Managing Depression and Anxiety in the Elderly Patient - Center on ...

Managing Depression and Anxiety in the Elderly Patient - Center on ...

Elizabeth A. Crocco, MD

Assistant Clong>inong>ical Professor

Chief, Division of Geriatric Psychiatry

Department of Psychiatry ong>andong> Behavioral Sciences

Miller School of Medicong>inong>e/University of Miami

Question 1

• You have been treatong>inong>g a 75 year old female over ong>theong>

past 3 months for depression with 100 mg of sertralong>inong>e

daily. It was ong>theong> patients first episode. Currently ong>theong>

patient reports a resolution of all her symptoms ong>andong>

she feels “back to herself”. She is complaong>inong>ong>inong>g of some

mild mornong>inong>g nausea that she attributes to ong>theong>

medication, ong>andong> she would like to discontong>inong>ue ong>theong>

sertralong>inong>e. What do you recommend?

Question 1

1) ong>Patientong> is now free of depressive symptoms ong>andong>

through ong>theong> acute phase of ong>theong> depressive episode

ong>andong> may now stop ong>theong> medication.

2) ong>Patientong> must contong>inong>ue treatment for 6 months to

prevent relapse of ong>theong> depressive episode

3) ong>Patientong> must contong>inong>ue treatment for 6 months to

prevent relapse but she may cut ong>theong> dose ong>inong> half to

mong>inong>imize side effects

4) ong>Patientong> must contong>inong>ue treatment for a mong>inong>imum of 2

years to prevent a subsequent depressive episode

Question 2

• A 70 year old patient presents to your office

complaong>inong>ong>inong>g of severe nervousness, constant worry,

ong>andong> palpitations. After a full medical workup you

attribute her symptoms to anxiety ong>andong> a clong>inong>ical

depression. You begong>inong> treatong>inong>g her with an

antidepressant medication. Several days later you

receive a call that her anxiety is no better ong>andong> she

requests additional help. In ong>theong> short term, you decide

to prescribe a benzodiazepong>inong>e. Which of ong>theong> followong>inong>g

agents is ong>theong> most appropriate choice?

Question 2

1) chlordiazepoxide

2) diazapam

3) oxazepam

4) chlorazepate

Question 3

• Which of ong>theong> followong>inong>g is NOT a major risk factor for

completed suicide?

1) Male gender

2) Medical comorbidity with frequent visits to PCP

3) Poor adherence to medical treatment

4) Widowed or divorces status

5) Poor concentation, anhedonia, ong>andong> ong>inong>somnia

Demographic Transition

• By 2045, average life expectancy ong>inong> ong>theong> US will be 80


• By 2030, almost 20% of Americans will be 65+

• By 2030, proportion of older Hispanics will nearly

double from 5.6% to 10.9%

Geriatric specialty shortages

• Without significant national changes, older Americans

will lack access to affordable, quality healthcare

(Institute of Medicong>inong>e Report 2008)

• 1 geriatric psychiatrist for every 10,000 Americans

older than 75 (estimated need is 5000, only 1600

board- certified specialists)

• Only 65% of psychiatrists currently accept Medicare

Prevalence of Geriatric Mental Illness

• Older adults more likely to seek MH care ong>inong> primary

care settong>inong>gs

ong>Depressionong> ong>andong> cognitive disorders most commonly


Geriatric ong>Depressionong>

• Increased rates of depressive symptoms (10-37%) but

decreased rates of DSM-criteria(2-4%)

• 17-35% ong>inong> Primary Care Settong>inong>gs

• 25% of Hospitalized patients ( 11% Major ong>Depressionong>)

• 24-47% of Nursong>inong>g Home residents

Geriatric ong>Depressionong>

Primary care physicians often have difficulty recognizong>inong>g

severe depression (Passik, et al. J Clong>inong> Oncol,1998)

Somatic presentation are often most promong>inong>ent

Reasons for Under-recognition of

Geriatric ong>Depressionong>

• Symptoms attributed to chronic medical conditions

• Often do not complaong>inong> of depressed mood or cryong>inong>g

spells, only anhedonia

ong>Depressionong> as “normal” part of agong>inong>g

• Psychosocial ong>andong> physical losses divert attention from

consideration of depression diagnosis

• Stigma

Mong>inong>ority disparities

• Ethnic ong>andong> racial mong>inong>orities are less likely than

Caucasian elderly to seek specialty MH care

• More likely to express psychological distress

through somatic symptoms

• Barriers: language, stigma, lack of transportation,

costs, waits for appoong>inong>tments, cultural distance

with provider, mistrust

• Use of complimentary ong>andong>/or alternative medicong>inong>e

Diagnostic Criteria for Major

Depressive Disorder

DSM-IV criteria ong>inong>clude 5 or more of ong>theong> followong>inong>g

symptoms are present for 2 or more weeks:

Must have:

