December 6, 2023 • 14 mins
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Explore the intersection of depression and neurocognitive disorders in elderly patients. The discussion highlights the challenges in differentiating between depression and apathy, the importance of accurate diagnosis, and the appropriate pharmacological considerations for treatment. Join us as we delve into the complexities of mental health in the aging population.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Thanh (00:01):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:03):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:06):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:09):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:19):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:43):
Only on The Y in Psychiatry.
Dr. Amayo (00:47):
Welcome back to the Y in psychiatry.
Today we'll be talking aboutdepression and neurocognitive
disorders.
So when I'm seeing a patientwith Parkinson's disease or a
patient with some form ofdementia, I've noticed that it
is hard to tell if they havedepression or their mental
status exam is just acontinuation of their disease
process.
So I guess my question today tois how depression or disease how
can you tell the difference inthis population?
Dr. Handratta (01:07):
So that's a very good question.
A lot of people get confusedbetween depression and dementia,
and patients with dementia canalso have depression.
And you talked about twoseparate population,
Alzheimer's, dementia, andParkinson's disease.
In Parkinson's disease, it'svery difficult actually to say
whether the patient's lack offacial emotion, the mask face.
(01:29):
Is because the disease or thepatient actually has depression.
So one thing that I tell peopleand I like usually tell my
residents, medical student andmy fellows is that the type of
skills that you're going to usewill make a difference.
So in our population who doesn'thave dementia, and in the
younger population we use PHQ9.
(01:50):
PHQ nine actually has a lot ofquestions on the neuro, which
data symptoms.
If you use PHQ nine in anelderly population that has
dementia, then it becomesconfusing because you can get
false positive.
Because as we age, we willactually accumulate a lot of
those neurovegetative symptoms,right?
Decreased energy, problem withsleep, problem with appetite
(02:12):
slowing up our psychomotoractivity.
So we use something called as ageriatric depression scale.
Because geriatric depressionscale focuses more on the
affective symptoms rather thanthe neurovegetative symptoms.
So it's usually scored out of15, anything, five and above is
considered to be positive.
And when you're scoring thegeriatric depression scale, you
(02:33):
have to look at the instructionbecause some of them are scored
in the reverse way.
So this is just a yes and noquestion.
So it's very important actually,what kind of scales you're
using.
Now when you see a patient withdementia who also complain of
depression.
So you have to treat theunderlying depression because if
you don't treat the underlyingdepression, it's going to lead
(02:55):
to a poor prognosis.
It can lead to a rapid declinein the cognitive functioning,
plus it can decrease the qualityof life for the patient as well
as for the caregiver.
Plus it also increases the riskof institutionalization, so it's
extremely important actually todiagnose depression in patients
with dementia and treat itaccordingly to improve the
(03:15):
quality of life.
Okay.
Did I answer the question?
Dr. Amayo (03:19):
So to help differentiate depression from
neurocognitive disorder, you'resaying we should use the
geriatric depression scale whichis a scale that's got out of 15
five and above is positive, andit's also important to treat
depression in this populationcause not using depression, at
least to worse outcomes?
Poor cognitive function, harderfor the caregivers and just
overall poor prognosis.
(03:39):
And then my next question is, Iknow apathy is a significant
problem in this population andsometimes it's hard for me to
differentiate between apathy anddepression.
Why?
Why is that?
Dr. Handratta (03:49):
So apathy is actually a lack of motivation.
It's a lack of motivation forgoal-directed behavior.
For example, goal-directedbehavior is the inability of the
patient to start a conversation.
Doing basic task in life.
So they will have a decreasedmotivation for this
goal-directed behavior.
They'll have decreasedmotivation for goal-directed
(04:10):
cognitive activities like lackof ideas, curiosity, when
they're in a social setup.
And there's also a decrease inthe emotion.
They don't respond to positiveas well as negative events.
So a lot of times family membersactually look at the patient and
say that, Hey, they're notshowing any emotions at all.
Most likely this is depression.
ANd they actually come to theprovider because the main
(04:30):
complaint is that the patient isnot engaging in day-to-day
activities.
So naturally it means that thepatient is depressed.
