45: Depression & Other Mental Health Issues

General Principles in Older Adults

By 2020, depression will rank second only to cardiovascular disease as a cause of global disability and a major public health problem in older people. The prevalence of major depression is estimated at 1% to 2% for elders in the community and 10% to 12% for those in primary care settings. However, even in the absence of major depression as defined by Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria, up to 27% of elders experience substantial depressive symptoms that may be relieved with intervention. For institutionalized elders, the rates of major depression are much higher: 12% for hospitalized elders and 43% for permanently institutionalized elders.

The World Health Organization Primary Care Study reported that 60% of primary care clinic patients treated with antidepressant medication still met criteria for depression 1 year later, with similar efficacy rates for antidepressants reported in older adults and those younger than the age of 60 years. However, depression is often missed or inadequately managed in older adults, sometimes because of the belief that depression is an inevitable process of aging or because treatment may be risky or ineffective. Indeed, there are several reasons why optimal treatment of depression in the geriatric population may differ from that for younger populations. Higher rates of physical and cognitive comorbidity in older adults, different social circumstances, greater potential for polypharmacy, and age-related pharmacodynamic and pharmacokinetic susceptibility all suggest that this population should be considered separately.

Women are twice as likely to experience major depression as men. Other risk factors include prior episodes or a personal family history of depression, lack of social support, use of alcohol or other substances, and a recent loss of a loved one. Several medical conditions are also associated with an increased risk of depression, including Parkinson disease, recent myocardial infarction, and stroke. These conditions share common threads of loss of control of body or mind, increasing dependence on others, and increased social isolation.

Depression is associated with poorer self-care and slower recovery after acute medical illnesses. It can accelerate cognitive and physical decline and leads to an increased use and cost of health care services. Among depressed older adults who have had a stroke, rehabilitation efforts are less effective and mortality rates are significantly higher.

Clinical Findings

Symptoms & Signs

Major depression is defined as depressed mood or loss of interest in nearly all activities (anhedonia) or both for at least 2 weeks, accompanied by a minimum of 3 or 4 of the following symptoms (for a total of at least 5 symptoms): insomnia or hypersomnia, feelings of worthlessness or excessive guilt, fatigue or loss of energy, diminished ability to think or concentrate, substantial change in appetite or weight, psychomotor agitation or retardation, and recurrent thoughts of death or suicide. Severity of depression varies and is important in determining optimal treatment and prognosis. Mild depression is marked by few, if any, symptoms in excess of the minimum number required to meet the diagnostic criteria defined above, and it is accompanied by minimal impairment in functioning. Moderate depression includes a greater number and intensity of depressive symptoms and moderate impairment in functioning. Patients with severe depression experience marked intensity and pervasiveness of depressive symptoms with substantial impairment in functioning. Patients with less-severe depressive symptoms who do not meet criteria for major depression may also benefit from psychotherapy and pharmacotherapy.

Screening Tools

Older patients can have fewer mood and more somatic complaints, which are often difficult to differentiate from underlying medical conditions. Special screening tools that consider this difference have been developed for the older population. The Geriatric Depression Scale is widely used and validated in many different languages. Its shortened 15-item scale (Table 45–1) is often used for ease of administration. A separate 2-item scale consisting of 2 questions about depressed mood and anhedonia has also been shown effective in detecting depression in older adults (see Table 45–1). Screening alone has not been found to benefit patients with unrecognized depression, but in combination with patient support programs, such as frequent nursing follow-up and close monitoring of adherence to medication, it improves outcomes.

Differential Diagnosis

Diagnosing depression in older adults can be challenging because of the presence of multiple comorbid conditions. Many patients with mild cognitive impairment may have predominantly depressive symptoms. With effective treatment of depression, their cognitive performance frequently improves; however, their risk for developing dementia in their lifetime is roughly double the risk of nondepressed seniors. Bereavement often manifests with depressed mood, which may be appropriate given a patient’s recent loss. However, if depressive symptoms persist, further evaluation may be warranted.

Older patients who experience delirium caused by an underlying medical illness may have mood changes. Other comorbid psychiatric illnesses must also be considered, such as anxiety disorder, substance abuse disorder, or personality disorders. Patients with bipolar disorder or psychotic disorders may have depressed mood; thus, it is important to ask patients about prior manic episodes, hallucinations, or delusions.

Depression can also be confused with other medical conditions. Fatigue and weight loss, for example, may be associated with diabetes mellitus, thyroid disease, underlying malignancy, or anemia. Patients who have Parkinson disease may first present with depressed mood or flat affect. Sleep disturbances as a result of pain, nocturia, or sleep apnea may also lead to daytime fatigue and depressed mood.

