Geriatric Depression and Anxiety Jennifer Serafin RN, BSN, MS, GNP-c Objectives • Discuss the acetylcholine theory and how it impacts decisions and expected therapy outcomes in depression and anxiety treatment in older adults. • List 3 ways you could identify the symptoms of depression in the complex geriatric patient with multiple chronic conditions. • Describe one of the dangers of over-treating anxiety, especially regarding length of drug therapy, and the impact it could have on your elderly patient. Disclaimers • #1: I have no conflicts of interest. • #2: Some of the drugs I will discuss today will be recommended for off label use. • #3: I tend to use whatever (generic or trade) drug name is easiest for me say. The Aging Brain • There are many changes in the brain as we age. • Structural changes: Thinning of the cortex, loss of neurons and circuits, loss of overall volume • Chemical changes: Loss of neurotransmitters • Neuropsychological changes: Loss of orientation, attention, memory Prescribing Principles in the Elderly Beers Criteria Originally created by Dr. Mark H. Beers, a geriatrician with 12 experts (geriatricians, psychiatrists, pharmacists). Initially published in 1991 for nursing home residents, then revised in 1997 and 2003 to include elders in all healthcare settings. It is a list of potentially inappropriate medications (PIM) that should be used with caution in older persons. Beers Criteria, Revised 2012 AGS was asked to update the Beers group findings. › A review panel was used, which included many experts from different disciplines Not just physicians › Peer groups were given the panel’s findings for comment and review › The American College of Physicians Grading System was used to evaluate the literature Grade based on quality of evidence/research Beers Criteria, 2012 • Drug Classes to Avoid: • Meds that should be used with • Anticholinergics caution: • Alpha blockers • ASA: no evidence of benefit >80 • Amiodarone for prevention of cardiac events • Spirolactone • Psychotropics • Sulfanylureas • Reglan • SSI • Megace Anticholinergic Burden (ACB) • As people age, the Central Nervous System (CNS) is sensitive to adverse anticholinergic effects. This is due to: • The significant decrease in cholinergic neurons/receptors in the brain. • The reduction in hepatic metabolism and decreased renal excretion of medications. • The increase in blood–brain barrier permeability. ACB: The research • There is a dose relationship with ACB and the risk of developing dementia (Gray et al., JAMA, 2015). This will occur even with using low doses of the medications. The risk was using the drugs long term. • Longitudinal British Study (Fox et al., JAGS, 2011) reported: • For every anticholinergic drug taken, there is an increase in the risk of cognitive decline by 46% over 6 years • For every one point increase in the ACB score, the MMSE score declined by 0.33 over 2 years. • For every one point increase in the ACB score, there was a 26% increase in the risk of death. ACB Scale ACB Score 1 = Possible ACB Score 2 = Definite ACB Score 3 = Definite Anticholinergic Anticholinergic Effects Anticholinergic Effects Effects Alprazolam Amantadine Amitriptylline Atenolol Belladona Brompheniramine Captopril Cyclobenzaprine Chlorpheniramine Codeine Cyproheptadine Clomipramine Diazepam Carbamazepine Clozapine Digoxin Loxapine Dimenhydrinate Furosemide Meperidine Diphenhydramine Prednisone Molindone Hydroxyzine Nifedipine Oxcarbazine Paroxetine Warfarin Pimozide Promethazine Table. ACB Scoring of Select Drugsa - See more at: http://www.pharmacytimes.com/publications/issue/2012/April2012/The-Anticholinergic-Cognitive-Burden-#sthash.41DFSscl.dpuf Depression Depression: A significant issue • Depressed older adults use health services at high rates, engage in poor health behaviors, and are more disabled. • Depression is more common in people who have chronic illnesses and whose function becomes limited. • Older adults have the highest rates of suicide of any age group, particularly with older men. • Some estimates of the prevalence of MDD in older adults: • Community dwelling: 1% to about 5% • At home, but need caregiving: 13.5% • Hospitalized: 11.5% • General population: 10% What causes depression? • Genetic susceptibility (30-40%) • Psychosocial stress (60-70%): Altered stress hormone secretion • Chronic illness • Neurotransmitter depletion: either due to a loss of synaptic concentration or a receptor issue • Serotonin • Norepinephrine • Dopamine • Monoamine oxidase MDD: Criteria for Diagnosis • DSM V (May 2013): No change for MDD • Depressed mood and/or anhedonia (at least one) • At least 4 of these symptoms • Change in appetite • Change in sleep pattern • Change in psychomotor activity • Fatigue, loss of