Download Free Medical Geriatric Depression Diagnosis and Treatment PowerPoint Presentation

Geriatric Depression Diagnosis and Treatment PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical PowerPoint presentation titled "Geriatric Depression Diagnosis and Treatment" by David Mansoor, MD. This medical PowerPoint presentation talks about geriatric depression, also known as late-life depression, a common mental health disorder affecting older adults. The presentation talks about diagnosis and treatment of geriatric depression.

Tags : Geriatric Depression, Geriatric Depression Diagnosis, Geriatric Depression Treatment, late-life depression, mental health disorder

Published on : Mar 15, 2023 | Views : 1667 | Downloads : 0

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Geriatric DepressionDiagnosis and Treatment David Mansoor, MD Assistant Professor of Psychiatry OHSU/PVAMCJune 2021
Slide 2-

Disclosures None
Slide 3-

Objectives Introduction Assessment Differential Diagnosis & Other Considerations Loneliness Late onset depression Depression in Dementia Treatment Suicide risk
Slide 4-

Objectives Case (blue slides) Audience polling questions
Slide 5-

Introduction
Slide 6-

CASE Our patient is an 83-year old with a history of major depressive disorder, hypertension, and atrial fibrillation. She lives at home with her husband. Depression was previously well controlled on sertraline 200mg qday, but she has not taken it for about 5 years because of symptom improvement. She describes a return of depression symptoms over the prior 4 months.
Slide 7-

Audience Poll QUESTION: Is depression more common in older adults than in younger adults? Yes No
Slide 8-

Audience Poll QUESTION: Is depression more common in older adults than in younger adults? Yes No
Slide 9-

Introduction - Epidemiology Not a normal part of aging Prevalence of major depression is lower than in community dwelling elderly than in younger adult population 80% are treated in primary care clinics 12-month prevalence of MDE among US Adults (2012)1 1. Psychology Infographic, data courtesy of SAMHSA
Slide 10-

Introduction - Epidemiology Community dwelling elderly populations1 Prevalence about 1-5% More common in medically ill1 Chronic illness: 5-10% Hospitalized: 10-12% Nursing home: 14-42% Most common psychiatric disorder in the elderly 60% of geropsychiatry outpatients2 Annu Rev Clin Psychol. 2009 ; 5: 363–389 J Geriatr Psychiatry Neurol. 1997 Oct;10(4):136-41
Slide 11-

Introduction - Epidemiology Personal suffering and poor quality of life Decreased physical, cognitive, and social function Amplifies disabilities Hip fracture: greater frailty and poor long term recovery1 Stroke: poor functional outcome2 Heart disease: likely to comply with cardiac rehab and have prolonged recovery times3 Risk factor for developing DM, associated with worse outcomes4 BMC Geriatrics June 2013 Journal of Affective Disorders Volume 247, 15 March 2019, Pages 45-56 J Cardiopulm Rehabil Prev. 2009 Nov-Dec;29(6):358-64 Am J Med. 2008 Nov; 121(11 Suppl 2): S8–15.
Slide 12-

Introduction - Mortality 5201 US older adults followed over 6 years1 Relationship between depression and mortality After controlling for other mortality increasing risk factors, depression symptoms were associated with a 24% increase risk in mortality Depression, even subclinical, may be associated with increased mortality 1. Arch Intern Med 2000 Jun 26;160(12):1761-8
Slide 13-

Introduction - Mortality Depression at the time of admission to a nursing home increases the 1-year mortality 454 patients admitted to nursing home Evaluated by a psychiatrist Followed over a year JAMA 1991 May 22-29;265(20):2672. Controlled for other mortality risk factors MDD increased the likelihood of death by 59%
Slide 14-

Introduction - Mortality Increased mortality from suicide Older adults make up 13% of the population but account for 24% of suicides1 Predominant risk factor is depression (present in 85% of older adults who commit suicide)2 Tend to use more lethal means Highest rate of suicide is in the 85+ population 1. National Vital Statistics Reports 1999 2. Annu Rev Clin Psychol. 2009 ; 5: 363–389.
Slide 15-

