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Depression in Long-Term Care

      Objectives

      To review the diagnosis and treatment of depressive disorders in long-term care settings.

      Methods

      A review of the literature on the diagnosis and treatment of depression in long-term care.

      Results

      Up to 35% of residents in long-term care facilities may experience either major depression or clinically significant depressive symptoms. These symptoms are often not recognized for at least 2 reasons: depression is not the focus of physicians and nursing personnel and depression is frequently comorbid with other problems that are common in long-term care, such as cognitive impairment, medical illness, and functional impairment. Nevertheless, depression, once diagnosed, can be treated effectively in the nursing home setting. The foundation of treatment is pharmacotherapy, yet other therapeutic approaches, such as exercise and psychological therapies may be of value.

      Conclusion

      Depression, although often unrecognized in long-term care, is a treatable condition and deserves the attention of the entire medical and nursing staff.
      The single most significant change in US population demographics over the past 50 years is the aging of the population. In 2003, 35.9 million people were aged 65 and older. By 2030, this number is projected to be twice as large, growing to 72 million.
      • He W.
      • Sengupta M.
      • Velkoff V.A.
      • DeBarros K.A.
      US Census Bureau, Current Population Reports, P23–209, 65+ in the United States: 2005.
      As a result of this growth, the population of older adults in nursing homes is projected to increase over the next several years.
      • Lakdawala D.N.
      • Bhattacharya J.
      • Goldman D.P.
      • et al.
      Forecasting the nursing home population.
      Depression is the most common cause of morbidity and decreased quality of life in this expanding demographic group that forms the majority of long-term care residents.
      • Berkman L.
      • Berkman C.
      • Kasl S.
      • et al.
      Depressive symptoms in relation to physical health and functioning in the elderly.
      The aim of this review is to improve awareness regarding depression in long-term care settings, with a goal of improving recognition and management of depression in nursing home residents.
      Prevalence of depressive disorders in the long-term care setting varies across studies because of methodological differences. In one large study of a long-term care facility, 12.4% experienced major depression and 35.0% experienced significant depressive symptoms.
      • Parmelee P.
      • Katz I.
      • Lawton M.
      Depression among institutionalized aged: Assessment and prevalence estimation.
      In another study,
      • Payne J.
      • Sheppard J.
      • Steinberg M.
      • et al.
      Incidence, prevalence and outcomes of depression in residents of a long-term care facility with dementia.
      depression was found in 20.0% of patients admitted to a long-term care facility. Incidence of major depression at 1 year was 6.4%. In yet another nursing home study,
      • Teresi J.
      • Abrams R.
      • Holmes D.
      • Ramirez M.
      • Eimicke J.
      Prevalence of depression and depression recognition in nursing homes.
      prevalence of major depressive disorder among testable subjects was 14.4% (15.0% could not be tested) and prevalence of minor depression was 17.0%. Less than 50.0% of cases were recognized by nursing and social work staff. Thus, depressive disorders are widely prevalent in nursing homes, contributing substantially to disability in this frail population, and yet are often overlooked.

      Diagnostic Criteria

      In the nursing home setting, 4 different clinical entities are particularly relevant, namely major depressive disorder, dysthymic disorder, minor depression (and other similar constructs), and depression concurrent with Alzheimer’s disease (Table 1).
      Table 1Differential Diagnosis of Depressive Symptoms in Nursing Home Patients
      Major Depressive Disorder: Presence of at least 5 of 9 depressive symptoms for at least 2 weeks and impaired social functioning (see text for specific symptoms)
      Minor Depression: Not meeting above criteria but significant subthreshold symptoms
      Dysthymia: Low-grade depression symptoms that are chronic (>2 years)
      Depression in Alzheimer’s disease: Specific criteria proposed that require only 3 symptoms, with irritability as a qualifying symptom (see text for details)

