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EARLY INTERVENTIONS IN GERIATRIC

EARLY INTERVENTIONS IN GERIATRIC DEPRESSION

1Abhishek Pathak, 2 JS Yadav, 3 Samiksha Kaur, 4 Shweta Singh

Senior Resident, Dept of Psychiatry IMS BHU,Varanasi.1 Assistant Prof. AIIMS, New Delhi,2 Psychologist SRLN hospital Varanasi,3 Junior resident, Dept of Anatomy, IMS, BHU Varanasi4

Abstract

Geriatric depression is a common but frequently unrecognized or inadequately treated condition in the elderly population. Manifestations of major depression in elderly persons may hinder early detection; anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders are more frequent. Like major depression, minor depression, which is often ignored, produces morbidity for elderly persons. Both major and minor depressions are associated with high mortality rates if left untreated. The frequent atypical presentation of depressive disorders in older persons, the resistance of many elderly people to acknowledge and report their symptoms to their primary care physician, and the increasing pressure of primary care physicians to spend less time with their patients contribute to the low recognition rate of depression in this age group.

Introduction


Depression in elderly persons is a serious public health problem, (1) resulting in impaired physical, mental, and social functioning that burdens families and society. Despite the common occurrence of depression in elderly persons, recognition of depression remains a problem (2-4). Manifestations of major depression in elderly persons may hinder early detection; anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders are more frequent. As a result, treatment is often delayed, if initiated at all. Untreated severe depression (similar to other chronic medical conditions such as chronic obstructive pulmonary disease) can result in increased mortality

Etiology

Depression in older persons can be divided into early-life onset (before age 65 years), which recurs into old age, and late-life onset (after age 65 years), which begins in old age. Like early-onset depression, the specific cause of late-life depression remains unclear. However, biological, psychological, and social factors collectively have been associated with both early-life and late-life depressive disorders. Although a known increased familial risk exists, no single biological factor has been identified as the cause of late-life depression. Genetic links have been studied, but no single gene has been associated with late-life depression. Many neurotransmitters, including catecholamine, serotonin, dopamine, and -aminobutyric acid, may contribute to the development of depressive symptoms. For example, both catecholamine excess and deficit have been linked to depression, which makes it less likely that catecholamine changes alone are the biological factor responsible for this condition. Low levels of cerebrospinal fluid 5-hydroxyindoleacetic acid, the principal metabolite of serotonin, are found in young and old patients with depression who commit suicide. Older people experience cerebrovascular changes much more often than do younger people. The “vascular depression hypothesis” proposes that cerebrovascular lesions disrupt the prefrontal systems or their modulating pathways, resulting in a distinctive clinical picture of depression in elderly persons characterized by apathy, motor retardation, and greater cognitive impairment (5,6).  Among the psychological stressors are changes in status that occur when individuals transition from an active work life to retirement. Death and deteriorating health of friends, loved ones, and other supportive people can strongly affect the development of depression. Social factors that can predispose elderly persons to depression include widowhood or divorce, a low socioeconomic level, poor social support, and recent adverse and unexpected life events (7). Men may be more adversely affected by these changes, which may account for the sex difference in the incidence of depression and suicide in the elderly population.(8) Finally, elderly persons have more medical and/or neurologic disorders than younger adults, and these comorbid conditions directly and indirectly increase the occurrence of late-life depression.

Clinical Feature and Course

Early-life-onset major depression recurring into old age and late-life-onset major depression often vary according to age at onset, course of illness, and prognosis. By definition, early-life-onset major depression begins in early adulthood and often runs a long-term course, continuing into late adulthood. Late-life depression occurs more frequently in the context of medical illness, has a higher rate of cognitive impairment, and often is associated with cerebrovascular abnormalities. Emery and Oxman (9) proposed that late-life mood disorders and cognitive abnormalities may exist on a continuum and that major depression with extensive cognitive impairment is the pivotal condition linking the two. Although the basic criteria for MDD in early life and late life are similar, comorbid conditions may be more prominent in late-life depression. Anxiety, somatic complaints, memory loss, or cognitive impairment may be the most prominent presenting symptoms.(10) Comorbid psychosis is common in elderly persons. Along with psychoses, elderly persons with MDD have frequent suicidal thoughts or plans. Elderly patients with depression discuss suicide less openly, use more violent methods, and are more likely to complete suicide. (11, 12)

