Geriatric Mood and Anxiety Disorders: 5 Things you need to know about Treating Depression in the Elderly

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1 Geriatric Mood and Anxiety Disorders: 5 Things you need to know about Treating Depression in the Elderly Kiran Rabheru MD, CCFP, FRCP Geriatric Psychiatrist, The Ottawa Hospital Professor, University of Ottawa

2 Faculty/Presenter Disclosure Faculty: DR. KIRAN RABHERU Relationships with commercial interests: NONE

3 Disclosure of Commercial Support This program has received financial support from N/A This program has received in-kind support from N/A Potential for conflict(s) of interest NONE

4 Mitigating Potential Bias NONE

5 1. Beware of Ageism

6 2. Recognize Geriatric Depression

7 3. It is very common & has a big impact on QoL

8 4. Optimize what you can

9 5. Treatment makes people feel better

10 Recognition Psychological Hopelessness Helplessness Guilt Suicidal CORE SYMPTOMS Depressed Mood or Lack of Interest & Pleasure Physiological Sleep Appetite Weight Energy Concentration In older adults: Less mood symptoms Somatic symptoms Agitation & Anxiety Psychotic symptoms

11 Stressors Physical Illness*** surgery, immobility Sensory deprivation Social isolation / Rejection Economic / Living Conditions Loss of significant other Retirement

12 Depression is common! Major Minor Community 1-3%.15% Primary care: 10% % Medical / Surgical: 15%.30% Long Term Care: 15%....30% 13% annual incidence of new episodes in nursing homes Nelson JC. Treatment of Major Depression. In: Nelson JC, Ed. Geriatric Pyschopharmacology. New York: Marcel Dekker; 1998 Blazer DG: Epidemiology of late-life depression, in Diagnosis and Treatment of Depression in Late Life. Edited by Schneider LS, Reynolds CF, Lebowitz BD, et al. Washington, DC, American Psychiatric Press, 1994, pp 9-19 Lyness JM, King DA, Cox C, et al: The importance of subsyndromal depression in older primary care patients: prevalance and associated functional disability. J Am Geriatr Soc 1999; 47: Beekman ATF, Copeland JRM, Prince MJ. Review of community prevalence of depression in late life. Britisch Journal of Psychiatry 1999;174:

13 % in Remission Achieving Remission: When Are The Chances Greatest? 60% 50% 50% 40% 30% 20% 10% 5% 0% Keller et al, Arch Gen Psych, 1992; 49: months months During the first 6 months of treatment!

14 Depression is treatable. Severe: Major depression : Use Meds / ECT. treated successful in very old & early old. (1) Advanced Minor Depression/Dysthymia: Use Meds SSRI (Paroxetine) showed moderate benefit. (3) Mild Minor Depression: May not need meds / High Placebo response. SSRI (Paroxetine) not clearly superior to placebo..may help more severely ill patients (2) Antidepressants are safe and effective in the treatment of late-life depression. (4) 1) Gildengers AG, Houck PR, Mulsant BH, Pollock BG, Mazumdar S, Miller MD, Dew MA, Frank E, Kupfer DJ, Reynolds CF 3rd. J Affect Disord 2002 May;69(1-3): Course and rate of antidepressant response in the very old. 2) Burrows AB, Salzman C, Satlin A, Noble K, Pollock BG, Gersh T. Depress Anxiety 2002;15(3): Randomized, placebo-controlled trial of paroxetine in nursing home residents with non-major depression. 3) Williams JW Jr, Barrett J, Oxman T, Frank E, Katon W, Sullivan M, Cornell J, Sengupta A. JAMA 2000 Sep 27;284(12): Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. 4) Kasckow JW, Welge J, Carroll BT, Thalassinos A, Mohamed S. Am J Geriatr Psychiatry 2002 May-Jun;10(3):344-7 Citalopram treatment of minor depression in elderly men: an open pilot study.

15 Placebo Trials JAMA 2002 Apr 10;287(14): Placebo response in studies of major depression: variable, substantial, and growing. Walsh BT, Seidman SN, Sysko R, Gould M. The response to placebo in published trials of antidepressant medication for MDD is highly variable and often substantial and has increased significantly in recent years, as has the response to medication. DRUGS: NECESSARY BUT NEVER SUFFICIENT ALONE!!

16 Teaching an old dog new tricks! It may be difficult but it IS possible!

17 Depression in the Elderly: Treatment Program Strong doctor-patient relationship Environmental, Social, Recreational, Supportive & Spiritual Interventions Psychoeducation include Family Medication Drug: TCAs, SSRIs & Novels Dosage Duration ECT for severe cases

18 All Antidepressants work: Choose based on target symptoms and side effect profile Antidepressants Modes of Action Serotonin, Norepinephrine & Dopamine

19 Adverse Effects of Neurotransmitter Activity and Receptor Binding Sedation/drowsiness Weight gain Blurred vision Dry mouth Constipation Sinus tachycardia Urinary retention Memory dysfunction ACh block Psychomotor activation Psychosis DA reuptake inhibition Antidepressant 5HT 2 Stimulation 5-HT reuptake inhibition Sexual dysfunction Activating side effects Nausea GI disturbances Activating effects Priapism Alpha 2 block Postural hypotension Dizziness Reflex tachycardia NE reuptake inhibition Dry mouth Urinary retention Activating effects Tremor Adapted from Richelson E. Current Psychiatric Therapy. 1993;

20 Importance of Mental Health Mental health is fundamental to health

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