Current Geriatric Diagnosis & Treatment, 1st Edition

Section III - Common Disorders in the Elderly

14. Depression & Other Mental Health Issues

Mary A. Norman MD

Mary E. Whooley MD

Kewchang Lee MD

DEPRESSION

ESSENTIALS OF DIAGNOSIS

  • Depressed mood.
  • Loss of interest or pleasure in almost all activities.
  • Unintentional weight change, lack of energy, change in sleep pattern, psychomotor retardation or agitation, excessive guilt, or poor concentration.
  • Suicidal ideation or recurrent thoughts of death.
  • Somatic rather than mood complaints in the elderly.

General Considerations

The prevalence of major depression is estimated at 1–2% for elders in the community and 10–12% for those in primary care settings. However, even in the absence of major depression as defined by Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) criteria, up to 27% of elders experience substantial depressive symptoms that may be relieved with intervention. For institutionalized elders, the rates of major depression are much higher: 12% for hospitalized elders and 43% for permanently institutionalized elders.

Women are twice as likely to experience major depression as men. Other risk factors include prior episodes or a personal family history of depression, lack of social support, use of alcohol or other substances, and a recent loss of a loved one. Several medical conditions are also associated with an increased risk of depression, including Parkinson's disease, recent myocardial infarction, and cerebrovascular accident. These conditions share common threads of loss of control of body or mind, increasing dependence on others, and increased social isolation.

Depression is associated with poorer self-care and slower recovery after acute medical illnesses. It can accelerate cognitive and physical decline and leads to an increased use and cost of health care services. Among depressed elderly who have had a stroke, rehabilitation efforts are less effective and mortality rates are significantly higher.

Clinical Findings

  1. SYMPTOMS & SIGNS

Major depression is defined as depressed mood or loss of interest in nearly all activities (or both) for at least 2 weeks, accompanied by a minimum of 3 or 4 of the following symptoms (for a total of at least 5 symptoms): insomnia or hypersomnia, feelings of worthlessness or excessive guilt, fatigue or loss of energy, diminished ability to think or concentrate, substantial change in appetite or weight, psychomotor agitation or retardation, and recurrent thoughts of death or suicide (Table 14-1). Severity of depression varies and is important in determining optimal treatment and prognosis. Patients with less severe depressive symptoms who do not meet criteria for major depression may also benefit from psychotherapy and pharmacotherapy.

  1. SCREENING TOOLS

Elderly patients can have fewer mood and more somatic complaints, which are often difficult to differentiate from underlying medical conditions. Special screening tools that consider this difference have been developed for the elderly population. The Geriatric Depression Scale is widely used and validated in many different languages. Its shortened 15-item scale (Table 14-2) is often used for ease of administration. A separate 2-item scale consisting of 2 questions about depressed mood and anhedonia has also been shown effective in detecting depression in the elderly (see Table 14-2). Screening alone has not been found to benefit patients with unrecognized depression, but in combination with patient support programs, such as frequent nursing follow-up and close monitoring of adherence to medication, it improves outcomes.

Table 14-1. Diagnostic criteria for depression.

Diagnostic category

Criteriaa

Duration

Dysthymia

3 or 4 dysthymic symptoms,b including depressed mood

≥ 2 year

Major depression

≥ 5 depressive symptoms,c including depressed mood or anhedonia

≥ 2 week

   Mild

Few (if any) symptoms in excess of those required for the diagnosis; minimal impairment in functioning

   Moderate

Greater number and intensity of depressive symptoms; moderate impairment in functioning

   Severe

Marked intensity and pervasiveness of depressive symptoms; substantial impairment in functioning

aFrom the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
bDysthymic symptoms include depressed mood, poor appetite or overeating, sleep disturbance, lack of energy, low self-esteem, poor concentration, and hopelessness.
cDepressive symptoms include depressed mood, enhedonia, weight change, sleep disturbance, psychomotor problems, lack of energy, excessive guilt, poor concentration, and suicidal ideation.

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Differential Diagnosis

Diagnosing depression in the elderly can be challenging because of the presence of multiple comorbid conditions. Many patients with mild cognitive impairment may have predominantly depressive symptoms. With effective treatment of depression, their cognitive performance frequently improves; however, these patients still are at high risk for progression to dementia within the next 3 years. Bereavement often manifests with depressed mood, which may be appropriate given a patient's recent loss. However, if depressive symptoms

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persist longer than 2-3 months, a diagnosis of major depression should be considered.

Table 14-2. Geriatric depression scale (short form).a

Depression Scale

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 that 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

         SCORE:

_______

Directions:Score 1 point for each bolded answer. A score of 5 or more is a positive screen for depression.
Two-Question Case-Finding Instrumentb

1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?

Yes/No

2. During the past month, have you often been bothered by having little interest or pleasure in doing things?

Yes/No

Directions:Yes to either question is a positive screen for depression.

aFrom Sheikh, JI, Yesavage JA: Geriatric depression scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontology 1986;5:165. Used with permission.
bFrom Whooley MA et al: Case-finding instrument for depression: Two questions are as good as many. J Gen Intern Med 1997;12:439. Used with permission.

Elderly patients who experience delirium caused by an underlying medical illness may have mood changes. Other comorbid psychiatric illnesses must also be considered, such as anxiety disorder, substance abuse disorder, or personality disorders. Patients with bipolar disorder or psychotic disorders may have depressed mood; thus, it is important to ask patients about prior manic episodes, hallucinations, or delusions.

Depression can also be confused with other medical conditions. Fatigue and weight loss, for example, may be associated with diabetes mellitus, thyroid disease, underlying malignancy, or anemia. Patients who have Parkinson's disease may first present with depressed mood or flat affect. Sleep disturbances as a result of pain, nocturia, or sleep apnea may also lead to daytime fatigue and depressed mood.