Comorbidities

Psychiatric Disorders

As mentioned earlier, anxiety frequently accompanies major depression in elderly persons. Generalized anxiety or panic symptoms in the elderly population include tremor, body aches and pains, fatigability, restlessness, palpitations, dizziness, faintness, diaphoresis, paresthesia, nausea and vomiting, frequent urination, facial flushing, insomnia, and dyspnea (13). The somatic focus of anxiety symptoms may be mistakenly ascribed to medical illnesses and hence easily missed. Substance abuse in the elderly population is frequently unrecognized. It may directly or indirectly affect the prevalence and severity of depressive disorders (14, 15). Substances most frequently abused by elderly persons include nicotine, sedative-hypnotics, and alcohol (16).  Sedative hypnotics often prescribed for insomnia or anxiety, may contribute to both depression and cognitive changes in older people. Alcohol abuse and/or dependence are a growing problem for the elderly population. Alcohol abuse or dependence should be considered in patients who have frequent falls, head injuries, weakness, suicidal attempts and especially cognitive changes (17).

Neurologic Disorders

The most common neurologic disorders associated with depression are Alzheimer disease, Parkinson disease, and cerebrovascular disorders. The occurrence of depression in conjunction with neurologic disease results in substantially increased morbidity, especially in the form of cognitive impairment (7).

Medical Disorders

Many medical disorders are associated with higher rates of depressive symptoms. Individuals with diabetes, coronary artery disease, and cancer have higher rates of depression (18). Hypothyroidism, autoimmune diseases, connective tissue disorders, and some infections, especially those producing pneumonia, commonly cause depressive symptoms. Most medications have been associated with depression, but the most common ones include corticosteroids and sedative-hypnotics. Differentiating symptoms of primary depressive problems from symptoms of coexisting medical illness may be problematic. One approach is to determine whether an individual meets criteria for MDD by use of Endicott substitution criteria (19). In this approach, somatic symptoms in the medically ill are substituted with non somatic alternatives, like change in weight and appetite with tearfulness and depressed mood, sleep problems with social withdrawal, fatigue with pessimism and self-pity, and poor concentration with lack of reactivity.

Evaluation

A diagnosis of major depression requires a careful medical history and thorough medical and neurologic evaluations. Focusing on recent life changes, social factors, and the presence of medical or neurologic symptoms is important. The screening medical assessment should include an electrolyte panel, fasting serum glucose level, serum glutamic-oxaloacetic transaminase, serum creatinine level, complete blood cell count, sensitive thyroid-stimulating hormone, electrocardiography, chest radiography, and urinalysis. A thorough neurologic examination should determine the need for further neuropsychological testing and neuroimaging. Neuropsychological testing helps physicians distinguish depressive disorders from central nervous system (CNS) dysfunction. The goals of neuropsychological evaluation in this setting are to establish cognitive status, distinguish depression from dementia or age-appropriate cognitive decline, and make psychological management recommendations on the basis of findings (20, 21). Basically, the diagnosis is made on the basis of a history augmented with a physical and fine-tuned by laboratory studies. There is no biological marker or test that makes the diagnosis, though for some subtypes of depression, such as vascular depression, the presence of subcortical white matter hyper intensities on magnetic resonance imaging scanning are critical to the diagnosis (22, 23). Screening is beneficial when standardized screening scales such as the Geriatric Depression Scale (GDS) or the CES-D are used (24, 25). Cognitive status should be assessed with the Mini-Mental State Examination (MMSE), given the high likelihood of comorbid depression and cognitive dysfunction (26). Nutritional status is most important to evaluate in the depressed elder, including height, weight, history of recent weight loss, lab tests for hypo-albuminemia, and cholesterol, given the risk for frailty and failure to thrive in depressed elders, especially the oldest old (27). General health perceptions as well as functional status (activities of daily living) should be assessed for all depressed elderly patients (28). Other factors critical to assess in the diagnostic workup include social functioning (29), medications (many prescribed drugs can precipitate symptoms of depression), mobility and balance, sitting and standing blood pressure, blood screen, urinalysis, chemical screen (e.g., electrolytes, which may signal dehydration) and an electrocardiogram if cardiac disease is present (especially if antidepressant medications are indicated) (27).