      Major Depressive Disorder

      To meet criteria for a diagnosis of major depressive disorder, the older adult must exhibit at least 1 of 2 symptoms, depressed mood and/or lack of interest, for at least 2 weeks. In the nursing home, older adults are more likely to complain of loss of interest rather than overt depressed mood. Even so, the diagnosis can be made using the criteria listed below. For a diagnosis of major depression, the older adult must exhibit an additional 4 or more of the following symptoms for at least 2 weeks. Older adults tend to differ somewhat from middle-aged adults in the presentation of these criteria symptoms.
      • Blazer D.
      • Bachar J.
      • Hughes D.
      Major depression with melancholia: A comparison of middle-aged and elderly adults.
      • Feelings of worthlessness or inappropriate guilt (guilt is less frequent among older adults than among younger adults)
      • Diminished ability to concentrate or make decisions (older adults are no more likely to complain of difficulty with concentration and memory than younger adults unless they experience comorbid depression and dementia [see later in this article] but are more likely to exhibit positive findings on psychological testing than younger adults when depressed)
      • Fatigue (a common symptom regardless of age in the moderate to severely depressed and complicated by comorbid physical illness)
      • Psychomotor agitation or retardation (either can be seen in late life and agitation is frequent in the nursing home)
      • Increase or decrease in weight or appetite (weight loss is very common, whereas weight gain is rarely seen in older patients)
      • Recurrent thoughts of death or suicide (older adults may ruminate about death during a depressive episode although they are not as likely to express suicidal thoughts as younger adults
        • Blazer D.
        • Hughes D.
        • George L.
        The epidemiology of depression in an elderly community population.
        ).
      Psychotic depression is a subtype of major depression that is frequently seen in the elderly, although it is more commonly seen in inpatients and in patients in long-term care than community samples of the elderly.
      • Meyers B.
      Geriatric delusional depression Clin Geriatr Med 1992;8:299–308; Kivela S, Pahkala K, Laippala P. Prevalence of depression in an elderly Finnish population.
      It is usually characterized by severe depressive symptoms, together with delusions and/or hallucinations. The most common delusions seen in the elderly are somatic and persecutory delusions.
      • Baldwin R.C.
      Delusional depression in elderly patients: Characteristics and relationship to age at onset.
      In the nursing home, an older depressed patient may be overtly delusional yet cooperative and easily managed because of decreased functional capacity.
      Dysthymic disorder is a less severe but more chronic variant of depression. To meet criteria the older adult must experience symptoms most of the time for at least 2 years.
      American Psychiatric Association
      DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders.
      Although it is rare for dysthymic disorder to start in late life, it can persist into late life from midlife.
      • Blazer D.
      Dysthymia in community and clinical samples of older adults.
      • Devenand D.
      • Noble M.
      • Singer T.
      • et al.
      Is dysthymia a different disorder in the elderly?.
      Therefore, chronic but less severe depression in the nursing home may not so much be secondary to living situation as a pattern laid down many years before admittance to long-term care.
      The term “minor depression” is not a formal diagnosis in DSM-IV-TR, although symptoms for minor depression are suggested in the Appendix. The diagnosis is made when the core symptoms are present along with 1 to 3 additional symptoms for at least 2 weeks. The construct of “subthreshold” or “subsyndromal” depression is an important one in the geriatric population, possibly as important as major depressive disorder itself, given the high prevalence of subthreshold depressive symptoms in this population, both in community and long-term care samples, with implications for determining threshold for treatment.
      Minor depression variously defined has been associated with impairment similar to that of major depression, including impaired physical functioning, disability days, poorer self-rated health, use of psychotropic medications, perceived low social support, female gender, and being unmarried.
      • Beekman A.
      • Deeg D.
      • van Tilberg T.
      • Smit J.
      • Hooijer C.
      • van Tilberg W.
      Major and minor depression in later life: A study of prevalence and risk factors.
      • Hybels C.
      • Blazer D.
      • Pieper C.
      Toward a threshold for subthreshold depression: An analysis of correlates of depression by severity of symptoms using data from an elderly community survey.
      Studies have attempted defining this construct with suggested cut-off scores on depression rating scales, with one study suggesting a score of 16+ on the Center for Epidemiologic Studies Depression Scale (CES-D) but not meeting criteria for major depression,
      • Beekman A.
      • Deeg D.
      • van Tilberg T.
      • Smit J.
      • Hooijer C.
      • van Tilberg W.
      Major and minor depression in later life: A study of prevalence and risk factors.
      and another suggesting a score of 11 to 15 on the CES-D.
      • Hybels C.
      • Blazer D.
      • Pieper C.
      Toward a threshold for subthreshold depression: An analysis of correlates of depression by severity of symptoms using data from an elderly community survey.
      Another variant described in the elderly cohort is “depression without sadness,” a presentation of depressive symptoms without actual sadness or low mood.
      • Gallo J.
      • Rabins P.
      • Lyketsos C.
      Depression without sadness: Functional outcomes of nondysphoric depression in later life.
      There are several additional subtypes suggested, and a future challenge for the field of geriatric psychiatry is to develop an agreed upon definition of what constitutes clinically significant subthreshold depression that warrants treatment.
      Some investigators have recently proposed criteria for “depression of Alzheimer’s disease (AD).”
      • Olin J.
      • Schneider L.
      • Katz I.
      • et al.
      Provisional diagnostic criteria for depression of Alzheimer Disease.
      In persons who meet criteria for a dementia of the Alzheimer’s type, the appearance of 3 of the following symptoms would qualify for the diagnosis: depressed mood, anhedonia, social isolation (not a symptom criteria for major depression), poor appetite, poor sleep, psychomotor changes, irritability (not a symptom of major depression), fatigue and loss of energy, feelings of worthlessness, and suicidal thoughts. Psychotic symptoms such as delusions and hallucinations can be present not only in dementia, but also in dementia comorbid with depression. Therefore, when depression and psychosis coexist in an AD patient, both should be diagnosed.