A complete history and physical examination, including assessment of cognitive status, is critical in the evaluation of depression in older adults. Because depression is a clinical diagnosis, no routine laboratory tests are indicated. Testing may be tailored to each patient based on their underlying comorbidities and presenting symptoms. A complete review of medications, both prescription and nonprescription, is essential. Medications, such as benzodiazepines, opioid analgesics, glucocorticoids, interferon, and reserpine, may cause depressive symptoms. Contrary to earlier beliefs, β blockers have not been proven to cause depression. Screening for alcohol and other substance use or addiction is another important part of the medical history. Substance use can interfere with compliance and contribute to high relapse rates, although active substance abuse should not preclude treatment for depression. For patients who struggle with addiction, “dual diagnosis” programs (alcohol or other substance dependence and psychiatric disorder) may be optimal.

Treatment

Patient & Family Education/Supportive Care

Educating patients and families about depression is the cornerstone of successful treatment. Depression continues to carry a stigma in many communities and cultures. Appropriate education can help patients understand that their condition results from a combination of inherited factors and personal and environmental stressors. Providers should also emphasize that physical symptoms and sleep disturbances are characteristic of depression; thus, relief of depression could make other physical symptoms more bearable. Encouraging physical activity with a family member or friend can be a simple, effective step toward improving social support and overall well-being.

Involving families in the care of older patients is crucial for both diagnosing depression and developing an effective treatment plan. However, caregivers of older patients, especially if impaired physically or cognitively, may experience considerable stress and depression as well. Referred to as caregiver burden, this is an all-encompassing term used to describe the physical, emotional, and financial toll of providing care. In particular, when patients with dementia have depression, their caregivers report higher levels of burden. Many programs are available that may alleviate stress and promote positive social interactions for patients. Adult day programs, senior centers, and senior support groups can be helpful resources for patients and their families, and geriatric social workers can assist with finding appropriate programs for each patient. Caregiver support groups and formal respite programs are also available in many communities.

Pharmacotherapy

Antidepressants

Selection—

Overall, antidepressants, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and selective serotonin-norepinephrine reuptake inhibitors (SNRIs), are equally effective in the treatment of geriatric depression. However, because of side-effect profiles and propensity for drug interactions, monoamine oxidase inhibitors (eg, phenelzine and tranylcypromine) and tertiary amine TCAs (eg, amitriptyline, imipramine, and doxepin) are rarely used in older adults. The SSRI class includes citalopram, escitalopram, fluoxetine, paroxetine, and sertraline; examples of SNRIs are venlafaxine, desvenlafaxine, and duloxetine. Fluoxetine is generally avoided in older adults because of its long half-life and inhibition of the P450 system. Choice of therapy among the remaining drugs is generally determined by side-effect profile and the patient’s comorbid symptoms such as anxiety, insomnia, pain, and weight loss, although anxiety and insomnia do not necessarily predict a better response to more sedating medications. Renal and hepatic functions are also important considerations in older adults and should be assessed before initiation of therapy.

SSRIs are relatively safe in overdose. Thus, they are a reasonable first choice in treating older patients with depression. However, the Food and Drug Administration has recently posted a warning of cardiac arrhythmias associated with high doses of the SSRI citalopram hydrobromide (Celexa). Citing increased risk of QT interval prolongation and torsade de pointes through postmarketing reports of citalopram, the FDA announced a maximum daily dose of 20 mg for all patients older than age 60 years. The warnings do not apply to its racemic drug, escitalopram (Lexapro), which is the S-enantiomer of the citalopram molecule.

Other agents offer unique advantages: Mirtazapine stimulates appetite and can help with insomnia, and bupropion can reduce craving in smoking cessation. Secondary amine TCAs (eg, nortriptyline, desipramine) can offer beneficial effects for patients with neuropathic pain, detrusor instability, or insomnia. SNRIs, which have serotonergic and noradrenergic activity, are other effective alternatives that may also be useful in treating anxiety and neuropathic pain.

Dosage—

In general, older patients should begin an antidepressant by taking half of the manufacturer-recommended starting dose (to minimize side effects), but the medication should be titrated to the recommended target dose in weekly increments. Older patients are frequently undertreated because the provider fails to adequately titrate the dose to a therapeutic level. If minimal or no benefit occurs by 4–6 weeks and side effects are tolerable, the dose should be increased. The full effect may not be seen for 8–12 weeks in older patients. If a therapeutic dose has been reached and maintained for 6 weeks and the patient has not adequately responded, one should consider switching to a different agent or augmenting with an additional agent. Although serum drug levels are not useful for SSRIs, levels of TCAs can be measured to assess adherence.

Side effects—

Side effects differ depending on the type of antidepressant. Most side effects lessen within 1–4 weeks from the start of therapy, but weight gain and sexual dysfunction may last longer. For the SSRIs, the most common side effects include nausea and sexual dysfunction. Sexual dysfunction may respond to treatment with sildenafil, but switching antidepressant medication or lowering the dose of SSRI and augmenting with an additional agent may be necessary. The TCAs have more anticholinergic properties and may lead to dry mouth, orthostasis, and urinary retention.

Cautions & interactions

1. Cardiovascular disease—TCAs can be associated with orthostatic hypotension and cardiac conduction abnormalities, leading to arrhythmias. Recently, citalopram has been implicated in potentially dangerous arrhythmias. Therefore, electrolyte and/or electrocardiographic monitoring is recommended for patients at risk for arrhythmias if these agents are considered.