1) Depressed mood or

2) Anhedonia

Criteria for Major Depressive


3) Change ong>inong> weight or appetite

4) Insomnia or hypersomnia

5) Psychomotor agitation or retardation

6) Low energy

7) Feelong>inong>gs of worthlessness or guilt

8) Poor concentration

9) Recurrent suicidal thoughts or attempt

Consequences of Untreated


• Worldwide, depression is second leadong>inong>g cause of

disability adjusted life years

• Poorer adherence

• Increased health services utilization

• Greater mortality due to concurrong>inong>g cardiovascular


• Increased risk for suicide


40% of elderly suicide completers saw ong>theong>ir primary care

physician durong>inong>g ong>theong> week prior

ong>Elderlyong> white men are disproportionately most likely to

complete suicide

Risk Factors for Suicide

(Based on ong>theong> SAD PERSONS Scale)


Age >45

ong>Depressionong> with predomong>inong>antly poor concentration,

ong>inong>somnia, complete anhedonia, irrational


Severe anxiety

Risk Factors for Suicide

Alcohol or drug use

Organized Plan

Previous attempt

Lack of social support

Separated, divorced or widowed

Multiple comorbid medical illnesses with frequent PCP


Comorbid ong>Anxietyong>

• Often ong>theong> most promong>inong>ent presentong>inong>g symptom along

with ong>inong>somnia

• Decreased response rate to antidepressants

• Longer time to response ong>andong> remission

Comorbid ong>Anxietyong>

Generalized anxiety ong>andong> panic symptoms may

accompany depression ong>inong> ong>theong> elderly

The somatic focus of anxiety may be mistakenly ascribed

to medical diagnoses

Treatment of Geriatric ong>Depressionong>:

The Acute Phase

• Goal is remission of illness

• Lasts about 12weeks/3 months

• Treatment regimen must be carefully monitored

• First long>inong>e antidepressant treatment is SSRI’S for both

efficacy ong>andong> safety

• Start at ½ usual adult dosage

Treatment of Geriatric ong>Depressionong>:

The Acute Phase

• Close monitorong>inong>g on a weekly basis is required at this

phase of treatment for ong>theong> followong>inong>g :

• Side effects/adverse reactions

• Deterioratong>inong>g clong>inong>ical condition

• Suicide risk

• Medical co-morbidity

• Support system

• Adherence to treatment

Treatment of Geriatric ong>Depressionong>:

The Acute Phase

Referral to a psychiatrist should be considered with ong>theong>


Suicidal ideation

Complex medical co-morbidity

Severe depression with psychotic features

Neglect/lack of social support

Alcohol ong>andong> drug abuse

Treatment resistance

Treatment of ong>Anxietyong> ong>inong> Geriatric


Antidepressants such as SSRI’s ong>andong> SNRI’s are ong>theong> safest .

Sedative hypnotics such as benzodiazepong>inong>es can be very

efficacious ong>inong> ong>theong> short term, but must be used with

extreme caution ong>inong> ong>theong> elderly

They may contribute to worsenong>inong>g depression, cognitive

changes, ong>andong> higher rates of falls/ong>inong>juries

Should choose short actong>inong>g agents with nonactive

metabolites (lorazepam, oxazepam, temazepam)

Treatment of Geriatric ong>Depressionong>:

The Contong>inong>uation Phase

• Goal is to contong>inong>ue ong>theong> preservation of remission of

ong>theong> illness

• Lasts about 6 months

• Contong>inong>uation of antidepressant treatment at ong>theong> full

dose that resulted ong>inong> remission is essential

Treatment of Geriatric ong>Depressionong> :

The Maong>inong>tenance Phase

• Goal is to maong>inong>taong>inong> treatment to prevent recurrence of

anoong>theong>r depressive episode

• The more episodes of depression, ong>theong> higher ong>theong>

likelihood of recurrence

• In adults, ong>theong> chance of recurrence is > 90% after 3 or

more episodes

Treatment of Geriatric ong>Depressionong>:

The Maong>inong>tenance Phase

ong>Depressionong> tends to reoccur ong>inong> ong>theong> elderly

• Rates of recurrence of 50-90 percent over a period of 2-

3 years

• Studies ong>inong>dicate that preventong>inong>g ong>theong> recurrence of

depression ong>inong> geriatric patients require contong>inong>ued

treatment with antidepressants for at least 2 years

(Reynolds, et al, NEJM, 2006)

• Contong>inong>uous Maong>inong>tenance treatment for at least 2years

is recommended ong>inong> over 65 patients, despite ong>theong>

number of previous episodes.

ong>Depressionong> ong>andong> Collaborative Care

• Collaborative Care

embedded MH providers

structured collaboration b/PC ong>andong> MH

disease self-management

monitor antidepressant adherence

time-limited psychoong>theong>rapy

stong>andong>ardized tools for screenong>inong>g

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