And a lot of times physiciansget confused and they basically
treat the patient like they havedepression.
Dr. Amayo (04:43):
But, but it is not quite depression, but it's like
depression?
Dr. Handratta (04:46):
Yes.
Because the geriatric depressionscore will be negative in these
patients because they're notdepressed.
They just have a decrease in themotivation to do everything.
Lack that motivation.
Theyll lack that umph,basically.
And we'll talk actually aboutthe areas of the brain that can
get involved.
Dr. Amayo (05:02):
Yeah.
I guess in, and this is specificto this population, so if I get
a 20 year old with apathy-likesymptoms would it matter as much
if I give them an SSRI, if Ijust treat them as depression?
Or does, or do I need to stillworry about is this depression
or is this apathy in thatpopulation?
Dr. Handratta (05:17):
That's a great question.
So younger population, when youuse an SSRI or SNRI especially
SSRI, as you increase the doseof SSRI.
Serotonin and dopamine workagainst each other.
So when you increase theserotonin too much, there's a
neural mechanism that isinvolved: the ventral tegmental
area, which is actually adopaminergic center in the
(05:38):
midbrain.
Yeah.
That usually sends dopaminergicsignals into your nucleus
accumbens.
That's a mesolimbic pathway.
And to your cerebral cortex,that is a mesocortical pathway.
So the meso limbic pathway, thedopaminergic system will be
affected if there's too muchserotonin in the system.
So you can actually induceapathy in a younger population
if you use a very high dose of srri, or they have a polymorphism
(06:01):
in one of their serotoninreceptors in the ventral
tegmental area.
Dr. Amayo (06:04):
So that is why SSRI caused that mutant effect,
that's a side effect of SSRIwhen they feel like everything
is dull and nothing is asexciting.
Okay?
So that's why that happens.
And so in let's, so how can wedifferentiate apathy from
depression in our olderpopulation?
Dr. Handratta (06:19):
So the best way actually to treat a patient in
psychiatry is using scales.
And also the scales help you toknow how you are how the patient
is responding to the treatment,right?
So we know that for thedepression, we use geriatric
depression score scale.
Yep.
For apathy, there's somethingcalled an apathy evaluation
scale, right?
So when a family membercomplains of, like a lack of
(06:44):
motivation.
The patient doesn't do anything,so I, what I do is that I also
introduce the a apathyevaluations scale.
It's out of 72, so the score isbetween 18 to 72.
Higher the score more is theapathy.
Then now apathy and depression.
They can also coexist.
Or they can be two separateentities.
Dr. Amayo (07:02):
Of course, right?
Make my job harder.
Dr. Handratta (07:05):
Now, it's very important to differentiate
between the two because theylook very similar, but the
treatment is very different.
The neural circuitry that isinvolved in depression and the
neuro circuitry involved inapathy are very different.
So one of the problem is that ifyou treat depression, and you
ignore apathy.
Now, suppose that the patienthad apathy, but you misdiagnosed
depression and use an SSRI orSNRI.
(07:27):
seRotonergic Drugs can makeapathy worse.
so when they have apathy, youbasically use a dopaminergic
agent or you use acholinesterase inhibitor.
So research data shows that whenyou use cholinesterase
inhibitor, it increases theactivity in your ventral
striatum.
There's a nucleus accumbens, thereward center of the brain.
So a lot of times when thepatient has Alzheimer's dementia
(07:47):
and you're using acholinesterase inhibitor, it can
help with apathy.
Please don't use cholinesteraseinhibitors in frontal temporal
dementia because apathy is alsoseen in front of temporal
dementia because they have nocholinergic deficit, so you
cannot use a cholinesteraseinhibitor, frontal temporal
dementia.
That is one thing I want peopleto actually take home, you can
use choline inhibitor in othercondition, but not to treat
(08:10):
apathy in patients withfrontotemporal dementia.
Ok.
So patients will have dementia,especially like in patients with
Alzheimer's dementia.
The approximate prevalence rateof apathy in Alzheimer's
dementia is about 80%.
Very high right.
Apathy can also be seen inpatients who have subcortical
dementia, like Parkinson'sdisease, dementia, right?