      Screening for Depression in Nursing Homes

      Given the magnitude of the problem of depression in nursing homes, adequate screening would be the first important step in addressing this issue. The minimum data set, a federally mandated periodic assessment of nursing home residents, includes information on mood and anxiety symptoms. Unfortunately, the validity of this instrument for diagnosing depression compared to standard screening tools has been found to be poor.
      • Schnelle J.F.
      • Wood S.
      • Schnelle E.R.
      • Simmons S.F.
      Measurement sensitivity and the Minimum Data Set depression quality indicator.
      • McCurren C.
      Assessment for depression among nursing home elders: Evaluation of the MDS mood assessment.
      • Anderson R.L.
      • Buckwalter K.C.
      • Buchanan R.J.
      • Maas M.L.
      • Imhof S.L.
      Validity and reliability of the Minimum Data Set Depression Rating Scale (MDSDRS) for older adults in nursing homes.
      • Hendrix C.C.
      • Sakauye K.M.
      • Karabatsos G.
      • Daigle D.
      The use of the Minimum Data Set to identify depression in the elderly.
      The Geriatric Depression Scale (GDS) is the most studied screening tool in cognitively intact nursing home patients.
      • Abraham I.L.
      The Geriatric Depression Scale and Hopelessness Index: Longitudinal psychometric data on frail nursing home residents.
      • Baker F.M.
      • Miller C.L.
      Screening a skilled nursing home population for depression.
      • Rinaldi P.
      • Mecocci P.
      • Benedetti C.
      • et al.
      Validation of the five-item geriatric depression scale in elderly subjects in three different settings.
      • Jongenelis K.
      • Pot A.M.
      • Eisses A.M.
      • et al.
      Diagnostic accuracy of the original 30-item and shortened versions of the Geriatric Depression Scale in nursing home patients.
      The scale is well validated in this population for both major and minor depression, and has high sensitivity and specificity in its 30-item version. The shorter versions of the GDS are also well validated, with the 10-item GDS being recommended as the best tradeoff between ease of administration and sensitivity in nursing home patients.
      • Jongenelis K.
      • Pot A.M.
      • Eisses A.M.
      • et al.
      Diagnostic accuracy of the original 30-item and shortened versions of the Geriatric Depression Scale in nursing home patients.
      The Cornell Scale for Depression in Dementia
      • Alexopoulos G.S.
      • Abrams R.C.
      • Young R.C.
      • Shamoian C.A.
      Cornell Scale for Depression in Dementia.
      is a validated instrument for demented patients in general although it has not been specifically validated in demented patients in nursing homes. The scale is a semi-structured interview of an informed caregiver, and thus its validity in the nursing home setting cannot be assumed. However, it has been compared to the GDS and found to have better validity in demented patients than the GDS.
      • Korner A.
      • Lauritzen L.
      • Abelskov K.
      • et al.
      The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia A validity study.

