Carbidopa

Depression in the elderly is a growing concern and is considered a serious public health problem because it is not a normal consequence of aging. Depression is known to be under-recognized and under-treated, especially in non-psychiatric settings like hospitals, outpatient settings, and nursing homes. Functional and cognitive decline is common with depression and one study revealed Major Depressive Disorder to be an independent factor that increased the risk of death by 59% in the nursing home setting. The prevalence of clinically significant depression in nursing homes ranges from 24% to 50%.1 However, depression remains under diagnosed and under treated in nursing home residents.

People in later stages of life may experience stressful events that put them at higher risk for developing depression. The American Medical Directors Association (AMDA) Clinical Practice Guidelines2 for depression identify risk factors that include:

* Change in environment or new admission to a long term care facility

* Personal or family history of depression or mood disorders

* New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of family member or friend

* History of attempted suicide

* History of psychiatric hospitalization

* Alcohol or substance abuse

* Medical diagnoses such as Alzheimer's disease, Parkinsons disease, certain stroke syndromes, cardiovascular disease and cancer

* Certain medications such as carbidopa/levodopa, beta-adrenergic antagonists, clonidine, benzodiazepines, barbiturates, anticonvulsants, H2 blockers

The AMDA Guidelines also identify signs and symptoms suggestive of depression that are seen in LTC. These include somatic complaints, particularly pain. Other symptoms include:

* Increased or excessive utilization of health services/ resources

* Decreased socialization or attendance at activities

* Apathy or "model patient" behavior

* Combative or resistive behavior

* Delusions

* Paranoia

* Sleep disorders

* Poor appetite or weight loss

Among the recommendations of an expert interdisciplinary panel led by the American Geriatrics Society and the American Association for Geriatric Psychiatry3 are for routine and regular screening for depression in every nursing home resident. The consensus statement outlines numerous approaches for nursing home staff to improve the environment for residents, thus enhancing their independence, sense of well-being, and quality of life.

There is a multitude of screening instruments available to screen for depression. The Geriatric Depression Scale (GDS) was developed in 1983 by Yesavage and Brink to assess depression in geriatric populations. In 1986 the GDS short form (15 questions) was created and has 90% specificity and 80% sensitivity for recognizing depression in hospitalized patient and nursing home residents. For nursing home residents, a two-step approach is often utilized to increase sensitivity and specificity. A Mini-Mental State Exam (MMSE) is administered first to assess cognitive function. Residents with a MMSE of 15 or greater are screened with the GDS. Those residents with a MMSE of less than 15 are screened with a tool appropriate for their degree of cognitive impairment (e.g. Cornell Scale for Depression in Dementia or CSD

In general, pharmacological treatment of depression in older people is similar to that in other adults, but the selection of medications is more complex because of side effects and interactions with other medications for concomitant somatic disorders. Consistent evidence indicates that older patients, even the very old, respond to antidepressant medication. About 60 to 80% of older patients respond to treatment, while the placebo response rate is about 30 to 40%.4 These rates are comparable to those demonstrated in other adult populations. Treatment response is typically defined by a significant reduction-usually 50% or greater-in symptom severity. Nonetheless, because patients 75 years old and older have higher prevalence of medical co morbidity, both they and their physicians are often reluctant to add another medication to an already complex regimen in a frail individual. However, newer antidepressants are less frequently associated with factors contraindicating their use. Moreover, because the very old are also at high risk for adverse medical outcomes of depression and for suicide, treatment may be favored.5

Several forms of psychotherapy are effective for the treatment of late-life depression, including cognitive-behavioral therapy, interpersonal psychotherapy, problem-solving therapy, brief psychotherapy, and psychodynamic psychotherapy. Reminiscence therapy is an intervention developed specifically for older adults on the premise that reflection upon positive and negative past life expetiences enables the individual to overcome feelings of depression and despair. Group therapy has been utilized extensively in geriatric patients in order to facilitate peer identification and to specifically address the common issues faced by this population. Both group and individual formats have been employed successfully in geriatric patients.

Adjunctive psychosocial interventions, such as exercise, recreational therapy, and activities therapy have been utilized to supplement fotmal pharmacologie and psychosocial interventions and may support improved treatment response.

A system-wide interdisciplinary approach is needed that will assist the treating physician to identify signs of depression early and provide appropriate treatment or referral to a mental health specialist. The leadership of the nursing facility must be committed to meeting the needs of the residents at multiple levels, including psychosocial. The complex interaction of physical, mental, social and biological factors associated with depression and the potential devastating outcomes associated with lack of recognition make it imperative for a facility to make the assessment and management of depression an effective process.

REFERENCES

1. National Institute of Mental Health. Overview of Depression [Webpage] 2002; http://www.nimh.nih.gov/publicat/ depression.cfm. (Accessed 8 Jan 2004)

2. American Medical Directors Association. Depression clinical practice guideline. Columbia, MD: AMDA 1996. Currently under revision.

3. American Geriatrics Society and American Association for Geriatric Psychiatry. Consensus statement on improving the quality of mental health care in US nursing homes: Management of depression and behavioral symptoms associated with dementia. JAGS 2003;51; 1287-98.

4. Harman JS, Schulberg HC, Mulsant BH, et al. The effect of patient and visit characteristics on diagnosis of depression in primary czre. J Fam Pract 2001 ;50:1068.

5. Uncapher H, Arean PA. Physicians are less willing to treat suicidal ideation in older patients. JAm Geriatr Soc 2000;48:188-92.

This article has been provided courtesy of the Michigan Quality Improvement Organization.

CORRESPONDENCE:

Gail Patry, RN

Quality Partners of Rhode Island

235 Promenade Street, Suite 500, Providence, RI 02908

Copyright Rhode Island Medical Society Aug 2004
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