Malaysian Healthy Ageing Society Professor David Ames BA MD - PowerPoint PPT Presentation

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Professor David Ames BA MD FRCPsych FRANZCP University of Melbourne Professor of Ageing and Health Director National Ageing Research Institute PO Box 2127, RMH, 3050, Victoria dames@unimelb.edu.au Detection and management of late life depression

SYMPTOMS OF DEPRESSION • Low mood • Loss of interest • Lack of energy • Sleep disturbance • Appetite/weight change • Agitation or retardation • Guilt • Thoughts of death/suicide • Poor concentration • Loss of confidence

Is late life depression different from depression at earlier ages? (1) • Depression at all ages has similar core features • The elderly are more likely than the young to have comorbid dementia or physical ill health or to have been recently bereaved. • Current diagnostic criteria proscribe the allocation of a primary depressive diagnosis in some of these circumstances. • Some elderly people with depressive syndromes get classed as having an organic mood disorder, dementia with depressed mood or normal bereavement reaction.

Is late life depression different from depression at earlier ages? (2) • Less subjective lowering of mood • Fewer suicidal thoughts • More hypochondriasis • More somatic complaints • More weight loss • More constipation • More frequent subjective and objective cognitive difficulty • These studies relate to hospital inpatients and maybe biased by variable admission thresholds for individuals at different ages

EPIDEMIOLOGY Severe/major depressions 0.5 to 3% Mild/non major depressions 6 to 20% Women : men 7 : 3 Physical ill health, stressful life events and poor social support are risk factors

Depression is far more common among those in residential care and among elderly people in general hospital wards than among those living at home.

AETIOLOGY OF LATE LIFE DEPRESSION • Genetics • Sex • Age related physiological or anatomical change • Physical illness/disability • Substance use and iatrogenesis • Personality factors • Social factors • Adverse life events

GENETICS With age genetic factors become less important, accounting for 8% rather than 20% of the variance in the occurrence of late life depression

SEX As at all ages women are more prone to depression than men. Male rates of depression come closer to female rates at the more severe end of the spectrum.

AGE RELATED PHYSIOLOGICAL CHANGES • Alterations in cortisol secretion • TRH/TSH alterations

AGE RELATED NEUROANATOMICAL CHANGE • Larger ventricles • Increased deep white matter lesions • Sulcal widening

DEEP WHITE MATTER LESIONS • To be distinguished from periventricular lesions • Appear to predispose to first onset depression in late life • Appear to worsen prognosis

DWMHs AND LATE ONSET DEPRESSION • Excess of large DWMHs in patients with late onset psychotic depression (Lesser et al., 1991) • Late onset major depression associated with higher rate of caudate HIs and large DWMHs compared to early onset major depression (Figiel et al., 1991) • Late onset and negative family history for mood disorders are associated with more severe DWMH (Hickie et al., 1995) • Many investigators have seen higher prevalence of severe WHIs in late onset depression compared to early onset depression with few negative findings

DEPRESSION IS HIGHLY PREVALENT IN PATIENTS WITH CEREBROVASCULAR DISEASE • 30% to 50% of patients had depression at initial evaluation after stroke (Robinson and Starkstein 1999) • Cerebrovascular disease frequently observed in patients with late onset depression • Patients with hypertension, CAD, diabetes and vascular dementia often have depression • Relationship between depression and cerebrovascular disease – Depression may be an understandable psychological response to stroke – Depression may be a direct consequence of ischaemic brain damage or focal neurological lesions – Depression may be a risk factor to both for stroke or vascular risk factors – Both conditions (depression and cerebrovascular disease) may co- exist by chance

POST STROKE DEPRESSION (PSD) • Occurs in 20% to 50% of patients in the first year after stroke (House et al., 1991; Robinson et al., 1987) • Rate of major depression may be 0% to 25% • Rate of minor depression may be 10% to 30% • Controversial whether this is more common than in patients with other severe physical illnesses • Depression is not the only psychiatric disorder to emerge after stroke