A complete history and physical examination, including assessment of cognitive status, is critical in the evaluation of depression in the elderly. Because depression is a clinical diagnosis, no routine laboratory tests are indicated. Testing may be tailored to each patient based on their underlying comorbidities and presenting symptoms. A complete review of medications, both prescription and over the counter, is essential. Medications such as benzodiazepines, narcotics, glucocorticoids, interferon, and reserpine may cause depressive symptoms. Contrary to earlier beliefs, β-blockers have not been proven to cause depression. Screening for alcohol and other substance use or addiction is another important part of the medical history. Substance use can interfere with compliance and contribute to high relapse rates, although active substance abuse should not preclude treatment for depression. For patients who struggle with addiction, “dual diagnosis” programs (alcohol or other substance dependence and psychiatric disorder) may be optimal.

Treatment

  1. PATIENT & FAMILY EDUCATION/SUPPORTIVE CARE

Educating patients and families about depression is the cornerstone of successful treatment. Depression continues to carry a stigma in many communities and cultures. Appropriate education can help patients understand that their condition results from a combination of inherited factors and personal and environmental stressors. Providers should also emphasize that physical symptoms and sleep disturbances are characteristic of depression; thus, relief of depression should make other physical symptoms more bearable. Encouraging physical activity with a family member or friend can be a simple, effective step toward improving social support and overall well-being.

Involving families in the care of elderly patients is crucial for both diagnosing depression and developing an effective treatment plan. Caregivers of elderly patients, especially if impaired physically or cognitively, may be experiencing considerable stress and depression as well. Many programs are available that may alleviate stress and promote positive social interactions for patients. Adult day programs, senior centers, and senior support groups can be helpful resources for patients and their families, and geriatric social workers can assist with finding appropriate programs for each patient. Caregiver support groups and formal respite programs are also available in most communities.

  1. PHARMACOTHERAPY
  2. Antidepressants
  3. Selection—Overall, antidepressants, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and newer agents, are equally effective in the treatment of geriatric depression (Table 14-3). However, because of side effect profiles and propensity for drug interactions, monoamine oxidase inhibitors (eg, phenelzine and tranylcypromine) and tertiary amine TCAs (eg, amitriptyline, imipramine, and doxepin) are rarely used in the elderly. Likewise, fluoxetine is generally avoided in the elderly because of its long half-life and inhibition of the P450 system. Choice of therapy among the remaining drugs is generally determined by side effect profile and the patient's comorbid symptoms such as anxiety, insomnia, pain, and weight loss, although anxiety and insomnia do not necessarily predict a better response to more sedating medications. Renal and hepatic functions are also important considerations in the elderly and should be assessed before initiation of therapy.

SSRIs are safe in overdose and have no known adverse cardiac effects. Thus, they are a reasonable first choice in treating elderly patients with depression. Other agents also offer unique advantages: Mirtazapine stimulates appetite and can help with insomnia, and bupropion can reduce craving in smoking cessation. Secondary amine TCAs (eg, nortriptyline, desipramine) can offer beneficial effects for patients with neuropathic pain, detrussor instability, or insomnia. Venlafaxine, which has serotonergic and noradrenergic activity, is another effective alternative that is also useful in treating anxiety and neuropathic pain.

  1. Dosage—In general, elderly patients should begin an antidepressant by taking half of the manufacturer-recommended starting dose (to minimize side effects), but the medication should be titrated to the recommended target dose in weekly increments (see Table 14-3). Elderly patients are frequently undertreated because the provider fails to adequately titrate the dose to a therapeutic

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level. If minimal or no benefit occurs by 4-6 weeks and side effects are tolerable, the dose should be increased. The full effect may not be seen for 8-12 weeks in elderly patients. If a therapeutic dose has been reached and maintained for 6 weeks and the patient has not adequately responded, one should consider switching to a different agent or augmenting with an additional agent. Although serum drug levels are not useful for SSRIs, levels of TCAs can be measured to assess adherence.

Table 14-3. Selected antidepressants for use in elderly patients.a

Generic name

Trade name

Initial dose

Target doseb

Cost per monthc

Other indications

Serotonin-norepinephrine reuptake inhibitors:

   Citalopram

Celexa

10 mg qd

20-40 mg qd

$$

OCD; diabetic neuropathy; poststroke depressiond; panic disorder

   Ecitalopram

Lexapro

5-10 mg QD

10-20 mg QD

$$

 

   Fluoxetine

Prozac

10 mg qAM$

20-40 mg qAM$

$$

Bulimia; OCSd

   Paroxetine

Paxil

10 mg qd or qhs

10-40 mg qd/qhs

$$

OCDd; panic disorders,d migraine, social phobiasd PTSD, premature, ejaculation

   Sertraline

Zoloft

25 mg qAM$

50-200 mg qAM$

$$$

OCD; panic disordersd; PTSDd; premature ejaculation

Secondary amines:
   Tricyclic:

      Desipramine

Norpramin

10 mg qd or qhs

20-150 mg qd/qhs

$

Attention deficit disorder (ADD);dbulimia neuropathic pain; postherpetic neuralgia; panic disorder; PTSD

      Nortriptyline

Aventyl, Pamelor

10 mg qhs

20-100 mg qhs

$

ADD; chronic low back pain; irritable bowel syndrome; neuropathic pain; panic disorder

   Bicyclic:

      Venlafaxine

Effexor

12.5 mg bid

75 mg bid

$$$

Generalized anxiety disorder (XR formulation only)d; neuropathic pain; OCD

Effexor XR

37.5 mg qd

75-150 mg qd

$$

 

Serotonin antagonist:

   mirtazapine

Remeron

7.5 mg qhs

15-45 mg qhs

$$$

Anxiety; insomnia; weight loss

Norepinephrine-dopamine reuptake inhibitor:

   bupropion

Wellbutrin

75 mg bid

100 mg tid

$$$

ADD; anorgasmia; smoking cessation (SR form only)d

Wellbutrin SR

75 mg qAM$

150 mg bid

$$$

Serotonin antagonist and reuptake inhibitor:

   Nefazodone

Serzone

50 mg bid

150 mg bid

$$

Panic disorder; PTSD

   Trazodonee

Desyrel

25-50 mg qhs

50-200 mg qhs

$

Insomnia

Psychostimulants:

   Methylphenidate

Ritalin

2.5-5 mg at 7 AM$ and noon

5-10 mg at 7 AM$ and noon

$

ADDd

Dextroamphetamine

Dexedrine

2.5-5 mg qAM$

2.5-5 mg at 7 AM$ and noon

$

ADDd

aThe information provided is intended only as a guide for the treatment of depression in medical outpatients. Providers should refer to the package inserts or consult with a pharmacist for individual dosing recommendations, precautions, and drug interactions.
bThe target dose is the dose likely to be effective for a typical geriatric patient.
cAverage wholesale price range in U.S. dollars for a 30-day supply of usual target dose. $, $30-$50; $$, $51-$80; $$$, ≥ $80.
dApproved by the U.S. Food and Drug Administration for this indication.
eTrazodone is too sedating at therapeutic doses for depression; it is best used in lower doses (50-100 mg) as an adjunctive therapy for patients with insomnia.
Adapted from Whooley MA, Simon GE: Managing depression in medical outpatients. N Engl J Med 2000;343:1942. Used with permission.

  1. Side effects

Side effects differ depending on the type of antidepressant (Table 14-4). Most side effects lessen within 1–4 weeks from the start of therapy, but weight gain and sexual dysfunction may last longer. For the SSRIs, the most common side effects include nausea and sexual dysfunction. Sexual dysfunction may respond to treatment with sildenafil (Viagra), but switching antidepressant mediation or lowering the dose of SSRI and augmenting with an additional agent may be necessary. The TCAs have more anticholinergic properties and may lead to dry mouth, orthostasis, and urinary retention.

  1. Cautions & interactions
  2. Cardiovascular disease—TCAs can be associated with orthostatic hypotension and cardiac conduction abnormalities, leading to arrhythmias. Before initiation of therapy, providers should obtain an electrocardiogram and proceed with caution if conduction delays such as first-degree atrioventricular block or bundle branch block are present.
  3. Hypertension—Venlafaxine may increase diastolic blood pressure.
  4. Hepatic disease—Most antidepressants are hepatically cleared and should be used with caution in patients with liver disease. Nefazodone in particular should not be used in patients with liver disease or elevated transaminases because it has been associated with an increased risk of hepatic failure and interacts with other hepatically cleared medications, including simvastatin and lovastatin.
  5. Cognitive impairment—TCAs and certain SSRIs such as paroxetine have stronger anticholinergic effects and should be avoided in patients with cognitive impairment to avoid increasing confusion.
  6. Seizure disorders—Bupropion lowers seizure thresholds.
  7. Suicidal ideation—TCAs are lethal in overdose and should be avoided in actively suicidal patients. SSRIs are relatively safe in overdose.
  8. Psychostimulants—Psychostimulants such as dextroamphetamine (5–10 mg/day) or methylphenidate (2.5–5 mg/day) are sometimes indicated as either a primary or an adjuvant treatment for depression with predominant vegetative symptoms. At the end of life, patients may not have time to wait 4–6 weeks for the benefits of antidepressant medication, and psychostimulants can be effective within hours. In the setting of depression after an acute medical illness, psychostimulants offer a fast means to enhance recovery and participation in rehabilitation. Typical side effects include insomnia and agitation, but these may be lessened by taking the medication early in the day in divided doses (morning and noon). Another common side effect is tachycardia.
  9. Herbal remedies—Many herbal remedies claim to be effective in treating depression, but further evidence is still needed to determine whether these “dietary supplements” (eg, Hypericum perforatum[St. John's wort]) have a role in the treatment of depression. H perforatumshould not be used in conjunction with SSRIs because the combination may lead to serotonergic syndrome, which is characterized by changes in mental status, tremor, gastrointestinal upset, headache, myalgia, and restlessness. It may lower the concentration of certain drugs, such as warfarin, digoxin, theophylline, cyclosporine, and HIV-1 protease inhibitors. Other common herbal remedies such as kavakava and valerian root have not been proven effective for treating depression. Herbal remedies should not be substituted for proven depression therapies.
  10. PSYCHOTHERAPY

Cognitive-behavioral therapy (CBT), problem-solving therapy (PST), and interpersonal psychotherapy (IPT) are effective treatments for major depression either alone or in combination with pharmacotherapy. CBT focuses on identifying negative thoughts and behaviors that contribute to depression and replacing them with positive thoughts and rewarding activities. PST teaches patients techniques to identify routine problems, generate multiple solutions, and implement the best strategy. IPT focuses on recognizing and attempting to resolve personal stressors and relationship conflicts that lead to depressive symptoms.

Typically, these therapies should be continued once or twice weekly for 6–16 sessions. In patients with severe depression, combination therapy with psychotherapy and pharmacotherapy is superior to either treatment alone. Psychoanalytic and psychodynamic therapies have not proved effective for treatment of major depression.

  1. ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) is an effective treatment for geriatric depression. Response rates for refractory depression are quite high at 73% for the young-old (60–74 years) and 67% for the old-old (> 75 years). Typical side effects include confusion and anterograde memory impairment, which may persist for 6 mo. ECT may be first-line therapy for severely melancholic patients, for those at high risk for suicide, and for medically

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ill patients whose hepatic, renal, or cardiac diseases preclude the use of other antidepressants.

