At times depression among elderly is often confused with dementia. 18. I would like to thank Dr Martha Donnelly for her encouragement and support in the preparation of this manuscript. Besides these, benzodiazepines are often prescribed as adjunctive treatment during the initial phase of treatment. Yes/No, Do you think it is wonderful to be alive now? Geriatric mental health therapy is focused on the psychological and emotional needs of individuals over the age of 60. [1] Epidemiology However, it is important to note that these are screening questionnaires/scales, and detailed interview will be required for confirming the diagnosis. The Cochrane Database of Systematic Reviews, 14(11), 147. 6. In many elderly patients psychosocial issues like social isolation, neglect by the family etc contribute to the onset and or continuation of depression. Accordingly, short-acting agents should be tapered more slowly. Nonetheless, in recent years there is an increasing body of literature specific to the elderly (as referenced below), which helps guide the clinician in the appropriate prescription and use of antidepressants in this patient population. If feasible, standard scales may be used to record these dysfunctions. A prospective 12 year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Accessed 24 September 2010.www.ccsmh.ca/en/guidelinesUsers.cfm. Health Canada advises consumers about important safety information on atypical antipsychotic drugs and dementia [press release 15 June 2005]. She is also a psychiatrist with the UBC Hospital Mood Disorders Centre, and the Geriatric Psychiatry Outreach Team at Vancouver General Hospital. Depression is elderly is also often associated with use of certain medications (Table-5). Am J Psychiatry 2004;161:2050-2059. Geriatric depression is often accompanied by anxiety symptoms and/or insomnia. Electroconvulsive therapy (ECT) is recommended as a first-line treatment for psychotic depression in the elderly,[17] with a recovery rate of over 80% and a faster and fuller response compared to medication. However, it is also important to consider all the contributing factors towards the depressive symptoms (e.g., medical causes) to avoid use of unnecessary medications. Continuation and maintenance treatment for depression in older people. Available data suggest that in elderly patients with mild to moderate depression, psychotherapeutic interventions are as effective as antidepressants. Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder. A systematic approach to pharmacotherapy for geriatric major depression. %PDF-1.5 It addresses three developmental cohorts: At baseline, these need to be noted and subsequently monitored. Many medical conditions seen in the elderly, such as dementia, Parkinson disease, and cardiovascular problems can be worsened by a tricyclic antidepressant. There is no evidence of an increase in suicidal ideation due to antidepressant use in the elderly.[21]. <> In term of augmentation strategies, although it has not been evaluated thoroughly, lithium is usually recommended as the first choice. These symptoms must be present for at least 2 weeks for considering the diagnosis of depression among patients with definite diagnosis of Alzheimer's disease as per the DSM-IV criteria. Accordingly efforts must be made to improve the social support of the patient. The therapist then reviews the interpersonal skills (specifically, perspective-taking and effective communication) that the patient has learned and emphasizes use of these skills outside of the office. Below is the complete list of questions found in the short form GDS: Choose the best answer for how you have felt over the past week. Vancouver Group. JjYXGrQ& PUE@#u$cA{z4# This is an excellent and comprehensive article about mental health and its treatments. Upon initially being prescribed medication, the patient will likely see the prescriber at least a few times within the first eight weeks to check whether he/she is taking the medication as prescribed, as well as to determine whether the dose is optimal and whether the patient is experiencing any adverse side effects. Suicide risk assessment. Int J Geriatr Psychiatry 2009;24:556-562. The available treatment options for management of depression can be broadly categorised into antidepressants, somatic treatments and psychosocial interventions. In 1983, Dr. Yesavage J. Like the GDS-30, you will answer all 15 questions and tally up the total score. Management of depression is an ongoing process, which requires continuous assessment of course of symptoms and acceptability of treatment. Psychological Medicine, 42(6), 1163-1173. https://doi.org/10.1017/S0033291711002042. Current version of the CPGs is an update of the earlier version of CPGs for management of depression in elderly. Previous depression. However, some of the authors consider this terminology to be irrelevant to significant proportion of the elderly patients in whom overall medical burden contributes to their depression. https://www.simonandschuster.com/books/Where-To-Go-From-Here/Linda-M-Feldman/9781476728315, Campbell, R., & Svensson, C. (2015). Yoga an also be done sitting. 28. Electroconvulsive therapy in old-old patients. They may present with chronic unexplained physical symptoms, cognitive symptoms, change in behaviour, anxiety and worries, irritability and dysphoria, etc. Scales can also be used to rate the severity of depression among elderly. Yes/No, Do you frequently worry about the future? Personality type (e.g., relationship or dependence problems). Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in 17. IPT conceptualizes depression as consisting of three components: While IPT is not expected to have an impact on personality due to the short treatment duration, the interpersonal communication skills attained in treatment may mitigate the impact of ones personality difficulties on his/her relationships. Adding, changing, or increasing the intensity of psychotherapy may be considered for patients who do not respond to medication treatment. YES / NO, Are you in good spirits most of the time? Antidepressant pharmacotherapy in the treatment of depression in the very old: A randomized, placebo-controlled trial. In case inpatient care facilities are not available, then the patient and/or family must be informed about such a need and admission in nearest available inpatient facility can be facilitated. Reappraisal of the treatment regimen also includes evaluation of patient adherence and pharmacokinetic/pharmacodynamic factors. Clinical handbook of psychological disorders (4th ed., pp. j-t4+Teb?e"[j^]p8[ 4A6SS)*#8'. According to a Statistics Canada report in 2005, the suicide rate for elderly men is almost twice that of the nation as a whole.6 Effectively lethal self-harm behaviors increase with age, with the most common means of suicide in older men being firearms and hanging, and in older women being self-poisoning and hanging.[6]. While assessing depression among elderly, it is important to remember that although many elderly have depressive symptoms, they do not fulfil the criteria of major depression. Reminiscence/life review therapy for depression. Acog Guidelines For Treatment Of Depression In PregnancyDepression is a common illness that can be mild or very serious. If the decision is made to discontinue or terminate psychotherapy in the maintenance phase, it needs to be individualized as per the patient's needs. Efficacy of antidepressants for late-life depression: a meta-analysis and meta-regression of placebo-controlled randomized trials. If there is significant improvement but not full remission after 4 weeks on the optimized antidepressant, the recommendation is to wait another 4 weeks and then consider add-on treatment if remission is still not achieved. Tricyclic antidepressants are lethal in overdose and are avoided for this reason. For some patients, maintenance treatment may be required indefinitely. Patients who have had their dose increased, should be monitored for an increase in the severity of side effects or emergence of newer side effects. Among the various scales, GDS is the most well validated scale for use in elderly with intact cognitive functions. The short form of the GDS is more appropriate for older adults who are physically ill and individuals with mild to moderate dementia. Accordingly, the clinicians can use ready reckoner or online drug interaction calculators to evaluate for the possible drug interactions. We are experimenting with display styles that make it easier to read articles in PMC. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. If you answered yes to question 2, you would give yourself another point. [17], ECT is a relatively safe, well-tolerated, and effective treatment for depression. Other factors which also influence the frequency of psychotherapy sessions include severity of illness, the patient's cooperation with treatment, the availability of social supports, cost, geographic accessibility, and presence of comorbid general medical problems. [1] Add-on options include either an antidepressant of a different class, another agent such as lithium, or psychotherapy such as cognitive-behavioral therapy or interpersonal therapy. While switching to a second antidepressant, clinicians should remember that there is some evidence to suggest that venlafaxine may be useful in patients, who don't respond to initial pharmacotherapy. Roose SP, Sackeim HA, Krishnan KR, et al. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary . Caregiving responsibilities for person with a major disease (e.g., dementia). In choosing an antidepressant it is recommended that selection be based on the best side effect profile and lowest risk of drug-drug interactions. In presence of comorbid physical illnesses, the usual starting dose in an elderly may be one-fourth of the adult dose. For other patients, such as those in whom active psychotherapy is being conducted, the frequency required may be as high as multiple times a week. National Institute for Health and Clinical Excellence (NICE), Depression: management of depression in primary and secondary care (Clinical guideline 23). However, it is important to remember that DSM-5 has not incorporated this entity in its classificatory system. 11. The term Treatment resistant depression (TRD) is usually used, when the depression fails to respond to two adequate trials of antidepressant medications. The current Canadian practice guidelines for the treatment of depression in the elderly were developed by the Canadian Coalition for Seniors Mental Health (CCSMH) in 2006. Following any revision or refinement of treatment, the patient should continue to be closely monitored. Switching to a different antidepressant medication is a common strategy for treatment-refractory patients, especially those who have not shown at least partial response to the initial medication regimen. SSRIs considered to have the best safety profile in the elderly are citalopram, escitalopram, and sertraline. Development and validation of a geriatric depression screening scale: a preliminary report. Recommendations