Description
Apply information from the Aquifer Case Study to answer the following discussion questions:Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not? Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up
Unformatted Attachment Preview
Family Medicine 03: 65-year-old female with insomnia
User: ARIADNA ZARZUELA
Email: ariadna.zarzuela@stu.southuniversity.edu
Date: October 9, 2023 2:40 PM
Learning Objectives
The student should be able to:
Summarize the key features of a patient presenting with depression capturing the information essential for differentiating between the common
and “don’t miss” etiologies.
Describe the initial management of patients who present with insomnia.
Interpret information from a patient history and examination to determine that depression is the most likely diagnosis.
Describe common effects and side effects of antidepressant medications.
Describe the initial management of depression including therapy and pharmaceutical options.
Describe the initial management of common diagnoses that present with dementia.
Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with insomnia in
the elderly.
Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with depression.
Describe the initial management of patients who present with depression.
Discuss depression in the context of culture and social determinants of health.
Discuss who should be screened for elder abuse depending on gender, age, and risk.
Communicate respectfully with a patient who does not fully adhere to their treatment plan for depression.
Elicit a focused history that includes information about self-management of depression.
Elicit a focused history that includes information about self-management of insomnia.
Give examples of health care disparities.
Knowledge
Common Causes of Insomnia in the Elderly
1. Issues that may lead to an environment that is not conducive to sleep .
Specific examples include: noise or uncomfortable bedding.
You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night’s sleep.
2. The use of prescription, over-the-counter, alternative, and recreational drugs might affect sleep.
Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
3. Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.
Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may
report loud snoring or cessation of breathing during sleep.
4. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
5. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and
during sleep respectively.
As with sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these
movements.
6. Disturbances in the sleep-wake cycle include jet lag and shift work.
7. Patients with depression and anxiety commonly present with insomnia.
Any patient presenting with insomnia should be screened for these disorders.
8. Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
9. Pain or pruritus may keep patients awake at night.
10. Those with GERD may report heartburn, throat pain, or breathing problems.
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These patients may also have trouble identifying what awakens them.
Detailed questioning may be needed to elicit the symptoms of this disorder.
11. Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies
may be required to detect this problem.
12. Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS) , this has
progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours,
waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be
difficult to distinguish from insomnia.
Good Sleep Hygiene
Your Personal Habits
Fix a bedtime and an awakening time. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if
you are retired or not working, this is an essential component of good sleeping habits.
Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late
afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you
limit the nap to 30 to 45 minutes and can sleep well at night.
Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate
sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.
Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as
chocolate, so be careful.
Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.
Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise
within two hours before bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem,
and make appropriate changes.
Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can
keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.
Block out all distracting noise, and eliminate as much light as possible.
Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is
associated with sleeping.
Getting Ready For Bed
Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.
Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety
and reduce muscle tension.
Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it
useful to assign a “worry period” during the evening or late afternoon to deal with these issues.
Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until
sleepy.
Turn off all electronic devices at least 30 minutes before bedtime. The artificial light generated by a laptop, tablet, or cell phone
screen can interfere with your body’s sleepiness cues.
Getting Up in the Middle of the Night
Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to
sleep within 15 to 20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack,
do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or
engaging activities such as office work, housework, etc. Do not watch television.
Risk Factors for Completed Suicide
Sex: The person most likely to succeed in a suicidal attempt is an adult male. While females are more likely to attempt suicide, males are more likely
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to complete one.
Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age .
Elderly persons attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status to be poor, experience
poor sleep quality, lack a confidante, and experience stressful life events.
Importantly, approximately 75% of elderly persons who commit suicide had visited a primary care physician within the preceding month, but
their symptoms were not recognized or treated, underscoring that physicians must be tuned in to the signs and symptoms of depression and
risks for suicide. Drug overdose is the most common means of suicide in the elderly, making the safety of medications chosen to treat the
condition important.
Previous attempts: Having previously attempted suicide is a risk factor for completed suicide.
Military Service: The suicide rate of military veterans in the United States is higher than that of the general population.
Poverty by itself has not been found to be a risk factor for completed suicide, though it can contribute to psychosocial stress and the development of
depressive symptoms.
Major Depression Diagnostic Criteria
For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.
A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.
Depressed Mood
(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):
Sleep: Insomnia or hypersomnia nearly every day.
Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.
Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt
about being sick).
Energy (decreased): Fatigue or loss of energy nearly every day.
Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or
as observed by others).
Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a
month).
Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness
or being slowed down).
Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
Major Depressive Disorder versus Bereavement
The presence of certain symptoms that are not characteristic of a “normal” grief reaction may be helpful in differentiating bereavement from a Major
Depressive Episode. The table below adapted from the DSM V discusses some potential differences:
Major Depressive Episode
Bereavement (Grief)
Persistent depressed mood and inability to anticipate
happiness or pleasure
Feelings of emptiness and loss
Depression persistent, not tied to specific thoughts or
preoccupations
Depressed feelings often decrease in intensity over days to weeks and occur in
waves, associated with thoughts of the deceased
Pervasive unhappiness and misery
Grief may be accompanied by positive emotions and humor
Self-critical or pessimistic ruminations
Preoccupation with thoughts and memories of the deceased
Feelings of worthlessness and self-loathing
Self-esteem is generally preserved. May be self-deprecating—feeling they should
have done more or told the deceased how much he or she was loved
Suicidal ideation because of feeling worthless, undeserving of Individual thinks about death and dying, generally focused on the deceased and
life, or unable to cope with the pain of depression
possibly about joining the deceased
Risk factors for Late-life depression
Risk factors for late-life depression include:
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Female sex
Social isolation
Widowed, divorced, or separated marital status
Lower socioeconomic status
Comorbid general medical conditions, e.g. stroke, heart disease and cancer
Uncontrolled pain
Insomnia
Functional impairment
Cognitive impairment
Depression in the Elderly
Depression is a very serious disease in the elderly:
Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.
Alcohol and drug abuse are very common comorbidities complicating depression.
Completed suicide is more common in older depressed patients.
Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
1. RISK FACTORS
a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B
personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk
c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, and command hallucinations
d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization
e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g., loss of relationship, financial or health
status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual
abuse. Social isolation
f. Change in treatment: discharge from psychiatric hospital, provider or treatment change
g. Access to firearms
2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
a. Internal: ability to cope with stress, religious beliefs, and frustration tolerance
b. External: responsibility to children or beloved pets, positive therapeutic relationships, and social supports
3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, and intent
a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
b. Plan: timing, location, lethality, availability, and preparatory acts
c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) versus non-suicidal self injurious actions
d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal versus self-injurious.
e. Explore ambivalence: reasons to die versus reasons to live
›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above
4. RISK LEVEL/INTERVENTION
a. Assessment of risk level is based on clinical judgment, after completing steps 1–3
b. Reassess as patient or environmental circumstances change
5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with
significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plans should include roles for parent/guardian.
Screening for Depression
The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression , but especially patients with chronic diseases
like diabetes, as they are at high risk for depression.
The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:
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“Over the past two weeks, have you often been bothered by either of the following problems?”
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
If positive, it should be followed up by a diagnostic instrument such as:
PHQ-9
Geriatric Depression Scale – Short Form (GDS-SF) (.pdf)
Screening for Dementia in Geriatric Patients with Depression
While screening for dementia in asymptomatic individuals is not recommended (I statement), screening is important in geriatric patients with
depression because the Geriatric Depression Scale is less sensitive in patients experiencing dementia.
Two dementia screening tools are:
The Mini-Cog exam
The Mini-Mental State Exam (MMSE)
The Mini-Cog exam is faster and more sensitive and specific than the MMSE.
Sensitivity Specificity
Mini-Cog 99%
93%
MMSE
92%
91%
Patient Health Questionnaire, Two-Item Version (PHQ-2)
The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression when staff-assisted depression care supports
are in place to assure accurate diagnosis, effective treatment, and follow-up. Many family physicians and students are familiar with the nine-item
depression survey from the Patient Health Questionnaire (PHQ-9), which has been demonstrated to be useful in diagnosis and tracking the severity
of symptoms among patients with major depression. The length of the questionnaire has been a barrier to its use as a screening tool in primary care,
where physicians are under considerable time pressure and face competing demands.
More recently, a shortened two-item version (PHQ-2) has been developed and validated in primary care. The PHQ-2 asks patients, “Over the last
two weeks, how often have you been bothered by any of the following problems?” The two symptoms are “little interest or pleasure in doing things”
and “feeling down, depressed, or hopeless.” For each question the patient can answer:
Not at all (0 points)
Several days (1 point)
More than half the days (2 points)
Nearly every day (3 points)
The score from the two symptom questions are then added together into a final score.
Side Effects of SSRI/SNRIs
Common side effects of SSRI/SNRIs include:
Headaches
Sleep disturbances (drowsiness and, less frequently, insomnia)
Gastrointestinal problems such as nausea and diarrhea
Sexual dysfunction
They can also cause:
Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death)
Increased risk of gastrointestinal bleeding
In the elderly you also have to be concerned about an increased risk for falls with these medications, and recent studies show that they might have
adverse effects on bone density.
