Depression Flashcards
prevalence
-aged over 65- 10-15%
Depressive disorders in hospitalised patients
-2-3x more common in hospitalised patients, nursing home residents or outpatients with chronic medical disorders
Medical disorders
- Cardiovascular disease
- CNS disease
- Cancer
- all associated with high risk for depression
Depression in dementia
-25%
Racial differences
- elderly african americans have been noted to have less depression than elderly caucasians
- may be due to communities
Clinical features
- low mood is less prominent in depression affecting patients in old age
- hypochondriasis or deluisons are common
- poor memory
- late onset neurotic symptoms
- apathy and poor motivation may predominate
- anorexia, weightloss and anergia
- paranoia and delusions
Risk factors for late life depression
- female sex
- poor health
- disability
- poor perceived social support
Neuroimaging studies in late onset depression
- includes ischemic changes, reduction in grey matter volume in frontal and temporal lobes
- sulcal widening
- reduction in the volume of the caudate nucleus
- ventricular enlargement
- reduction in volume of the hippocampus
CT
-cortical atrophy and ventricular enlargement
MRI
- atrophy
- ventricular enlargement
- lesions in basal ganglia
SPECT
-reduced cerebral blood flow, sparing the posterior parietal cortex
Antidepressants
- response rate is comparable to younger adults
- NNT=4
- lower doses should be used initially
- needs long maintenance period
- SSRI is first line
SSRIs
- can cause GI haemorrhage
- can induce hyponatraemia
- takes 6-8 weeks to respond to antidepressants
- 30% do not respond
ECT
- remains the most effective treatment available for severe depression
- recovery rate is 80%
- well tolerated in the elderly
- memory impairment is worse with bilateral electrode lacement
Psychological intervention
- rarely offered
- but may be as effective as medication
- combination of antidepressants and psychotherapy is more effective than the single use of either
- CBT is very good
- interpersonal therapy is good for relapse prevention
Prognosis
- older adults are thought to be at greater risk for chronicity of depression than younger persons
- may not actually be any different in rate of remission but relapse rates are higher
Mortality
- higher in older patients with depression because of concurrent physical disorders
- depression exacerbates the poor outcome of medical illnesses
- 4x more likely to die within 4 months of an MI than those without depression
Risk of CV disease
- platelet aggregation is raised in depressed patients
- depression may increase the risk of CV disease
Inflammatory markers in depression
- poor T-cell responses to mitogens
- high concentrations of plasma interleukin 6
- these increase risk for bone resporption and predispose for fractures
Geriatric depression scale
- 15 items
- score of over 5 suggests depression
BASDEC
- brief assessment schedule depression cards
- true or false answers
- designed for liaison psychiatry
Hamilton rating scale
- has a number of somatic items
- less appropriate for older subjects
MADRS
- sensitive to change in depressive illness
- not reliably answered by patients with dementia
Depressive sign scale
-nine items to help detect depression in people with dementia
CSDD
- cornell scale for depression in dementia
- best valadated scale for detecting depression in dementing patients
Patient health questionnaire
- PHQ-9
- 9 item self-report scale widely used in UK primary care
- easy use has demonstrated sensitivity to change
- less validated among older older subjects
Cognitive impairment in depression
- deficits in attention and executive dunctions seen in late onset depression
- pseudodementia occurs
- 40% develop true dementia within 3 years of follow up
Vascular depression
- cerebral ischemic damage to the frontal subcortical circuits could predispose, precipitate and perpetuate late onset depression
- vascular risk factors were found to be highly significantly associated with late onset depression
- affected individuals have more apathy, retardation and lack of insight with less agitation
Deep white matter lesions
- more common in depressed than non-depressed older people
- more common in late onset than early onset depression
- seen on MRI
