Depression in elderly

Depression in the elderly (Psychiatry)

1. Depression In Elderly Slam 201002414 71913993

2. Presentation Outline Definition Introduction Epidemiology Causes and Risk Factors Diagnosis Approach Screening Differential diagnosis Treatment Prognosis

3. Definition Depression A spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioral, or somatic regulation and associated with significant functional impairment and a reduction in the capacity for pleasure and enjoyment

4. INTRODUCTION Depression in older adults is a widespread problem, but it is not a normal part of aging. It is often not recognized or treated.

5. What are the differences between older and younger persons with mental illness? Assessment is different : e.g. cognitive assessment needed, recognize sensory impairments, allow more time Symptoms of disorders may be different : e.g. different symptoms in depression Treatment is different : e.g. different doses of meds, different psychotherapeutic approaches Outcome may be different : e.g. psychopathology in schizophrenia may improve with age

6. EPIDEMIOLOGY AMONG OLDER ADULTS Minor depression is common 15% of older persons overall 50% long-term care Causes  use of health services, excess disability, poor health outcomes, including  mortality Major depression is not common 1% – 2% of physically healthy community dwellers 12-16% in long-term care Elders less likely to recognize or endorse depressed mood

7. Prevalence of Depression

8. Causes Unlike depression in early life, genetic factors are less important in depression that starts later in life. Late onset depression is associated with a higher frequency of : Cognitive impairment Cerebral atrophy Deep white matter changes

9. Major Depression in Neurologic Disorders Associated with Aging Stroke 40-60% Parkinson Disease 30-40% Alzheimer’s Disease 20-40%

10. Risk Factors for Late Life Depression female sex, being single or divorced Recent bereavement Fear of death Role transition Frustration with memory loss stressful life events

11. Comorbid Conditions with High Risk Depression Alcohol dependency/Substance abuse Cerebrovascular/neurodegenerative disease Cancer COPD Chronic pain CHF/CAD/MI DM/electrolyte imbalance Head trauma/ Orthostatic hypotension Abuse Schizophrenia

12. Vascular depression (depression due to vascular lesions): more common in late-onset disease. Increasingly evident that cerebrovascular disease seemingly plays a role in depression beginning in late life. Cerebrovascular disease may predispose or perpetuate some geriatric depressive syndromes. Such patients seem more resistant to treatment. Supported by comorbidity of depression and vascular risk factors and the association of ischemic lesions to distinctive behavioral symptoms. Vascular lesions include periventricular hyperintensity , deep matter hyperintensity , and subcortical gray matter hyperintensity . Disruption of prefrontal systems may be responsible.

13. DSM-IV DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION Gateway symptoms (must have 1) Depressed mood Sad Emptiness Helpless Hopelessness Loss of interest or pleasure ( anhedonia ) Other symptoms Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue and Loss of energy Feelings of worthlessness or guilt Difficulty concentrating, making decisions Recurrent thoughts

14. ICD 10 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION Depressed mood , loss of interest and enjoyment , and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common . reduced concentration and attention; reduced self-esteem and self-confidence; ideas of guilt and unworthiness (even in a mild type of episode); bleak and pessimistic views of the future; ideas or acts of self-harm or suicide; disturbed sleep diminished appetite.

15. Diagnostic Approach to Clinical Depression

16. Screening for Depression R ecommended screening adults for depression to assure accurate diagnosis, effective treatment, and follow-up Patient Health Questionnaire (PHQ9) Geriatric Depression Scale Beck Depression Inventory

17. DIFFERENTIAL DIAGNOSIS Medical illness can mimic depression Thyroid disease Conditions that promote apathy Dementia has overlapping symptoms Impaired concentration Lack of motivation, loss of interest, apathy Psychomotor retardation Sleep disturbance PSYCHOTIC DEPRESSION Occurs in 20-45% of hospitalized elderly depressed patients and 15% of elderly depressives in the community. Patients have sustained paranoid, guilty, or somatic delusions (plausible but inexplicably irrational beliefs Delusions are more commonly mood-congruent Auditory hallucinations are less common

18. Medications causing symptoms of depression Anabolic steroids Anti- arrythmics Anti- convulsants Barbituates Benzodiazepenes Carbidopa /Levodopa Clonidine Digitalis Glucocorticoids H2 Blockers Metoclopramide Opioids Some Beta-blockers

19. STEPS IN TREATING DEPRESSION Acute — reverse current episode Continuation—prevent a relapse Continue for 6 months Prophylaxis or maintenance—prevent future recurrence Continue for 3 years or longer

20. TYPES OF THERAPY FOR DEPRESSION Non Medical Interventions Medical Intervention Psychotherapy Pharmacotherapy Vagal Nerve stimulation Electroconvulsive therapy (ECT ) Combination therapy

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