Managing Depression in Long-Term Care

Basic Principles & Upcoming Changes

by Barry Jay Kaplan with Steven Levenson, MD, CMD

The AMDA Clinical Practice Guideline on Depression was recently re-evaluated by a steering committee to determine which information works and which sections need updating, according to AMDA's Director of Clinical Affairs, Jacqueline Vance, RNC. The CPG is now undergoing a thorough review, and a preliminary draft of the revision should be ready by early 2003.

This Special Report provides a look at the key points of the current CPG, its implementation in long-term care, and areas that are likely to change.

Is it Depression?

The definition of depression has not changed. The DSM-IV defines major depression as depressed mood or loss of interest or pleasure in previously enjoyed activities, plus five or more of the following symptoms, lasting for two weeks:

• Weight loss or gain.
• Insomnia or hypersomnia.
• Psychomotor retardation (agitation).
• Decreased energy.
• Guilt feelings.
• Inability to concentrate.
• Thoughts of suicide.

In addition, when depression is present, these symptoms produce social impairment and are not related to substance abuse or to bereavement. The many complications inherent in assessing, managing, and preventing depression are further complicated when they occur in the long-term care setting in a geriatric population with its own set of physical, emotional, and environmental variables.

Caregivers must be able to recognize who has depressive symptoms, assess the symptoms, and do a root-cause analysis and diagnosis, so that not only the symptom, but the cause can be treated.

Underlying conditions such as hypothyroidism, cardiovascular disease, pulmonary pathology, anemia, and stroke can all cause depressive symptoms that, if not recognized as such, may lead to profound physical effects.

If someone has had a heart attack, treatment of their post-recovery depression can be as important as treatment of their heart with beta blockers and ACE inhibitors, "and yet we don't pay the same attention to the risk factors of depression," as for heart attacks, observed David Smith, MD, a Professor of Family Medicine at Texas A&M College of Medicine in College Station and President of Geriatric Consultants of Central Texas.

There are several triggers for depression in long-term care, added Charles Cefalu, MD, Professor and Director for Geriatric Program Development, LSU Health Science Center, New Orleans, LA. "In any older patient in long-term care, where you suspect depression there is invariably chronic illness and usually a loss--of a limb, a spouse one, a pet, financial or long-term independence--or the move to a nursing home.

"Sadness is a normal response to change," he continued. "But when the manifestation becomes vegetative symptoms, and is clearly not transitional, and when it goes from normal mood variations to a chronic persistent state that lasts for months, it is depression".

Medication side effects from such drugs as long-acting benzodiazepines, steroids, non-steroidal anti-inflammatories, and antihistamines can manifest as depressive symptoms, Dr. Cefalu cautioned (see box at right). Dr. Smith suggested that digitalis and beta blockers be added to the list of medications with these potential effects, along with cardiac antiarrhythmics, antihypertensive medications, and seizure medications.

Mental status is another possible trigger. "A patient who is chronically confused should be evaluated to see if the confusion is being misdiagnosed as dementia," said Dr. Cefalu. "This is common in Alzheimer's or stroke-related dementia, hypertension, and with diabetes related depressive symptoms."

Although patients in the early stages of Alzheimer's disease may recognize that they are ill and become depressed, it is important to remember that apathy is also common in individuals with dementia, and that apathy--which is a cognitive problem, not a mood problem--is not equivalent to depression. Distinguishing apathy from depression has important treatment implications, because these disorders respond to different interventions (J Am Geriatr Soc 2001;49:1700-1707).

Differential Diagnosis

Assessment of geriatric depression is different from assessing depression in younger people. In older patients, the presentation often is nonspecific--confusion, loss of appetite, anorexia, weight loss, or fatigue. In long-term care residents, as noted earlier, there is apt to be a sense of loss. "Some realize they've lost their independence and understand they're near the end of life. These emotions factor into depression," Ms. Vance said.

But, added Dr. Smith, "in older adults, depression often doesn't look like sadness, and so it is harder to identify than in younger people. This is especially so for people who have cognitive impairment. Because these individuals often can't articulate their feelings, you have to look at changes in their behavior, such as more agitation, more wandering, hitting, biting, and carrying on. It's a complex situation and requires individualization, and that is a problem because of time and staff shortage.

"The question is: who's watching?" Dr. Smith continued. "There is a minimum assessment on admission, and one of the Resident Assessment Protocols is mood state. But physical functions, nutrition, and hydration are clinically linked to depression, so depression should be considered as a cause of changes in status such as weight loss or activity level."