      Diagnostic Workup of Depression

      As defined by DSM-IV-TR, the diagnosis of major depression can be made on the basis of the presence of 5 of 9 depressive symptoms. In addition to the current symptomatology, an adequate assessment also includes personal or family history of past depressive episodes, history of suicidality, and history of substance abuse, as all of these can influence prognosis for the current episode of depression (Table 2). Also important are past treatment trials and response (to guide current treatment), and assessment of current suicidal ideation and imminent risk of self-harm (to guide location of treatment, inpatient versus outpatient). Cognitive status should be assessed with the Mini-Mental State Examination (MMSE), given the high likelihood of comorbid depression and cognitive dysfunction.
      • Folstein M.
      • Folstein S.
      • McHugh P.
      Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician.
      Because a variety of medical conditions can mimic depression in old age, a minimum workup includes basic metabolic panel, complete blood count, thyroid function tests, and serum vitamin B12 and folate levels. Nutritional status is important to evaluate in the depressed elder, especially the oldest old, given the risk for frailty and failure to thrive in depressed elders.
      • Blazer D.
      Psychiatry and the oldest old.
      • Fried L.
      • Walston J.
      Frailty and failure to thrive.
      Laboratory tests need not be repeated if they have been performed in the past year, or since onset of depressive symptoms, whichever is more recent. A review of current medications is also essential because of the long list of medications that can cause symptoms similar to those of depressive disorder. Unless a medication is thought to definitively contribute to significant depressive symptoms and safer alternatives are available, discontinuation of medications for other indications may not be a viable option in this population, which often has significant medical comorbidity.
      Table 2Workup of Depression in Nursing Home Patients
      -Screening: Geriatric Depression Scale
      -Present illness history including assessment of suicidal ideation, current medications
      -Past history including antidepressant trials
      -Cognitive screen: MMSE
      - Laboratory tests: Basic metabolic panel, complete blood count, TSH, free T4, serum B12 and folate levels, serum albumin in case of poor nutrition
      -EKG if a tricyclic antidepressant is being considered
      -Polysomnography if a sleep disorder is suspected
      -MRI to confirm diagnosis of vascular depression
      MMSE, mini-mental state exam; TSH, thyroid-stimulating hormone; EKG, electrocardiogram; MRI, magnetic resonance imaging.

      Etiology

      Biological, psychological, and social factors contribute to the etiology of depression in nursing home patients. Biological factors include a strong association with medical illnesses such as cardiovascular disease, Parkinson’s disease, hip fractures, pain, and urinary incontinence. “Vascular depression” is a term used to describe late-life depression associated with vascular changes in the brain, and characterized by executive dysfunction.
      • Alexopoulos G.S.
      • Meyers B.S.
      • Young R.C.
      • Kakuma T.
      • Silbersweig D.
      • Charlson M.
      Clinically defined vascular depression.
      Changes in the brains of depressed older patients seen on imaging include structural abnormalities in areas related to the cortical–striatal–pallidal–thalamus–cortical pathway,
      • George M.
      • Ketter T.
      • Post R.
      Prefrontal cortex dysfunction in clinical depression.
      smaller size of the orbital frontal cortex in late-life depression,
      • Lai T.
      • Payne M.
      • Byrum C.
      • Steffens D.
      • Krishnan K.
      Reduction of orbital frontal cortex volume in geriatric depression.
      and smaller left hippocampal volumes in depressed patients who go on to develop dementia.
      • Steffens D.
      • Payne M.
      • Greenberg D.
      • et al.
      Hippocampal volume and incident dementia in geriatric depression.
      The most important psychosocial factors that play a role in the development of depression include the losses inherent in old age, such as those of health or significant others, as well as loneliness experienced by patients in nursing homes. Patients who identify religion as the most important factor in coping, termed “religious coping,” show improved emotional and physical health,
      • Koenig H.
      • Cohen H.
      • Blazer D.
      • et al.
      Religious coping and depression in elderly hospitalized medically ill men.
      suggesting that religion may be a protective factor in development of depressive symptoms.

      Treatment

      The evidence base for treatment of depression in the elderly is expanding, with evidence for both biological and psychological therapies.