2. Hypertension—Venlafaxine and desvenlafaxine may increase systolic and diastolic blood pressure.

3. Electrolyte abnormalities—Serotonin-reuptake inhibitors may induce hyponatremia.

4. Hepatic disease—Most antidepressants are hepatically cleared and should be used with caution in patients with liver disease. Nefazodone in particular should not be used in patients with liver disease or elevated transaminases because it has been associated with an increased risk of hepatic failure and interacts with other hepatically cleared medications, including simvastatin and lovastatin.

5. Falls—Serotonin-reuptake inhibitors have been associated with an increased risk in falls particularly in older patients with dementia. Fall risk assessment should be included in part of overall medical evaluation.

6. Bleeding risk—Serotonin-reuptake inhibitors may increase bleeding risk and interact with anticoagulant medications such as warfarin. International normalized ratio levels should be closely monitored with initiation of treatment with SSRI’s.

7. Cognitive impairment—TCAs and certain SSRIs, such as paroxetine, have stronger anticholinergic effects and should be avoided in patients with cognitive impairment to avoid increasing confusion.

8. Seizure disorders—Bupropion lowers seizure thresholds.

9. Suicidal ideation—TCAs are lethal in overdose and should be avoided in actively suicidal patients. SSRIs and SNRIs are relatively safe in overdose.

10. Serotonin syndrome—Use of serotonergic antidepressants may lead to serotonin syndrome, a potentially life-threatening condition associated with increased serotonergic activity in the central nervous system. Although classically described as a triad of mental status changes (headache, confusion, agitation), autonomic hyperactivity (diaphoresis, hypertension, tachycardia, nausea, diarrhea), and neuromuscular abnormalities (tremor, myoclonus, hyperreflexia) serotonin syndrome can span a spectrum of clinical findings ranging from benign to lethal. Given the increased use of serotonergic agents in medical practice, and the syndrome’s potential for rapid onset, with its clinical course developing over 24 hours, providers are advised to remain vigilant for this condition. The central principles to the management of suspected serotonin syndrome are (a) discontinuation of all serotonergic agents, and (b) supportive care aimed at normalization of vital signs.

Psychostimulants—

Psychostimulants, such as dextroamphetamine (5–10 mg/day) or methylphenidate (2.5–5 mg/day), are sometimes indicated as either a primary or an adjuvant treatment for depression with predominant vegetative symptoms. A newer stimulant, modafinil (Provigil), which increases monoamines, has also been used as an adjunct to traditional antidepressants. With its additional histaminergic effects, modafinil is considered by some to be a “wakefulness promoting agent,” and unlike the classic amphetamine-like stimulants, is considered to have limited abuse potential. At the end of life, patients may not have time to wait 4–6 weeks for the benefits of antidepressant medication, and psychostimulants may offer more immediate relief. In the setting of depression after an acute medical illness, psychostimulants may offer a faster means to enhance recovery and participation in rehabilitation. Typical side effects include insomnia and agitation, but these may be lessened by taking the medication early in the day in divided doses (morning and noon). Another common side effect is tachycardia.

Herbal remedies—

Many herbal remedies claim to be effective in treating depression, but further evidence is still needed to determine whether these “dietary supplements” (eg, Hypericum perforatum [St. John’s wort]) have a role in the treatment of depression. H. perforatum should not be used in conjunction with SSRIs because the combination may lead to serotonergic syndrome, which is characterized by changes in mental status, tremor, gastrointestinal upset, headache, myalgia, and restlessness. It may lower the concentration of certain drugs, such as warfarin, digoxin, theophylline, cyclosporine, and HIV-1 protease inhibitors. Other common herbal remedies such as kava kava and valerian root have not been proven effective for treating depression. Herbal remedies should not be substituted for proven depression therapies.

Psychotherapy

Cognitive–behavioral therapy (CBT), problem-solving therapy, and interpersonal psychotherapy are effective treatments for major depression, either alone or in combination with pharmacotherapy. CBT focuses on identifying negative thoughts and behaviors that contribute to depression and replacing them with positive thoughts and rewarding activities. Problem-solving therapy teaches patients techniques to identify routine problems, generate multiple solutions, and implement the best strategy. Interpersonal psychotherapy focuses on recognizing and attempting to resolve personal stressors and relationship conflicts that lead to depressive symptoms.

Typically, these therapies should be continued once or twice weekly for 6–16 sessions. In patients with severe depression, combination therapy with psychotherapy and pharmacotherapy is superior to either treatment alone. Psychoanalytic and psychodynamic therapies have not proved effective for treatment of major depression.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an effective treatment for geriatric depression. Response rates for refractory depression are quite high at 73% for the young-old (age 60–74 years) and 67% for the old-old (age >75 years). Typical side effects include confusion and anterograde memory impairment, which may persist for 6 months. ECT may be first-line therapy for severely melancholic patients, for those at high risk for suicide, and for medically ill patients whose hepatic, renal, or cardiac diseases preclude the use of other antidepressants.

