in symptoms after at least 4 weeks at
maximum tolerated or recommended dose
• Insufficient improvement after 8 weeks at maximum
tolerated or recommended dose

When recovery is incomplete after an adequate trial,

consider:
• Further 4 weeks of treatment, with or without
augmentation (meds or psychotherapy)
• Switching to another antidepressant
▫ When switching, it is safe to reduce the first
medication while starting the alternate (cross-over
titration)
▫ Consider specific interaction profiles
 Long-term Treatment Guidelines:
• After 1st episode continue to treat for at least a year
• Monitor for recurrence up to 2 years
• Medication discontinuation should be slow (over
months)
• Patients with partial resolution of symptoms, more than
2 episodes, severe or difficult to treat depression, or
treatment requiring ECT, should receive indefinite
treatment
• Treatment response in nursing home patients should be
evaluated monthly after initial improvement, and at
quarterly care conferences and annual assessment once
remission is achieved
• Consider tolerance of treatment versus risks of
discontinuation
Generic Name Start ing Average Maximum
dose, Dose, Recommended
mg/d mg/d Dose, mg/d
SSRI
Citalopram 20-40 20 for those QTc prolongation
10 older than 65 y
40 for others
Escitalopram 10-20 10 for those QTc prolongation
5 older than 65 y
20 for others
Sertraline Modapex 25 50-150 200 Like all SSRIs, risk of nausea,
SIADH
Fluoxetine Prozac 80 Not preferred long acting,
20
need wash up duration before
add other ttt
SNRI
Venlafaxine Effexor 37.5 75– 375* Might increase blood pressure
225
deluxetine 60
cymbatex 30 Help with neuropathic
pain, stress
incontinence
Tricyclic (secondary) better than tertiary in elderly
Desipramine Norpramin 10–25 50– 300 Anticholinergic properties;
150 cardiovascular side effects;
Nortriptyline Aventyl 10–25 40– 200 monitor
100 blood levels
Tricyclic (tertiary)
Imipramine Tofranil 25 300 Anticholinergic properties;
Amitriptyline Elavil 300 cardiovascular side effects;
25 monitor
blood levels
Other
Bupropion Wellbutrin 100 100, 150, twice Might cause seizures
twice daily
daily
Mirtazapine Remeron 15 30–45 45 Might cause sedation,
especially at
lower doses
Trazodone Trittico 50 600 Sedation, orthostatic
hypotension, priapism
nefazodone serozone 50 mg 150 mg bid
bid
Methylphenidate Ritalin 2.5mg 5-10
at7am, mg at
noon
7am,
noon
MAOIs
Phenelzine Nardil Orthostatic hypotension,
Tranylcypromine Parnate hypertensive crisis, Fatal
serotonin syndrome possible if
taken with SSRI, meperidine
ANTIDEPRESSANTS TO AVIOD IN THE
ELDERLY
• Too many side effects:
• Older TCA’s:
▫ amitriptyline, clomipramine, doxepin,
imipramine, protriptyline, trimipramine
• MAOI’s:
▫ phenelzine, tranylcypromine
PREFERRED ANTIDEPRESSANTS

• SSRI’s
• fewer side effects
▫ sertraline
▫ good safety record
▫ Citalopram
▫ more expensive
▫ escitalopram
• TCA
• least expensive
▫ Nortriptyline
• Others
• activation, tremor
▫ Wellbutrin
• anxiolytic, somatic
▫ trazodone
• sleep, appetite
▫ mirtazapenine
ACCEPTABLE ANTIDEPRESSANTS
• TCA • Sedation,
▫ Desipramine hypotension

• HCA
▫ Trazodone • cognitive slowing

• SNRI • Dizzy, anorexia,

▫ Effexor nausea, BP increase
What are side effects of TCA’s?

• Anticholinergic
• Orthostatic hypotension
• Sedation
• Cardiotoxicity

Which TCA’s might you use in the elderly?

• Nortriptyline (least alpha-adrenergic blockade)
• Desipramine (least anticholinergic)
Anticholinergic side effects of TCA’s

• Dry mouth
• Urinary retention
• Constipation
• Blurred vision
• Confusion
Other Drugs
• Newer atypical anti-psychotics:
▫ for behavior issues
▫ Risperdal (risperidone), Seroquel (quetiapine),
Zyprexa (olanzapine)
• Psychostimulants
▫ for severe apathy
▫ Methylphenidate (Ritalin)
 The SSRI’s

• Paroxetine (Paxil) - most anticholinergic, short

half-life
• Sertraline (Zoloft)
• Citalopram (Celexa) and Escitalopram (Cipralex)
• Fluvoxamine (Luvox)
• Avoid Fluoxetine (Prozac) in seniors
- long half-life
What are the SSRI’s side effects?

• Headache
• Agitation
• Anorexia
• Nausea
• Diarrhea
• Sexual dysfunction
• Sleep loss (Insomnia)
• Hyponatremia (SIADH)*
• EPSE*
Side effects of “other” antidepressants
• Serotonin-norepinephrine reuptake
inhibitors:
Venlafaxine (Effexor)
▫ Elevated blood pressure
• Norepinephrine-dopamine reuptake
inhibitor:
Bupropion(Wellbutrin)
▫ Seizures
▫ Anxiety
▫ Least sexual dysfunction
• Serotonin antagonist:
Mirtazapine(Remeron)
▫ Sedation
▫ Weight gain
Guidelines for Starting Antidepressants:
“Start low, go slow”
• Start at half the dose of younger people
• Aim to reach an average dose at one month
 PROGNOSIS?
• Similar response rates to younger
patients
Other Treatments
• Counseling
• Electro-convulsive therapy (ECT)
• Support Groups
• Day Hospital Treatment programs
• Social/ Community groups
• Combination of medications and above
items
• Volunteer work
• Hobbies
• Pet therapy
Other Treatments
• Music therapy
• Humor therapy
• Reminiscence
• Depression education
• Bereavement therapy
Electroconvulsive Therapy
• Relatively safe (complication rate 1 in 1400
treatments, mortality rate 1 in 10,000)
• Effective - about 80% respond, although this
drops to 50% if all other modalities have been
tried
• Particularly useful for active suicidal ideation,
psychotic depression, Parkinson’s-related
depression, and for medication failures
• Very effective short term, but with high relapse
rates over next 6-12 months.
• Drug therapy can reduce relapse
PSYCHOTHERAPY

• Cognitive-behavioral therapy (CBT), problem-

solving therapy (PST), and interpersonal
psychotherapy (IPT) are effective treatments for
major depression either alone or in combination
with pharmacotherapy.