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.
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
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
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?
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.
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.
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?
Newer generation antidepressants (non TCAs or MAOIs) are pretty safe and well tolerated.
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.
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 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 ].
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).
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
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
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
Listeners will diagnose depression and dementia in older adults and develop a practical approach to the management of depression and dementia in older adults.
After listening to this episode listeners will…
Dr Popeo and The Curbsiders report no relevant financial disclosures.
Numbers 7-8 below are papers on Geriatric Psychiatry by Dr. Popeo and friends
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