(08:33):
Or patients with subcorticalstroke can also actually have
apathy.
Dr. Amayo (08:36):
Is there a medication for those patients?
Dr. Handratta (08:38):
The best thing to use is go for a dopaminergic
agent like you can use bupropionor you can use a stimulant.
If there's no cardiaccontraindication or the patient
doesn't have seizures, then youdefinitely can use a stimulant
in elderly population.
Methylphenidate is a preparationthat has been studied for the
treatment of depression as anaugmentation strategy in elderly
(08:58):
patients.
But again, there is no clinicaltrial.
There's no FDA approvedmedication to treat apathy.
Dr. Amayo (09:06):
That makes sense.
Yeah.
Okay.
Lemme see if I get it straight.
Especially in our elderlypopulation, it's significant.
It's important for us todifferentiate between apathy and
depression because sometimes ourcommon antidepressants don't
work if they have apathy, I, wegive them an SSRI or an SNRI can
worsen the apathy And one way tohelp differentiate apathy is
using the apathy evaluationscale.
And then especially in thispopulation cholinesterase
(09:28):
inhibitors for patients with,say, Alzheimer's or a
neurocognitive disorder.
Cholinesterase inhibitors helpswith apathy as well as dopamine
agents like buproprion, and insome cases stimulants however,
for the cholinesteraseinhibitors to be careful with
patients with patient with FTDfrontotemporal dementia do not
have a as it they acetylcholinedysfunction in their pathology.
(09:49):
Is that correct?
Dr. Handratta (09:50):
That's right.
Dr. Amayo (09:51):
So now has me thinking.
It seems like a minefield,pharmacological minefield.
So what pharmacological pitfallshould I be concerned about or
aware of when I'm seeing thispatient?
I'm actually seeing onetomorrow.
So what's steps or what thingsshould I make sure eye I am
watchful for?
Dr. Handratta (10:10):
Got it.
So when you're treating patientswith dementia and they have
depression, How do they haveapathy?
Whatever you are actuallytreating and whatever you are
diagnosed the patient with.
Now the treatment of depression.
Now apathy separate.
Now we are not talking aboutapathy.
The patient suppose that doesn'thave apathy, they just have
depression.
You can use any antidepressantlike the antidepressant you use
(10:33):
in younger patient population,right?
Only thing I want you guys toremember is that start low and
go slow in an elderly patient.
Okay, because the entiremetabolism changes.
It slows down in elderlypatients, plus elderly patients
are also on polypharmacy, so youhave to look at a lot of drug
interactions.
Plus elderly patients will alsohave other medical
(10:55):
comorbidities, right?
Like they can be hypothyroid,they can have liver disease,
they can have kidney problems,they can have cardiovascular
problems, and they can also havehyponatremia.
So you have to look at medicalcomorbidities before you decide
which particular antidepressantyou are going to use.
Dr. Amayo (11:14):
And so if they have apathy or if they have
depression and apathy, still thesame method, use a common
antidepressant, start low.
Go slow.
Dr. Handratta (11:21):
Yeah.
So when they have apathy withdepression, then.
Again, there's no placebocontrol clinical trials, right?
So when there is apathy withdepression, I usually go with
something that is moredopaminergic in nature and
doesn't have the serotonergiceffect to it.
For example, bupropion is not abad choice in this particular
patient population if they haveapathy along with depression, or
(11:44):
you can actually use acholinesterase inhibitor if it's
a patient with Alzheimer'sdementia.
And see if the apathy actuallyimproves.
And once the apathy is improved,you can actually then do a
geriatric depression scale andsee the patient now has
depression.
Okay?
And then treat the depressionaccordingly.
But I'll be very careful withthe serotonergic agent if the
patient actually has apathy.
Apathy, okay?
(12:05):
But at the same time, we alsovery careful with Bupropion and
dopaminergic agent.
If the patient has a psychoticsymptoms, please do not use a
dopaminergic agent.
Okay?
Dr. Amayo (12:18):
That's why, I guess that's why I like this
formulation.
You're considering with that,with those mixtures.
So it seems like overall youwanna verify if they have
depression or apathy or if theyhave both.