Introduction – Risk Factors Annu Rev Clin Psychol. 2009 ; 5: 363–389.
Slide 16-

Introduction – Protective Factors Annu Rev Clin Psychol. 2009 ; 5: 363–389.
Slide 17-

Introduction – Natural History A persistent disorder Amsterdam Study1 277 depressed elderly 6 years of follow-up with 14 assessments Remission: 23% Unfavorable fluctuating course: 44% Severe chronic course: 32% The frailer elderly had the worse outcomes Of note, the majority were not treated for depression Beekman et al, 2002
Slide 18-

Assessment
Slide 19-

Assessment The diagnosis of depression is made based on DSM-V diagnostic criteria Collection of symptoms that occur over a minimum duration of time The symptoms cause distress and/or some type of dysfunction The symptoms are not better accounted for by some other condition (medical condition or a substance)
Slide 20-

Case Our patient describes a loss of interest in activities that were previously enjoyable, poor sleep, low energy, reduced appetite, forgetfulness, and feelings of worthlessness.
Slide 21-

Audience Poll Question: Which of the following symptoms is required to make a diagnosis of depression? Sleep changes Appetite changes Loss of interest Poor memory Worthlessness
Slide 22-

Audience Poll Question: Which of the following symptoms is required to make a diagnosis of depression? Sleep changes Appetite changes Loss of interest Poor memory Worthlessness
Slide 23-

Assessment: Diagnosis Symptoms 2 weeks duration Sleep changes Interest (loss) Guilt/worthlessness Energy loss Concentration difficulty Appetite change Psychomotor changes Suicidal thoughts Depressed mood or anhedonia + four or more of the others
Slide 24-

Assessment: Diagnosis Vegetative symptoms: appetite/weight change, disturbed sleep, psychomotor agitation or retardation, low energy Affective/cognitive symptoms: depressed mood, anhedonia, guilt/worthlessness, poor concentration, suicidal ideation of thoughts of death Less useful in medically ill persons
Slide 25-

Assessment: Clinical Presentation Harder to spot than in younger patients Often occurs in the context of complex medical and social circumstances Less likely to report feeling depressed (especially the oldest old) Often present with Physical complaints: headache, fatigue, dizziness, muscle pain, low energy Low motivation, loss of interest Weight loss Sleep complaints Memory complaints
Slide 26-

Assessment: Clinical Presentation Behavioral regression Neglect of hygiene Neglect of housekeeping Loss of social contact Loss of physical activity Separation from medical care Failure to thrive Weight loss, decreased appetite, poor nutrition, and inactivity Depression can be a cause and consequence Is prevalent and predictive of outcome
Slide 27-

Assessment: Screening PHQ-9 Incorporates DSM-5 depression diagnostic criteria Rates the frequency of sxs, which factors into scoring of severity Not at all, several days, more than ½ days, nearly every day… Scores 10/15/20 : mild/mod/severe Scores > 10 have 88% sensitivity and specificity
Slide 28-

Assessment: Screening Geriatric Depression Scale 15- or 30-point scale Yes/no questions, self report None of the items query somatic complaints, rather, questions inquire about the respondent's perspective on their life over the previous week 84% sensitivity and 95% specificity at a cut-off value of 11 (30-pt scale) Less validity with increasing cognitive impairment
Slide 29-

Assessment: Screening Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with your memory than most? Do you think it is wonderful to be alive? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better oÄ than you are?
Slide 30-

Assessment: Screening Cornell Scale for Depression in Dementia Used to screen for depression in persons with dementia (moderate to severe) Caregiver is asked to describe the resident's behavior observed during the week prior to the interview Five domains with 19 symptoms Mood, Behavior, Vegetative, Cyclic functions, Cognitive Time consuming (20 minutes) Variability in psychometric properties depending on the study
Slide 31-