Psychiatric Therapy

Psychiatric consultation is recommended for those patients with a history of mania or psychosis, for those who have not responded to a trial of 1 or 2 medicines, and for those who require combination therapy or ECT. Immediate psychiatric evaluation is required for any patients who, after probing, admit to having active plans to harm themselves. Risk factors for suicide in older patients with major depression include older age; male gender; marital status of single, divorced, or separated and without children; personal or family history of a suicide attempt; drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with access to firearms or other lethal means (eg, stockpiled medications). If medications and weapons are present and cannot be removed from the patient’s home, consider adding “weapon at home” to the patient’s problem list to highlight potential suicide risk.

Follow-up

Pharmacotherapy—

Older patients should be monitored closely during the initial 3 months of treatment. Many medical outpatients who receive a prescription for an antidepressant terminate treatment during the first month, when side effects may be at a maximum and before therapeutic effects are evident. Older patients should be monitored closely in the first 1–2 weeks of therapy to assess side effects and encourage continued therapy. They should have a minimum of 3 visits (in person or by telephone) during the first 12 weeks of antidepressant treatment.

Older patients must be informed that antidepressants usually take 4–6 weeks, but may take 8 weeks or longer, to have a full therapeutic effect and that only approximately 50% of patients respond to the first antidepressant prescribed. Patients who have not responded after an adequate trial of medication or who have had intolerable side effects may switch either to another medication within the same class (different SSRI) or to a different class of medications. When switching among SSRIs or between TCAs and SSRIs, no washout period is required (with the exception of switching from fluoxetine, because of its long half-life). However, abrupt cessation of shorter-acting antidepressants (eg, citalopram, paroxetine, sertraline, or venlafaxine) may result in a discontinuation syndrome with tinnitus, vertigo, or paresthesias. Referral for psychiatric consultation is recommended if a patient fails to respond to 2 different medication trials.

Once remission has been achieved, antidepressants should be continued for at least 6 months to reduce the risk of relapse. Patients who are at high risk of relapse (2 or more episodes of depression in the past or major depression lasting more than 2 years) should be continued on therapy for 2 years or possibly indefinitely. Many recommend lifelong therapy, even if it is the patient’s first episode of major depression and especially if depression is severe and related to life changes that are not expected to improve. Follow-up visits should be arranged at 3–6-month intervals. If symptoms return, the medications should be adjusted or changed or the patient referred for psychiatric consultation.

If the patient and physician agree to a trial discontinuation of therapy, medications should be tapered over a 2–3-month period, with at least monthly follow-up by telephone or in person. If symptoms return, the patient should be restarted on medications for at least 3–6 months.

When patients fail to respond to adequate trials of 2 medications for major depression, a diagnosis of treatment-resistant depression is considered. One must review the case and consider that the original diagnosis may be inaccurate. What first appeared as depressive symptoms may be a manifestation of underlying anxiety or cognitive impairment. Apathy may be one of the first symptoms seen in dementia prior to more obvious cognitive symptoms. One must then verify that the patient actually received the medication that was prescribed. A simple investigation may reveal that the patient never filled the prescription or was never given medication by caregivers. Finally, one must ensure that the patient had adequate trials of medications (6–8 weeks) and that this trial was performed at a therapeutic dose.

Any patient who has had an adequate trial of 2 different medications without acceptable response should be referred to a psychiatrist for augmentation therapy. As shown from the federally funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, the largest real-world study of treatment-resistant depression, patients with persistent depression have the potential to improve after several medication treatment trials; however, the odds of remission diminish as additional treatment strategies are needed. Lithium may be used in low doses in older adults with careful monitoring of side effects. Small doses of liothyronine (T₃) can be used safely in euthyroid patients. In addition, combinations of 2 antidepressant medications may be synergistic, with low doses of 1 antidepressant enhancing response to an antidepressant of another class.

Structured psychotherapy—

Patients who have been referred to psychotherapy must still be monitored closely by their primary care clinicians because patients tend to discontinue therapy even more frequently than antidepressant treatments. The benefits of psychotherapy are generally evident by 6–8 weeks. The addition of pharmacotherapy should be considered for patients who have not fully responded to psychotherapy alone by 12 weeks. A combination of psychotherapy and pharmacotherapy may be more effective for moderate depression than either treatment alone.

Prognosis

Depression is often a chronic or relapsing and remitting disease. Greater severity of depression, persistence of symptoms, and a higher number of prior episodes are the best predictors of recurrence. The lifetime risk of suicide in patients with major depression is 7% for men and 1% for women.

Many depressed elders contemplate suicide. Primary care providers must recognize the risk factors for suicide in patients with major depression: older age; male gender; being single, divorced, or separated and without children; personal or family history of a suicide attempt; drug or alcohol abuse; severe anxiety or stress; physical illness; and a specific suicide plan with access to firearms or other lethal means. Providers should ask patients whether they ever think of hurting themselves or taking their life. If the patient responds positively, physicians should ask whether they have a plan and, if so, what it is. Asking patients about stockpiled medications or weapons in their home is also critical in assessing the suicide risk. If medications and weapons are present and cannot be removed from the patient’s home, consider adding “weapon at home” to the problem list to highlight potential suicide risk. Actively suicidal patients with intent and plan require emergent psychiatric evaluation either through emergency departments or local psychiatric crisis units.

