Depression in the Elderly Flashcards
Depression is more common in which patient - community, hospital, long term care
Long term care
Why is depression more common in long term care patient
Relocation
Social factors
Co-morbidity
Medication side effects
Relocation
Lack of ind. and stimulation
Deteriorating sense of integrity
Deficiencies in care
Lack of pos. reinforcement
Social Factors
Loss of social support
Bereavement
Retirement
Loss of autonomy, status and independence
Co-Morbidity
Chronic disease associated with high prevalence of depression
Co-morbidity - stroke association with depression
30-60%
Co-morbidity - Coronary artery disease prevalence with depression
8-44%
Co morbidity - Cancer prevalence with depression
1-4%
Co-morbidity - Parkinsons prevalence with depression
40%
Co-morbidity - Dementia prevalence with dementia
20-40%
Medication side effects - in general older adults take an average of how many medications
What about in LTC?
4
8 in LTC setting
Medication side effects - Depressant effects
1/4 of those medications may have a depressant effect
2 main barriers of depression in older adults
Under recognition
Under treatment
Consequences of undertreated depression
Diminished functioning
Slower recovery
Inc mortality
Suicide
Suicide - adults over age of 65 comprise what percentage of population and what percent of suicide deaths
13% of US pop
nearly 18% of suicide deaths
Highest rate of suicide in US
White men age 85 or older
Risk factors for suicide
Recent losses Major medical issues Social isolation Being widowed (w attempt more, m are more effective)
Sx of depression
Inc somatic complaints Sleep issues Loss of appetite Feelings of worthlessness Paranoia Pseudodementia
DSM IV criteria
at least 5 sx present in a 2 week period and can’t be due to other things
Diagnosing Depression
DSM criteria
Mini mental scale
Geriatric depression scale
Hamilton depression rating scale
Two question screener
During past month have you been bothered by feeling down, depressed or hopeless
During the past month, have you been bothered by little interest or pleasure in doing things
Geriatric Depression Scale
Long form and short form
Screening tool
Self administered
Yes/no responses
Sensitive (85) and specific (95) at score of 11
Not reliable in those with cog impairment
Hamilton Depression Rating Scale
Commonly used
Administered by HCP
Score of 18 is cutoff for depression
Validity not well tested
Dementia vs. Depression - what is the relationship
50% of patients with dementia are depressed
Dementia vs. Depression - cognition
Patients with depression do not lost intellectual capacity - executive function
Barriers to seeking treatment
Stigma with depression
Pts may not realize they are showing signs of depression
They may think it is normal part of aging
Might think it is due to their illness
Denial
Financial barrier
Treatments for depression
Nonpharacologic
Medications
Herbal medications
Electroconclusive therapy
Non-pharmacological Interventions
Socialization Spirituality Exercise Regular outdoor activity Positive thinking Daily pleasureable activity
Pscyhotherapy - what percentage of residents in LTC facility
20-30%
Benefits of psychotherapy
Improved outcomes
Combination of psychotherapy and antidepressants - best treatment outcomes
Electroconclusive Therapy
Indicated for older pts who are unresponsive to tx
Several studies have shown safety and effectiveness in older adults
Side effects for ECT
Short term confusion and memory impairment
Medications
SSRI
Other antidepressants
Tri-cyclic antidepressants
Monoamine oxidase inhibitors
Rule of thumb with antidepressants
Start low, go slow
Taper slow
How do antidepressants work?
Etiology of depression is certain NT deficiencies
Antidepressants work on different NTs
SSRI - mechanism of action
Inc level of serotonin
Commonly used SSRIs
Prozac Paxil Zoloft Celexa Lexapro
SSRI
1st line of therapy for older adults
Better tolerated but more $
SSRI can also be used for
General axiety disorder
Panic disorder
OCD
SSRI Side effects
GI sx Anxiety Hyponatremia Sexual dysfunction Weight gain Fatigue or insomnia
Duloxetine
Also indicated for diabetic neuropathy
Side effects - nausea, insomnia, somnolence
Venlaxafine
Act as SSRI at low dose
Inhibits uptake of NE at higher doses
Effective for depression, GAD
Side effects - nausea, hypertension, sexual dysfunction
Wellbutrin
Generally safe and well tolerated
Inc activity of Dop and NE
Also used for smoking cessation
Side effects - insomnia, anxiety, tremor, seizures
Mirtazapine
Inc Ser and NE
Associated with weight gain, inc appetite
May be used in older adults who are having failure to thrive
Very sedating
TCAs mechanism of action
Blocks the reuptake of NE and serotonin
Appropriate TCAs for older adults
Nortriptyline
Desipramine
TCAs to avoid in older adults
Amitriptyline
Doxepin
Imipramine
Maprotiline
Side effects of TCAs
Anticholinergic properties - Orthostatic hypertension - Constipation - Urinary retention - Blury vision/dry mouth - Cardiac conduction problems Sedation Weight gain Lower seizure threshold
MAOIs
Phenelzine
Tranylcypromine
MAOI side effects
Life threatening hypertensive crisis can occur if dont watch diet
Orthostatic hypertension
Use of SSRI and MAOI together leads to serotonin syndrome
Serotonin Syndrome
Caused by use, overdose, or combined use of medications like SSRI and MAOI
Cognitive sx of serotonin syndrome
Confusion, agitation, anxiety, irritability, and drowsiness
Autonomic NS overactive - Serotonin Syndrome
Hyperthermia, diaphoresis, tachycardic, tachypnea, hypertension, dilated or unreactive pupils, GI symptoms
Neuromuscular signs with serotonin syndrome
Hyperreflexia, tremor, muscular rigidity, ataxia, clonus, nystagmus
Antianxiety medications
Might be first type of drug given to patients exhibiting jittery, nervous type of behavior
Ex of antianxiety medications
Diazepam (20-100 hrs)
Lorazepam (10-20 hrs)
Chloridiazepoxide (5-20 hrs)
Antianxiety medications also used as
Side effects include
muscle relaxants
Side effects include sedation
Sedative-hypnotic agents
Benzodiazepines with greater sedation rate
Barbituate
Ex of benzodiazapine
Triazolam (2 hr)
Temazapam (8-22 hr)
Ex of barbituate
Secobarbital (15-40 hr)
Side effects of sedative-hypnotic agents
Motor problems, confusion, anxiety, headache, hypotension
Tend to have addictive effeccts particularly the seconal
Antipsychotics
Several major drug classifications
Impair synaptic transmission of dopamine pathways
Anticholinergic effects
Ex of antipsychotics
Chloropromazine hydrochloride Prochlorperazine Thioridazine hydrochloride Haloperidol Triflupromazine HCl Risperidone