energy • Feelings of worthlessness or guilt • Diminished ability to think, concentrate, or make decisions • Recurrent thoughts of death, suicide • Symptoms cause distress or impairment in functioning • Symptoms not caused by medical condition or substance • DSM V also added: • 3 manic symptoms is depression with “mixed features” • Bereavement vs depression is now based on clinician’s judgement Screening for Depression • GDS: Geriatric Depression Scale: • PHQ-9: Patient Health • Good: Questionnaire • Easy to give (yes/no format) • Based on DSM criteria • Available in 25 languages • Rates severity of symptoms • Developed for elderly • Available in multiple languages specifically • Pfizer owns copyright, but • Proven reliable in research makes it available for clinicians • Bad: to use at no cost. • There are no questions about suicide • Does not measure depression symptom severity Screening Tools: GDS • Choose the best answer for how you have felt over the past week: • 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO • 1. Are you basically satisfied with your life? YES / NO • 10. Do you feel you have more problems with memory than most? YES / NO • 2. Have you dropped many of your activities and interests? YES / NO • 11. Do you think it is wonderful to be alive now? YES / NO • 3. Do you feel that your life is empty? YES / NO • 12. Do you feel pretty worthless the way you are now? YES / NO • 4. Do you often get bored? YES / NO • 13. Do you feel full of energy? YES / NO • 5. Are you in good spirits most of the time? YES / NO • 14. Do you feel that your situation is hopeless? YES / NO • 6. Are you afraid that something bad is going to happen to you? YES / NO • 15. Do you think that most people are better off than you are? YES / NO • 7. Do you feel happy most of the time? YES / NO • Answers indicating depression are in bold; score one point for each bolded answer. A score of 0 to 5 is normal • A score > 5 suggests depression • 8. Do you often feel helpless? YES / NO A score ≥ 10 is almost always indicative of depression • PHQ-9 and PHQ-2 • The PHQ-2 is the first 2 items of the PHQ-9 • Little interest in doing things • Feeling down or hopeless • It is a screen for depression; patients who screen positive should be further evaluated. • The PHQ-2 has been validated in 3 studies (Gilbody, Richards, Brealey, and Hewitt, 2007). Differential Diagnosis of MDD • Medication side effects/ adverse events • Hypoactive delirium • Hypothyroidism • Severe medical illness: • Cancer • Severe infection • Cardiovascular disease • Substance abuse: ETOH, marijuana Neurotransmitters Mechanisms of Action for Antidepressants Serotonin • Mood: Feelings of well being and happiness • Appetite • Serotonin is found naturally in plants, seeds, fungi • Derived from tryptophan: 90% regulates the intestines, rest goes to the platelets and the CNS • Diets high in carbs causes the body to release insulin, which stimulates serotonin • Sleep Treatment of MDD: SSRI’s • Drugs: Citalopram (Celexa), Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac), Escitalopram (Lexapro), Fluvoxamine (Luvox) • Mechanism of Action: Work by inhibiting reuptake of Serotonin in the synaptic cleft (decrease NE, decrease D) • Adverse events: • QT prolongation: Citalopram, Escitalopram • Sexual dysfunction • Increase risk of fracture: Falls or change in bones? • Risk is greater than with steroids or PPIs (2013 study) • Akathisia (restlessness) • Insomnia/drowsiness • Weight gain/ loss • HA, dry mouth, nausea/vomiting, diarrhea QT prolongation… • QT interval: Measure of the time between the start of the Q wave and the end of the T wave on the EKG waveform. • Represents electrical depolarization and repolarization of the ventricles. • Prolonged intervals increases the risk for ventricular arrhythmias, such as Torsade's de Pointes. It is also a risk factor for sudden death. • Risks: female, family hx of sudden cardiac death, class III antiarrhythmic drugs • Definitions of normal QT vary: equal to or less than 0.40 s (≤400 ms) to 0.44s (≤440ms). • “Borderline Q Tc" in males: 431-450 ms, and in females: 451-470 ms • “Abnormal" Q Tc” in males: above 450 ms, and in females: above 470 ms • >500 or a change of >60 ms if on SSRI: STOP drug and get a cardiology referral Examples of QT prolongation Also for serotonin stimulation…. • Drugs: Trazadone (Desyrel) and Nefaxodone (Serzone) • Mechanism of Action: (SARI) Serotonin Antagonist Reuptake Inhibitor, which is like a SSRI • Side effects: • HA, dizzy, nausea • PRIAPISM (epi) • Less cardiac symptoms than the TCA’s • Useful with anxiety (panic) and insomnia Serotonin problems • Serotonin Toxicity: Usually caused by too many drugs on board (MAOI & SSRI together, for example) • Symptoms: Agitation, restlessness, D/N/V,