General Principles in Older Adults

Bipolar disorder is a less-common diagnosis in older adults, with an overall low prevalence of <1% in community-dwelling elders, but a 10% rate in some nursing home populations. Many patients with bipolar disease require special considerations as they age because of comorbid conditions and diminished ability to tolerate psychiatric medications. Late-onset mania is often secondary to underlying medical conditions and is frequently associated with neurologic abnormalities such as cerebrovascular accident and cognitive impairment. Older patients with bipolar disorder have an increased 10-year mortality rate compared with those who have depression alone (70% vs. 30%).

Differential Diagnosis

Bipolar disorder is diagnosed when a patient meets criteria for a manic episode. A manic episode is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and with ≥3 of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences. Although major depressive episodes are common in bipolar disorder, they are not required for the diagnosis. The presence of mania is key to the differentiation between depressive disorder and bipolar disorder.

A variety of conditions may mimic a manic episode. Patients with dementia, particularly frontotemporal dementia, may be disinhibited and hypersexual. Brain tumors, cerebrovascular accidents, and partial-complex seizures may also lead to bizarre, disinhibited behaviors. Older patients who are prone to delirium can have waxing and waning levels of consciousness with some periods of hyperarousal. In addition, some medications may have unexpected effects in older patients. Glucocorticoids, thyroxine, and methylphenidate may lead to acute mania. Even sedative medications (eg, benzodiazepines) may have a paradoxical effect in older adults and lead to agitation. As in younger populations, substance intoxication or withdrawal from cocaine, alcohol, or amphetamines and endocrine disorders, such as hyperthyroidism or pheochromocytoma, can lead to symptoms consistent with mania.

Treatment

Mood stabilizers have been the hallmark of treatment for bipolar disease. Valproic acid and carbamazepine are generally favored over lithium in older adults because of lithium’s side effect profile and narrow toxic–therapeutic window (Table 45–2). Antipsychotic medication can be used in acute treatment of manic episodes associated with bipolar, maintenance treatment of bipolar, or when psychotic features are present. In general, the newer antipsychotic agents, such as olanzapine and risperidone, are better tolerated by older adults than the older neuroleptics with their extrapyramidal side effects and high risk of tardive dyskinesia, especially in women. Additionally, recent data have suggested typical antipsychotics, in particular Haldol, may have statistically significantly elevated mortality rates compared to atypical antipsychotics. Among the atypical antipsychotics, olanzapine, risperidone, quetiapine, ziprasidone, and asenapine are approved for acute treatment of mania and as adjunctive treatment with lithium or valproate. Only aripiprazole is approved as monotherapy for the maintenance treatment of bipolar. Antidepressants are often used as an adjunct to mood stabilizers for patients with depression but should not be used alone because of the risk of transforming a depressive episode into a manic episode.

Panic Disorder

General Principles in Older Adults

The lifetime prevalence rate of panic disorder is 1.5% to 2%, increasing to 4% in the primary care setting. The rate among community-dwelling elders is <1%. Depression is also present in 50% to 65% of patients with panic disorder; the suicide rate for these patients is 20% higher than that for depressed patients without panic disorder. Panic disorder may be associated with agoraphobia, which can be particularly disabling in older adults.

Differential Diagnosis

A panic attack is defined as an abrupt surge of intense fear or discomfort with 4 or more of the following symptoms: palpitations; sweating; trembling or shaking; shortness of breath; choking sensation; chest pain or discomfort; nausea or abdominal distress; dizziness or unsteadiness; chills or heat sensations; numbness or tingling; derealization or depersonalization; fear of losing control; and fear of dying. DSM-5 criteria for panic disorder include recurrent unexpected panic attacks, with at least 1 of the attacks having been followed by 1 month or more of either 1 or both of the following: persistent concern or worry about additional attacks or their consequences, or a significant maladaptive change in behavior related to the attacks.

Because the likelihood of physical disease is much higher than in younger populations, panic disorder is more difficult to distinguish from other life-threatening events in older patients. Acute coronary syndromes, cardiac arrhythmias, acute bronchospasm, and pulmonary embolism may lead to symptoms consistent with panic attacks. Endocrine disorders, particularly hyperthyroidism and pheochromocytoma, can mimic panic disorder. In acutely hospitalized patients, alcohol, caffeine, and tobacco withdrawal may present as agitation, worry, and other physical symptoms. Abrupt discontinuation of a short-acting antidepressant, anxiolytic, or opioid analgesic medication may also trigger panic symptoms. Older patients who suffer from panic disorder often have comorbid psychiatric diagnoses such as posttraumatic stress disorder (PTSD), generalized anxiety disorder, and depression.