Case In addition to usual depression symptoms our patient reports the recent onset of memory difficulty. She said she has a hard time concentrating and remembering recent events as well as events that took place years ago. Her son confirms. He says she gets very upset over her forgetfulness and answers, “I don’t know,” to most of his questions. There are no difficulties with IADLs. On brief cognitive testing she is fully oriented. With considerable encouragement she participates in tests of attention and verbal memory which are within normal limits.
Slide 32-

Assessment: Unique Features Cognitive complaints Pseudodementia Term first used in the 1950s to describe patients with symptoms of dementia that resolved with treatment of underlying psychiatric illness A syndrome of cognitive impairment that mimics dementia but is caused by depression “Pseudo” because it’s not due to neurodegenerative disease Symptoms develop with depression symptoms and improve with improvement in depression
Slide 33-

Assessment: Unique Features It can be challenging to determine the cause of cognitive symptoms, especially given the prevalence of depression in persons with dementia Patients with pseudodementia frequently complain of memory loss and the inability to think or concentrate Symptoms occur in the context of depression
Slide 34-

Assessment: Unique Features
Slide 35-

Assessment: Unique Features Elderly hospitalized patients with MDD1 23 with “reversible dementia,” 34 with intact cognition Longitudinal results: 43% with reversible dementia progressed to dementia vs 12% with intact cognition progressed to dementia Some studies report up to 70% converstion2 Harbinger of neurodegeneration? These patients need ongoing monitoring of cognitive function Alexopoulos et al, Am J Psychiatry, 1993 J Affect Disord. 2007 Aug; 101 (1-3): 123-9
Slide 36-

Assessment: Unique Features Psychotic symptoms are often associated with severe depression in the elderly Psychosis: loss of touch with reality Hallucinations: false sensory perception Visual: “seeing things” Auditory: “hearing things” Other sensory modalities Delusions: firmly held, fixed false belief
Slide 37-

Audience Poll QUESTION: In older adults with depression, which type of psychotic symptom is most common? A. Visual hallucinations B. Auditory hallucinations C. Olfactory hallucinations D. Delusions
Slide 38-

Audience Poll QUESTION: In older adults with depression, which type of psychotic symptom is most common? A. Visual hallucinations B. Auditory hallucinations C. Olfactory hallucinations D. Delusions
Slide 39-

Assessment: Unique Features Severe depression Mood congruent delusions Guilt, disease, suspiciousness, nihilism, sin, deserved punishment Hallucinations AH: less common but can occur; often derogatory or with commands pertaining to suicide VH: very rare Differential should include delirium, dementia, and substance use disorders
Slide 40-

Assessment: Workup History of present illness When did the symptoms start? Inquire about SIGECAPS How have they progressed? Have symptoms impacted function? Are there accompanying symptoms? Cognitive impairment? Psychotic symptoms? Suicidal thoughts?
Slide 41-

Assessment: Workup Past psychiatric history Previous depressive episodes Previous treatment and response Suicide attempt history Broader psychiatric history: psychosis, mania, anxiety Past medical history History of medical conditions associated with depression? Are mood symptoms out of proportion to what you’d expect?
Slide 42-

Assessment: Workup Medications Assess current medications Are they on any medicines which might be causing or contributing to current symptoms? Are they compliant with medications? Substance Use Alcohol, marijuana Illicit drugs
Slide 43-

Assessment: Workup Physical exam Vitals Weight, blood pressure Neuro Gait, muscle tone, tremor, muscle strength, reflexes, frontal release signs Evidence endocrine abnormalities (exopthalmos, dry skin, alopecia, orthostasis, hypertension, stretch marks)
Slide 44-

Assessment: Workup Labs CBC Chemistry panel LFTs TSH Serum B12 Urinalysis (if there are symptoms of a UTI)
Slide 45-