Before concluding that someone is depressed or should be placed on antidepressants, however, it is important to rule out other reasons for these non-specific symptoms, including apathy, lethargy due to medical illnesses, adverse drug reactions, and self-destructive dementia-related behaviors. In addition, episodic sadness or statements of unhappiness such as "I'd rather not be alive" are not necessarily problematic and should not precipitate a rush to treatment (see the June 2002 issue of the American Journal of Geriatric Psychiatry).

Pharmacological Management

Although medications may be the only effective intervention in those with major depression, other approaches may be equally effective in individuals with lesser degrees of the condition. Studies have shown that a significant number of individuals with depressive symptoms may improve with a placebo. Therefore, antidepressants should not be initiated without carefully reviewing the individual's overall situation and risk factors with a physician or another qualified health care practitioner.

When antidepressants are used, it is important to remember that here, too, management is different than in the younger population.

One major difference is that the elderly have many more comorbidities and often take several other medications that can interact with antidepressants to cause serious problems. "We use the same drugs in the young and the old, but the difference is in how the person reacts," said Barbara Resnick, PhD, a Geriatric Nurse Practitioner and Associate Professor at the University of Maryland School of Nursing.

"We have relatively safe antidepressants in low doses so the risk of harm is small, what we call nuisance side effects," added Dr. Cefalu. "The first line treatment is with SSRIs [selective serotonin reuptake inhibitors], although the physician must always be on the lookout for specific contraindications." Although these medications may be comparatively safe by themselves, it is important to remember that potential interactions with cardiac, antihypertensive, and other psychoactive medications including antipsychotics and sedatives/hypnotics may occur.

"We must choose the antidepressants to fit the susceptibility of side effects as well as for efficacy," emphasized Dr. Smith. "Interactions are well known, so it's valuable to have a good clinical pharmacy oversee prescriptions."

Although dosages may ultimately be the same as those given to younger patients, differences in body systems between older and younger patients must be taken into account.

"Fluoxetine works great on kids because it is the longest-lasting SSRI, so even if they skip a dose there'll still have a blood level of the drug," noted Dr. Resnick, who is also a member of Caring's Editorial Board. "But in older people, the drug stays around longer, and we might need to get it out of their systems faster. So in giving antidepressants to older depressed adults, you have to understand the [physiology]."

Age-related factors such as differences in absorption because liver and kidney functions are slowed down, as well as metabolism and response, all enter into the decision-making process.

Will a drug make an individual's losses go away? "No," said William Simonson, PharmD, Chairman of the Board of the American Society of Consultant Pharmacists. "But they can treat the biochemical disorder that causes depression and ameliorate such symptoms as loss of appetite."

Pharmacists perform monthly evaluations in long-term care as a condition of Medicare/Medicaid, said Mr. Simonson. "State surveyors check to make sure medication reviews are performed. Reviews are comprehensive, covering all the medications a patient is taking and ensuring that the documented diagnoses support their use. Reviews also include potential interactions, and note any unnecessary drugs or drugs that are not correctly monitored. This is an ongoing process to optimize pharmacotherapy."

Although treated patients may improve, some of the treatment with medications is overzealous. " We need to slow down," Ms. Vance said. "Patients may appear to have depression but proving it, and distinguishing it from other conditions, may take a more careful assessment. Too often, people want a quick fix."

Direct caregivers may accurately note the depressive symptoms, but not follow through with a more detailed evaluation. "The CPGs are practical, outlining what needs to be done," Ms. Vance added, "but it's often easier to pick up the phone and say: 'depression.'"

Non-Pharmacologic Treatment

Non-drug treatments, including diet, social interaction, counseling, and exercise, are also used to treat geriatric depression.

"Medication is more effective when taken along with exercise," said Dr. Resnick. "Exercise has that 'good feeling' effect. People feel they've accomplished something. They can lift their grocery bags more easily. It can also decrease the stiffness of arthritic pain and can help prevent falls by strengthening muscles."

Electroconvulsive therapy (ECT) is also effective in some depressed older people, especially those who don't respond to medication, and some members of the CPG steering committee believe that the guidelines should take a stronger stance in its favor, Dr. Resnick said.

"If a patient can tell you they're depressed because of a situation, they're not likely to get a response from medication. Rather, they need to learn how to cope with the situation. If they're depressed and say they don't know why, they need drugs because the reason is likely to be chemical. They may also respond to ECT, although it has side effects such as memory loss."

ECT is especially effective in emergency situations for the psychotically distressed, when they have stopped eating or are suicidal, observed Eric Tangalos, MD, CMD, Chairman of the Division of Community Internal Medicine and Director of the Program on Aging at Mayo Clinic in Rochester, MN. "For the elderly, it works well and quickly. The older and sicker the person, the safer it is in comparison to drug therapy, and it's neither dangerous nor experimental."