MECHANISMS OF POST STROKE DEPRESSION Lesions affecting frontal subcortical circuits within the basal ganglia seem to be connected to post stroke depression

VASCULAR DEPRESSION • Late onset depression • Reduced depressive ideation (e.g. guilt) • Reduced insight • More overall morbidity • Apathy and retardation • More cognitive impairment • Poorer recovery from depression

PHYSICAL ILLNESS/DISABILITY • The strongest association with late life depression • e.g. r = 0.4 in US/UK study • Urinary incontinence • Chronic pain • Activity limitation

DEPRESSION IN CARDIOVASCULAR DISEASE • Psychiatric disorders following MI are common • Detectable in 1/3 people following MI while in hospital • Half of these people have major depression that is likely to persist • Major depression may be associated to adverse outcomes including increased mortality, morbidity and delayed return of functioning • Major depression particularly common in subjects with prolonged history of cardiac disease prior to MI, multiple psychosocial stressors and past history of depression • This depression is particularly likely to be associated with adverse outcomes when it is not a first episode but represents a relapse or recurrence

SUBSTANCE USE • Alcohol and other substances

IATROGENESIS • A wide range of therapeutic compounds has the potential to initiate a worsened depression • Anti-hypertensives • NSAIDs • Sedatives • etc

DRUG GROUPS IMPLICATED IN DRUG INDUCED MOOD CHANGE Effect Drug Groups Implicated Linked to depression Steroids, clonidine, calcium channel blockers, digoxin Possible link to depression Statins, beta blockers, ACE inhibitors Possible link to increased Beta blockers, calcium channel suicide risk blockers

IATROGENESIS A wide range of therapeutic compounds has the potential to initiate a worsened depression • Anti-hypertensives • NSAIDs • Sedatives • etc

PERSONALITY FACTORS The DSM IV clusters can be stereotyped as the weird, the wild and the worried. Studies of personality difficulties in late life are few and far between. Some older people with personality difficulties survive to old age. These individuals are likely to have fewer social supports and are more likely to enter residential care because of decreased social contact.

SOCIAL FACTORS • Isolation • Entry to residential care • Narcissistic society • Societal view of ageing

CONSEQUENCES OF DEPRESSION • Not trivial • May affect incidence and outcome of physical disorders

COMMUNITY STUDIES • At least eight well designed large community based studies examined the association between depression and development of cardiovascular disease • All but one has shown an association between depression and development of cardiovascular disease after controlling for pre-existing cardiovascular disease, use of antidepressants and other coronary risk factors including smoking • Depression predicts: (i) deaths from cardiovascular disease (RR 1.5 to 3.9) (ii) deaths from CHD (RR 1.3 to 5.2) (iii) MI (RR 1.7 to 4.5) (iv) Development of symptomatic IHD/angina (RR 2.1 to 4.6)

IMPACT OF AFFECTIVE DISORDERS ON THE COURSE OF ESTABLISHED CARDIOVASCULAR DISEASE • In ambulant patients with IHD prevalence of major depression is approximately 1.5 x general population rate • At the time of MI depression prevalence is 3 to 4 x general population (13 to 19%) • 26% of those with cardiac failure have major depression • 17% of those with other cardiac disorders have major depression • Rates lowest in outpatients, highest in more severely ill patients • Depression in cardiovascular patients is associated with increased mortality, increased morbidity (angina, arrhythmias, re-hospitalisation and delayed return to work) and reduced quality of life

DEPRESSION AND MORTALITY • Major depression following MI is associated with an increased risk of mortality at 6 months (hazard ratio 4.3) (Frasure-Smith et al., 1993) • Association remains after controlling for severity of physical factors related to infarct and has been found in other studies with relative risk varying from 1.4 to 2.5 after adjustment • Other studies by Frasure-Smith and colleagues reinforce the presence of this association

5 year risk of cardiac mortality and depressive symptoms 896 Post MI patients (Lesperance et al., 2002)

RELATIVE RISK OF MORTALITY • Depression 3.54 • Left ventricular failure 3.59 • Diabetes 2.72 (Welin, 2000)