Assessment: Workup Additional studies Sleep study Sleep disordered breathing, abnormal sleep behavior Neuroimaging New onset depression, focal neurologic findings, dementia evaluation Neuropsychological testing Atypical cognitive symptoms
Slide 46-

Differential Diagnosis
Slide 47-

Differential Many factors contribute to make the detection of depression in older adults particularly difficult Concurrent medical illness, social isolation, the occasional absence of obvious depressed mood Differentiation from other disorders and the role other related factors play in the diagnosis is a common problem Overattributing depression symptoms to physical illness leads to underdiagnosis Failing to take symptoms of physical illness into account can lead to overdiagnosis Lebowitz et al., 1997; Berger et al., 1998; Gallo et al., 1997
Slide 48-

Differential Psychiatric Bipolar disorder, schizophrenia, anxiety, substance use Endocrine Cushing’s, thyroid, hypogonadism Neuro Parkinson’s, seizure disorder, CVD Neoplasm Brain, pancreatic, paraneoplastic syndromes Infectious HIV, SARS-CoV-2 Head injury B12 deficiency Chronic pain Sleep disorders Delirium Dementia
Slide 49-

Case You notice in the chart that our patient has a history of regular alcohol use. You inquire about recent use, and she reports drinking 2 (sometimes 3) glasses of wine at night to help with sleep. At first 1 glass per night helped but it became less helpful over time and so she’s been drinking more.
Slide 50-

Differential Substance induced depression Substance use is increasing in older adults 12-month prevalence of alcohol use disorder is about 2%1 Cannabis use by adults 65 years and older increased from 0.4% in 2006 and 2007 to 2.9% in 2015 and 20162 Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief3 1.4% of adults over 50 used prescription opiates nonmedically over the prior year4 Center for Behavioral Health Statistics and Quality, 2019 2. Addiction. 2017; 112(3): 516-525 3. N Engl J Med. 2018 December 13; 379(24): 2351-2360 4. J Am Geriatr Soc. 2009
Slide 51-

Differential Substance induced depression Prominent disturbance in mood, or anhedonia, that predominates the clinical picture Evidence from the history, physical exam, or labs of substance use The substance must be capable of producing the symptoms Can be illicit or prescription Symptoms develop after exposure to a drug and persist beyond the expected length of physiologic effects
Slide 52-

Differential Substance induced depression First step is to ask for example, “Do you drink alcohol?” Next step is to quantify, ”How much do you drink?” Can use The Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G) Consider UDS, consider asking family
Slide 53-

Differential Non-prescription drugs Alcohol, heroin, cannabis, amphetamines (during withdrawal), cocaine (during withdrawal) Medications Benzodiazepine, opioids, anticholinergic, corticosteroid, stimulant withdrawal, antiepileptic medications, alpha-2 agonist, GnRH agonist, interferon
Slide 54-

Differential Medication effect Consider temporal onset of symptoms in conjunction with starting a new medication or medication change Consider risk factors: Prior history of depression Prior history of drug induced depression Dose is a factor some drugs
Slide 55-

Differential Substance induced depression, treatment May need to treat mood symptoms depending on severity, but focus of treatment should be on substance use Sometimes this is not possible when medication induced, so would focus on treating depression while minimizing exposure to the offending medication as much as possible
Slide 56-

Other Considerations
Slide 57-

Audience Poll Depression and loneliness describe the same phenomenon True False
Slide 58-

Audience Poll Depression and loneliness describe the same phenomenon True False
Slide 59-

Loneliness Though highly correlated, loneliness is different than depression Depression is characterized by pervasive symptoms (depressed mood, worthlessness, vegetative changes, etc) Loneliness is a response to lack of social connectedness Need to belong is a motivational drive, like hunger Painful emotional state caused by the perception of isolation or the subjective feeling of being alone
Slide 60-

Loneliness “Loneliness reflects how you feel about your relationships. Depression reflects how you feel, period.”1 Cacioppo, J. T., & Patrick, W. (2008). Loneliness: Human nature and the need for social connection (p. 317). New York: W.W. Norton & Company, Inc.
Slide 61-

