Old age affective disorders

Question 1

Depression in the Elderly

Answer 1

Common and has increased Morbidity and Mortality

Under-diagnosed and under-treated but treatable

Question 2

Prevalence of Depression in the elderly

Answer 2

Wide Variation - lowest in those living independently.10-20% will have mild depression, a 1:2 male/female ratio. 1/3 of elderly people seeing GP and 1/4 using homecare. 1/4 of elderly people with chronic conditions. Up to 1/2 of people in care homes

Question 3

Aetiology of depression in the elderly

Answer 3

Genetics less important than in the young - Hx of depression increases risk, as do negative life events
RFs –> dementia, alcohol, lack of social support, medication (steroids, digoxin, B blockers)

Question 4

Reasons depression is underdiagnosed in the elderly

Answer 4

Older people may not verbalise (aphasias) - may focus on somatic symptoms due to stigma
Complicated by co-existing dementia
Doctors may view it as ‘just a part of aging’

Question 5

Symptoms of depression in the elderly

Answer 5

Traditional cognitive and biological symptoms
In the elderly –> more cognitive deficits (pseudodementia)
May somatise or show significant behavioural disturbance
If severe then may have psychotic symptoms

Question 6

ICD 10 criteria for depression in the elderly

Answer 6

At least 2 of 3 core symptoms - low mood for >2wks, loss of interests/pleasure, low energy
Plus cognitive and biological symptoms (1 for mild, 3 for moderate or 5 for severe)

Question 7

Assessment of depression in the elderly

Answer 7

Full history possibly with collateral history
Assess risks –> self harm, falls, neglect, risk to others
Full physical exam –> exclude physical illness being causative or co-morbid

Question 8

Management of Depression

Answer 8

Psychosocial –> increased support, activity scheduling, address isolation. Psychological –> CBT is good in mild to moderate
Biological –> address pain & underlying physical disorder, antidepressants or mood stabilisers, ECT

Question 9

SSRIs in the elderly

Answer 9

Generally well tolerated - can cause GI irritation/bleeds
Can increase anxiety/agitation and potential for withdrawal symdrone
Citalopram can cause QT prolongation

Question 10

Other antidepressants in the elderly

Answer 10

SNRI - Venlafaxine - GI SEs and increased BP
NASSA - Mirtazapine - sedation and weight gain
TCAs - Amitripyline - anticholinergic and cardiac SEs, overdose risk
All can cause significant hyponatraemia

Question 11

NASSA

Answer 11

Noradrenergic and specific serotonergic antidepressant

Main one is Mirtazapine which can cause sedation and weight gain

Question 12

ECT

Answer 12

Response rate is over 50%, so better than the other options - saves lives in high risk group but involves GA
Temporary confusion and memory loss and stigma
Used in severe depression where there is a risk of death

Question 13

Suicide in the elderly

Answer 13

20% of suicides are in >65yos - 60-90% associated with depression - rate has reduced in elderly but still high
Any self harm in the elderly is likely to be associated with significant intent so all attempts should be thoroughly assessed

Question 14

Epidemiology of Suicide

Answer 14

M:F 2:1 - rates highest in 60-75yrs men

Increased relative risk of dying in depressed independent of suicide as well.

Question 15

Anxiety disorders in the elderly

Answer 15

Under diagnosed as ageist assumption that the elderly are anxious - requires awareness as may not self present
Anxiety is a common feature of depression as well
1/3 of anxious patients is over 65

Question 16

Aetiology of Anxiety

Answer 16

Similar to depression - personal history, chronic physical illness, Traumatic event, Loss life events

Question 17

Phobias

Answer 17

Similar in prevalence to in young people

Specific and leads to avoidance and hyper-vigilance behaviour

Question 18

GAD

Answer 18

Generalised anxiety disorder
Increasing prevalence with age
Women more than men

Question 19

Panic disorder

Answer 19

Recurrent panic attacks without specific triggers
Significantly co-morbid with depression and GAD
Female more than male

Question 20

Treatment of anxiety

Answer 20

CBT and other psychological therapies usually first line
Social interventions - treat underlying medical conditions
SSRIs are most effective, can also use pregabalin and maybe antipsychotics but avoid Benzos

Question 21

Grief management

Answer 21

Normalisation of experience. Grief counselling – useful for simple grief reactions. Tasks of grieving – Accept the reality of loss, experience/expression of loss, adjustment to life without deceased, withdrawal of the emotional attachment and reinvestment into new things/people

Question 22

Types of Complicated grief

Answer 22

Chronic – prolonged, intense and guilty with self blaming
Inhibited – somatic rather than affective symptoms
Delayed – emerge only after a delay
Treat with guided morning, CBT and gradual behavioural activation