Cause that would direct ourtreatment.
So with apathy, lean motor,cholinesterase inhibitors, and
the pulmonary agent.
But be careful if this, if theyhave FTD, Stay away from the
cholinesterase inhibitors ifthey have psychotic symptoms,
(12:40):
stay away from the dopaminergicagents as well.
Dr. Handratta (12:43):
I'll make one more small comment before
Dr. Amayo (12:45):
oh, yeah.
Dr. Handratta (12:45):
So be careful with the antidepressant.
You can use any antidepressant.
All right.
It's, there's nocontraindication for
antidepressants, but be verycareful when you're using
antidepressant that has lot ofcytochrome interaction, like
fluoxetine.
Ok.
Paroxetine.
Fluvoxamine because these arethe three antidepressants, will
interact with a lot ofcytochrome P450 inhibiting it.
(13:06):
So if you don't want to actuallyhave the headaches of looking at
the cytochrome P450 interaction,some of the antidepressants,
which you don't have to worryabout cytochrome interaction are
venlafaxine, desvenlafaxine,escitalopram,mirtazapine so
these are some of theantidepressants that you can use
in elderly patient if you don'twant to think about drug
interaction, right?
(13:28):
But always please make sure thatwhen you're diagnosing a patient
with depression, rule outbipolar disorder.
That is one thing you always dowhen you're evaluating a patient
with depression.
Whether the patient is young orelderly, you have to make sure
they don't have bipolardisorder.
Dr. Amayo (13:43):
So yeah, those two things.
Bipolar disorder and signify ifit's just apathy or apathy and
depression and stay away fromthose medications.
That has a lot of cytochromeinteractions with other
medications.
Thank you.
And that's all we have for the Yin Psychiatry.
Dr. Handratta (13:57):
Thank you guys
Katrina (14:01):
Thank you for joining us on today's episode.
Feel free to tap that ourtireless team is already hard at
work, cobbling together anotherpotpourri of fascinating
discussion for next week, so besure to tune in, visit our
website and our podcast feed andlet us know your thoughts on the
episode.
Subscribe so you don't miss ourreleases every Wednesday.
(14:21):
Until next time, keep smiling,keep shining, and stay curious.
Welcome to the Y in Psychiatry!
Dr. Amayo (00:03):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:06):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:09):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:19):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:43):
Only on The Y in Psychiatry.
Dr. Amayo (00:47):
Welcome back to the Y in psychiatry.
Today we'll be talking aboutdepression and neurocognitive
disorders.
So when I'm seeing a patientwith Parkinson's disease or a
patient with some form ofdementia, I've noticed that it
is hard to tell if they havedepression or their mental
status exam is just acontinuation of their disease
process.
So I guess my question today tois how depression or disease how
can you tell the difference inthis population?
Dr. Handratta (01:07):
So that's a very good question.
A lot of people get confusedbetween depression and dementia,
and patients with dementia canalso have depression.
And you talked about twoseparate population,
Alzheimer's, dementia, andParkinson's disease.
In Parkinson's disease, it'svery difficult actually to say
whether the patient's lack offacial emotion, the mask face.
(01:29):
Is because the disease or thepatient actually has depression.
So one thing that I tell peopleand I like usually tell my
residents, medical student andmy fellows is that the type of
skills that you're going to usewill make a difference.
So in our population who doesn'thave dementia, and in the
younger population we use PHQ9.
(01:50):
PHQ nine actually has a lot ofquestions on the neuro, which
data symptoms.
If you use PHQ nine in anelderly population that has
dementia, then it becomesconfusing because you can get
false positive.
Because as we age, we willactually accumulate a lot of
those neurovegetative symptoms,right?
Decreased energy, problem withsleep, problem with appetite
(02:12):
slowing up our psychomotoractivity.
So we use something called as ageriatric depression scale.
Because geriatric depressionscale focuses more on the
affective symptoms rather thanthe neurovegetative symptoms.
So it's usually scored out of15, anything, five and above is
considered to be positive.
And when you're scoring thegeriatric depression scale, you
(02:33):
have to look at the instructionbecause some of them are scored
in the reverse way.