Table 14-4. Frequency of side effects associated with antidepressant medications.a

Medication

Sedation

Agitation

Anticholinergic effectsb

Postural hypotension

Gastrointestinal upset

Sexual dysfunction

Weight gain

Weight loss

Selective serotonin reuptake inhibitors

      Citalopram

0

0

0

0

++

++

0

+

      Ecitalopram

+

0

0

0

++

++

0

0

      Fluoxetine

0

++

0

0

++

+++

0

+

      Paroxetine

++

0

+

0

++

+++

0

+

      Sertraline

+

+

0

0

++

+++

0

+

   Tricyclics-secondary

      Desipramine

++

0

++

++

+

+

+

0

      Nortriptyline

+++

0

++

++

+

+

+

0

   Bicyclics

      Venlafaxinec

+

+

+

0

+++

++

0

+

Serotonin antagonists: mirtazapine

+++

0

++

+

0

0

++

0

Norepinephrine-dopamine reuptake inhibitors: bupropion

+

++

+

0

++

0

+

++

Serotonin antagonist and reuptake inhibitors

   Nefazodone

++

0

+

+

+

0

+

+

   Trazadone

++++

0

+

++

+

0

+

+

aFrequency of side effects: 0, none; +, minimal, ++, low; +++, moderate; ++++, high.
bIncluding dry mouth, dry eyes, blurred vision, constipation, urinary retention, tachycardia, and confusion.
cMay cause dose-related elevation in diastolic blood pressure; monitoring of blood pressure is recommended.
Adapted with NEJM permission from Whooley MA, Simon GE, “Managing Depression in Medical Outpatients,” NEJM 2000;343(26):1942-1950.

  1. PSYCHIATRIC THERAPY

Psychiatric consultation is recommended for those patients with a history of mania or psychosis, for those who have not responded to a trial of 1 or 2 medicines, and for those who require combination therapy or ECT. Immediate psychiatric evaluation is required for any patients who, after probing, admit to having active plans to harm themselves. Risk factors for suicide in elderly patients with major depression include older age; male gender; marital status of single, divorced, or separated and without children; personal or family history of a suicide attempt; drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with access to firearms or other lethal means (eg, stockpiled medications). If medications and weapons are present and cannot be removed from the patient's home, then consider adding “weapon at home” to the patient's problem list to highlight potential suicide risk.

  1. FOLLOW-UP
  2. Pharmacotherapy—Elderly patients should be monitored closely during the initial 3 mo of treatment. Many medical outpatients who receive a prescription for an antidepressant terminate treatment during the first month, when side effects may be at a maximum and before therapeutic effects are evident. Elderly patients should be monitored closely in the first 1–2 weeks of therapy to assess side effects and encourage continued therapy. They should have a minimum of 3 visits (in person or by telephone) during the first 12 weeks of antidepressant treatment.

Elderly patients must be informed that antidepressants usually take 4–6 weeks, but may take 8 weeks or longer, to have a full therapeutic effect and that only about 50% of patients respond to the first antidepressant prescribed. Patients who have not responded after an adequate trial of medication or who have had intolerable side effects may switch either to another medication within the same class (different SSRI) or to a different class of medications. When switching among SSRIs or between TCAs and SSRIs, no wash-out period is required (with the exception of switching from fluoxetine, because of its long half-life). However, abrupt cessation of shorter acting antidepressants (eg, citalopram, paroxetine, sertraline, or venlafaxine) may result in a discontinuation syndrome with tinnitus, vertigo, or paresthesias. Referral for psychiatric consultation is recommended if a patient fails to respond to 2 different medication trials.

Once remission has been achieved, antidepressants should be continued for at least 6 mo to reduce the risk of relapse. Patients who are at high risk of relapse (2 or more episodes of depression in the past or major depression lasting more than 2 years) should be continued on therapy for 2 years or possibly indefinitely. Many recommend lifelong therapy, even if it is the patient's first episode of major depression and especially if depression is severe and related to life changes that are not expected to improve. Follow-up visits should be arranged at 3- to 6-mo intervals. If symptoms return, the medications should be adjusted or changed or the patient referred for psychiatric consultation.

If the patient and physician agree to a trial discontinuation of therapy, medications should be tapered over a 2- to 3-mo period, with at least monthly follow-up by telephone or in person. If symptoms return, the patient should be restarted on medications for at least 3–6 mo.

When patients fail to respond to adequate trials of 2 medications for major depression, a diagnosis of treatment-resistant depression is considered. One must review the case and consider that the original diagnosis may be inaccurate. What first appeared as depressive symptoms may be a manifestation of underlying anxiety or cognitive impairment that is not being adequately treated. One must then verify that the patient actually received the medication that was prescribed. A simple investigation may reveal that the patient never filled the prescription or was never given medication by caregivers. Finally, one must ensure that the patient had adequate trials of medications (6–8 weeks) and that this trial was performed at a therapeutic dose.

Any patient who has had an adequate trial of 2 different medications without acceptable response should be referred to a psychiatrist for augmentation therapy. Lithium may be used in low doses in the elderly with careful monitoring of side effects. Small doses of liothyronine (T3) can be used safely in euthyroid patients. In addition, combinations of 2 antidepressant medications may be synergistic, with low doses of 1 antidepressant enhancing response to an antidepressant of another class.

  1. Structured psychotherapy—Patients who have been referred to psychotherapy must still be monitored closely by their primary care clinicians because patients tend to discontinue therapy even more frequently than antidepressant treatments. The benefits of psychotherapy are generally evident by 6–8 weeks. The addition of pharmacotherapy should be considered for patients who have not fully responded to psychotherapy alone by 12 weeks. A combination of psychotherapy and pharmacotherapy may be more effective for moderate depression than either treatment alone.

Prognosis

Depression is often a chronic or relapsing and remitting disease. Greater severity of depression, persistence of

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symptoms, and a higher number of prior episodes are the best predictors of recurrence. The lifetime risk of suicide in patients with major depression is 7% for men and 1% for women.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association, 1994.

