Depression Flashcards
What is the epidemiology of depression in old age?
Commonest old age psychiatric disorder 10-15% in older people generally 25-30% in residential home settings 30-35% in nursing home 40-45% in post-stroke survivors 25% of suicides are of older people Men >75 y/o historically have had the highest rates of suicide in nearly all industrialised countries- however, rates have declined M:F 3:1 well established that dementia is likely to be protective
How does illness contribute to suicide?
Illness contributes to suicide in 60-70%- higher rates in elderly males than females- especially important in the 3 months prior to death o Epilepsy o Multiple sclerosis o Huntington’s Chorea o Head injury o Peptic ulcer o Rheumatoid arthritis o Association with cancer is inconsistent
What is suicide in the elderly associated with?
Older men Widower status or bereavement Living alone, social isolation Chronic physical ill health or pain Alcohol abuse Depressive episode Seen GP in last month <70% Risk with previous attempts, planning and sleep disorders
What is the ICD-10 criteria set 1?
Abnormally depressed mood, present for most of the day and almost every day, mostly uninfluenced by circumstances, and sustained for at least 2 weeks
Loss of interest/pleasure in activities which are usually pleasurable
Decreased energy or increased fatiguability
What is the ICD-10 criteria set 2?
Loss of confidence or self esteem
Unreasonable feelings of self reproach or excessive and inappropriate guilt
Recurrent thoughts of death or suicide or any suicidal behaviour
Diminished ability to think or concentrate
Subjective or objective psychomotor retardation or agitation
Sleep disturbance of any type
Change in appetite with corresponding weight change
What is the classification for depression?
Mild- at least 2 symptoms from set 1 and additional symptom/symptoms from set 2 to give a total of least 4
Moderate- at least 2 symptoms from set 1 and additional symptoms from set 2 to give a total of least 6
Severe- all 3 symptoms from set 1 and additional symptoms from set 2 to give a total of least 8,
plus/Minus psychotic symptoms
What is used for treatment of resistant depression?
Augmentation with lithium/antipsychotics
Addition of second antidepressant
Patients with 2 prior episodes and functional impairment should be treated for at least 2 years
ECT is supported in severe and treatment resistant depression
What are the problems associated with using antipsychotics in the elderly?
Augmentation with lithium/antipsychotics
Addition of second antidepressant
Patients with 2 prior episodes and functional impairment should be treated for at least 2 years
ECT is supported in severe and treatment resistant depression
High risk: Clozapine, haloperidol, phenothiazines
Moderate risk: Second generation, sulpride
Monitoring: Pre-treatment then every 3-6 months
What are the issues of using antidepressants in the elderly?
Citalopram can reduce apathy, irritability and hallucinations
Only useful if underlying depression
Takes 6-8 works to reach full clinical effectiveness and risk of agitation/suicidal thoughts in first 4 weeks
High risk: TCAs
Moderate risk: trazodone, MAOIs
Low risk: SSRIs, mirtazapine, venlafaxine, duloxetine, aglomelatine
What are the side effects when using antipsychotics in the elderly?
Problems with temperature regulation (hypo and hyper), Weakened immune system (neutropenia and pneumonia high risk with clozapine),
Postural hypotension, Worsening cognitive function, confusion, lethargy, daytime sedation.
Increased risk of cerebrovascular events and cardiovascualr events higher in elderly compared to adults, even when dementia not present.
Diabetes in over 66 years is exacerbated by ANY antipsychotic
What are the issues with using hypnotics in the elderly?
Medication should NOT be first choice Chronic insomnia rarely benefitted by hypnotics High risk of ataxia, confusion, unsteady gait, slurred speech and daytime sedation Prolonged impairment of attention and cognition for up to 6 months after stopping Z-drugs Zopiclone and zolpidem are short acting Zaleplon is longer acting Benzodiazepines Temazepam is short acting Nitrazepam is long acting Clomethiazole Melatonin Licensed for max 13 weeks for >55 years.
What cautions should be taking when prescribing lithium in the elderly?
Narrow Therapeutic Window
Avoid in severe cardiovascular disease
Caution in renal impairment and avoid in severe
Caution in thyroid problems
What cautions should be taken when prescribing benzodiazepines in the elderly?
Sedation, gait disturbances, cognitive impairment, hypotension, reduced psychomotor performance
Falls risk when high doses initiated or combined with hypnotics
Only use in anxiety where severe and debilitating or causing extreme distress
Licensed for 2-4 weeks
What are the risk factors for paranoid disorder in old age?
Female Living alone Never marries Sensory impairment Paranoid or Schizoid personality Socially isolated
What are causes of psychosis in old age?
Delirium Dementia Delusional disorder Organic: Post CVA Subdural haemotoma Epilepsy Uraemia Hepatic encephalopathy