Loneliness Social isolation doesn’t always cause loneliness Can imagine persons who are socially isolated but do not feel lonely because they don’t desire social contact Balance between actual and desired (amount, quality) social contact
Slide 62-

Loneliness 24% of community dwelling adults age 65 and older in the United States were socially isolated1 Plenty of changes associated with age increase the risk of social isolation in older adults Financial limitations Transportation Role transitions Loss of family and friends Functional changes (incontinence, reduced mobility, etc) Cognitive decline, sensory changes Social isolation  loneliness  depression 1. J Gerontol B Psychol Sci Soc Sci. 2020
Slide 63-

Loneliness The subjective feeling of loneliness is highly associated with depression in the elderly1 20% of geriatric depression cases are linked to loneliness2 Depression can further exacerbate social isolation International Journal of Geriatric Psychiatry. 2009. 24(7), 694-700 The Lancet Psychiatry, 2020; DOI: 10.1016/S2215-0366(20)30383-7 Depression Social Isolation
Slide 64-

Loneliness Important to consider social prescribing to build relationships, social skills training, and psychotherapies that target negative feelings of loneliness
Slide 65-

Case Given on the recent onset of mood symptoms you inquire about recent stressors. Our patient reports not having spent time with her grandchildren in over a year because of Covid isolation precautions. She’s worried about acquiring the virus and has had very little social contact with others.
Slide 66-

SARS-CoV-2 Older adults have experienced greater effects from the pandemic Higher mortality rates, more complications, greater disruptions to daily routine Asking older adults to adapt to newer technologies to stay connected Increased risk of social isolation and loneliness, reduced physical activity
Slide 67-

SARS-CoV-2 Early population-based studies did not show a large impact on mental health and wellbeing1 More recent studies have shown more of an effect Negative impacts on activity, quality of sleep, and wellbeing2 Higher rates of depression and anxiety than before the pandemic3 26% in 2020 compared to 11% in 2018 JAMA. 2020;324(22):2253-2254 Scientific Reports (2021) 11:4636 Kaiser Family Foundation 2021
Slide 68-

SARS-CoV-2 During lockdown loneliness and decreased physical activity associated were more symptoms of poor mental health, especially depression1 Focus on keeping older adults socially engaged and physically active 1. International Psychogeriatrics , Volume 33, May 2021 , pp. 505 - 514
Slide 69-

Late Onset Depression Late onset depression: first episode age of onset after age 60 LOD represents ~50% of geriatric depression cases1 Predominantly linked to cerebrovascular disease Depression symptoms + cognitive impairment Executive dysfunction, slower processing speed More likely to persist after treating depression 1. Annu Rev Clin Psychol. 2009
Slide 70-

Late Onset Depression Vascular depression proposed as a distinct diagnostic entity in 1997 Emerged from the finding that patients with LOD had high rates of hyperintensities on MRI A consequence of chronic ischemic lesions / atherosclerosis CVD predisposes, precipitates, or perpetuates geriatric depressive symptoms .
Slide 71-

Late Onset Depression Ischemic lesions in the frontal subcortical limbic circuits may contribute to the development of late-onset depression Executive dysfunction, apathy, and psychomotor slowing Chronic symptoms Difficult to treat with standard antidepressants
Slide 72-

Late Onset Depression Doesn’t alter treatment, though perhaps more frequent follow up and supportive interventions are needed May affect presenting symptoms, complicate the diagnosis, and influence treatment outcome
Slide 73-

Depression and Dementia Normal aging is associated with cognitive changes Cognitive impairment frequently accompanies depression Depression is a common symptom in dementia Depression and dementia can co-exist
Slide 74-

Depression and Dementia Depression occurring at any age is associated with a twofold increase in risk of developing dementia1 It is important to monitor cognition in an older person with a history of depression Regular cognitive screening after the age of 65 1. Nat Rev Neurol. 2011 May 3; 7(6): 323–331.
Slide 75-