Hirschfeld RM et al: The National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression. JAMA 1997;277:333. [PMID: 9002497]

Sable JA et al: Late-Life Depression: How to identify its symptoms and provide effective treatment. Geriatrics 2002;57:18. [PMID: 11851203]

Whooley MA et al: Management depression in medical outpatients. N Engl J Med 2000;343:1942. [PMID: 11136266]

Wilson K et al: Antidepressants versus placebo for the depressed elderly (Cochrane Review). In The Cochrane Library (series 1). Update Software, 2003. [PMID: 114055969]

SUICIDE

Many depressed elders contemplate suicide. Primary care providers must recognize the risk factors for suicide in patients with major depression: older age; male gender; being single, divorced, or separated and without children; personal or family history of a suicide attempt; drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with access to firearms or other lethal means. Providers should ask patients whether they ever think of hurting themselves or taking their life. If the patient responds positively, then physicians should ask whether they have a plan and, if so, what it is. Asking patients about stockpiled medications or weapons in their home is also critical in assessing the suicide risk. If medications and weapons are present and cannot be removed from the patient's home, then consider adding “weapon at home” to the problem list to highlight potential suicide risk. Actively suicidal patients with intent and plan require emergent psychiatric evaluation either through emergency departments or local psychiatric crisis units.

BIPOLAR DISORDER

ESSENTIALS OF DIAGNOSIS

  • History of manic episode: grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased activity, excessive spending, hypersexuality.
  • May be associated with psychosis.
  • Depressive episodes may alternate with mania.
  • Mania may present for the first time in elderly patients, usually in those with a history of depressive episodes.

General Considerations

Bipolar disorder is a less common diagnosis in the elderly, with an overall low prevalence of < 1% in community-dwelling elders but a 10% rate in some nursing home populations. Many patients with bipolar disease require special considerations as they age because of comorbid conditions and diminished ability to tolerate psychiatric medications. Late-onset mania is often secondary to underlying medical conditions and is frequently associated with neurological abnormalities such as cerebrovascular accident and cognitive impairment. Elderly patients with bipolar disorder have an increased 10-year mortality rate compared with those who have depression alone (70% vs. 30%).

Differential Diagnosis

DSM-IV criteria for bipolar disorder include those for major depressive episode (see Table 14-1) and for manic episode, which is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week and with ≥ 3 of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences. The presence of mania is key to the differentiation between depressive disorder and bipolar disorder.

A variety of conditions may mimic a manic episode. Patients with dementia, particularly frontotemporal dementia, may be disinhibited and hypersexual. Brain tumors, cerebrovascular accidents, and partial-complex seizures may also lead to bizarre, disinhibited behaviors. Elderly patients who are prone to delirium can have waxing and waning levels of consciousness with some periods of hyperarousal. In addition, some medications may have unexpected effects in older patients. Glucocorticoids, thyroxine, and methylphenidate may lead to acute mania. Even sedative medications (eg, benzodiazepines) may have a paradoxical effect in the elderly and lead to agitation. As in younger populations, substance intoxication or withdrawal from cocaine, alcohol, or amphetamines and endocrine disorders such as hyperthyroidism or pheochromocytoma can lead to symptoms consistent with mania.

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Treatment

Mood stabilizers have been the hallmark of treatment for bipolar disease. Valproic acid and carbamazepine are generally favored over lithium in the elderly because of lithium's side effect profile and narrow toxic-therapeutic window (Table 14-5). Antipsychotic medication can be used when psychotic features are present. In general, the newer antipsychotic agents such as olanzapine and risperidone are better tolerated by the elderly than the older neuroleptics with their extrapyramidal side effects and high risk of tardive dyskinesia, especially in women (Table 14-6). Olanzapine is approved as monotherapy for acute mania, although it does not have prophylactic effects against future manic episodes. Antidepressants are often used as an adjunct to mood stabilizers for patients with depression but should not be used alone because of the risk of transforming a depressive episode into a manic episode.

ANXIETY & STRESS DISORDERS

Panic Disorder

ESSENTIALS OF DIAGNOSIS

  • Sudden, recurrent, unexpected panic attacks, characterized by palpitations, dizziness, sensation of dyspnea or choking.
  • Attacks may include trembling, chest pain or discomfort, nausea, diaphoresis, paresthesias, and depersonalization.
  • Sense of doom, fear of death.
  • Persistent worry about future attacks.
  • Can be accompanied by a fear of being in places where attack might occur (agoraphobia).

Table 14-5. Mood stabilizers.

Generic name

Trade name

Initial dose

Target dose

Comments

Lithium

Lithobid, Eskalith

300 mg qd or bid

600–1200 mg/day in divided doses bid or tid

Monitor drug levels, renal function, thyroid function; diuretics and ACE inhibitors increase levels; avoid dehydration and many NSAIDS because of toxicity

Carbamazepine

Tegretol

200 mg qd or bid

400–1000 mg/day

Monitor blood count, liver function tests, drug levels

Valproic acid

Depakote

250 mg qd or bid

500–1500 mg/day

Monitor blood count, liver function tests, drug levels

ACE, angiotensin-converting enzyme; NSAIDs, nonsteroidal anti-inflammatory drugs.

General Considerations

The lifetime prevalence rate of panic disorder is 1.5–2%, increasing to 4% in the primary care setting. The rate among community-dwelling elders is < 1%. Depression is also present in 50–65% of patients with panic disorder; the suicide rate for these patients is 20% higher than that for depressed patients without panic disorder. Panic disorder may be associated with agoraphobia, which can be particularly disabling in the elderly.

