Depression is common in elderly patients, especially among those with medical illness and in institutional settings. Yet diagnosis of depression can be a challenge. Often patients do not experience sadness or report depression to their physicians. In older patients, somatic symptoms associated with depression are common, but can easily be attributed to medical illness, which is often present. In the nursing home it is often the staff or family who note a change in the patient. Common behaviors observed are loss of interest, change in appetite, or increased irritability. Depression, when present, can interfere with functioning. Decrements in personal hygiene and gait have been associated with depression. Depression can increase mortality associated with medical illness. When depressed elderly are admitted to a nursing home they are more likely to die than their nondepressed peers. Only a few studies have examined treatment of the most frail patients, namely those in nursing homes. Katz et al performed the first placebo-controlled study finding nortriptyline (Pamelor) was effective. But only about 20% of those screened could participate in the study. Recently a study of paroxetine (Paxil) has been completed in nursing home patients with mild depression, finding no advantage over placebo. A large open study of mirtazapine (Remeron SolTab) has recently been completed. One hundred nineteen patients (mean age 82.9) were recruited at 30 nursing home sites. Patients were treated for 12 weeks with mirtazapine orally disintegrating tablets, starting with 15 mg/d and advancing to a mean dose of 19.4 mg/d. Response on the CGI scale was 54% at 12 weeks. The overall discontinuation rate was 34.7%, while the dropout rate for adverse events was 11.3%. Adverse events in > 10% of patients included urinary tract infection, upper respiratory infection, somnolence, fall, and accidental injury. The rate of falls was similar to that observed in other nursing home studies. These studies also raise issues of interest to the clinician in terms of how to monitor depression in the nursing home setting. Improved care of the frail elderly is critical because few treatments in medicine more directly affect the quality of life of our older patients than treatment of depression.
Objectives 1) Recognize the symptoms of depression in older nursing home patients 2) Be familiar with the evidence for treatment of depression in long term-care 3) Be able to treat depression in nursing home patients
References Nelson JC. Diagnosis and treatment of major depression. In: Nelson JC, ed. Geriatric Psychopharmacology. New York, NY: Marcel Dekker; 1997.
Katz I, et al. J Clin Psychiatry. 1990;51(suppl 7):41-48.
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