Depression and Dementia High rates of depression in persons with MCI 32%1 High rates of depression in persons with dementia2 Vascular: 24.7% Alzheimer’s: 15% Lewy body: 21% The emergence of new depressive symptoms in older adults should raise concern for underlying/emerging cognitive impairment J Clin Psychiatry 2018;79(5):17r11772 JAMA Psychiatry. 2017;74(1):58–67.PubMed CrosRef
Slide 76-

Depression and Dementia It can be hard to separate one from the other Focus on treating mood symptoms Assess cognitive function at baseline and over time 30pt mental status exam (eg, SLUMS) Considering neuroimaging and reversible dementia labs as part of the work-up if there is concern that symptoms are due to dementia
Slide 77-

Treatment
Slide 78-

Treatment Effective treatment is associated with improved emotional, social, and physical function and quality of life Primary modalities Antidepressants Psychotherapy Behavioral activation, exercise Electroconvulsive therapy, RTMS Consider patient preference, treatment history, treatment availability, and coexisting medical and psychiatric conditions
Slide 79-

Treatment Three stages of treatment Acute: treat to remission Continuation: treat to prevent recurrence of the same episode (relapse) Maintenance (prophylaxis): treat to prevent future episodes (recurrence)
Slide 80-

Audience Poll QUESTION: Which category of antidepressant should be considered first line in treating geriatric depression MAO-I TCA SSRI SNRI C & D
Slide 81-

Audience Poll QUESTION: Which category of antidepressant should be considered first line in treating geriatric depression MAO-I TCA SSRI SNRI C & D
Slide 82-

Treatment SSRIs Serotonin reuptake inhibitor First line, effective and well tolerated SNRIs Serotonin and norepinephrine reuptake inhibitor Also considered first line, though might be less well tolerated in the very old May be helpful for comorbid neuropathic pain TCA Higher dropout rate than with the above because of tolerability Anticholinergic, cardiac side effects
Slide 83-

Treatment Atypical antidepressants Bupropion: NE and DA reuptake inhibitor Mirtazapine: not a reuptake inhibitor Serotonin receptor modulator, alpha 2 blocker (increase NE release) Great for appetite and sleep SARIs Serotonin antagonist and reuptake inhibitors Trazodone, nefazodone, vilazodone* MAOI Monoamine oxidase inhibitor Prevents breakdown of monoamines in the synaptic cleft Lots of drug-drug and drug-food interactions
Slide 84-

Treatment SSRI Citalopram: start 10mg, increase to 20mg dose max Sertraline: start 50mg, increase up to 200mg in 50mg increments Paroxetine: avoid (anticholinergic) Fluoxetine: start 10mg qday, increase up to 60mg Fluvoxamine: avoid (drug interactions) Escitalopram: start 5mg, increase to 10mg SNRI Venlafaxine: start 75mg qday, increase to 225mg Duloxetine: start 30mg qday, increase to 60mg Desvenlafaxine: start 50mg qday, increase to 100mg
Slide 85-

Treatment SARI Vilazodone: start 10qd x 7d, then 20qd x7 days; may go to 40qday Nefazodone: start 50mg bid up to 150mg bid Atypical Antidepressants Bupropion XL: start 150mg qday, up to 450mg Mirtazapine: 7.5mg qHS up to 45mg
Slide 86-

Treatment Antidepressant monotherapy is preferred in order to minimize side effects, cost, and enhance likelihood of adherence Start low and titrate slowly Allow 4-6 weeks of treatment to elicit a full response Only 40-65% of patients will have an adequate response to any given antidepressant If no response, consider switching within class or out of class to a new antidepressant
Slide 87-

Treatment If partial response, can consider: SSRI + atypical antipsychotic Aripiprazole, brexpiprazole, quetiapine Or SSRI + bupropion, or SSRI + buspirone Or refer for psychotherapy Continue treatment or 9-12 months to reduce risk of recurrence of depression (recurrence rates can be as high as 70%)
Slide 88-