So this is just a yes and noquestion.
So it's very important actually,what kind of scales you're
using.
Now when you see a patient withdementia who also complain of
depression.
So you have to treat theunderlying depression because if
you don't treat the underlyingdepression, it's going to lead
(02:55):
to a poor prognosis.
It can lead to a rapid declinein the cognitive functioning,
plus it can decrease the qualityof life for the patient as well
as for the caregiver.
Plus it also increases the riskof institutionalization, so it's
extremely important actually todiagnose depression in patients
with dementia and treat itaccordingly to improve the
(03:15):
quality of life.
Okay.
Did I answer the question?
Dr. Amayo (03:19):
So to help differentiate depression from
neurocognitive disorder, you'resaying we should use the
geriatric depression scale whichis a scale that's got out of 15
five and above is positive, andit's also important to treat
depression in this populationcause not using depression, at
least to worse outcomes?
Poor cognitive function, harderfor the caregivers and just
overall poor prognosis.
(03:39):
And then my next question is, Iknow apathy is a significant
problem in this population andsometimes it's hard for me to
differentiate between apathy anddepression.
Why?
Why is that?
Dr. Handratta (03:49):
So apathy is actually a lack of motivation.
It's a lack of motivation forgoal-directed behavior.
For example, goal-directedbehavior is the inability of the
patient to start a conversation.
Doing basic task in life.
So they will have a decreasedmotivation for this
goal-directed behavior.
They'll have decreasedmotivation for goal-directed
(04:10):
cognitive activities like lackof ideas, curiosity, when
they're in a social setup.
And there's also a decrease inthe emotion.
They don't respond to positiveas well as negative events.
So a lot of times family membersactually look at the patient and
say that, Hey, they're notshowing any emotions at all.
Most likely this is depression.
ANd they actually come to theprovider because the main
(04:30):
complaint is that the patient isnot engaging in day-to-day
activities.
So naturally it means that thepatient is depressed.
And a lot of times physiciansget confused and they basically
treat the patient like they havedepression.
Dr. Amayo (04:43):
But, but it is not quite depression, but it's like
depression?
Dr. Handratta (04:46):
Yes.
Because the geriatric depressionscore will be negative in these
patients because they're notdepressed.
They just have a decrease in themotivation to do everything.
Lack that motivation.
Theyll lack that umph,basically.
And we'll talk actually aboutthe areas of the brain that can
get involved.
Dr. Amayo (05:02):
Yeah.
I guess in, and this is specificto this population, so if I get
a 20 year old with apathy-likesymptoms would it matter as much
if I give them an SSRI, if Ijust treat them as depression?
Or does, or do I need to stillworry about is this depression
or is this apathy in thatpopulation?
Dr. Handratta (05:17):
That's a great question.
So younger population, when youuse an SSRI or SNRI especially
SSRI, as you increase the doseof SSRI.
Serotonin and dopamine workagainst each other.
So when you increase theserotonin too much, there's a
neural mechanism that isinvolved: the ventral tegmental
area, which is actually adopaminergic center in the
(05:38):
midbrain.
Yeah.
That usually sends dopaminergicsignals into your nucleus
accumbens.
That's a mesolimbic pathway.
And to your cerebral cortex,that is a mesocortical pathway.
So the meso limbic pathway, thedopaminergic system will be
affected if there's too muchserotonin in the system.
So you can actually induceapathy in a younger population
if you use a very high dose of srri, or they have a polymorphism
(06:01):
in one of their serotoninreceptors in the ventral
tegmental area.
Dr. Amayo (06:04):
So that is why SSRI caused that mutant effect,
that's a side effect of SSRIwhen they feel like everything
is dull and nothing is asexciting.
Okay?
So that's why that happens.
And so in let's, so how can wedifferentiate apathy from
depression in our olderpopulation?
Dr. Handratta (06:19):
So the best way actually to treat a patient in
psychiatry is using scales.
And also the scales help you toknow how you are how the patient
is responding to the treatment,right?
So we know that for thedepression, we use geriatric
depression score scale.
Yep.
For apathy, there's somethingcalled an apathy evaluation
scale, right?
