DEPRESSION IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Withdrawal from usual activities or therapies
  • Depressed mood or affect most of day, almost every day
  • Irritable mood, psychomotor agitation or retardation
  • Fatigue, loss of energy, worse than baseline
  • Feelings of worthlessness, hopelessness, helplessness, guilt
  • Anorexia with or without weight loss
  • Major change in sleep pattern with insomnia or daytime hypersomnia
  • Restlessness and difficulty concentrating
  • Suicidal thoughts or comments
  • Frequent crying
  • Increased somatization
  • Increased complaints of pain

 

CONTEXT / / COMMUNICATION

All residents diagnosed with depression merit laboratory work-up for treatable conditions. The health care agent and/or resident should be contacted by the MD/NP
or facility nurse if an antidepressant is to be started.

 

ASSOCIATED RISKS

  • Medical conditions: HF, MI, thyroid disease, hyperparathyroidism, neoplasm of pancreas, CVA (especially left hemisphere), dementia, epilepsy, MS, PD, HD, anemia, chronic pain, history of depression, functional loss
  • Social conditions: placement, death of non-resident family member, death of roommate, loss of autonomy, new roommate, interpersonal relationship difficulties with staff or other residents
  • Drugs: ETOH, b-blockers, Clonidine, Aldomet, NSAID, Barbituates, Benzodiazepines, Antineoplastics, Narcotic analgesics, Carbidopa/levodopa, Anticonvulsants, H2 blockers

 

PHYSICAL EXAMINATION

  • Pertinent to known medical diagnosis and overall medical status
  • Current weight and weight pattern
  • Orthostatic BPs and AP

 

DIAGNOSTIC WORK-UP

  • Laboratory testing: serum level of drugs, TSH, & B12 if not recently done, CBC and BMP, LFTs if considering SSRI, Effexor or Serzone, if weight loss present additional lab work and UCS may be indicated, [Watch for hyponatremia when on SSRIs]
  • MMSE if not recently done
  • EKG if Trazadone or TCA to be used
  • Target specific symptoms to be treated

 

DRUG TREATMENT

  • Overall advice: review current medications for contraindications or interactions
  • Start low and go slow: allow 2-4 wk before side effects resolve and at least 6-8 wk for optimal effect
  • If prior treatment for depression was effective and with acceptable risk resume same drug
  • If prior treatment not effective select new drug as below
  • For 1st occurrence treat for a minimum of 3 months, continuing for another 6-9 months after complete response
  • If 2nd recurrence treat for a minimum of 9 - 12 months
  • If 3rd occurrence consider lifelong therapy
  • Consider psychiatric consultation for recurrent depression with short intervening periods of recovery, failure of two treatments, complicated medication regimes, psychotic depression, bipolar disorder, high lethality
  • Consider referral to psychiatrist for consideration of ECT when resident cannot take antidepressants, no response to drugs, significant weight loss and when it is not feasible to wait for antidepressants to take effect
  • Discontinuation syndrome more prominent in Paxil than Zoloft so taper where possible

Depression + Symptom

Drug

Starting Dose

Anxiety and/or agitation

Celexa or Lexapro or Trazodone or

Remeron 

10 mg hs or 50 mg hs

7.5 mg HS

Anorexia/weight loss

Remeron

15 mg HS

Atypical depression

Zoloft or Celexa or Lexapro

25 mg qd or 10 mg hs

Cardiac arrhythmia/conduction disturb

Zoloft or Celexa or Lexapro or Serzone

25 mg qd or 10 mg hs or 50 mg bid

Constipation

Zoloft or Celexa or Lexapro or Wellbutrin

25 mg qd or 10 mg hs or 25 mg bid

Dementia or delirium risk

Celexa or Lexapro or Wellbutrin

10 mg hs or 25 mg bid

Delusional or psychotic

Celexa +/- Risperdal

10 mg hs + 0.5 mg hs

Glaucoma

Zoloft or Celexa or Lexapro or Wellbutrin

25 mg qd or 10 mg hs + 25 mg bid

Hepatic inhibition

Wellbutrin or Celexa or Lexapro or Trazadone

25 mg bid or 10 mg hs or 50 mg hs

Hypertension

Celexa or Lexapro or Effexor

10 mg hs or 25 mg bid

Insomnia

Serzone or Pamelor or Trazodone

50 mg bid or 25 mg hs or 50 mg hs

Obesity

Zoloft or Paxil or Wellbutrin

25 mg qd or 10 mg qd or 25 mg bid

Orthostatic hypotension

Zoloft or Celexa or Lexapro or Wellbutrin

25 mg qd or 10 mg hs or 25 mg bid

Pain

Celexa, Lexapro, Elavil

10 mg QD or 10 mg hs

Panic disorder

Celexa or Lexapro or Paxil

10 mg hs or 10 mg qd

Parkinsons Disease

Pamelor

 

10 - 25 mg hs

Seizures

Celexa or Paxil

10 mg qhs or 10 mg qd

 

References for Depression

  1. Alexopoulos, GS: Depression and Other Mood Disorders in Clinical Geriatrics, Vol. 8, No. 11, October 2000, 69-82.
  2. Bair, MJ et al: Depression and Pain Comorbidity in Arch Intern Med, Vol. 163, No. 10, 2003, 2433-2445.
  3. Blazer, DG, Grossberg, GT, et al: Managing depression in the elderly in Patient Care Nurse Practitioner, May, 1998, 11-21.
  4. Burke, WJ et al: Management of Anxiety in Later Life in Annals of Long-Term Care, Vol. 12 No. 8, August 2004, 28-33.
  5. Gottfries, CG, Pollock BG: Citalopram: Its Use in Elderly Patients in Annals of Long-Term Care, Vol. 7, No. 5, 1999, 181-189.
  6. Hay, DP, Hay, L. et al: Depression in Elderly Nursing Home Residents in Nursing Home Medicine, Vol. 4, No. 4, April, 1996, 104-110.
  7. Kellner, CH, Koenig, HC et al: Effective approaches to depression in older patients in Patient Care, September 15, 2000, 65-80.
  8. Kelsey, JE: The Use of Antidepressants in Long-Term Care and the Geriatric Patient in Supplement to Geriatrics, Vol. 53, Suppl. 4, December, 1998.
  9. Kennedy, GJ: Psychopharmacology of Late-Life Depression in Annals of Long-Term Care, Vol. 9, No. 3, March 2001, 35-40.
  10. Omnicare Formulary: Geriatric Pharmaceutical Care Guidelines, 1999 edition, 123-142.
  11. Reuben, DB, Grossberg, GT et al: Depression in Geriatrics At Your Fingertips, 1998/99 Edition, 48-53.
  12. Reynolds, C.: Depression: Making the diagnosis and using SSRIs in the older patient in Geriatrics, Vol. 51, No. 10, October, 1996, 28-34.

MS/8.99
EMS
Revised 1.06

 

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