Older antidepressants such as TCAs can cause arrhythmias. Citalopram and Escitalopram can cause QT interval prolongation at higher doses,
especially in the face of hypokalemia and hypomagnesemia or when combined with other medications that have this same effect. Reports of
symptomatic arrhythmia are uncommon.
Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.
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Depression in minority populations
U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant Hispanics are up to 50% lower
than U.S.-born Hispanics.
Due to factors such as economics, culture, and language barriers, Hispanics have their depression identified less frequently than non-Hispanic
whites. This holds true in some other ethnic groups as well, such as Black people.
Psychotic features in depression are no more common in minority populations than non-Hispanic whites.
Research shows that Asian Americans, Black people, and Hispanics with depression are less likely than Whites to perceive a need for
mental health treatment. This was particularly true for Hispanics interviewed in Spanish (as opposed to those interviewed in English), suggesting
acculturation may play a role in this disparity.
Hispanics and other ethnic and economic minorities are less likely to receive adequate therapies. It is important for clinicians to recognize that there
are disparities in outcomes for minority patients with depression and to take steps to mitigate them. Such steps could include patient-centered
communication, addressing social determinants of health, and reflection about implicit biases.
Definition of Racial and Ethnic Disparities
Although race is a social construct and not a marker of biological difference, the ways that race has been used over the centuries to determine
differential access and rights have had real effects on health, leading to racial and ethnic health disparities. For example, in the U.S., the prevalence
of obesity among Hispanic children and adolescents in 2016 was 25.8%, compared to 14.1% for non-Hispanic White children and adolescents. Race
and ethnicity do not cause obesity, but the barriers that some populations disproportionately face, such as inequitable distribution of economic,
educational, and environmental resources, psychosocial stressors, or adverse childhood experiences, may put them at increased risk for obesity.
Pregnancy-related mortality for Black, American Indian, and Alaskan Native women is two to three times higher than for White, Hispanic, and
Asian/Pacific women, regardless of socioeconomic status or education level. The cause for this disparity is not well understood but systemic
discrimination and implicit racial bias in medical treatment are thought to play a role. Some proposed interventions to mitigate this disparity include
using standardized protocols in the hospital and addressing implicit bias in the health care workforce. More information about implicit bias can be
found later in this case.
Elder Abuse
Early research indicates the following risk factors for abuse:
1. Dementia.
2. Shared living situation of elder and abuser (except in financial abuse).
3. Caregiver substance abuse or mental illness.
4. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder’s dependency and the resulting stress has not been found to
predict abuse.
5. Social isolation of the elder from people other than the abuser.
Clinical Skills
Complementary and Alternative Therapies
When obtaining a medication history, health care providers should ask routinely about herbal and other supplements – as well as over-the-counter
medications and nutritional supplements. Patients frequently will not mention the use of complementary and alternative medical treatment unless
they are asked about them. Be respectful when patients discuss alternative therapies, even if you are unfamiliar or skeptical about a particular
treatment.
Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce side effects, just like
conventional drugs. Even where they were obtained is important, as supplements have repeatedly been found to be contaminated with other herbs,
heavy metals, and even prescription drugs. Only a few herbs have been scientifically studied, so information on their effectiveness is limited. St.
John’s Wort has been shown possibly to be effective for short-term treatment of mild to moderate depression but data from trials is mixed.
Management
Treatments for Primary Insomnia in the Elderly
Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and
multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines behavioral treatments, resulting in improvements lasting
up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:
Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually
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been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency
increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is
sustained) until the individual’s optimal sleep time is obtained.
Relaxation therapy: Structured exercises designed to reduce somatic tension (eg, abdominal breathing, progressive muscle relaxation;
autogenic training) and cognitive arousal (eg, guided imagery training; meditation) that may perpetuate sleep problems.
Agents evaluated in older patients:
Class
Benzodiazepine Receptor
Agonists
Agents
Improves
zolpidem
(Ambien)
SOL
eszopiclone
(Lunesta)
Strength of
evidence
Considerations
Risks for falls and fractures, mood alteration
SOL, TST, WASO, sleep
efficiency
low
Short term use only
Use lower doses
Tricyclic Antidepressants
doxepin
SOL, TST, WASO
low to moderate
Anticholinergic effects, sedation, and orthostatic
hypotension
Orexin Receptor Antagonist
suvorexant
(Belsomra)
SOL, WASO
moderate
Decreased alertness and increased fatigue
morning after use
SOL
low
Somnolence, mood alteration and dizziness
Melatonin Receptor Agonist ramelteon
Abbr: SOL – sleep onset latency, TST – total sleep time, WASO – wake after sleep onset
Benzodiazepines and orexin receptor antagonists can be effective but have more complications and the additional risk of addiction.
