Depression in the Older Adult. Barbara Callahan MS, ANP BC, GCNS - BC

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1 Depression in the Older Adult Barbara Callahan MS, ANP BC, GCNS - BC

2 Presenter Disclosure Information Barbara Callahan, MS, ANP-BC, GCNS-BC Depression in the Older Adult FINANCIAL DISCLOSURE: No relevant financial relationship exists

3 Faces of DEPRESSION

4 Objective Identify two cardiac effects of antidepressants

5 Demographics The oldest old, people over the age of 85yoa is the fastest growing segment of the population The number of people over the age of 100 years old doubled in the 1980s The Baby Boom generation will have a huge impact on health care utilization and financing (The National Institute on Aging and the American Association of Retired Persons, 1999)

6 Demographics on Depression Nearly 5 million of the 31 million Americans age 65 and older have depression (Lebowitz, 1996) Late-life depression occurs within a context of medical illnesses, disability, cognitive dysfunction, and psychosocial adversity, frequently impeding timely recognition and treatment of depression, with subsequent unnecessary morbidly and death (Lebowitz, 1996)

7 What is Depression? Depression is defined as a syndrome comprised of a constellation of affective, cognitive, and somatic or physiological manifestation (National Institutes of Health, 1992) Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and/or guilt. It is a disorder that extinguishes the spark of life. It is often misdiagnosed in the older adult and has the potential to destroy their quality of life, if not life itself.

8 QUESTION As one ages, it is expected to be depressed 1. True 82% 2. False 18% True False

9 Prevalence Community dwelling (13%) Medical outpatients (24%) Acute care (30%) Nursing homes (43%) (Blazer, 2002a)

10 Risk Factors Living alone Having little or no social support Being unmarried or widowed Going through recent bereavement Enduring chronic pain Being a caregiver Having a history of depression Having a history of chronic illness Being incontinent Fearing death Abusing substances Having a history of suicide attempts Having a functional disability such as loss of mobility or vision (especially a recent loss)

11 Risk Factors (all of these often coexist with Chronic Conditions Diabetes Stroke Heart disease Lung disease Arthritis Comorbidities Cancer Thyroid failure Post menopause Chronic pain Malnutrition Functional disabilities depression) Medical Conditions Infection Incontinence Anemia Hypothyroidism Hyponatremia Hypercalcemia Hypoglycemia Congestive heart failure Kidney failure

12 Symptoms According to the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition, text revision (DSM-IV-TR). Depressed mood most of the time Marked decrease in interest and enjoyment of most activities (anhedonia) Significant increase or decrease in weight Insomnia or hypersomnia Agitation or slowness Fatigue Feelings of guilt or worthlessness Indecisiveness or a reduced ability to concentrate Recurrent thought of death, suicidal ideation, or suicide attempt.

13 Symptoms According to DSM-IV-TR, five or more of these symptoms (except for weight change) must be evident nearly every day for a two week period, and at least one complaint must be either depressed mood or loss of interest or enjoyment before a diagnosis of depression can be made.

14 Symptoms Symptoms common to older adults include: Sleep disturbance Decreased appetite Weight loss Irritability Psychomotor retardation Difficulty with concentration Fatigue Feeling of hopelessness Anxiety/worry Anhedonia Unexplained somatic complaints

15 Screening Tools Yesavage Geriatric Depression Scale (GDS) Available at (www.hartfordign.org/publication/trythis) Screen for depression in older adults Score greater than 5 is suggestive of depression and follow up is warranted Takes approximately 5 minutes to complete Has been validated and used extensively with medically ill older adults Available in several languages The Cornell Scale for Depression in Dementia Beck Depression Inventory

16 Assessment Assess presence and severity of symptoms Assess suicide risk Rule out medical causes Include: Past medical and psychiatric history Medications and substances Family and personal history

17 Goals of Treatment The primary goals of treatment and intervention include early recognition of the symptoms, prevention of recurring episodes, and mitigation of the effects of the current episode of depression.

18 Treatment National Mental Health Association found that: Only 38% of adults aged 65 and over believe that depression is a health problem. Furthermore, 58% believe that it is normal for people to get depressed as they grow older. Finally, more than any other group, people in this age group believed they could handle it themselves.