Differential Diagnosis

A panic attack is defined as a discrete period of intense fear or discomfort with 4 or more of the following symptoms: palpitations, sweating, trembling or shaking, shortness of breath, choking sensation, chest pain or discomfort, nausea or abdominal distress, dizziness or unsteadiness, derealization or depersonalization, fear of losing control, and fear of dying. DSM-IV criteria include recurrent or unexpected panic attacks, with at least 1 of the attacks having been followed by ≥ 1 mo of at least 1 of the following: persistent concern about having additional attacks, worry about the implication of the attack or its consequences, or a significant change in behavior related to the attacks.

Because the likelihood of physical disease is much higher than in younger populations, panic disorder is more difficult to distinguish from other life-threatening events in elderly patients. Acute coronary syndromes, cardiac arrhythmias, acute bronchospasm, and pulmonary embolism may lead to symptoms consistent with panic attacks. Endocrine disorders, particularly hyperthyroidism and pheochromocytoma, can mimic panic disorder. In acutely hospitalized patients, alcohol, caffeine, and tobacco withdrawal may present as agitation, worry, and other physical symptoms. Abrupt discontinuation of a short-acting antidepressant, anxiolytic, or narcotic medication may also trigger panic symptoms. Older patients who suffer from panic disorder

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often have comorbid psychiatric diagnoses such as posttraumatic stress disorder (PTSD), generalized anxiety disorder, and depression.

Table 14-6. Commonly used antipsychotics.

Generic name

Trade name

Initial dose (mg)

Target dosagea(mg/day)

Available routes of administration

Older agents
   D2 Antagonists-high potencyb

      Haloperidol

Haldol

0.5

0.5–1

PO, IV, IM, depot

Newer agents:
   Serotonin Dopamine Receptor Antagonists

      Risperidone

Risperdal

0.5

1–1.5

PO

      Olanzapine

Zyprexa

2.5

2.5–5

PO

      Quetiapine

Seroquel

25

50–200

PO

aTarget dose is the usually effective dose for organic psychosis or agitation in the elderly. Patients with formal thought disorder may require higher doses in consultation with a psychiatrist.
bTypical antipsychotics carry an increased risk relative to atypical antipsychotics of extrapyramidal side effects, including akathisia, bradykinesia, rigidity, and tardive dyskinesia.

Treatment

CBT has been proven effective for the treatment of panic disorder. Patients often go into a complete remission after as few as 12 weekly sessions. CBT is particularly helpful in preventing relapse and treating agoraphobia. Antidepressants, particularly SSRIs and TCAs, are helpful. Benzodiazepines may also be used as a brief adjunctive therapy while awaiting the clinical response to antidepressants or CBT. Whenever possible, long-term therapy with benzodiazepines should be avoided because of the potential risk of falls, cognitive impairment, and dependence.

Perhaps the most important aspect of treatment is education for the patient and family. Understanding the symptoms of panic disorder and developing ways of coping are essential for effective management of the disease.

Social & Specific Phobias

ESSENTIALS OF DIAGNOSIS

  • A phobia is an irrational fear leading to intentional avoidance of a specific feared object, event, or situation.
  • Exposure to this phobic object may result in symptoms similar to those of a panic attack.
  • Patient is aware that his or her fear is irrational.

General Considerations

The prevalence of phobias is 5–6% in the elderly. Phobias present with features similar to panic disorder but are triggered by a specific event. Late-onset phobias are often associated with a recent life event such as a fall or injury. Social phobias affect 3% of the elderly and can lead to increasing isolation. Simple phobias are thought to be more common than social phobias, affecting 5–12% of the general population.

Differential Diagnosis

Social phobia (also known as social anxiety disorder) is defined by DSM-IV criteria as a marked and persistent fear of social situations. Exposure to these situations provoke anxiety and may lead to a panic attack. The patient realizes that the fear is excessive and either avoids the situation or endures it with great anxiety. The avoidance or anxiety associated with the situation interferes with the patient's normal routine, occupation, or relationships. Specific phobia is a fear of certain objects or situations with acknowledgment that the fear is unreasonable. Specific phobias may also impair a patient's ability to function normally.

In the elderly, new phobic symptoms may represent delusions associated with dementia or delirium. Patients with dementia or delirium are not typically aware of the irrational nature of their delusions in contrast to patients with phobia. Less common causes of phobia include brain tumors or cerebrovascular accidents. The psychiatric differential diagnosis of phobia includes depression, schizophrenia, and schizoid and avoidant personality disorders. Social phobia and alcohol dependence often coexist; therefore, probing for alcohol use is an important part of the assessment. Although both phobic disorders and panic disorder may present with

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panic attacks, patients with phobias do not experience recurrent unexpected attacks; rather, their anxiety symptoms are always associated with a specific object or situation.

Treatment

The first-line therapy for specific phobias is behavioral therapy. Techniques may include relaxation therapy, cognitive restructuring, and systematic exposure to the feared object or situation. Use of antidepressants, particularly SSRIs, may be beneficial for generalized social phobia. Beta-adrenergic antagonists such as propranolol may also be effective treatments when administered before a foreseeable feared event or situation. Benzodiazepine use may be necessary but in general should be used with caution because of adverse effects on balance and cognition. Most patients are able to adapt or overcome their phobias and can lead relatively normal lives; if not, they should be referred for evaluation by a mental health specialist.

Generalized Anxiety Disorder

ESSENTIALS OF DIAGNOSIS

  • Unrealistic or excessive worry about 2 or more life circumstances.
  • Worry is recurrent and difficult to control.
  • Physiological symptoms of restlessness, fatigue, irritability, muscle tension, and sleep disturbance.

General Considerations

Anxiety symptoms are often a normal reaction to the surrounding environment. Anxiety disorders tend to begin in early adulthood and continue throughout a patient's lifetime with periods of relapses and remissions. The lifetime prevalence of generalized anxiety disorder is 5%; estimates in elders range from 2–7%. Anxiety may increase in the elderly as a result of isolation, loss of independence, illness, disability, and bereavement.