Antihistamines, antidepressants including trazodone (in the absence of depression), anticonvulsants, and antipsychotics are associated with more
risks than benefits in older adults.
The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular
physical activity in the elderly, assuming there are no other contraindications to such activity.
There is limited research, particularly in the elderly, on complementary therapies including melatonin, L-Tryptophan, valerian, chamomile, kava, and
wuling. What evidence that does exist suggests that any potential benefit is equaled or exceeded by potential adverse effects, particularly in the case
of valerian. They are not recommended.
Antidepressant Medications
Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are
four major classes of antidepressants:
Class
Mechanism
Examples
Citalopram (Celexa)
Fluoxetine (Prozac)
Selective serotonin reuptake
inhibitors (SSRIs)
Selectively block reuptake of serotonin, potentiating serotonin’s effect on Fluvoxamine (Luvox)
the postsynaptic neuron
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Nortriptyline (Pamelor)
Tricyclic antidepressants (TCAs)
Block reuptake of norepinephrine and serotonin, potentiating their effects Amitriptyline
on the postsynaptic neuron
Clomipramine (Anafranil)
Doxepin (Sinequan)
Phenelzine (Nardil)
Monoamine oxidase (MAO)
inhibitors
Block presynaptic catabolism of norepinephrine and serotonin (rarely
used today)
Serotonin and norepinephrine
reuptake inhibitors
Block reuptake of norepinephrine and serotonin, increasing their
concentration/availability
Venlafaxine (Effexor) and
Duloxetine (Cymbalta)
Others
Norepinephrine and dopamine reuptake inhibitors
Bupropion (Wellbutrin)
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Serotonin antagonist and reuptake inhibitors
Nefazodone (Serzone) and
Trazodone (Desyrel)
Norepinephrine and serotonin antagonist, antihistaminic effects
Mirtazapine (Remeron)
Serotonin partial agonist and reuptake inhibitor
Vilazodone (Viibryd)
Management of Depression
When treating patients with major depression disorder, a biopsychosocial approach should be considered. “Bio” refers to pharmacotherapy; “psycho”
refers to psychotherapy; and “social” refers to the identification of life stressors.
While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most
beneficial and comprehensive therapy, and is associated with the highest rates of remission.
Medication:
In a first episode of depression, it’s usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a
high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and – in the elderly, who
experience increased rates of recurrence – continuous therapy should be considered.
SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects
compared to the older tricyclics and, unlike the tricyclics, have little risk of overdose. A tricyclic such as amitriptyline would not be a first-line
approach because of its multiple side effects including anti-cholinergic effects and sedation.
Psychotherapy:
Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can
be especially useful for patients who want to avoid medication.
Exercise:
Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression
and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination with other modalities.
Avoidance of other substances:
Additionally, avoidance of recreational drugs and excessive alcohol use is a necessary part of any treatment regimen.
ECT:
While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients
with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy and seems to improve mild cognitive
impairment in depressed elderly.
Antidepressant Profiles
Effectiveness:
The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all equally effective in geriatric
patients but recent analysis shows SNRIs have a higher rate of adverse reactions. While matching the patient’s symptoms with the drug’s profile,
keep in mind that each patient’s reaction to a medication is different and the final selection needs to be individualized.
Cost:
Cost is another strong consideration. There are now generic preparations of many antidepressants, making them more affordable.
Drug-drug interactions:
Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.
Side effects
While antidepressants are relatively safe, there are potential side effects that vary in frequency and intensity between medications and the individual
patient.
Profiles
Drug
Comments
Unusually long half life (two to four days), so effects can last for weeks after discontinuation.
Fluoxetine
(Prozac)
Sertraline
(Zoloft)
Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and
insomnia.
In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessivecompulsive, panic, and posttraumatic stress disorders.
More gastrointestinal side effects than the other SSRIs.
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Side effects can include significant weight gain, impotence, sedation, and constipation.
Paroxetine
(Paxil)
Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.
Paxil is Pregnancy Category D
Fluvoxamine
(Luvox)
Particularly useful in obsessive-compulsive disorder.
Citalopram
(Celexa)
Most common side effects include nausea, dry mouth, and somnolence.
Escitalopram
(Lexapro)
Approved specifically for Generalized Anxiety Disorder.
Greater frequency of emesis compared to other SSRIs.
Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.
Overall, fewer side effects than citalopram.
Adherence to Antidepressant Medication in the Elderly
Providers note that adherence to depression treatment in older adults occurs only about half the time. The r