19 Treatment Modalities Pharmacologic Electroconvulsive Therapy Psychotherapy

20 Antidepressants When prescribing an antidepressants consider: Previous response to treatment Side effect profile Interactions with other medications

21 Pharmacotherapy Mantra: Start Low, Go Slow This is the mainstay treatment for older adults with moderate to severe depression. The percentage of adults ages 65 years and older who use antidepressants grew from 9.3% in 1993 to 11.7% in (Mamdani, MM. et al. Am J Psychiatry, 2000).

22 Three Major Classifications of Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI). First line drug therapy and most commonly prescribed antidepressants, especially for older adults. More tolerable, safe and simple to use Examples: Sertraline (Zoloft) and Escitalopram HBr (Lexapro) Tricyclic Antidepressants However, these drugs may exacerbate existing problems common in older adults, constipation, cognitive impairment, dry mouth, arrhythmias, orthostatic hypotension., and cardiotoxicity Examples: Amitriptyline (Elavil) and Desipramine HCL (Norpramine) Monoamine Oxidase Inhibitors (MAOIs) rarely used Used less frequently because of the potential for serious adverse effects. Generally not used in older adults unless all else fails.

23 Side Effects SSRIs: Headache Agitation Anorexia Nausea Diarrhea Sleep Loss Hyponatremia

24 Side Effects TCA side effects are common: Anticholinergic effects Orthostatic hypotension Sedation Cardiotoxicity

25 QUESTION Are there any cardiac side effects with the use of Tricyclic Antidepressants? 1. TRUE 92% 2. FALSE 8% TRUE FALSE

26 Electroconvulsive Therapy Treatment of choice for older persons with severe depression Improvement rate in older persons who do not respond to antidepressant drugs is 80% Primary ECT is justifiable as a first line of therapy for the following: Need for rapid, definitive treatment response on either medical or psychiatric grounds Risks of other treatments outweigh the risks of ECT History of poor drug response Patient preference WORKS FAST!

27 Psychotherapy Appropriate for all forms of depression Options include: Individual Group Family Aim: Help depressed individuals thoughtfully examine their behaviors, beliefs, emotions, stressors and personal relationships in order to lead to lasting change in factors that may have contributed to the development of depression. Problem Solving Therapy Reminiscence Therapy Psychotherapy is especially effective in preventing relapses of episodic depression (30% relapse rate of depression in older persons).

28 QUESTION Which of the following are appropriate treatment interventions for depression 1. Pharmacological Treatment 2. Electroconvulsive Therapy 3. Psychotherapy 4. All of the above Pharmacological Treatment Electroconvulsive Therapy 96% 2% 0% 2% Psychotherapy All of the above

29 Suicide The highest rate of completed suicide of any age, gender, or ethnic group is among OLDER WHITE MEN. The risk of suicide is higher in older adults than the rate for younger people (up to six times more frequent in older white men over 85 years of age). In 2002 people ages 65 years to 74 years represented 13.5% of suicides, but those 85 years and older represented 18% of suicides; 9.9% of suicides were committed by people 15 to 24 years. (McIntosh JL, USA suicide: 2001, official final data

30 Suicide 60% of completers are men 75% of attempters are women

31 Case Study Mrs. G. is a 75 year old female living alone in her house in New Hyde Park. Her husband died suddenly two years ago of a heart attack. Their two children are alive and living out of the state. Both of her sons maintain weekly phone contact with Mrs. G. and visit usually once a year. Mrs. G. has been doing well until about 6 weeks ago when she fell in her apartment and sustained bruises but did not require a hospital visit. Since then, she has been preoccupied with her failing eyesight and decreased ambulation. She does not go shopping as often, stating she doesn t enjoy going out anymore and feels very sad and teary. Mrs. G. states that her shopping needs are less, since she is not as hungry as she used to be and besides I m getting too old to cook for one person only. What risk factors account for Mrs. G s symptoms of depression? What are Mrs. G s depressive symptoms? What might be some treatment strategies for Mrs. G?

32 Nursing Interventions Develop an individualized plan: Safety precautions Remove or control etiologic agents Monitor or promote nutrition, elimination, sleep/rest patterns, and physical comfort especially pain control Promote physical function Enhance social support Maximize autonomy Structure and encourage daily participation in therapies and activities Monitor response to medications and therapies Provide emotional support

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