Differential Diagnosis

The diagnosis of generalized anxiety disorder is characterized by the following according to DSM-IV criteria:

  • Excessive anxiety and worry about 2 or more life circumstances occurring more days than not for at least 6 mo.
  • Worry is difficult to control.
  • Anxiety and worry are associated with at least 3 of the following: restlessness, easy fatigability, difficulty with concentration, irritability, muscle tension, sleep disturbance.

Diagnosing generalized anxiety in elders can be complicated because many underlying illnesses may have similar symptoms. The differential diagnosis for generalized anxiety disorder includes the physical illnesses discussed previously for panic disorder. In addition, chronic medication or substance use and subsequent withdrawal may lead to anxiety symptoms. Caffeine, nicotine, and alcohol are common culprits. Elderly patients are much more sensitive to commonly used over-the-counter medications such as pseudophedrine, which may cause restlessness, anxiety, and confusion. Up to 54% of patients who suffer from generalized anxiety disorder have comorbid depression. Obsessive-compulsive disorder, somatoform disorder, and personality disorders may also present with symptoms of anxiety. Psychiatric consultation should be initiated if the diagnosis is in question.

Treatment

CBT is one of the most effective treatments for generalized anxiety disorder. Relaxation techniques and biofeedback may also alleviate symptoms. Several antidepressants (paroxetine, extended-release venlafaxine) also have significant anxiolytic properties and may be effective for both anxiety and depression. When depression and anxiety occur together, one should treat the depression first; doing so may improve the symptoms of both disorders. Anxiolytic medications such as buspirone (5–30 mg twice daily) may be effective. Benzodiazepines should be used with caution in the elderly because they can cause a paradoxical effect and may also lead to falls and cognitive impairment.

Posttraumatic Stress Disorder

ESSENTIALS OF DIAGNOSIS

  • History of exposure to a traumatic event.
  • Intrusive thoughts, nightmares, and flashbacks.
  • Avoidance of thoughts, feelings, or situations associated with the trauma.
  • Isolation, detachment from others, emotional numbness.
  • Symptoms of arousal such as sleep disturbance, irritability, and hypervigilance.
  • Frequently associated with depression and substance abuse.

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General Considerations

PTSD is associated with a lifetime prevalence of 1.2% in women and 0.5% in men. Symptoms of PTSD may persist into older age. In addition, symptoms can remain hidden until an older age when patients have new experiences (deaths, medical illness, disability) that trigger memories of former events or lose the capacity to compensate for lifelong symptoms because of cognitive impairment or other medical illness. However, some studies have shown that increased age may actually protect against the development of PTSD. Other protective factors include marriage, social support, and higher socioeconomic status.

Differential Diagnosis

Per DSM-IV criteria, the patient has been exposed to a traumatic event in which he or she experienced or witnessed an event outside the range of usual human experience. Symptoms may be grouped into 3 categories and may persist for > 1 mo.

  1. Persistent reexperience of the traumatic event by ≥ 1 of the following: recurrent and intrusive recollections, dreams, acting or feeling as if the traumatic event were recurring (reliving experience, hallucinations, illusions, and dissociative flashbacks).
  2. Avoidant symptoms with ≥ 3 of the following: avoiding thoughts, feelings, activities, places, or people associated with the trauma; inability to remember important aspects of the trauma; decreased interest in activities; feeling of detachment from others; restricted range of affect or sense of foreshortened future
  3. Arousal symptoms indicated by ≥ 2 of the following: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, or an exaggerated startle response.

Other anxiety disorders can present with symptoms of hyperarousal similar to those in patients with PTSD. Major depressive disorder and adjustment disorders can also present with numbing or avoidant symptoms. During a period of bereavement, patients can have visions or dreams about the deceased. Other psychotic disorders may be confused with PTSD, but patients with PTSD may also experience psychotic-like symptoms during severe episodes. Substance use or withdrawal may contribute to symptoms. Organic brain syndrome resulting from prior head injury may be associated with symptoms similar to those of PTSD; the presence of visual hallucinations is particularly suggestive of an organic cause. Patients with delirium may also appear hyperaroused or be prone to illusions. There is a high comorbidity of depression and alcohol abuse among patients with PTSD.

Treatment

Antidepressants, particularly SSRIs and TCAs, are indicated for treatment of PTSD (see Table 14-3). Both individual and group CBTs are also effective in the treatments and may be used alone or in combination with pharmacological therapy. Antiadrenergic agents such as clonidine may be helpful for symptoms of increased arousal, although one must consider related side effects such as orthostasis. Benzodiazepines can often worsen symptoms of PTSD and should be avoided. Antipsychotic medications are occasionally necessary for the treatment of associated psychotic symptoms (see Table 14-5).

SCHIZOPHRENIA & PSYCHOTIC DISORDERS

ESSENTIALS OF DIAGNOSIS

  • Loss of ego boundaries and gross impairment in reality testing.
  • Prominent delusions or auditory or visual hallucinations.
  • Flat or inappropriate affect
  • Disorganized speech, thought processes, or behavior.

General Considerations

Psychotic symptoms may be due to a long-standing psychotic illness that has persisted into older age or may present for the first time in later life in association with underlying medical conditions, especially dementia. Estimates for schizophrenia in the elderly population range from 0.1–0.5%. The prevalence of other psychotic syndromes such as paranoid ideation is higher, estimated at 4–6% in the elderly population, and is frequently associated with dementia. Patients with Alzheimer's disease have a particularly high incidence of

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psychosis; 50% manifest psychotic symptoms within 3 years of diagnosis.

Differential Diagnosis

The diagnostic criteria for schizophrenia include ≥ 2 of the following characteristic symptoms present for at least 1 mo: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms such as flattened affect. These symptoms must also be associated with social or occupational dysfunction. Patients commonly will not volunteer psychotic symptoms unless specifically asked by their provider after a trusting relationship has been established. If psychosis is suspected, it is important to ask patients and family members specifically about auditory and visual hallucinations, delusions, ideas of reference, and paranoid ideation. Visual hallucinations are associated more strongly with underlying organic cause.