Management

Most elderly patients present to their primary care physicians for their mental health problems. Elderly individuals with depression often overuse inpatient and outpatient health services before their illness is recognized.(30) Early recognition and treatment of depression may help alleviate this problem. Short-term and long-term treatment includes pharmacological and non pharmacological management. The goals in treating depression in elderly persons include resolution of symptoms, prevention of relapse and recurrence, and improvement of functional capacity.

Non pharmacological Interventions

Supportive psychotherapy along with structured forms of therapy such as cognitive behavioral psychotherapy and interpersonal psychotherapy, have been shown in randomized clinical trials to be as efficacious as medications for cognitively intact elderly patients with mild to moderate depression (31,32). Most of the randomized clinical trials have focused on the evaluation of cognitive-behavioral therapy (CBT), brief dynamic therapy (BDT), interpersonal psychotherapy (IPT), reminiscence therapy (RT), and the combination of these interventions with medication (33-39).

Behavioral and cognitive-behavioral therapies

Behavioral therapy (BT) and CBT have received the most research attention of any psychotherapeutic interventions for late-life depression. Thus, cognitive-behavioral therapies treat depression by teaching patients methods for regulating their affect, remaining engaged in pleasant activities as a means of warding off depression, and changing behaviors through a problem-solving process. (40) CBT was found superior to usual care for depression (41), Pill-placebo (42), and no treatment (43). For instance, Gallagher-Thompson and colleagues (44) found that cognitive and behavioral interventions along with brief dynamic therapy maintained significant improvement of depressive symptoms over a 2-year period in comparison to control group.

Interpersonal psychotherapy

 Interpersonal psychotherapy (45) consists of elements of psychodynamic-oriented therapies (exploration and clarification of affect) and CBT (behavior change techniques and reality testing of perceptions) that are used to address four areas of conflict: (a) unresolved grief; (b) role transitions; (c) interpersonal role disputes; and (d) interpersonal deficits. A major limitation of the IPT literature is that most research has studied IPT in conjunction with medication or pill-placebo, making it difficult to evaluate the stand-alone efficacy of the intervention. Combined treatment with IPT and antidepressant medication may produce the best relapse prevention during the maintenance phase after acute treatment, whereas IPT plus pill placebo produces the worst rates (46).

Brief psychodynamic therapy

From a brief dynamic perspective, depression is often conceptualized from a psychodynamic Perspective as being the result of unresolved, unconscious conflicts, usually stemming from childhood. The goal of this type of therapy is for the patient to understand and cope better with these feelings. As such, brief psychodynamic therapies focus on the reflection of past experiences, clarification of affect, the therapeutic relationship, and the confrontation of maladaptive interpersonal patterns, wishes, or conflicts (47). As discussed previously in the review of CBT, BDT has been found to be an effective intervention for treating major depression in older adults (48)

Reminiscence therapy

Reminiscence therapy has been proposed to counteract learned helplessness by promoting an individual’s feeling of control over past and present life   events (49). Wang and colleagues (50) have shown that an intervention consisting of a life review intervention resulted in a significant decrease in a report of selected depressive symptoms among elderly nursing home residents in Taiwan, compared with no-treatment control participants.