are based on a systematic review of the scientific evidence, a weighing of the benefits and harms of interventions, consideration of what is known about patient values and preferences, and consideration of the applicability of the evidence across demographic . Because of this, some clinicians prefer to use the GDS-30 in their clinical practice. Int J Clin Pract 2007;61:1283-1293. Psychoeducation need to address the issues of knowledge about the illness, available treatment options, time to response, side effects with medications, need for medication and treatment adherence, providing information about the course and outcome, impact of stressors on the course of illness, improving adaptive coping skills, risk of relapse and identification of early signs of relapse, address stigma and encourage maintenance of healthy life style. APA's Clinical Practice Guideline recommends three . Older adults are often in a stage of life when they reflect on the life lived and whether they achieved what they desired. Kok RM, Nolen WA, Heeren TJ. Widowed or divorced status. [26], In an open-label trial of risperidone augmentation of patients who had failed to remit on a previous antidepressant, most patients reached remission, although when a placebo arm was introduced there was a nonsignificant delay in the time until relapse for the risperidone group versus the control group.[27]. Depression is a true and treatable medical condition, not a normal part of aging. IPS also published revised CPGs for management of depression in adult patients in the year 2017. Selective serotonin reuptake inhibitors (SSRIs) are regarded as the treatments of choice for first line management of elderly depressed patients [30,31,32,33,34]. Remission in depressed geriatric primary care patients: a report from the PROSPECT study. Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants. If maintenance phase treatment is not indicated for patients who remain stable following the continuation phase, patients may be considered for discontinuation of treatment. J Clin Psychol 1994;50:256-260. Psychotherapies that meet criteria as evidence-based treatments for geriatric depression include CBT, behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and reminiscence therapy. Accessed 22 October 2010.www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2005/2005_63-eng.php. [14] Also, antidepressants have similar efficacy when used to treat elderly patients with and without multiple medical comorbidities. CBT can teach people how to differentiate between their thoughts and feelings and regulate their feelings by questioning their assumptions and beliefs. The information below about the recommended interventions is intended to provide clinicians with a basic understanding of the specific treatment approach. The commonly reported side effects of ECT include an increased risk of falls, post-ECT delirium or dementia. Yes/No, Do you have trouble concentrating? Patients who do not respond to the first line treatments may require use of lithium and thyroid supplements as augmenting agents. Over the years it is increasingly understood that there is no absolute contraindication for ECT. Now I am elderly, and my experience has been that many psychiatrists do not take this into consideration, especially with prescribing medicine. 19. Yes/No, Are you bothered by thoughts you can t get out of your head? The functionality is limited to basic scrolling. If no new information emerges which can explain the patient's inadequate response, depending on the severity of depression, ECT may be considered. If there is no significant improvement after 2 to 4 weeks on an average therapeutic dose, further increases should be made until there is either a clinical improvement, intolerable side effects, or the maximum suggested dose is reached. Dosing However, it is unclear whether depression without sadness is an idiopathic depression, a depression secondary to medical illness, or a non-affective syndrome related to chronic medical disease. Neuropsychopharmacology 2006;31:178-181. When using antidepressant medication to treat the elderly, it is important to be aware that older adults have response rates similar to those of younger adults. All patients and their caregivers need to be educated about symptoms of depression, available treatment modality, course of disorder and time to response to treatment. Education regarding available treatment options will help patients make informed decisions, anticipate side effects and adhere to treatments. Grover S, Malhotra N. Depression in elderly: A review of Indian research. When used, these must be used for shortest possible duration and the patients and the caregivers must be informed about the anticipated side effects and risks of over-sedation. in Medical Journals, visit www.icmje.org. Cole MG, Elie LM, McCusker J, et al. Below is the complete list of questions found in the GDS-30 (30-item questionnaire): Choose the best answer for how you felt over the past week. Limitations of the geriatric depression scale Second-generation antidepressants (selective serotonin reuptake inhibitors SSRIs, serotonin-norepinephrine reuptake inhibitors SNRIs or norepinephrine/dopamine reuptake inhibitors NDRIs) are recommended for older adults due to the reduced risk of side effects and safety in the event of overdose. It has been reported that women more often report mood-related symptoms when compared to men. http://guidedlifestories.com/books/guided-life-stories/, Korte, J., Bohlmeijer, E.T., Cappeliez, P., Smit, F., & Westerhof, G.J. The