Acute Management of Late-Life Depression V. Gardner and D.C. Steffens

CO-MORBIDITY OF PHYSICAL ILLNESS: THE INTERFACE OF PRIMARY CARE AND PSYCHIATRY

Accurate diagnosis is a prerequisite for effective treatment. Elderly patients with depression present to their primary care physicians and psychiatrists in a complex manner, and signs and symptoms of physical illness and depression overlap. Even the normal effects of ageing may cause diagnostic difficulties and restrict treatment options. Many primary care physicians diagnose and treat late-life depression without referral. However, those patients who fail two or three trials with antidepressants, usually selective serotonin re- uptake inhibitors (SSRIs) or newer agents, are commonly referred to a psychiatrist for further management. These patients represent a treatment challenge and may require more complex medication regimens. Hospitalization may be necessary to enable close monitoring and minimise risk of self-neglect, suicidality and treatment side effects. Primary care physicians also refer for the following reasons: suicidality, co-morbidity with substance abuse, dementia, anxiety disorder, presence of psychosis (delusions, hallucinations), catatonia, bipolar disorder and inability to tolerate antidepressant treatment²‘³.

Depression is often co-morbid with other physical diseases. Approximately 80% of older adults suffer from at least one chronic health problem⁴. The prevalence of co-morbid depression may be up to 30% in stroke patients, 18% in myocardial infarction patients, 51% in patients with hip fracture and 50% in patients with chronic pain¹. Existence of an undiagnosed and untreated depression with these illnesses leads to higher disability⁵. The diagnosis of depression in the context of established physical illnesses may be challenging, and the hospital environment provides the necessary monitoring and support staff when complicated medication changes are required. For example, a patient with cardiovascular disease may present with decreased energy and apathy. Determining whether this is caused by a compromised cardiac status, a medication side effect, or is actually a symptom of depression may be difficult without hospitalization, close monitoring and various medication trials.

Formerly, hospitalization was favoured for the initiation of tri- cyclic antidepressant therapy in elderly patients with unstable cardiac disease. First-line treatment with SSRIs has made this less often necessary, though older people are also vulnerable to adverse effects of SSRIs such as hyponatraemia.

Co-morbid neurological illness is also common in geriatric depression. Patients with depressive symptoms following a cerebrovascular accident also present a diagnostic challenge. There may be communication difficulties or other neurological abnormalities. Depression may be diagnosed only by the report of the nursing staff and family, who observe apathy, irritability, tearfulness and weight loss⁷. Patients with Parkinson’s disease may develop an affective illness or psychosis, which may be secondary to treatment with L-dopa or dopaminiergic agonists. Hospitalization may be required for medication changes if outpatient support is inadequate.

Severe anorexia, weight loss and refusal to eat are indications for hospitalization for safe and effective treatment^1,8. Poor oral intake commonly accompanies severe depression, but it may also result from a variety of medical conditions. For example, individuals with active rheumatoid arthritis may experience insomnia, fatigue and poor appetite equally from their physical illness or an associated depression⁹.

SUICIDE RISK AND THE DECISION TO HOSPITALIZE

Suicidality is the most common reason for psychiatric hospitaliza- tion. The goals for inpatient treatment are: (i) the preservation of life and safety; (ii) the elimination of suicidal intent and ideation and treatment of underlying disorders; and (iii) the improvement of intrapsychic capabilities, personal factors and psychosocial circumstances to facilitate coping after discharge and decreasing risk of the return of suicidality. However, implementation of these treatment plans is predicted on the initial detection of suicidality.

Careful assessment of suicide risk in depressed older adults is thus vital. The elderly are less likely to have made a prior suicide attempt, but they consistently demonstrate a higher rate of completed suicides¹⁰. The ratio of attempted to completed suicides decreases with age from 200:1 in young adulthood to 4:1 in the elderly¹¹. The higher rate is due primarily to the increased frequency of deaths among older, white males. In 1992, people 65 and older accounted for 13% of the population but almost 20% of suicides. Even though the frequency of suicide has increased among older persons in the United States, the prevalence is not as high as that of other industrialized societies¹².

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