Especially in the elderly, new psychotic symptoms carry a vast and complicated differential. New-onset psychotic symptoms can be attributed to medications, changes in environment, organic causes, including dementia, or a combination of these factors. Because psychosis may be the presenting sign of dementia, any elderly patient with new-onset psychosis should have a thorough cognitive screen. Prominent visual hallucinations are one of the hallmarks of Lewy body dementia. Patients with Alzheimer's disease frequently have fixed delusions regarding people stealing their possessions or marital infidelity. The dementia associated with Parkinson's disease may include negative symptoms of schizophrenia, such as flat affect.

Other central nervous system diseases such as brain tumors, partial seizures, multiple sclerosis, or cerebral systemic lupus erythematosus can also cause psychotic symptoms. Patients with major depression or bipolar disorder may experience psychotic features. Infections, endocrinopathies (thyroid, diabetes, adrenal), and nutritional deficiencies (vitamin B12, thiamine) may lead to psychosis. Finally, elderly patients can be especially sensitive to medications that trigger psychotic symptoms such as steroids or levodopa. Because of the large differential diagnosis, collateral information regarding the patient's baseline mental status, psychiatric history, and onset of symptoms is critical in the evaluation of psychotic symptoms.

Treatment

  1. PHARMACOTHERAPY

Antipsychotic agents such as risperidone, olanzapine, quetiapine, and clozapine are the mainstays of treatment for psychotic symptoms (see Table 14-6). Ziprasidone has been approved by the Federal Drug Administration, but data in the elderly are not yet available. Because of their lower incidence of extrapyramidal side effects, these agents are much better tolerated than the older antipsychotic agents, such as haloperidol and trifluoperazine (Stelazine). However, haldoperidol remains the treatment of choice in hospitalized patients requiring intravenous medications for acute psychosis or agitation, because none of the newer agents is available in intravenous form. Unlike older neuroleptics, which mainly treat positive symptoms (eg, delusions, hallucinations), the newer agents effectively manage both positive and negative psychotic symptoms (eg, flat affect, social withdrawal). The main side effects of newer agents are sedation and dizziness. Patients may experience akathisia and parkinsonism (eg, stiffness and rigidity) and, with longer term use, tardive dyskinesias, although the risk of such side effects is lower than with high-potency traditional antipsychotic drugs. Risperidone has been associated with a slightly increased incidence of strokes in patients with dementia. Unlike other newer agents, ziprasidone does not appear to cause weight gain and is useful in the treatment of obese patients. However, it is associated with QT prolongation and thus should be avoided in patients with underlying conduction disease and QT prolongation at baseline. Clozapine is often the treatment of choice for patients with severe resistant psychosis and those with disabling tardive dyskinesias. Clozapine, however, carries a 1–2% risk of agranulocytosis and, therefore, requires weekly blood monitoring. In addition, both clozapine and olanzapine have been associated with glucose dysregulation and thus should be used with caution in patients with diabetes mellitus. Dosages of antipsychotics used in elderly patients with dementia or acute delirium tend to be lower than those required for management of other psychotic disorders and may be only necessary for short periods of time (see Table 14-6).

To decrease inappropriate use of psychotropic medications and improve the quality of care in long-term care facilities, the Health Care Finance Administration's 1987 Omnibus Reconciliation Act outlined indications and prescribing guidelines for psychoactive medications used in the treatment of psychotic disorders and agitated behaviors associated with organic brain disorders. This act requires documentation of response in terms of specific target symptoms and careful monitoring of side effects. To avoid long-term side effects such as tardive dyskinesia, OBRA also recommends trial dose reductions of neuroleptics unless clinically contraindicated because of severity of symptoms.

  1. BEHAVIORAL THERAPY

Behavioral therapy may be effective for the management of psychosis and after the acute episode has resolved.

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Providing a stable living environment is critical to the successful treatment of psychosis. Medical compliance is difficult without close supervision by a family or staff member. Adult day facilities provide structured programs for patients and give critical respite to caregivers, thus allowing patients to remain in the community longer than they would otherwise be able to without nursing home care.

Dada F et al: Generalized anxiety disorder in the elderly. Psychiatr Clin North Am 2001;24:155. [PMID: 11225505]

Howard R et al: Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: An international consensus. Am J Psychiatry 2000;157:172. [PMID: 10671383]

Lang AJ, Stein MB: Anxiety disorders: How to recognize and treat the medical symptoms of emotional illness. Geriatrics 2001;56:24. [PMID: 11373949]

Targum SD, Abbott JL: Psychoses in the elderly: A spectrum of disorders. J Clin Psychiatry 1999;60(suppl 8):4. [PMID: 10335666]

Weintraub D, Ruskin PE: PTSD in the elderly: A review. Harv Rev Psychiatry 1999;7:144. [PMID: 10483933]

Young RC: Bipolar mood disorders in the elderly. Psychiatr Clin North Am 1997;20:121. [PMID: 9139286]

RELEVANT WORLD WIDE WEB SITES

Agency for Healthcare Research and Quality “AHCPR supported guidelines” for Diagnosis and Treatment of Depression in Primary Care: http://www.text.nlm.nih.gov

American Association for Geriatric Psychiatry: http://www.aagpgpa.org

American Medical Association: http://www.ama-assn.org/ama/pub/category/3457.html

Depression Awareness, Recognition, and Treatment (DART) program of the National Institute of Mental Health: http://www.nimh.nih.gov/publicat/index.cfm

National Center for PTSD: http://www.ncptsd.org

National Depressive and Manic-Depressive Association Depressive Association: http://www.ndmda.org

National Foundation for Depressive Illnesses: http://www.depression.org/

National Mental Health Association (Campaign on Clinical Depression): http://www.nmha.org/ccd