Late LIfe Depression Flashcards
Etiology
Dprssn = not normal aging
More common in elderly in LTC/medical settings
More common in hx of CVA, MI, CA
Drpssn S&S can precede medical illness
Can lead to increased ETOH and drug abuse
Untx dprssn can increase halth care costs
Untx’d dprssn leads to increased mortality
Why dx is difficult
Often S&S, like lack of energy attributed to old age
Pt’s neglect to mention S&S
Dprssn = neg. connotations among older adults
Pt’s don’t want to admit they are depressed
Screening
Include in routine exam
Do you often feel sad or blue?
Have you dropped many of your activities and interests?
Complete PHQ-9 or GDS q yr
Dx
SIG E CAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor retardation (rarely PM agitation) Suicidal thoughts
Most reliable sign of Late Life Dprssn
Anhedonia = lack of interest and pleasure
Distinguish things they can no longer do from those they can do but no longer enjoy
Ask about activities in past 24-48hrs and level of enjoyment of these
Depression vs Dementia
Dprssn: short duration, detailed cognitive loss or dysfxn, communication of distress, memory gaps for specific period of event, attention and concentration preserved, little effort to perform simple tasks, highlights failures, early loss of social skills, mood change pervasive, hx of psych illness
Dementia: Gradual, progressive duration, few c/o cognitive loss and usually imprecise, often unconcerned about changes, memory gaps for specific periods unusual, attn and concentration faulty, near miss answers frequent, struggle with tasks, delights in trivial accomplishments, social skills often retained, affects shallow, labile, uncommon for hx of psych illness
Memory improvement c tx
Improvement in concentration and thinking c tx of dprssn
If concurrent dprssn and early dementia/mild cognitive impairment, may have improvement c tx
Depression vs Grief
Death of loved one can produce sx much like dprssn
Grief less likely to cause prob’s in self esteem
Grief S&S should lessen w/i 6 mos - consider tx if meets criteria for dprssn p 8 wks
Hospice care decreased M&M for surviving spouse
Dysthymia
Chronic disorder
=depressive sx most days x2yrs but do not meet criteria for major depressive disorder (MDD)
Unclear if meds effective
high risk for MDD so monitor closely
Psychotic Depression
More common in older adults d/t vulnerability of brain
Delusions - paranoia, poor bodily fxns, persecution, jealousy
Hallucinations rare
More likely to have dementia sx
Suicide Risk
Elderly adults have higher suicide rate than any other age group, esp white non-hispanic men
Ask and accept what pt says
Suicide Screen
Assess lethality and availability of means
Examine protective factors: “what would your family do if you took your own life?” “What keeps you from going through with your plan?”
Document assessment of risk and determine plan: refer to mental health professional, talk to pt about hotline & local resources
Take steps to ensure immediate safety
Validate pt’s thoughts and feelings: “I understand that life seems not worth it to you anymore. I am concerned about you. Your life is important to me. I’d like to talk about this more.”
Reassess regularly
Suicide in LTC
Take suicidal thoughts seriously
Most common means of suicide in LTC: Jumping out of windows, hanging, cutting, OD on meds, Passive means: refusing food, meds
Assess suicide risk and take appropriate actions
Tx
Nonpharm:
CBT, interpersonal tx, group or individual tx
Bright light tx for SAD
Severe or psychotic - refer
Pharm: trial of tx x 4-6wks Tx for 6-12 months Tx resistance - consider switching med or adding 2nd line med or refer Labs: SSRI can cause hyponatremia
Choosing Antidepressants
1st line: SSRIs (start low)
Citalopram 5-10mg
Escitalopram 10mg
Sertraline 25mg
2nd line:
Venlafaxine, Duloxetine, Mirzapine, Buproprion
3rd line:
add 1st or 2nd line to aripirazole or quietapine
SSRI c buspirone (anxiety) or buproprione (energy)
Avoid: TCAs, St. John’s Wart