       Biological Treatment

      The mainstay of depression treatment in the elderly is antidepressant medication. Because of their better tolerability profiles, the selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants like bupropion are preferred to older tricyclic antidepressants (TCAs) (Table 3). Although there are several double-blind studies that compare individual TCAs to individual SSRIs, finding both equally efficacious, the majority of these do not have a placebo-control group.
      Table 3Comparison of Antidepressants Commonly Used in Nursing Home Patients
      AntidepressantStarting Dose; Usual Dose RangeCYP450 Enzyme InhibitionGeneric Availability
      Fluoxetine10 mg; 20–30 mgInhibits 3A4, 2C19, and 2D6Yes
      Paroxetine10 mg; 20–30 mgInhibits 2D6Yes
      Sertraline25 mg; 50–100 mgMild 2D6 inhibitionYes
      Citalopram10 mg; 20–30 mgMild 1A2, 2C19, and 2D6 inhibitionYes
      Escitalopram5 mg; 10–20 mgMild 1A2, 2C19, and 2D6 inhibitionNo
      Venlafaxine (extended release)37.5 mg; 75– 150 mgMild 2D6 inhibitionNo
      Bupropion (slow release)150 mg; 150–300 mgInhibits 2D6Yes
      Mirtazapine7.5 mg; 15–45 mgNo significant effectYes
      The SSRIs that have shown efficacy based on primary outcome measure in double-blind placebo controlled studies of elderly patients include sertraline,
      • Schneider L.S.
      • Nelson J.C.
      • Clary C.M.
      • et al.
      Sertraline Elderly Depression Study Group
      An 8-week multicenter, parallel-group, double-blind, placebo-controlled study of sertraline in elderly outpatients with major depression.
      citalopram,
      • Nyth A.L.
      • Gottfries C.G.
      • Lyby K.
      • et al.
      A controlled multicenter trial of citalopram and placebo in elderly depressed patients with and without concomitant dementia.
      paroxetine,
      • Rapaport M.H.
      • Schneider L.S.
      • Dunner D.L.
      • Davies J.T.
      • Pitts C.D.
      Efficacy of controlled-release paroxetine in the treatment of late-life depression.
      mirtazapine,
      • Halikas J.A.
      Org 3770 (mirtazapine) versus trazodone: A placebo controlled trial in depressed elderly patients.
      and bupropion.
      • Branconnier R.J.
      • Cole J.O.
      • Ghazvinian S.
      • Spera K.F.
      • Oxenkrug G.F.
      • Bass J.L.
      Clinical pharmacology of bupropion and imipramine in elderly depressives.
      There are at least 2 placebo-controlled trials of fluoxetine
      • Tollefson G.D.
      • Bosomworth J.C.
      • Heiligenstein J.H.
      • Potvin J.H.
      • Holman S.
      A double-blind, placebo-controlled clinical trial of fluoxetine in geriatric patients with major depression The Fluoxetine Collaborative Study Group.
      • Schatzberg A.
      • Roose S.
      A double-blind, placebo-controlled study of venlafaxine and fluoxetine in geriatric outpatients with major depression.
      and at least 1 trial each of venlafaxine
      • Schatzberg A.
      • Roose S.
      A double-blind, placebo-controlled study of venlafaxine and fluoxetine in geriatric outpatients with major depression.
      and escitalopram
      • Kasper S.
      • de Swart H.
      • Andersen H.F.
      Escitalopram in the treatment of depressed elderly patients.
      in the elderly that failed to show that the drug was significantly better than placebo in the primary outcome measure. We could not identify any studies of duloxetine with antidepressant response as a primary outcome measure in the elderly population. The failed trials and modest efficacy seen in geriatric depression trials in general can be attributed to high rates of placebo response even in large well-designed studies.
      • Schneider L.S.
      • Nelson J.C.
      • Clary C.M.
      • et al.
      Sertraline Elderly Depression Study Group
      An 8-week multicenter, parallel-group, double-blind, placebo-controlled study of sertraline in elderly outpatients with major depression.
      • Tollefson G.D.
      • Bosomworth J.C.
      • Heiligenstein J.H.
      • Potvin J.H.
      • Holman S.
      A double-blind, placebo-controlled clinical trial of fluoxetine in geriatric patients with major depression The Fluoxetine Collaborative Study Group.
      In the only placebo-controlled trial of depression in the “old-old” (age 75 and above), citalopram was no more effective than placebo.
      • Roose S.
      • Sackeim H.
      • Krishnan R.
      • et al.
      Antidepressant pharmacotherapy in the treatment of depression in the very old: A randomized, placebo-controlled trial.
      Of note, the subgroups of more severely depressed patients showed greater medication-placebo differences than those with less severe depression, suggesting that patients with less severe depression may have responded to the psycho-social aspects of treatment in a clinical trial, but more severely depressed responded only to the medication. Clinical trials of treatment of depression in the nursing home setting are very few. We found one placebo-controlled study of paroxetine in the treatment of non–major depression in nursing home patients that did not find paroxetine to be superior to placebo.
      • Burrows A.B.
      • Salzman C.
      • Satlin A.
      • Noble K.
      • Pollock B.G.
      • Gersh T.
      A randomized, placebo-controlled trial of paroxetine in nursing home residents with non-major depression.
      The decision about antidepressant choice in older adults is guided as much by efficacy as by the side-effect profile of the drug. Although the newer antidepressants are far better tolerated than TCAs, tolerability issues remain. With almost all antidepressants, there can be initial gastrointestinal (GI) side effects, headaches, and increased anxiety, most of which subside with time. Certain side effects of SSRIs can be even more serious in the elderly. Elderly inpatients on SSRIs or venlafaxine are at definite risk for developing hyponatremia (39% in one study) due to syndrome of inappropriate secretion of antidiuretic hormone and should have sodium levels checked before and after commencement of antidepressant medications.