Treatment

CBT has been proven effective for the treatment of panic disorder. Patients often go into a complete remission after as few as 12 weekly sessions. CBT is particularly helpful in preventing relapse and treating agoraphobia. Antidepressants, particularly SSRIs and TCAs, are helpful. Benzodiazepines may also be used as a brief adjunctive therapy while awaiting the clinical response to antidepressants or CBT. Whenever possible, long-term therapy with benzodiazepines should be avoided because of the potential risk of falls, cognitive impairment, and dependence.

Perhaps the most important aspect of treatment is education for the patient and family. Understanding the symptoms of panic disorder and developing ways of coping are essential for effective management of the disease.

Social & Specific Phobias

General Principles in Older Adults

The prevalence of phobias is 5% to 6% in older adults. Phobias present with features similar to panic disorder, but are triggered by a specific event. Late-onset phobias are often associated with a recent life event, such as a fall or injury. Social phobias affect 3% of older adults and can lead to increasing isolation. Simple phobias are thought to be more common than social phobias, affecting 5% to 12% of the general population.

Differential Diagnosis

Social phobia, also known as social anxiety disorder, is defined by DSM-5 criteria as a marked and persistent fear or anxiety about social situations, exposure to which almost always provokes these feelings. The patient fears that the patient’s response to the social situation will be negatively evaluated, and either avoids the situation or endures it with great anxiety. The avoidance, fear, or anxiety associated with the situation is disproportionate to any actual posed threat, and interferes with the patient’s occupation or relationships. Specific phobia is a fear or anxiety about certain objects or situations that is disproportionate to the actual danger posed by such, and may lead to impairment in a patient’s ability to function normally.

In older adults, new phobic symptoms may represent delusions associated with dementia or delirium. Patients with dementia or delirium are not typically aware of the irrational nature of their delusions in contrast to patients with phobia. Less-common causes of phobia include brain tumors or cerebrovascular accidents. The psychiatric differential diagnosis of phobia includes depression, schizophrenia, and schizoid and avoidant personality disorders. Social phobia and alcohol dependence often coexist; therefore, probing for alcohol use is an important part of the assessment. Although both phobic disorders and panic disorder may present with panic attacks, patients with phobias do not experience recurrent unexpected attacks; rather, their anxiety symptoms are always associated with a specific object or situation.

Treatment

The first-line therapy for specific phobias is behavioral therapy. Techniques may include relaxation therapy, cognitive restructuring, and systematic exposure to the feared object or situation. Use of antidepressants, particularly SSRIs, may be beneficial for generalized social phobia. Beta-adrenergic antagonists such as propranolol may also be effective treatments when administered before a foreseeable feared event or situation. Benzodiazepine use may be necessary but in general should be used with caution because of adverse effects on balance and cognition. Most patients are able to adapt or overcome their phobias and can lead relatively normal lives; if not, they should be referred for evaluation by a mental health specialist.

Generalized Anxiety Disorder

General Principles in Older Adults

Anxiety symptoms are often a normal reaction to the surrounding environment. Anxiety disorders tend to begin in early adulthood and continue throughout a patient’s lifetime with periods of relapses and remissions. The lifetime prevalence of generalized anxiety disorder is 5%; estimates in elders range from 2% to 7%. Anxiety may increase in older adults as a result of isolation, loss of independence, illness, disability, and bereavement.

The diagnosis of generalized anxiety disorder is characterized by the following according to DSM-5 criteria:

• Excessive anxiety and worry about a number of events or activities occurring more days than not for at least 6 months.

• Worry is difficult to control.

• Anxiety and worry are associated with at least 3 of the following: restlessness, easy fatigability, difficulty with concentration, irritability, muscle tension, sleep disturbance.

Diagnosing generalized anxiety in elders can be complicated because many underlying illnesses may have similar symptoms. The differential diagnosis for generalized anxiety disorder includes the physical illnesses discussed previously for panic disorder. In addition, chronic medication or substance use and subsequent withdrawal may lead to anxiety symptoms. Caffeine, nicotine, and alcohol are common culprits. Older patients are much more sensitive to commonly used nonprescription medications such as pseudoephedrine, which may cause restlessness, anxiety, and confusion. Up to 54% of patients who suffer from generalized anxiety disorder have comorbid depression. Obsessive–compulsive disorder, somatoform disorder, and personality disorders may also present with symptoms of anxiety. Psychiatric consultation should be initiated if the diagnosis is in question.

Treatment

CBT is one of the most effective treatments for generalized anxiety disorder. Relaxation techniques and biofeedback may also alleviate symptoms. Several antidepressants (paroxetine, extended-release venlafaxine) also have significant anxiolytic properties and may be effective for both anxiety and depression. When depression and anxiety occur together, one should treat the depression first; doing so may improve the symptoms of both disorders. Anxiolytic medications such as buspirone (5–30 mg twice daily) may be effective. Benzodiazepines should be used with caution in older adults because they can cause a paradoxical effect and may also lead to falls and cognitive impairment.

