Risk factors for depression in older patients include:

1. Significant medical problems
2. Retirement and loss of professional identity
3. Decreased independence
4. Decreased physical mobility
5. Memory impairment
6. Loss of close loved ones

While depression is diagnosed in older adults using the same criteria used to diagnose younger and middle-aged adults, symptom presentation can vary slightly.  Older patients may not explicitly report symptoms of sadness. Other clues that depression may be present include: unexplained or aggravated aches and pains; sleep disturbance; feelings of hopelessness or helplessness; anxiety and worries; concentration problems; lack of motivation and energy; slowed movement and speech; irritability; loss of interest in socializing and hobbies; and neglecting personal care.

Both the number of symptoms and the level of impairment from these presenting symptoms are important features in determining whether a diagnosis of major depressive disorder is warranted.

There is a complicated relationship between depression and dementia in older patients. Dementia can be a risk factor for depression and depression can be a risk factor for dementia. Additionally, older patients with depression can have memory and concentration troubles without also having dementia. The cognitive problems seen in depression and dementia are different from each other. Persons with depression commonly report trouble concentrating and being motivated. Persons with dementia present with short-term memory loss and word finding difficulties, and often may not be aware of the cognitive challenges.

Depression is also common in patients with mild cognitive impairment (MCI), occurring in up to 1/3 of patients with MCI. It is therefore important to assess for depressive symptoms in an older patient presenting with early and generally mild signs of cognitive impairment.

It is also important to be aware that medical problems and medications can cause depression in older adults. Medical problems that can cause depression, either directly or as a psychological reaction to the illness, include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia, lupus and multiple sclerosis.

Medications that can cause or worsen depression include: beta-blockers, sleeping medications, benzodiazepines, calcium-channel blockers, ulcer medications, steroids, cholesterol medications, and pain medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because of less efficient metabolism of medication.

The Geriatric Depression Scale is a validated screening tool for assessing for depression in older patients. It is a self-administered screen. A link and copy of the screening tool is included.

https://www.healthcare.uiowa.edu/igec/tools/depression/GDS.pdf

Next week’s e-weekly will address treatment of depression in older patients and how it is different than treatment of depression in younger adults.

First, it is important to identify and address any medical contributions to a person’s depression, including treatment(s) for an underlying medical condition or adjustment of a medication that may be causing affective or cognitive changes as side effects.  Prior to considering psychotropic medication for a patient’s depression, it would be important to determine if psychotherapy or increasing social engagement with family or the community could play a role in the treatment.

Psychotropic medication can be an important part of the treatment of depression, particularly in moderate-severe cases, but it is important to “start low and go slow”, to utilize the lowest effective dose and to monitor closely for side effects. Dementia, cardiovascular problems, diabetes, and Parkinson disease, which are commonly in older patients, can worsen with highly anticholinergic medications, like the tricyclic antidepressants. Because older patients are often on multiple medications, it is important to carefully review for potentially relevant drug-drug interactions.

The selective serotonin reuptake inhibitors (SSRIs) are the first line agents in this population. Possible side effects that are particularly important to monitor for in older patients include bone loss and increased risk for falls and fractures. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively. There can be an increased risk of developing hyponatremia secondary to a syndrome of inappropriate antidiuretic hormone secretion, so sodium levels should be monitored regularly in older patients taking SSRIs or SNRIs. The best SSRIs to consider in older patients are citalopram escitalopram and sertraline. For citalopram, an appropriate starting dose would be 5-10 mg and increasing in 5mg increments, and for sertraline starting at 25mg and increasing in 25mg increments. Other appropriate medication options are the SNRIs, mirtazapine, and bupropion.

As a group, older patients with depression are more likely than younger patients to show signs of cognitive impairment, including poor concentration, apathy, and poor motivation, as part of their presentation. If these cognitive defects persist even when the depression is treated this may be an indicator of a potential risk of an evolving dementia process.  There are times when an elderly patient may be less likely to respond to antidepressant medications, either with a less robust response overall and with a poor response to a first medication trial (up to 1 in 3).  One option in such a situation is to consider augmenting the antidepressant with a stimulant medication. If prescribed potential side effects need to be monitored carefully – appetite and sleep disturbance, increased irritability, and moodiness when the medication is wearing off. Also this option should generally be avoided in patients with significant histories of (recent) substance abuse and/or concurrent anxiety symptoms as stimulant medications can worsen make anxiety symptoms.

