​Kembara Xtra - Medicine - Geriatric Depression

​Kembara Xtra - Medicine - Geriatric Depression 

Introduction 

A primary mood disorder characterized by a depressed mood and/or a markedly decreased interest or pleasure in normally enjoyable activities most of the day, almost every
day for at least 2 weeks, and causing significant distress or impairment in daily functioning. Depression in older people can have a variety of distinct manifestations, and it's common for them to have co-occurring disorders, which can make treating it more difficult than depression in younger people.

Epidemiology (Incidence and Prevalence) 

Incidence between 2% and 10% of elderly people living in the community; between 5% and 10% of elderly patients treated in primary care clinics; between 10% and 37% of elderly patients hospitalized; between 12% and 27% of elderly people living in nursing homes.

Prevalence
The Global Burden of Disease Study from 2015 projected that the prevalence of depressive disorders among older individuals (>60 years old) was 4–6% among males and 5–8% among females. This estimate was based on the gender differences in the population.
In all age groups combined, suicide ranks as the 11th most common cause of death in the United States. 24 percent of all suicides are completed by those aged 65 and older, with the highest rates occurring in males aged 85 and older.

Causes and effects: etiology and pathophysiology 
• Abnormalities in neurotrophins, neurogenesis, neuroimmune systems, and neuroendocrine systems • A complicated interaction between hereditary, biological, psychological, and environmental aspects
Genetics
Possible mechanisms, including genetic influences on
monoamine transmission and associated transcriptional and
translational activity and dysregulation in biologic processes
and proteostasis involving C-peptide, FABP-liver, and ApoAIV
proteins

factors of danger 

Having a female genitalia, having a lower socioeconomic class, having a widowed, divorced, or separated marital status, having chronic physical illness or chronic pain, having a family history of depression, losing a loved one, and being a caregiver are all risk factors for developing depression.

Significant loss of independence Significant functional and cognitive impairment Lack of social support or separation from others Significant loss of independence Insomnia or sleep disturbances

Preventive Measures Although data is limited, there is a growing body of research that suggests the following strategies can prevent depression in older adults:
Adhering to conventional eating patterns, such as those of the Mediterranean, Japanese, or Norwegian cultures
Increasing the consumption of foods that are high in omega-3 polyunsaturated fatty acids (for example, salmon, tuna, sardines, and mackerel); Regularly engaging in physical activity and exercise;

Conditions That Often Occur Together 
Chronic disease (such as coronary artery disease [CAD], cerebrovascular disease [CVD], cancer, or Parkinson disease) is a condition that lasts for an extended period of time.
DIAGNOSIS
Criteria outlined in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Presenting History 
● Depressed mood most of the day, nearly every day,
and/or loss of interest/pleasure in life for at least 2 weeks
● The following are some examples of additional common symptoms:
– A sense of hopelessness, helplessness, or worthlessness – Sleeplessness and a loss of appetite or weight (or, in the case of atypical depression, hypersomnia accompanied by an increase in hunger or weight)
– Lethargy and a decrease in energy levels – Somatic symptoms (such as headaches and persistent pain)

- Having thoughts of dying or killing oneself Being screened with "SIGECAPS"
- Sleep: Variations from the baseline in sleep patterns, including but not limited to excessive sleep, early waking, or an inability to fall asleep
- Anhedonia: a state of having lost interest in things that were formerly pleasurable activities
– Guilt: excessive or inappropriate guilt that may or may not focus on a specific problem or circumstance – Energy: perceived lack of energy – Concentration: inability to concentrate on specific tasks – Appetite: increase in appetite or decrease in appetite – Psychomotor: restlessness and agitation or the perception that everyday activities are too strenuous to manage – Suicidality: the desire to end one's life or hurt oneself, harmful thoughts directed inwardly, recurrent thoughts of death

The Patient's Clinical Examination 
Examination of the patient's mental health in addition to a focused neurologic and physical assessment to rule out any other possible underlying issues

Differential Diagnosis 
Medical diseases, cognitive impairments, and drugs all taken at the same time might create symptoms that are similar to those of depression.