Posttraumatic Stress Disorder

General Principles in Older Adults

PTSD is associated with a lifetime prevalence of 1.2% in women and 0.5% in men. Symptoms of PTSD may persist into older age. In addition, symptoms can remain hidden until an older age when patients have new experiences (deaths, medical illness, disability) that trigger memories of former events or lose the capacity to compensate for lifelong symptoms because of cognitive impairment or other medical illness. However, some studies have shown that increased age may actually protect against the development of PTSD. Other protective factors include marriage, social support, and higher socioeconomic status.

Differential Diagnosis

Per DSM-5 criteria, the patient has been exposed in 1 or more of the following ways to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms may be grouped into 3 categories and may persist for >1 month.

1. Intrusive symptoms with ≥1 of the following: recurrent and intrusive recollections, dreams, dissociative reactions (eg, flashbacks), distress at exposure to cues to the event, or marked physiologic reaction to such cues.

2. Avoidant symptoms with 1 or both of the following: avoiding memories, thoughts, or feelings associated with the trauma; avoiding external reminders (eg, people, places, activities) associated with the trauma.

3. Negative alterations in cognition and mood, with >2 of the following: inability to remember aspects of the trauma; exaggerated negative beliefs or expectations about oneself, others, or the world; distorted blaming of oneself or others; persistent negative emotions (eg, fear, anger, guilt, shame); diminished interest or participation in activities; feeling of detachment or estrangement; inability to experience positive emotions.

4. Arousal symptoms indicated by ≥2 of the following: irritability or outbursts of anger, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, difficulty concentrating, or sleep disturbance.

Other anxiety disorders can present with symptoms of hyperarousal similar to those in patients with PTSD. Major depressive disorder and adjustment disorders can also present with numbing or avoidant symptoms. During a period of bereavement, patients can have visions or dreams about the deceased. Other psychotic disorders may be confused with PTSD, but patients with PTSD may also experience psychotic-like symptoms during severe episodes. Substance use or withdrawal may contribute to symptoms. Organic brain syndrome resulting from prior head injury may be associated with symptoms similar to those of PTSD; the presence of visual hallucinations is particularly suggestive of an organic cause. Patients with delirium may also appear hyperaroused or be prone to illusions. There is a high comorbidity of depression and alcohol abuse among patients with PTSD.

Treatment

Antidepressants, particularly SSRIs and TCAs, are indicated for treatment of PTSD. Both individual and group CBTs are also effective in the treatments and may be used alone or in combination with pharmacological therapy. Antiadrenergic agents such as clonidine may be helpful for symptoms of increased arousal, although one must consider related side effects such as orthostasis. However, recent trials have demonstrated the tolerability and effectiveness of prazosin, an α₁-adrenergic receptor antagonist, particularly in managing nightmares associated with PTSD. Benzodiazepines can often worsen symptoms of PTSD and should be avoided. Antipsychotic medications are occasionally necessary for the treatment of associated psychotic symptoms (see Table 45–2); however, recent data put into question the clinical benefits of risperidone (a very widely prescribed second-generation antipsychotic for PTSD), particularly in light of its potential side-effect profile.

General Principles in Older Adults

Psychotic symptoms may be attributable to a longstanding psychotic illness that has persisted into older age, or may present for the first time in later life in association with underlying medical conditions, especially dementia. Estimates for schizophrenia in the older population range from 0.1% to 0.5%. The prevalence of other psychotic syndromes, such as paranoid ideation, is higher, estimated at 4% to 6% in the older population, and is frequently associated with dementia. Patients with Alzheimer disease have a particularly high incidence of psychosis; 50% manifest psychotic symptoms within 3 years of diagnosis.

Differential Diagnosis

The diagnostic criteria for schizophrenia include ≥2 of the following characteristic symptoms present for at least 1 month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms such as flattened affect. These symptoms must also be associated with dysfunction in such areas as work, relationships, or self-care. Patients commonly will not volunteer psychotic symptoms unless specifically asked by their provider after a trusting relationship has been established. If psychosis is suspected, it is important to ask patients and family members specifically about auditory and visual hallucinations, delusions, ideas of reference, and paranoid ideation. Visual hallucinations are associated more strongly with underlying organic cause.

Especially in older adults, new psychotic symptoms carry a vast and complicated differential. New-onset psychotic symptoms can be attributed to medications, changes in environment, organic causes, including dementia, or a combination of these factors. Because psychosis may be the presenting sign of dementia, any older patient with new-onset psychosis should have a thorough cognitive screen. Prominent visual hallucinations are one of the hallmarks of Lewy body dementia. Patients with Alzheimer disease frequently have fixed delusions regarding people stealing their possessions or marital infidelity. The dementia associated with Parkinson disease may include negative symptoms of schizophrenia, such as flat affect.

Other central nervous system diseases, such as brain tumors, partial seizures, multiple sclerosis, or cerebral systemic lupus erythematosus, can also cause psychotic symptoms. Patients with major depression or bipolar disorder may experience psychotic features. Infections, endocrinopathies (thyroid, diabetes, adrenal), and nutritional deficiencies (vitamin B₁₂, thiamine) may lead to psychosis. Finally, older patients can be especially sensitive to medications that trigger psychotic symptoms such as steroids or levodopa. Because of the large differential diagnosis, collateral information regarding the patient’s baseline mental status, psychiatric history, and onset of symptoms is critical in the evaluation of psychotic symptoms.

