Geriatricdepression-老年抑郁症

1,Depression in Older People,Guanglei Xun Mental Health Center of Shandong Province,2,Introduction of Depression(1),Difinition of depressionDepressive disorder is characterized by depressed mood that is out of keeping with the circumstances. It may vary from low mood to melancholia, or even stupor.In severe cases, psychotic symptoms such as delusions and hallucinations may be present. Anxiety and motor agitation may be more prominent than depression in some cases.,3,Introduction of Depression(2),Core symptomsDepressed moodLoss of interest or pleasure Decreased energy, increased fatigue Additional symptomsLoss of confidenceInappropriate and excessive guiltRecurrent thoughts of death, suicidal thoughts or behaviourDiminished evidence of ability to think or concentrateChange in psychomotor activitySleep disturbanceAppetite change and corresponding weight change,4,Introduction of Depression(3),Duration: Symptom and severity criteria are met for at least 2 weeksSeverityimpairment of social functionindividual subjective distressundesirable outcomes on oneself,5,Geriatric Depression,Occurred in people aged 65 and above. 10% worldwide population is made up of older adults. Depressive disorder is one of the most common mental disorders in later life. The prevalence of geriatric depression is about 13.5%.Geriatric depression has specific features, which do not accord with the rigid diagnostic criteria.,Beekman AT.et al. British Journal of Psychiatry,1999,174:307-11,6,Types of Geriatric Depression,Endogenous depressionOrganic mood disorder Dysthymia Adjustment disorder Vascular depression,7,Vascular Depression a new category of geriatric depression(1),HypothesisDamage to end-arteries supplying subcortical striatal -pallidum-thalamus-cortical pathways disrupts the neuro- transmitter circuitry involved in mood regulation, and may cause depression.,8,Vascular Depression a new category of geriatric depression(2),FeaturesDepression arises in late lifeReduced insightApathy and retardationCognitive impairmentNeurological evidence of ischemic brain damage,9,Features of Geriatric Depression(1),Compared with young-adult depression, the depression in later life has special clinical featuresAnxietySomatizationAnxiety, somatization may be the most common symptoms, sometimes it covers up the depressed mood. Some geriatric depressive patients often go to see doctors in division of digestive diseases, division of cardiology, department of neuroloy, instead of the psychiatry.,10,Features of Geriatric Depression(2),ComorbidityDiabetesCushings diseaseCerebrovascular diseaseAlzheimers diseaseCancerChronic infectionsGeriatric depressive patients are more susceptible to physical disorders, and on the contrary, physical disorders such as cancer, stroke and Parkinsons disease often lead to depressive disorder in older people.,11,Features of Geriatric Depression(3),More severe cognitive dysfunctionMnemic dysfunctionExecutive dysfunctionAttention dysfunctionCo-exist with dementia,12,Features of Geriatric Depression(4),Refractorinesslonger course of treatmentcomorbidity of physical disordersinteractions of medicine,13,Risk Factors of Geriatric Depression,Poor health or disabilityIsolation or living aloneLack of social supportNegative life eventsPrevious history of depressionGender,14,Life Events in Geriatric Depression,BereavementSeparationAcute physical illnessMedical illness or threat to life of someone close Homelessness or moving into a new placeMajor financial crisisNegative interactions with family member or friendLoss of significant other(including a pet),15,Chronic Stress in Geriatric Depression,Declining health or have to depend on othersSensory loss or cognitive declineHousing problemsMajor problems affecting family memberSocioeconomic declineMarital difficultyRetirementSocial isolation,16,Neurobiological Basis of Geriatric Depression (1),Neurotransmitter changesSerotonin (5-HT)Dopamine (DA)Noradrenaline (NE),17,Neurobiological Basis of Geriatric Depression (2),Neuroendocrine changesHyperactivity and dysregulation of HPAHigh cortisol levelsDST (Dexamethasone suppression test),18,Neurobiological Basis of Geriatric Depression(3),Structural brain changesCerebral atrophyDeep white matter lesionsSubcortical lesions in gray matterDamage to the subcortical-frontal circuitry,19,Neurobiological Basis of Geriatric Depression(4),Functional brain changesPETSPECTRTIPevent related fMRI,20,Treatment in Geriatric Depression (1),PsychoeducationDepression is a treatable disorderAntidepressants are non-addictiveThe importance of complianceNot to stop treatment when recovery has occurred,21,Treatment in Geriatric Depression (2),AntidepressantsTricyclics(TCAs): seldom usedSelective serotonin reuptake inhibitors(SSRIs)FluvoxamineFluoxetineParoxetineSertralineCitalopram, S-citalopramOther newer antidepressantsTrazodoneMoclobemideVenlafaxineMirtazepineBupropion,22,Treatment in Geriatric Depression (3),AntidepressantsStrategy: start low, go slowEfficacy: little difference in efficacy between any class of antidepressantsResponse rate: 50%60%Acute treatment course: 12 weeksDrug interaction: citalopram has less interactions than other SSRIs,23,Treatment in Geriatric Depression (4),Considerations in selecting antidepressantSafetyTolerability and compliancePrior response to a particular agentDrug interactionsComorbidity (dementia,physical disorder),24,Treatment in Geriatric Depression (5),Other physical treatmentsElectroconvulsive therapy (ECT)Transcranial magnetic stimula