Hypothyroidism, a lack of vitamin B12 or folate, liver or renal failure, cancer, stroke, sleep difficulties, electrolyte imbalances, Cushing disease, and chronic fatigue syndrome are some examples of medical illnesses.
● Cognitive diseases: delirium, dementia and other neurodegenerative illnesses
Medications: interferon-alpha, beta-blockers, isotretinoin, benzodiazepines, glucocorticoids, GnRH agonists, levodopa, clonidine, H2 blockers; baclofen, phenobarbital, topiramate, triptans; varenicline, metoclopramide, reserpine;

Various other psychological conditions

Results From the Laboratory 

Initial Tests (lab, imaging)
Initial testing in the laboratory to rule out possible medical conditions that could be generating symptoms
CBC (anemia, infection) Urinalysis (urinary tract infection, glucosuria) Vitamin B12 and folic acid deficits Urinalysis (urinary tract infection, glucosuria) Thyroid-stimulating hormone (hypothyroidism)

Urine toxicology screen Comprehensive metabolic panel 24-hour urine free cortisol (test for Cushing disease)

Additional Examinations, as well as Other Important Factors
Additional testing, as necessary, to rule out the possibility of any medical conditions that could be confusing the issue (for example, a sleep study).


15- or 30-point scores on the Geriatric Depression Scale (GDS)

Beck Depression Inventory (BDI): a self-report rating scale consisting of either 21 or 13 items
Test Interpretation Using the Cornell Inventory for Depressive Symptoms in Dementia
Make sure you consult the relevant instructions for scoring and interpretation.

Management 
Even if a reduction of 50% in symptoms is considered clinically important on its own, the objective of treatment is to bring the patient to the point of remission, which is essentially the absence of depressed symptoms.

Methodology Used in General Treatment 
Alterations to one's way of life: Improve one's nutrition.
- Foster engagement in social activities.
It has been suggested that exercise and other forms of physical activity can help elderly people suffering from depression.
Studies do demonstrate some benefit from psychotherapy for older patients suffering from depression:
Cognitive-behavioral therapy, sometimes known as CBT Psychodynamic psychotherapy


Medication 



First Line

As a result of research showing that selective serotonin reuptake inhibitors (SSRIs), sometimes known as antidepressants, are helpful in treating depression in the elderly, they are currently the medication of choice.

There is no single SSRI that works noticeably better than the others in the class; the choice of drug is frequently determined by the side effect profile or by the practitioner's level of familiarity:
Citalopram should be used at a starting dose of 10 mg per day, with a treatment range of 10 to 20 mg per day. Sertraline should be taken at a starting dose of 25 mg per day, with a treatment range of 50 to 200 mg per day. Escitalopram should be taken at a starting dose of 5 to 10 mg per day, with a treatment range of 10 to 20 mg per day.
– The recommended starting dose of fluoxetine is 10 mg per day, with a therapeutic range of 20 to 60 mg per day.
- Paroxetine dosing should begin at 10 mg per day, with a therapeutic range of 20 to 40 mg per day.
It is not recommended to take monoamine oxidase inhibitors (MAOIs) when also taking selective serotonin reuptake inhibitors (SSRIs).
The most common adverse effects include an increased risk of falling, nausea, diarrhea, and sexual dysfunction
Two-Thirds Line
Atypical antidepressants are more successful than placebo in the treatment of depression in older adults; nevertheless, more research is required to more precisely identify the patient characteristics that impact response.
● Bupropion: Start at 150 mg/day. After three to four days, the dose should be raised. Treatment range from 300 to 450 mg/day. Avoid using in individuals who have an increased risk of seizure, tremors, or anxiety.

● Venlafaxine: Start at 37.5 mg/day extended-release and
titrate weekly. Treatment ranges from 150 to 225 mg per day; blood pressure should be monitored at higher doses.