      • Kirby D.
      • Harigan S.
      • Ames D.
      Hyponatraemia in elderly psychiatric patients treated with selective serotonin reuptake inhibitors and venlafaxine: A retrospective controlled study in an inpatient unit.
      Other serious side effects reported with SSRIs include the risk of falls
      • Thapa P.
      • Gideon P.
      • Cost T.
      • Milam A.
      • Ray W.
      Antidepressants and the risk of falls among nursing home residents.
      and hip fractures,
      • Schneeweiss S.
      • Wang P.S.
      Association between SSRI use and hip fractures and the effect of residual confounding bias in claims database studies.
      serotonin syndrome
      • Gillman P.
      The serotonin syndrome and its treatment.
      (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death), gastrointestinal bleeding,
      • de Abajo F.
      • Rodriguez L.
      • Montero D.
      Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: Population based case-control study.
      and insomnia. In fact, SSRIs can worsen restless legs and periodic limb movements and further contribute to sleep difficulties.
      • Yang C.
      • Winkelman J.W.
      • White D.P.
      The effects of antidepressants on leg movements.
      At times, the side-effect profile of a drug can be used to therapeutic advantage. For example, when insomnia is a prominent complaint in geriatric depression, mirtazapine may be the drug of choice. Alternately, a combination of an SSRI and trazodone can also be effective. Although trazodone is often favored as a sleep aid in general, it is important to remember that there are no data supporting its use in the treatment of chronic insomnia in the absence of depression. Given its side-effect profile in the elderly (orthostasis and rare but serious priapism), it should be used judiciously and at low doses in this population.
      In the STAR*D trial,
      • Trivedi M.H.
      • Rush A.J.
      • Wisniewski S.R.
      • et al.
      Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: Implications for clinical practice.
      which is the most significant effectiveness study of antidepressants to date (the majority of the sample had significant medical and psychiatric comorbidities), the response rates (47%) and remission rate (28%) after 14 weeks of an SSRI (citalopram) were not significantly different for older adults (approximately 25% of the sample of 2876 was over 51 years of age).
      A number of studies document the efficacy of antidepressant therapy for treating depression in dementia.
      • Kasper S.
      • de Swart H.
      • Andersen H.F.
      Escitalopram in the treatment of depressed elderly patients.
      • Reifler B.
      • Teri L.
      • Raskind M.
      • Veith R.
      • Barnes R.
      Double-blind trial of imipramine in Alzheimer’s disease patients with and without depression.
      • Lyketsos C.
      • Sheppard J.
      • Steele C.
      • et al.
      A randomized placebo-controlled, double-blind, clinical trial of sertraline in the treatment of depression complicating Alzheimer disease: Initial results from the Depression in Alzheimer Disease Study (DIADS).
      In general, SSRIs (sertraline and citalopram) have shown better efficacy and tolerability than tricyclic antidepressants. As such, SSRIs should be first-line treatment for depression in demented patients.
      In the treatment of geriatric depression in the context of cognitive complaints, it is preferable to use agents with low anticholinergic activity to avoid further compromise in cognitive function. Thus, TCAs should definitely be avoided, and among the SSRIs, paroxetine, which is most anticholinergic, should be avoided.
      From a practical standpoint as recommended by a consensus of geropsychiatrists,
      • Alexopoulos G.
      • Katz I.
      • Reynolds C.
      • Carpenter D.
      • Docherty J.
      The Expert Consensus Guideline Series: Pharmacotherapy of depressive disorders in older patients.
      the best approach to treating depression in nursing home patients would be to start out with an SSRI trial such as citalopram (20 to 30 mg), sertraline (50 to 100 mg), or paroxetine (20 to 30 mg). If a 6-week trial at adequate doses fails, then venlafaxine XR (75 to 150 mg), mirtazapine (15 to 30 mg), or bupropion SR (150 to 300 mg) can be tried. Starting dose in each case should be half of the lower dose of these suggested dose ranges (eg, 10 mg for citalopram), and as a rule titration should be gradual: “start low and go slow.” Treatment should be continued at the effective dose for at least 1 year. Psychotherapy should be added if appropriate and if resources are available. For minor depression or dysthymia, either medication alone or psychotherapy alone is appropriate. For psychotic depression, electroconvulsive therapy (ECT) or a combination of antidepressant and antipsychotic are recommended (Table 4).
      Table 4Treatment of Depression in Nursing Home Patients
      Major depressive disorder: Citalopram, sertraline, or paroxetine. If no response at 6 weeks, then switch to venlafaxine (extended release), or bupropion (slow release), or mirtazapine. If no response, consider ECT. Add psychotherapy if appropriate
      Psychotic depression: SSRI + antipsychotic medication, or ECT
      Persistent minor depression or dysthymia: Either SSRI or psychotherapy alone
      Depression comorbid with Alzheimer’s disease: SSRI and/or behavioral therapy
      ECT, electroconvulsive therapy; SSRI, selective serotonin reuptake inhibitor.