MRI findings in such patients include loss of brain volume and loss of white matter integrity. If the patient has severe, persistent or recurrent non-adherence with treatment, than there may be a need to evaluate the psychological conflicts or psychopathology which may be contributing to the non-adherence. Medical Journals. Accessed 22 October 2010.http://onlinelibrary.wiley.com.ezproxy.library.ubc.ca/doi/10.1002/gps.2564/full. c) Dance . Writing your legacy: The step-by-step guide to crafting your life story. International Committee of Medical Journal Editors (ICMJE), which meets annually. Biol Psychiatry 1988;23:271-284. Features that suggest that medications may be the preferred treatment modality include history of previous response to antidepressants, severity of symptoms, presence of marked sleep and appetite disturbances or agitation, or anticipation of the need for maintenance therapy. Two-year follow-up of elderly patients with mixed depression and dementia. Project ADAPT--Assuring Depression Assessment and Proactive Treatment--utilized existing primary care resources to overcome barriers to sustainability experienced by similar projects. There is also a black box warning on atypical antipsychotics because of their association with an increased risk of death, largely due to cerebrovascular events, among elderly demented patients compared with placebo. Grover S, Somaiya M. ECT in the Elderly: A Review. In any group of elderly people undergoing valve implementation or surgical aortic valve replacement, one in three will have depressive symptoms. If your responses match the depression-related answers, you will score one point for each. Geriatric AcademyAll Rights Reserved. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. However, the CANMAT recommendations are based on studies of younger adults and are not intended for the elderly. This comprehensive review allows the therapist to identify and work with one of the four problems areas focusing on specific themes that are commonly noted in older adults with depression: In the middle stages of treatment, the therapist and patient identify strategies to ameliorate the chosen problem area and improve the patients relationships, with the goal of reducing depressive symptoms. Stopping some medications suddenly (particularly venlafaxine and paroxetine) can lead to a withdrawal syndrome that includes anxiety, insomnia, and flu-like symptoms. On average, older adults receive 16 to 20 weekly sessions of IPT. Most importantly, a more comprehensive assessment of depression should be made for suicidality. Instead, the goal should be to increase the dose regularly as tolerated at 1- to 2-week intervals in order to reach an average therapeutic dose more quickly,[20] with the CCSMH guidelines suggesting therapeutic dosing be reached within a month. I would like to be able to send you an e-mail. [13] A full assessment for depression in the elderly includes the following: Review of diagnostic criteria according to DSM-IV-TR. These include exclusive approach, substitutive approach, best estimate approach and inclusive approach. The delayed clinical response to antidepressants makes it difficult to establish the optimal dose quickly. Management in some of these difficult situations is summarized in table-16. Formulation of treatment plan involves deciding about treatment setting, medications to be prescribed and psychological interventions to be used (Figure-1). An awareness of risk factors for depression in the elderly can guide screening. It is normal for our blood sugar (glucose) levels to rise and fall throughout the day and night. by Kobi Nathan, Pharm.D., M.Ed., CDP, BCGP, AGSF | Brain and Heart Health, Mental Health & Neurology. The aims of this study were as follows: 1. to evaluate the impact of health-related quality of life on depressive symptoms in elderly patients undergoing TAVI, and 2. to analyze beliefs about . Depression in elderly is also known as late life depression, which is further understood as late onset depression and early onset depression. 23. If at least moderate improvement is not observed following 48 weeks of pharmacotherapy, a thorough review must be done for re-evaluation of diagnosis, treatment adherence and pharmacokinetic/pharmacodynamic factors which may be affecting treatment. While using psychotherapy, the frequency of sessions must be guided by type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicidality. A small proportion of elderly patients who are prescribed antidepressants may go on to develop hyponatremia. Guiding autobiography groups for older adults: Exploring the fabric of life. Diagnostic and statistical manual of mental disorders. Brain changes due to vascular problems. Data from India reveals a wide variation in the prevalence rate of depression. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. The risk factor for suicide among elderly and those with depression include older age, male gender, severe anxiety, panic attacks, living alone, severe depression, bereavement (especially in men) and presence of comorbid alcohol misuse, physical pain and history of suicide attempts in the past. The long-form uses an 11-point cutoff and the short-form uses a 7-point cutoff. You can read my article on the causes, symptoms, types, and treatment of dementia here. This guideline is intended to provide recommendations for the treatment of depressive disor-ders (including major depression, subsyndromal depression, and persistent depressive disor-der.
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