For duloxetine, the recommended starting dosage is 20–30 mg daily. The recommended daily dosage for treatment ranges from 60 to 120 mg. May also be linked to having high blood pressure.
● Mirtazapine: Start at 7.5 to 15.0 mg nightly. The recommended dosage range is between 30 and 45 milligrams per day; side effects include dry mouth, weight gain, drowsiness, and cognitive impairment.
Desvenlafaxine: 50 milligrams once day, in the morning; larger doses do not give further benefit; 50 milligrams every other day if creatinine clearance is less than 30 milliliters per minute

Depression accompanied by thoughts of suicide, psychotic depression, bipolar disorder, concomitant substance misuse difficulties, polypharmacy, and severe or refractory illness are examples of conditions that warrant referral.

Extra Medical Intervention 

Patients who did not respond to the initial trial of an SSRI medicine should either try a new SSRI prescription, convert to an atypical antidepressant, or enhance their previous antidepressant with bupropion.
Antipsychotic medications of the second generation:
- Aripiprazole: 2 to 5 mg/day. The recommended dose range is 5–15 mg per day; side effects include drowsiness and potential for weight gain
- Used as an adjunct to the treatment of depression in combination with other antidepressant drugs
● Tricyclic antidepressants (TCAs):
- Nortriptyline, 25–50 milligrams on a nightly basis. Anticholinergic effects, weight gain, and an increased risk of falling are some of the side effects of this treatment, which ranges from 75 to 150 mg nightly. (5)[C]
– TCAs have been shown to be effective in treating
depression. Their utility as first agents — MAOIs that are successful in the treatment of depression in the elderly is, however, limited since senior patients find it difficult to tolerate them due to the side effect profile and the fact that they have the potential to be fatal in overdose. Because of the possibility for adverse effects and the requisite dietary restrictions, they are not utilized very frequently in clinical practice.

Although not approved by the FDA, buspirone, lithium, or triiodothyronine are used off-label to supplement a primary antidepressant. There is inconclusive evidence on the efficacy of antidepressants in the treatment of depression in people who have dementia.
Consideration should be made for a limited trial with close
monitoring for symptom improvement or side effects and
used only in patients with severe symptoms.

It has been demonstrated that older patients can experience remission of depression symptoms by the use of electroconvulsive treatment (ECT).
However, because there is not enough data to support its use, it should only be explored as a possibility for individuals who have severe or psychotic depression.

Alternative Medicine 

It's possible that the benefits of St. John's wort are minor, yet it can interact negatively with some medications.

Tryptophan and hydroxytryptophan: 150 to 300 mg/day, with a potential for efficacy

Admission 
If an immediate safety risk is evident (for example, someone who is acutely suicidal), or if the individual is unable to appropriately care for oneself as a result of depression, inpatient care is necessary.

Keep in Touch 

It is vital to have open communication with the patient in order to prevent premature withdrawal of therapy as a result of the delay in benefit following the commencement of antidepressant therapy. This is due to the fact that antidepressant therapy takes some time to show its benefits. An adequate explanation of
potential side effects with instructions to call the office
before discontinuing therapy is imperative.

Patient Monitoring It is necessary to admit a patient who suffers from severe depression and shows signs of suicidality. Patients should be monitored for worsening anxiety symptoms or an increase in suicidality, particularly in the week following the beginning of a new antidepressant regimen or the switching of antidepressants.

Diet 

Patients who are on MAOIs are advised to stay away from foods that are high in tyramine, such as specific cheeses and wines.

It may take between two and four weeks of taking medication for any therapeutic effect to be noticed, and it may take between six and eight weeks for the medication to reach its optimum level of effectiveness. Depression is a treatable disorder.
The symptoms of depression tend to come back again and over again.


Estimates for initial clinical response and remission range anywhere between 30 and 70 percent of patients being declared in remission.

Complications include an impairment in social, occupational, or interpersonal functioning; difficulty performing activities of daily living and self-care; an increase in the consumption of medical services and an increase in the expenditures of care; an increased risk of suicidal ideation; and so on.