It is our hope that this series on assessing for and treating depression in older patients has been helpful for working with older patients in your practice.

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March 11, 2017
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Pharmacological options include benzodiazepines, non-benzodiazepines, antidepressants and antihistamines. There is limited evidence on their long-term safety particularly with cognitively-impaired older adults. For this reason, it is important to use these medications with caution, for the shortest period of time as needed, and to follow the motto “start low and go slow”. Benzodiazepines are commonly used, but they have little effect on the sleep maintenance problems that are most commonly seen in older adults with dementia. In addition, they can have problematic side effects, including sedation, confusion, anterograde amnesia, and rebound insomnia, which can make the behavioral disturbance seen with dementia worse. The newer generation non-benzodiazepines have shorter half-lives and fewer side effects, but there is limited data on their use in older patients with dementia.

Antidepressants, including Trazodone, the SSRIs and Remeron, are sometimes used to help with sleep problems, in some cases to take advantage of their side effect of sedation and in other cases because there is concern about co-morbid depression. Trazodone has been found in small studies to be helpful short-term with improving total sleep time and sleep efficiency. Antihistamines are commonly used in this situation, partly because of the availability over-the-counter, but there are side effect concerns, including sedation, cognitive impairment, and anticholinergic responses. Because of these side effect risks, they should be avoided as first-like agents in older patients. Supplemental melatonin has not been found to be helpful as a stand-alone treatment for insomnia in patients with dementia in studies, but ramelteon, a melatonin agonist, has been shown some promising results in general studies, to improve sleep efficiency and increase total sleep time. In addition, it is not associated with side effects that are seen with other medications used for sleep disturbance, like cognitive impairment and daytime sleepiness. It would be helpful for more studies to be done with this agent in older patients.

It is our hope that this article has been helpful in addressing the common issue of sleep disturbance in patients with dementia, to begin thinking about how to determine the cause and the best treatment approach.

Reference: Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.

In order to discuss appropriate treatment, it is first important to understand the causes of sleep disturbance in this population. The causes of sleep disturbance in patients with dementia include: (1) physiologic changes that occur as part of dementia as well as normal aging; (2) primary sleep disorders such as sleep apnea and restless leg syndrome that can occur co-morbidly; (3) medication side effects; (4) environmental and behavioral factors, including poor sleep hygiene practices; and (5) a combination of the above.  With Alzheimer’s dementia, the sleep disturbance is thought to be a result of a progressive deterioration and decrease in the number of neurons in the suprachiasmatic nucleus (SCN), which lead to fluctuations in neurohormones that are important in the homeostatic stability of the circadian rhythm.

It is often difficult to determine the exact cause for an older patient presenting with insomnia. Older adults are at risk for a variety of age-related comorbid conditions, such as ischemic heart disease, diabetes, depression, renal failure, arthritis and pulmonary disorder, which can

further exacerbate sleep disturbances. To make things more complicated, many of the medications used to treat these chronic diseases can have varying effects on sleep. For example, narcotic analgesics that are used to treat chronic pain can cause excessive daytime somnolence, and bronchodilators that are used commonly for pulmonary disorders can have nighttime stimulating effects.

Often, patients with dementia need medication to manage their behavioral symptoms. Medications that are commonly used to treat the behavioral disturbances seen in dementia can have a negative impact on a patient’s sleep. Acetylcholinesterase inhibitors can cause nighttime activation and dream disturbances. Antipsychotic medications can cause daytime sleepiness and somnolence. When using these medications, it is important to individualize the treatment and assess for risks and benefits related to a medication.

Part 2 of this article will discuss treatment options, both non-pharmacological and pharmacological, for patients with insomnia related to dementia.

Reference:
Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.