Pharmacological   intervention

Four issues must be addressed when considering pharmacological interventions in treating depression in the elderly population: (a) response vs. remission, (b) safety, (c) length of short-term treatment, and (d) need for continuation and/ or maintenance therapy. Evidence for the efficacy of antidepressant medication in the treatment of geriatric depression is emerging. Schneider and Olin (51) reviewed literature about antidepressant use in short-term management of late-life depression and found that tricyclic antidepressants and brief structured psychotherapy were both efficacious. In their randomized controlled trial, Reynolds et al (52) confirmed the efficacy of pharmacological (nortriptyline) interventions, nonpharmacological interventions (interpersonal therapy), or both in the treatment of major depression in the elderly population. Roose and Sackeim (53) recently reviewed randomized placebo-controlled clinical trials of antidepressant medication for late-life depression. Only 4 placebo-controlled trials and 6 comparative trials exist currently. The agents studied include nortriptyline, phenelzine, fluoxetine, sertraline, citalopram, paroxetine, mirtazapine, and venlafaxine. The results are mixed, and no single agent or class of agents has been found to be clearly superior to the others. However, all the trials reported response (but not necessarily remission) to the antidepressant medications. The newer agents appear to have fewer adverse effects than the older agents in the geriatric population. On the basis of current evidence for efficacy and safety, guidelines for pharmacological treatment of late-life depression were developed by the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) group. Selective serotonin reuptake inhibitors are the recommended first-line antidepressant (54, 55). In general, it is acceptable to initiate doses at half the usual adult dosage and then titrate slowly for a few weeks to the optimal dose, if tolerated. An adequate medication trial requires 6 or more weeks of a recommended dosage. Treatment of major depression in the setting of comorbid anxiety, drug dependence, or medical or neurologic disorder is less clear. Benzodiazepines are effective in reducing anxiety symptoms and are widely prescribed. However, benzodiazepine use in elderly persons can be problematic. Complications include over sedation, cognitive impairment, falls, paradoxical agitation, intoxication, abuse, withdrawal, and depression. Short-acting benzodiazepines with non active metabolites (lorazepam, oxazepam, temazepam) are the preferred agents for this population (56). They should be used short term until the diagnosis of underlying depression is addressed. Treatment of depression in the context of substance abuse, especially alcohol or sedative-hypnotic dependence, is unclear. Mild symptoms of depression often resolve with the treatment of substance dependence within weeks to months. However, if symptoms are moderate to severe, treatment of both conditions should occur simultaneously. Well controlled trials of antidepressants vs placebo in patients with major depression and another condition have reported mixed results. Although response to pharmacological agents is common, complete remission from depression is less frequent. Factors contributing to full remission have not been fully elucidated. However, several psychosocial and clinical factors have been identified as predictors of remission from depression. Better rates of remission are reported for persons with adequate social support, better medical health, early and aggressive treatment with antidepressants and/or antipsychotics, and use of electroconvulsive therapy (ECT) when appropriate. After short-term remission of depressive symptoms, continuation of treatment during the next 6 months helps prevent relapse. Some physicians advocate long term treatment for patients who have recurrent depressive episodes.

Combined Medication and Psychotherapy

In geriatric patients with recurrent major depression, maintenance treatment with nortriptyline   or IPT is superior to placebo in preventing or delaying recurrence. Combined treatment using both appears to be the optimal clinical strategy in preserving recovery (57). Combined treatment with nortriptyline and IPT is also more likely to maintain social adjustment (performance-impaired or not, interpersonal behaviour -hypersensitivity, friction quarrelling, satisfaction-loneliness) than treatment with either alone.

ECT and Other Physical Modalities

Electroconvulsive therapy remains the treatment of choice for severe MDD in geriatric patients with psychotic depression, for those who cannot tolerate the adverse effects of antidepressant medications, or for those in whom antidepressant drug therapy has failed. Electroconvulsive therapy for depression is safe and effective and has an 80% to 90% remission rate in elderly patients. ECT can be lifesaving for the most severely ill. Subjects with psychotic depression respond poorly to antidepressants but well to ECT (58). Memory problems remain the major adverse effect from ECT that affects quality of life. Memory problems are usually transient and clear within weeks following treatment. A relatively new procedure that could replace ECT in some situations is repetitive transcranial magnetic stimulation (rTMS).  In one study executive function improved in both middle-aged and elderly depressed subjects with rTMS compared with same treatments (59).  

Conclusion

Late-life depression is under-recognized and undertreated in older adults. Primary care physicians are often the first medical contact that geriatric patients will make when depressive symptoms develop. Older people with depression often present with unexplained physical symptoms that impair their ability to function and enjoy life. Improved detection of depression in older persons and earlier interventions with treatment by psychiatrists are crucial in preventing disability and suicide. Empirical trials are needed that evaluate the selection and effectiveness of pharmacologic combination therapy and other treatment strategies for treatment resistant and partially responsive major depressive disorder in older adults.


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