Treatment Lots of choices Consider past treatment Assess for medications that were historically effective or ineffective or intolerable Consider drug-drug interactions Consider drug-disease interactions
Slide 89-

Audience Poll QUESTION: Which antidepressant pharmacologic regimen would you consider for our patient? A. Sertraline 25mg per day B. Sertraline 25mg per day plus mirtazapine 7.5mg qhs Sertraline 25mg per day plus escitalopram 5mg qday D. Sertraline 200mg per day
Slide 90-

Audience Poll QUESTION: Which antidepressant pharmacologic regimen would you consider for our patient? A. Sertraline 25mg per day B. Sertraline 25mg per day plus mirtazapine 7.5mg qhs Sertraline 25mg per day plus escitalopram 5mg qday D. Sertraline 200mg per day
Slide 91-

Treatment – Side Effects SSRI/SNRI GI upset Dry mouth Falls RLS Restlessness Headache Tremor Reduce libido Hyponatremia1 Up to 12% (paroxetine) Bupropion Elevated blood pressure Seizures Mirtazapine Weight gain Sleepiness Glucose intolerance Antipsychotics Metabolic Stroke/mortality 1, Fabian TJ, Amico JA, Kroboth PD, et al. Paroxetine induced hyponatremia in older adults a 12-week prospective study. Arch Intern Med. 2004;164:327-332.
Slide 92-

Treatment Exercise can have a powerful antidepressant effect Tai-Chi can improve mood, cognition, quality of life, and overall energy in older adults with depression Adequate first line treatment for older adults with mild to moderate depression
Slide 93-

Treatment Referral to mental health provider for psychotherapy Various types of psychotherapies help with depression CBT: IPT thoughts feelings behavior depression interpersonal difficulties loss --- Supportive therapy, problem solving therapy
Slide 94-

Treatment Electroconvulsive Therapy Efficacy rates are high! From 60 to 90% Uses electricity to induce a brief seizure while under anesthesia Consider referral in patients who have severe symptoms that is resistant to other treatments or patients at risk for harm because of psychosis, SI, or severe malnutrition Very well tolerated and no absolute contraindications Requires referral to a psychiatrist
Slide 95-

Treatment Repetitive transcranial magnetic stimulation Focal magnetic field is used to create an electric current that modulates activity in focused parts of the brain Useful for resistant mild/moderate depression Daily treatment (M-F), 30 treatments in total Well tolerated No anesthesia Headache, seizures Requires referral to a psychiatrist
Slide 96-

Suicide Risk
Slide 97-

Suicide Risk Elderly comprise 13% of population but account for 24% of all suicides 10th leading cause of death in elders in the US in 201811 The most common cause is untreated depression The rate of male suicides in late life is about 5 times greater than for female suicides, elderly white males at highest risk The rate of suicide for women declines after age 60 Firearms are the most common means used for completing suicide among the elderly www.americashealthrankings.org
Slide 98-

Suicide Risk The act of completing suicide is rarely preceded by only one cause or one reason Risk factors The recent death of a loved one Physical illness, uncontrollable pain or the fear of a prolonged illness Perceived poor health Social isolation and loneliness Substance use Access to a means
Slide 99-

Suicide Risk Intervention Inquire about thoughts of dying or suicide Ask about intent: plan? access to means? Address modifiable risk factors Suicide safety plan Warning signs, internal coping strategies, social supports, family and friends for crisis help, professionals and agencies Refer and schedule close follow up to bridge care Hospitalize when indicated
Slide 100-

Summary Low rates of depression in healthy community dwelling older adults, but prevalence increases in medical settings Diagnosis made using DSM 5 criteria, but this can be confounded factors unique to aging Treatment consists of antidepressants, psychotherapy, and brain stimulation therapies
Slide 101-

Send me an email to say hi! mansoord@ohsu.edu