- Is increasing sadness a part of normal aging?
Increasing sadness is not a part of normal aging. However, all health care workers in the long-term care setting should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. It has been estimated that between 12 percent and 16 percent of older adults living in long-term care facilities have major depression, 50 percent may have a minor depressive disorder, and up to 70 percent may at one time experience depressed, sad, or blue mood. Additionally, in the elderly, depression with medical comorbidity is the norm rather than the exception. Depression is known to increase disability and mortality and increase use of health care services.
- What are some tools used to screen patients for depression?
Depression screening tools include Geriatric Depression Scale (GDS); Cornell Scale for Depression in Dementia (CSDD); Center for Epidemiologic Studies of Depression Scale (CED-D); and Patient Health Questionnaire 9 (PHQ 9).
- What are the criteria for a diagnosis of major depression?
If at least five of the following symptoms are present for at least 2 weeks and if the patient has no history of a prior manic episode, major depression is likely to be a correct diagnosis: weight loss or gain, insomnia or hypersomnia, psychomotor retardation (agitation), decreased energy, guilt feelings, inability to concentrate, and thoughts of death or suicide (life not worth living).
- Why is it important to recognize patients with minor depression?
It is important to recognize these patients because evidence suggests that some patients with minor depression and its functional and social consequences may benefit from some of the same kinds of interventions that are helpful for patients with major depression.
Treatment for depression is effective, even in the frail elderly. Practitioners and caregivers in the long-term care setting should address depression because this condition adversely affects the patient's ability to achieve his or her highest practicable level of well-being and because untreated depression is associated with increased morbidity and mortality.
- What are two key depressive symptoms in the elderly population?
The two depressive symptoms in the elderly population are depressed mood and thoughts of death or suicide. A patient may feel sad or frequently feel like crying or he or she may express the idea that life is not worth living. These symptoms should be heavily weighted when making a diagnosis.
- When should referral to a geriatric psychiatric unit or consultation with a psychiatrist who has expertise in the care of older adults be considered?
If the patient is psychotic, severely agitated, aggressive (i.e., potentially dangerous to self or others), neurovegetative, or suicidal, referral to a geriatric psychiatric unit or consultation with a psychiatrist who has expertise in the care of older adults may be considered. Serious grief or bereavement issues and psychiatric disorders other than depression may complicate a depressive episode. Other complicating behavioral comorbidities may include alcohol dependency, substance abuse, and dementia. A consultant with specific expertise in the psychiatric disorders of older adults may be helpful in evaluating the patient for complications of depression.
- Is electroconvulsive therapy (ECT) safe and effective in older adults?
ECT is both safe and effective in older adults and this technique may be considered when a rapid response is desired. ECT should be considered if the patient's condition is rapidly deteriorating or if antidepressant medication is not tolerated or has failed. However, it need not be reserved for cases of depression-associated psychosis, rapid deterioration, high suicide risk, or failed pharmacotherapy. ECT should be conducted only in an appropriately equipped setting under the supervision of an experienced psychiatrist and anesthesiologist.
- Is it true that older patients in general respond more slowly to antidepressant treatment and that it takes at least 12 weeks to identify nonresponders?
Beliefs that older patients in general respond more slowly to antidepressant treatment and that it takes at least 12 weeks to identify nonresponders are unsubstantiated. Another common belief is that a lower starting dose and slower dose escalation will improve drug tolerability in geriatric patients. The "start low, go slow" paradigm evolved when tricyclic antidepressants (TCAs) were the primary pharmacologic treatment for depression. Evidence does not support slow dose-escalation of TCAs to minimize side effects. Furthermore, the "start low, go slow" strategy is essentially untested for the selective serotonin reuptake inhibitors (SSRIs). Nevertheless, doses should be increased gradually.
- How long does it take to see an appreciable response to an antidepressant medication?
It may take several weeks to see an appreciable response to an antidepressant medication. The practitioner should assess the patient's response within 2 weeks of initiating therapy. Informed decisions about changing or continuing treatment may be made after 4 weeks and again after 6 weeks.
- Do older patients have an increased sensitivity to pharmacologic therapy then younger patients?
Older patients in general are more sensitive than younger adults to the adverse effects of antidepressant medications. However, to obtain a therapeutic response, older patients require drug concentrations similar to those that generally produce a therapeutic response in younger patients.
- Are any class of antidepressants more effective than the others?
No single class of antidepressant has been found to be more effective than another in the acute treatment of late-life depression. TCAs, SSRIs, and selective noradrenergic reuptake inhibitors (SNRIs) are all effective.
Following the era of TCAs, SSRIs quickly became the preferred agents because of their safety profile: relatively high tolerability, relatively low incidence of adverse events, and lower potential for drug-drug interactions. Be aware, however, that, although members of the SSRI class vary in their side-effect profiles, all have been associated with anxiety, insomnia, sexual dysfunction, weight loss, gastrointestinal side effects, dizziness, and other problematic side effects. SSRIs should be used with extreme caution in cachetic, malnourished elderly patients.
- What are some contraindications to specific antidepressants?
Absolute contraindications to specific antidepressants include: allergy to the antidepressant; nefazodone in combination with cisapride; and bupropion for a patient with seizures.
Relative contraindications to specific antidepressants include: tricyclic antidepressant for a patient with symptomatic benign prostatic hyperplasia, troublesome constipation, symptomatic or unstable ischemic heart disease, or orthostatic hypotension; trazodone for a patient with orthostatic hypotension; and SSRI for a patient with anorexia and significant weight loss. Venlafaxine may increase blood pressure, particularly at higher doses.
- What are the consequences of the drug selection for the facility?
If the facility uses a drug formulary, the practitioner should be familiar with the antidepressants on the formulary (including available strengths for titration and available forms of the drug [e.g., liquid, slow-release]). However, if no medication on the formulary is considered appropriate, steps should be taken to obtain a non-formulary item. Electrocardiogram and laboratory services should be utilized as indicated to monitor for antidepressant side effects. Facility staff should be capable of monitoring both medication efficacy and side effects.
- How long should the patient remain on antidepressant therapy once the goals of therapy have been met or remission has been achieved, provided the patient is not experiencing intolerable side effects?
For a first episode of major depression, recommendations for the duration of antidepressant pharmacotherapy range from 6 months to 1 year. Most members of an expert consensus panel on depression pharmacotherapy agreed that for a patient who has experienced two depressive episodes, the optimal duration of treatment is 2 to 3 years. For a patient who has experienced three depressive episodes, most panel members recommended treatment for more than 3 years. Some elderly patients with recurrent depression may need pharmacotherapy for an indefinite period.