So when a family membercomplains of, like a lack of
(06:44):
motivation.
The patient doesn't do anything,so I, what I do is that I also
introduce the a apathyevaluations scale.
It's out of 72, so the score isbetween 18 to 72.
Higher the score more is theapathy.
Then now apathy and depression.
They can also coexist.
Or they can be two separateentities.
Dr. Amayo (07:02):
Of course, right?
Make my job harder.
Dr. Handratta (07:05):
Now, it's very important to differentiate
between the two because theylook very similar, but the
treatment is very different.
The neural circuitry that isinvolved in depression and the
neuro circuitry involved inapathy are very different.
So one of the problem is that ifyou treat depression, and you
ignore apathy.
Now, suppose that the patienthad apathy, but you misdiagnosed
depression and use an SSRI orSNRI.
(07:27):
seRotonergic Drugs can makeapathy worse.
so when they have apathy, youbasically use a dopaminergic
agent or you use acholinesterase inhibitor.
So research data shows that whenyou use cholinesterase
inhibitor, it increases theactivity in your ventral
striatum.
There's a nucleus accumbens, thereward center of the brain.
So a lot of times when thepatient has Alzheimer's dementia
(07:47):
and you're using acholinesterase inhibitor, it can
help with apathy.
Please don't use cholinesteraseinhibitors in frontal temporal
dementia because apathy is alsoseen in front of temporal
dementia because they have nocholinergic deficit, so you
cannot use a cholinesteraseinhibitor, frontal temporal
dementia.
That is one thing I want peopleto actually take home, you can
use choline inhibitor in othercondition, but not to treat
(08:10):
apathy in patients withfrontotemporal dementia.
Ok.
So patients will have dementia,especially like in patients with
Alzheimer's dementia.
The approximate prevalence rateof apathy in Alzheimer's
dementia is about 80%.
Very high right.
Apathy can also be seen inpatients who have subcortical
dementia, like Parkinson'sdisease, dementia, right?
(08:33):
Or patients with subcorticalstroke can also actually have
apathy.
Dr. Amayo (08:36):
Is there a medication for those patients?
Dr. Handratta (08:38):
The best thing to use is go for a dopaminergic
agent like you can use bupropionor you can use a stimulant.
If there's no cardiaccontraindication or the patient
doesn't have seizures, then youdefinitely can use a stimulant
in elderly population.
Methylphenidate is a preparationthat has been studied for the
treatment of depression as anaugmentation strategy in elderly
(08:58):
patients.
But again, there is no clinicaltrial.
There's no FDA approvedmedication to treat apathy.
Dr. Amayo (09:06):
That makes sense.
Yeah.
Okay.
Lemme see if I get it straight.
Especially in our elderlypopulation, it's significant.
It's important for us todifferentiate between apathy and
depression because sometimes ourcommon antidepressants don't
work if they have apathy, I, wegive them an SSRI or an SNRI can
worsen the apathy And one way tohelp differentiate apathy is
using the apathy evaluationscale.
And then especially in thispopulation cholinesterase
(09:28):
inhibitors for patients with,say, Alzheimer's or a
neurocognitive disorder.
Cholinesterase inhibitors helpswith apathy as well as dopamine
agents like buproprion, and insome cases stimulants however,
for the cholinesteraseinhibitors to be careful with
patients with patient with FTDfrontotemporal dementia do not
have a as it they acetylcholinedysfunction in their pathology.
(09:49):
Is that correct?
Dr. Handratta (09:50):
That's right.
Dr. Amayo (09:51):
So now has me thinking.
It seems like a minefield,pharmacological minefield.
So what pharmacological pitfallshould I be concerned about or
aware of when I'm seeing thispatient?
I'm actually seeing onetomorrow.
So what's steps or what thingsshould I make sure eye I am
watchful for?
Dr. Handratta (10:10):
Got it.
So when you're treating patientswith dementia and they have
depression, How do they haveapathy?
Whatever you are actuallytreating and whatever you are
diagnosed the patient with.
Now the treatment of depression.
Now apathy separate.
Now we are not talking aboutapathy.
The patient suppose that doesn'thave apathy, they just have
depression.
