Depression in the geriatric by Dr. swati singh

GERIATRIC DEPRESSION
By-Dr.Swati

INTRODUCTION
• Depression is under-recognized and
undertreated in the older people.
• 15% - 27% older adults in community & up to
37% in primary care setting experience
depressive symptoms.
• Untreated depression can delay recovery or
worsen the outcome of other medical illnesses
via increased morbidity or mortality
• Depression is NOT a part of normal aging

WHAT IS DEPRESSION?
 DSM-5 Definition
 Five or more of the following must have
been present during the same 2-week
interval and represent a change from
baseline functioning
 One of the symptoms must be depressed
mood or loss of interest or pleasure

 Depressed mood
 Loss of interest in all or almost all
activities or pleasure
 Appetite change or weight loss
 Insomnia or hypersomnia
 Psychomotor agitation or
retardation

 Loss of energy or fatigue
 Feelings of worthlessness or excessive
guilt
 Difficulty with thinking, concentration, or
decision making
 Recurrent thoughts of death or suicide
 Preoccupation with somatic symptoms,
health status, or physical limitations

 For Major Depression, these
symptoms
 Produce social impairment
 Are not related to substance
abuse
 Are not related to bereavement
[the loss of a loved one by death]

 Types of Depressive Disorders
 Mild episode of major depression
 Moderate episode of major depression
 Severe episode of major depression
 Severe episode of major depression with
psychotic features

 Minor depression is common
 15% of older persons
 Causes ↑ use of health services, excess disability, poor
health outcomes, including ↑ mortality
 Major depression is not common
 1%–2% of physically healthy community dwellers
 Elders less likely to recognize or endorse depressed mood

RISK FACTORS
 Alcohol or substance abuse
 Current use of a medication associated with a high risk of
depression
 Hearing or vision impairment severe enough to affect
function
 History of attempted suicide
 History of psychiatric hospitalization
 Female gender
 Bereavement

COGNITIVE DEFICITS IN
GERIATRIC DEPRESSION
 Cognitive symptoms of severe depression can be misdiagnosed as
an early stage dementing disorder.
 The neuropsychological impairment seen frequently in geriatric
depression span across multiple cognitive domains. These include
impairments in episodic memory, recognition memory,verbal
fluency ,psychomotor speed.
 The specific structural abnormalities that contribute to symptoms
of depression have been identified in the orbitofrontal cortex, ant
cingulate,putamen, caudate head, hippocampus, amygdala

CAUSES
 As you grow older, you face significant life changes that
can put you at risk for depression.
 Health problems – Illness and disability; chronic or severe
pain; cognitive decline; damage to body image due to
disease.
 Loneliness and isolation – Living alone; a dwindling social
circle due to deaths or relocation;
 Reduced sense of purpose – Feelings of purposelessness
or loss of identity due to retirement or physical limitations
on activities.
 Fears – Fear of death or dying; anxiety over financial
problems or health issues.
 Recent bereavement – The death of friends, family
members, and pets; the loss of a spouse or partner.

DRUGS THAT MAY CAUSE
DEPRESSION SYMPTOMS

DRUG CLASS EXAMPLES
Angiotension-converting enzyme
inhibitors
Captopril,enalapril
Antibiotics Ciprofloxacin,dapsone,metronidazole
Anticholinergic Dicyclomine
Antivirals Acyclovir, nevirapine
Benzodiazepines Alprazolam, clonazepam, lorazepam
Calcium-channel blockers Verapamil, diltiazem
Opioids Codeine,morphine
NSAIDs Ibuprofen , indomethacin , naproxen
Parkinson drugs Levodopa ,pramipexole

DIFFERENTIAL DIAGNOSIS
 Thyroid disorders (hypo- and hyper-thyroidism)
 Dementia (or mild cognitive impairment)
 Bereavement
 Anxiety Disorder
 Substance Abuse Disorder
 Personality Disorder
 Diabetes mellitus
 Underlying malignancy
 Anemia
 Medication side effects

Most commonly used and
validated screening tool for
diagnosis of Depression in the
geriatrics patient:
 The Geriatric Depression Scale

• It can either be self administered or administered by a
clinician & takes approx. 5-7 minutes to complete. .
• The presence of 5 or more depression symptoms
responses suggests a positive screen for depression.
• The original instrument consist of 30 questions,although
shorter 15-item and ultrashort 4-item versions have been
developed.

Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression.

TREATMENT
 Effective management requires a biopsychosocial
approach, combining pharmacotherapy and
psychotherapy.
 Therapy generally results in improved quality of life,
enhanced functional capacity, possible
improvement in medical health status, and lower
health care costs.

NON
PHARMACOLOGICAL T/T
1. CBT:
 teaches individuals to identify maladaptive or distorted cognition &
learn to challenge them
 Increasing pleasurable activities and use techniques, such as
activity monitoring & scheduling.
2. IPT:
 focus on current relationship in 1 or more of problematic area of life:
grief, interpersonal conflicts, interpersonal deficits.
2. Life review intervention:
 focus on evaluating positive & negative events with the goal of
reframing & integrating these events by changing overview of
themselves & the events of their life.

NATURAL REMEDIES
 Exercise
 Yoga
 Tai-chi
 Massage
 Music therapy
 Spiritual/religious based therapy

COMPLEMENTARY &
ALTERNATIVE MEDICINES
1. FISH OIL
2. SAM(S-ADENOSYL METHIONINE)
3. FOLIC ACID

PHARMACOTHERAPY
 ANTIDEPRESSANTS SHOULD BE CONSIDERED IN PATIENTS WITH
MOD TO SEVERE DEPRESSION & IN PATIENT WITH A MILD TO MOD
DEPRESSION WHO WERE NOT RESPOND WITH NON-
PHARMACOLOGICAL TREATMENT.
 Selective Serotonin Reuptake Inhibitors (first line of drug because
of better safety profile)
 : fluoxetine
 Tricyclic Antidepressants : imipramine and amitriptyline(the use of
TCA has been limited bcz of safety profile, the major safety issue
is their cardiovascular effect)
 Monoamine Oxidase Inhibitors
 Other Antidepressants: mirtazapine

CONSEQUENCES AND
COMPLICATIONS OF
INADEQUATELY TREATED
DEPRESSION
 Recurrence, partial recovery, and
chronicity . . .
 ↑ disability
 ↑ use of health care resources
 ↑ morbidity and mortality
 Suicide (one fourth of
all suicides occur in
persons ≥ 65)

Depression in the geriatric by Dr. swati singh

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