Treatment

Pharmacotherapy

Atypical antipsychotic agents, such as risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, are the mainstays of treatment for psychotic symptoms and are approved for use in schizophrenia and bipolar disease (Table 45–3). Because of their lower incidence of extrapyramidal side effects, these agents are much better tolerated than the older antipsychotic agents, such as haloperidol and trifluoperazine. Recent data from multiple studies highlight the increased all-cause mortality rates in seniors with use of antipsychotic medications particularly when used in patients with dementia. Unlike older neuroleptics, which mainly treat positive symptoms (eg, delusions, hallucinations), the newer agents effectively manage both positive and negative psychotic symptoms (eg, flat affect, social withdrawal). The main side effects of newer agents are sedation and dizziness. Patients may experience akathisia and parkinsonism (eg, stiffness and rigidity) and, with longer term use, tardive dyskinesias, although the risk of such side effects is lower than with high-potency traditional antipsychotic drugs. Risperidone has been associated with an increased incidence of strokes in patients with dementia. Unlike other newer agents, ziprasidone does not appear to cause weight gain and is useful in the treatment of obese patients. However, it is associated with QT prolongation and thus should be avoided in patients with underlying conduction disease and QT prolongation at baseline. Clozapine is often the treatment of choice for patients with severe resistant psychosis and those with disabling tardive dyskinesias. Clozapine, however, carries a 1% to 2% risk of agranulocytosis and, therefore, requires weekly blood monitoring. In addition, both clozapine and olanzapine have been associated with glucose dysregulation and thus should be used with caution in patients with diabetes mellitus. Quetiapine is associated with an increase in cholesterol levels; lipid levels should be routinely monitored. Dosages of antipsychotics used in older patients with dementia or acute delirium tend to be lower than those required for management of other psychotic disorders and may be only necessary for short periods of time (see Table 45–3) as these medications now carry a FDA black-box warning for treatment of behavioral symptoms in older patients with dementia. (See Chapter 22, “Cognitive Impairment & Dementia,” for further details on dementia and antipsychotics use.)

Neuroleptic malignant syndrome (NMS) is a life-threatening emergency associated with the use of neuroleptic agents. NMS is characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and autonomic instability, and is associated with elevated plasma creatine phosphokinase. Although NMS is most often seen with the typical high-potency neuroleptic agents (eg, haloperidol, fluphenazine), every class of neuroleptic agents has been implicated, including the low potency (eg, chlorpromazine) and the newer atypical antipsychotic drugs (eg, risperidone, olanzapine), as well as the antiemetic metoclopramide. NMS may even occur when dopaminergic drugs, such as levodopa, are abruptly reduced or discontinued. Developing from over a few days to the first 2 weeks of neuroleptic therapy, this syndrome should be suspected when any 2 of the 4 following cardinal clinical features occur in the setting of neuroleptic use: mental status change, rigidity, fever, or autonomic instability. When there is any suspicion of NMS, neuroleptic agents should be withheld and patients should have close inpatient monitoring of clinical signs and laboratory values.

To decrease inappropriate use of psychotropic medications and improve the quality of care in long-term care facilities, the Health Care Finance Administration’s 1987 Omnibus Reconciliation Act (OBRA) outlined indications and prescribing guidelines for psychoactive medications used in the treatment of psychotic disorders and agitated behaviors associated with organic brain disorders. OBRA requires documentation of response in terms of specific target symptoms and careful monitoring of side effects. To avoid long-term side effects such as tardive dyskinesia, OBRA also recommends trial dose reductions of neuroleptics unless clinically contraindicated because of severity of symptoms.

Behavioral Therapy

Behavioral therapy may be effective for the management of psychosis and after the acute episode has resolved. Providing a stable living environment is critical to the successful treatment of psychosis. Medical compliance is difficult without close supervision by a family or staff member. Adult day facilities provide structured programs for patients and give critical respite to caregivers, thus allowing patients to remain in the community longer than they would otherwise be able to without nursing home care.

Agency for Healthcare Research and Quality. AHCPR supported guidelines” for Diagnosis and Treatment of Depression in Primary Care. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/archive.html

American Association for Geriatric Psychiatry. http://www.aagponline.org

American Medical Association. http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health.page?

Depression and Bipolar Support Alliance. http://www.dbsalliance.org/site/PageServer?pagename=home

Depression Awareness, Recognition, and Treatment (DART) program of the National Institute of Mental Health. http://www.nimh.nih.gov/health/topics/depression/index.shtml

Geriatric Mental Health Foundation. http://www.gmhfonline.org/gmhf

International Foundation for Research and Education on Depression (iFred). http://www.ifred.org

National Alliance of Mental Illness. http://www.nami.org/

National Center for PTSD. http://www.ptsd.va.gov/

National Mental Health Association (Campaign on Clinical Depression). http://www.mentalhealthamerica.net/go/depression