#115 Geriatric Depression: Diagnosis, Antidepressants, and More

September 24, 2018 | By Matthew Watto, MD

Geriatric depression got you down? Boost your spirits with tips and tactics from Geriatric Psychiatrist, Dennis Popeo MD, Clinical Associate Professor of Psychiatry at NYU Langone Medical Center. Topics include: suicide in the older adults; how to diagnosis depression in older adults; how to counsel patients about antidepressants, how to choose an antidepressant, how to monitor and titrate medications, and how long to continue therapy. Stay tuned for part two of our discussion with Dr Popeo on managing sleep and behavioral problems in older adult patients with dementia.

Credits

Written & Produced by: Jordana Kozupsky NP, Matthew Watto MD

Artwork by: Kate Grant MD

Hosts: Jordana Kozupsky NP, Matthew Watto MD

Editor: Matthew Watto MD

Guest: Dennis Popeo, MD

Pearls from Dr. Popeo

1. Advice for learners: Be open minded [about your career choice] because you might change your mind…and it’s not too late to make a change.
2. You won’t find depression unless you screen for it. Hand patients the PHQ-2 in the waiting room.  
3. Don’t be afraid to initiate treatment for depression. BUT, be systematic about following the treatment effects and side effects.
4. It’s okay to push the dosage of a medication if needed to control a patient’s symptoms.
5. Refer suicidal patients to a hospital or psychiatrist. “It’s not internal medicine 101”.
6. Selective serotonin reuptake inhibitors (SSRIs) are first line for the treatment of geriatric depression. Dr. Popeo finds mirtazapine useful for patients with poor appetite and poor sleep. Bupropion can be stimulating, but be careful in patients who are underweight (it decreases appetite), anxious (it worsens anxiety), or alcoholics (it lowers the seizure threshold) -Dr Popeo’s expert opinion.

In-depth Show Notes

Diagnosis

Symptoms of geriatric depression

In addition to the normal symptoms of depression contained in the PHQ-9 questionnaire, features of geriatric depression often include lack of motivation, irritability, and new problems with memory. Another red flag for geriatric depression is the patient who starts booking frequent appointments for vague physical complaints. Give that patient the PHQ-9. -Dr. Popeo’s expert recommendation

Some questions to ask

Are you having physical pain? Are you having any infectious symptoms? Are any of your chronic medical conditions acting up? Are you feeling more down or blue? How often do you feel this way? Have you lost interest or pleasure in doing things that you used to find fun?

Confirm the diagnosis

Dr. Popeo uses the PHQ-2 initially to screen for depression, and the PHQ-9 to diagnoses and track depressive symptoms at each visit. The PHQ-9 is a useful screening tool for diagnosis and screening for depression (Kroenke. J Gen Intern Med. 2001). Dr. Popeo feels the Geriatric Depression Scale is a bit long and cumbersome in comparison. Don’t forget to check for mimics of depression by sending an initial TSH, Vitamin B12 level, CBC and basic metabolic panel to rule out organic causes of depressive symptoms.

Suicide

Geriatric suicide happens! It’s okay to ask people if they are thinking about hurting themself. Men are more likely to use more lethal means like guns. Women tend to use pills. Look for statements like “it’s just not worth going on anymore.” Follow up with “have you ever thought about doing anything to end your life?”, “why not?”, “what would you think of doing?”, and “how close have you come?”. Dr. Popeo advises them to give weapons or pills to a close friend for the time being, and send them to the hospital for a psychiatric evaluation accompanied by a close friend or relative.

Firearm Safety

Ask the patient: Do you have firearms in the home? Do you have ammunition? Is the firearm in good working order? How close have you come to using it? Would you be okay with giving it to a relative or friend for safe keeping?

Antidepressants

Newer generation antidepressants (non TCAs or MAOIs) are pretty safe and well tolerated.

SSRIs

Dr. Popeo recommends an selective serotonin reuptake inhibitor (SSRI) for first line therapy. No single SSRI has proven superior. Escitalopram and sertraline tend to have less drug-drug interactions than fluoxetine or citalopram. Most patients with mild to moderate depression will tolerate an SSRI, but don’t be afraid to push the dose if patient is not having side effects and their symptoms remain uncontrolled.

Atypical agents

Bupropion

Bupropion can be used for its stimulant properties* in those with hypoactive depression, but it may curb appetite, or worsen anxiety. It also lowers the seizure threshold so use caution in alcoholics. A summary of these side effects can be found here – Hirsch et al. Atypical antidepressants: Pharmacology, administration, and side effects. UpToDate.com.

*Caution: As you may recall, The Dantastic Mr Tox and Howard warned us that bupropion aka “illbutrin” has a similar structure to “Bath Salts” and amphetamines. From the toxicologist’s perspective, this is an antidepressant with sympathomimetic properties which causes seizures and myocardial dysfunction. An overdose is very difficult to manage!