You can use any antidepressantlike the antidepressant you use
(10:33):
in younger patient population,right?
Only thing I want you guys toremember is that start low and
go slow in an elderly patient.
Okay, because the entiremetabolism changes.
It slows down in elderlypatients, plus elderly patients
are also on polypharmacy, so youhave to look at a lot of drug
interactions.
Plus elderly patients will alsohave other medical
(10:55):
comorbidities, right?
Like they can be hypothyroid,they can have liver disease,
they can have kidney problems,they can have cardiovascular
problems, and they can also havehyponatremia.
So you have to look at medicalcomorbidities before you decide
which particular antidepressantyou are going to use.
Dr. Amayo (11:14):
And so if they have apathy or if they have
depression and apathy, still thesame method, use a common
antidepressant, start low.
Go slow.
Dr. Handratta (11:21):
Yeah.
So when they have apathy withdepression, then.
Again, there's no placebocontrol clinical trials, right?
So when there is apathy withdepression, I usually go with
something that is moredopaminergic in nature and
doesn't have the serotonergiceffect to it.
For example, bupropion is not abad choice in this particular
patient population if they haveapathy along with depression, or
(11:44):
you can actually use acholinesterase inhibitor if it's
a patient with Alzheimer'sdementia.
And see if the apathy actuallyimproves.
And once the apathy is improved,you can actually then do a
geriatric depression scale andsee the patient now has
depression.
Okay?
And then treat the depressionaccordingly.
But I'll be very careful withthe serotonergic agent if the
patient actually has apathy.
Apathy, okay?
(12:05):
But at the same time, we alsovery careful with Bupropion and
dopaminergic agent.
If the patient has a psychoticsymptoms, please do not use a
dopaminergic agent.
Okay?
Dr. Amayo (12:18):
That's why, I guess that's why I like this
formulation.
You're considering with that,with those mixtures.
So it seems like overall youwanna verify if they have
depression or apathy or if theyhave both.
Cause that would direct ourtreatment.
So with apathy, lean motor,cholinesterase inhibitors, and
the pulmonary agent.
But be careful if this, if theyhave FTD, Stay away from the
cholinesterase inhibitors ifthey have psychotic symptoms,
(12:40):
stay away from the dopaminergicagents as well.
Dr. Handratta (12:43):
I'll make one more small comment before
Dr. Amayo (12:45):
oh, yeah.
Dr. Handratta (12:45):
So be careful with the antidepressant.
You can use any antidepressant.
All right.
It's, there's nocontraindication for
antidepressants, but be verycareful when you're using
antidepressant that has lot ofcytochrome interaction, like
fluoxetine.
Ok.
Paroxetine.
Fluvoxamine because these arethe three antidepressants, will
interact with a lot ofcytochrome P450 inhibiting it.
(13:06):
So if you don't want to actuallyhave the headaches of looking at
the cytochrome P450 interaction,some of the antidepressants,
which you don't have to worryabout cytochrome interaction are
venlafaxine, desvenlafaxine,escitalopram,mirtazapine so
these are some of theantidepressants that you can use
in elderly patient if you don'twant to think about drug
interaction, right?
(13:28):
But always please make sure thatwhen you're diagnosing a patient
with depression, rule outbipolar disorder.
That is one thing you always dowhen you're evaluating a patient
with depression.
Whether the patient is young orelderly, you have to make sure
they don't have bipolardisorder.
Dr. Amayo (13:43):
So yeah, those two things.
Bipolar disorder and signify ifit's just apathy or apathy and
depression and stay away fromthose medications.
That has a lot of cytochromeinteractions with other
medications.
Thank you.
And that's all we have for the Yin Psychiatry.
Dr. Handratta (13:57):
Thank you guys
Katrina (14:01):
Thank you for joining us on today's episode.
Feel free to tap that ourtireless team is already hard at
work, cobbling together anotherpotpourri of fascinating
discussion for next week, so besure to tune in, visit our
website and our podcast feed andlet us know your thoughts on the
episode.
Subscribe so you don't miss ourreleases every Wednesday.
(14:21):
Until next time, keep smiling,keep shining, and stay curious.
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