In the past, treatment with drugs for depressed people with suicidal ideation often resulted in suicide because the person developed more energy, which led more quickly to the suicide, according to Dr. Smith. "With ECT, suicidal thoughts go away first, and energy returns second. Disagreement about ECT comes from the public, who are influenced by the entertainment industry's portrayal of ECT in movies such as One Flew Over the Cuckoo's Nest, where it was used punitively."

ECT works by causing small seizures while the person is asleep, Dr. Smith explained. The length and magnitude of the seizures, as measured by EEG monitoring, are markers of improvement.

ECT and medications affect the brain in a similar fashion, he noted. "Both increase neurotransmitter concentration outside the cell. ECT does it with electricity and drugs do it by preventing the degradation of neurochemicals outside the cell." The only potential drug interaction is with the muscle relaxant used during the procedure.

There are some limitations to ECT use, however. The treatment may work for a while, but it can't be repeated indefinitely, nor will reimbursement cover repeated use of the procedure. It is therefore more likely to be used by a private-pay patient.

"The technique is faster to recovery, overall safer than drugs, and if hospitalization is needed, ECT is cheaper because the hospital stay will be shorter," said Dr. Smith. "In people with dementia, confusion may increase to the point where we must discontinue the treatment, and if anesthesia fails, there are sometimes bitten tongues and broken bones." Deaths during ECT are at the rate of 1 or 2 per 100,000.

Debunking Myths

Some practitioners still believe that depression is a character flaw and that people should just snap out of it. There is also still some sense of shame, emanating from staff, residents, and family, that makes people not accept psychiatric services.

"This is why physicians need to take care of depression," says Dr. Smith. "It's common and we ought to get good at it. We don't have to have psychiatrists see patients and come up against the bias of someone who does not want to accept that they may have mental illness."

There is also the myth that depression in old age is normal. "It's OK to be sad entering a nursing home," said Dr. Cefalu, "but not for the staff to have the attitude that the patient is old and that there is not a lot to do about it."

"The taboo of depression in older adults is as bad as cancer," Dr. Resnick added. "It's generational and if they don't admit it, it's hard to treat. Also, in long-term care, a lot of people will treat their depression with alcohol, which is itself a depressant, so its ameliorative effect doesn't last."

Patients sometimes buy into myths. "They think, 'I'm getting old and that's how it goes,' or 'I've lost all my friends, what can I expect?' or 'It's a weakness of mine. It's my own fault,'" observed Dr. Tangalos, who is also a member of Caring's Editorial Board. "It's all nonsense," he emphasized. "Depression is a disease."

Regulatory Considerations

The AMDA CPGs, Ms. Vance said, do not say much about regulatory issues, such as the MDS (Minimum Data Set) and quality indicators. Certain things about an individual's mood or history of depression that are checked on the MDS may trigger the Resident Assessment Protocol for possible depression. This, in turn, may trigger a quality indicator covering individuals with possible depression who are not receiving antidepressants.

This does not mean it is a requirement to treat everyone who has possible depression with antidepressants. However, facility staff should be able to explain, and should document, why they believed that the individual was not depressed or was depressed but did not need an antidepressant.

It is also recommended that staff clarify each individual's psychosocial history, and consider simple, low-risk interventions that often can improve a person's mood.

"Sometimes people are naturally gloomy and don't need medication," Ms. Vance said. "The social worker should have one-on-one conversations with patients. When people are adjusting to new situations, they need to be able to express themselves, and have the opportunity to bring things from home that are familiar and comforting."

She recalled a patient some years ago who manifested depressive symptoms. "One of the nurses wanted to call in a physician because the patient was depressed. It turned out that he missed his lounge chair. We brought it to his room and he felt as though he had some control over his surroundings and his life."

Conclusion

The DSM-IV is still the way to look at the situation to verify the presence of depression, said Dr. Tangalos, adding that the revised CPG should focus on making sure people are not undertreated.

"The revised guidelines should stress lengthening the time for antidepressant treatment even in the first bout and especially after the second. After the third bout, treatment should be lifelong. We taught people to go slow and stay low in terms of dosage. Slow may still be appropriate, but not dosages that are subtherapeutic," he said.

However, there should also be awareness that antidepressants can cause complications and that their use is not risk free, and that non-drug treatments are also available.

In addition, the revised CPGs should stress the importance of depression recognition, said Ms. Vance. "The current guidelines are effective, but more vigorous efforts at identifying depression in nursing home residents are required," she concluded.

Medical journalist Barry Jay Kaplan is a Contributing Writer to Caring. Steven Levenson, MD, CMD, is Chair of Caring's Editorial Board.

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