Mirtazapine

Mirtazapine may be more sedating and may stimulate appetite/weight gain. Thus, be careful in patients who are overweight or obese. An older review of RCTs containing more than 1700 patients found increased appetite and weight gain occurred in about 10-11 percent of patients and sedation/drowsiness in 19-23 percent of patients taking mirtazapine [Montgomery. Int Clin Psychopharmacol. 1995. PMID 8930008 ].

Medication initiation and titration

Start low and go slow. “If the patient is not having side effects and if you’re not seeing a good effect of the medication, then you really do need to push the dose”. Otherwise, you can’t call something a “treatment failure”. -Dr Popeo’s expert opinion

Serial PHQ-9s can be used to objectively track progress and show the patient that they are improving. The PHQ-9 can also identify plateaus and the need to push the dose (IMPACT program algorithm for depression – Unützer. JAMA 2002 PMID 12472325).

Counseling patients, tailoring expectations

It normally takes four to six weeks to reach an antidepressant’s peak effect, however, it may take eight to twelve weeks if slowly increasing the dose in an older adult. The neurovegetative symptoms like fatigue, poor sleep, and lack of appetite are often the first to improve on therapy. -Dr Popeo

Duration of therapy

Dr. Popeo recommends antidepressant therapy for a minimum of six to twelve months for an initial episode of depression. At that point, tapering off the medication can be attempted, but it carries a 30 percent risk of relapse. If relapse occurs then Dr. Popeo recommends at least two years of antidepressant therapy after recovery. If a patient has a third episode of major depression, then the chance of a fourth episode is about 100 percent so lifelong therapy is warranted. -Dr Popeo

Augmenting therapy

You might try adding or switching to an agent with a different mechanism of action altogether, but BE CAREFUL and consider referral to a psychiatrist if you get to this point. -Dr Popeo

Goals and learning objectives

Goals

Listeners will diagnose depression and dementia in older adults and develop a practical approach to the management of depression and dementia in older adults.

Learning objectives

After listening to this episode listeners will…

1. Diagnose depression in older adults
2. Individualize the management of depression in older adults
3. Assess the risk of suicide and ensure patient safety in older adults with depression
4. Counsel patients about the use of antidepressants
5. Titrate and monitor the effect of antidepressant medications

Disclosures

Dr Popeo and The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 A question for you, the listeners
• 01:12 Disclaimer, intro and guest bio
• 05:00 Getting to know our guest, recommendations for reading, and career advice
• 14:13 Case of geriatric depression; effective history taking; recognizing associated symptoms; depression scales
• 19:03 Suicide in older adults; firearm safety
• 24:26 Choice of therapy; Pharmacologic agents; Counseling patients and managing expectations; Dose titration and tracking symptoms
• 34:41 Augmenting therapy versus cross-titration to another agent; When is it okay to stop an antidepressant
• 40:50 Take home points
• 44:40 Outro

Links from the show

Numbers 7-8 below are papers on Geriatric Psychiatry by Dr. Popeo and friends

1. Steve the Cardigan Corgi on Instagram
2. Dr Popeo recommends The Real Housewives series; or really just all of reality TV
3. Dr Popeo recommends reading The New Yorker
4. For professional development he recommends The Harvard Business Review
5. Deep Work (book) by Cal Newport
6. Essentialism (book) by Greg McKeown
7. Wilkins KM et al. Six Things All Medical Students Need to Know About Geriatric Psychiatry (and How To Teach Them). Acad Psychiatry. 2017 Oct;41(5):693-700. doi: 10.1007/s40596-017-0691-7. Epub 2017 Mar 2. PMID: 28255854
8. Lehmann SW et al. Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report. Am J Geriatr Psychiatry. 2017 Oct;25(10):1041-1047. doi: 10.1016/j.jagp.2017.05.006. Epub 2017 May 12. PMID: 28642002
9. Study validating PHQ-9: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/
10. Effects of mirtazapine on the sleep wake rhythm of geriatric patients with major depression: an exploratory study with actigraphy. PMID: 22915486
11. Antidepressants for depressed elderly PMID: 16437456
12. Recovery from major depression in older adults receiving augmentation of antidepressant pharmacotherapy PMID: 17541048
13. Selective serotonin reuptake inhibitors for late-life depression: a comparative review. PMID: 11392444
14. A comparison of side effects of selective serotonin reuptake inhibitors and tricyclic antidepressants in older depressed patients: a meta-analysis. PMID: 15290699
15. An Evidence-Based Approach to Augmentation and Combination Strategies for Treatment-Resistant Depression PMC 2958866