       Electroconvulsive Therapy and Emerging Biological Therapies

      Although not a first-line treatment of depressive disorders for any age group, ECT remains the most effective short-term treatment for depression, particularly for severe depression and psychotic depression.
      • Flint A.
      • Rifat S.
      The treatment of psychotic depression in later life: A comparison of pharmacotherapy and ECT.
      There is evidence for efficacy of ECT in the treatment of geriatric depression.
      • Godber C.
      • Rosenvinge H.
      • Wilkinson D.
      • Smithes J.
      Depression in old age: Prognosis after ECT.
      • Benbow S.
      The use of electroconvulsive therapy in old-age psychiatry.
      • Fraser R.
      • Glass I.
      Unilateral and bilateral ECT in elderly patients.
      Data suggest that, in general, older patients respond just as well as younger patients to ECT,
      • O’Conner M.
      • Knapp R.
      • Husain M.
      • et al.
      The influence of age on the response of major depression to electroconvulsive therapy: A C.O.R.E. Report.
      but response may not be as good in the subgroup of the oldest old.
      • Cattan R.
      • Barry P.
      • Mead G.
      • Reefe W.
      • Gay A.
      Electroconvulsive therapy in octogenerians.
      Thus, ECT is a safe and effective treatment for older adults, and not contraindicated in nursing home patients.
      Newer therapies for depression include the Food and Drug Administration (FDA)-approved Vagal Nerve Stimulation (VNS) for treatment-resistant depression, and repetitive transcranial magnetic stimulation (rTMS) for depression, which is not FDA approved. There are no studies of VNS in geriatric depression, and very few data regarding rTMS in geriatric depression. Thus, there is an absence of strong evidence to support the use of VNS and rTMS in treatment of depressed older adults, especially those in nursing homes, at the present time.

       Light Therapy and Exercise

      One study of institutionalized elders found that 30 minutes of bright light daily improved depression.
      • Sumaya I.
      • Rienzi B.
      • Beegan J.
      • Moss D.
      Bright light treatment decreases depression in institutionalized older adults: A placebo controlled crossover study.
      Because increasing age has been associated with medical comorbidity and decrease in physical activity, the role of exercise has been explored in the treatment of depression. Aerobic exercise has been found to be as effective as medication in geriatric depression treatment at 16 weeks.
      • Blumenthal J.
      • Babyak M.
      • Moore K.
      • et al.
      Effects of exercise training on older patients with major depression.
      In 1 study of treatment of depressed patients with dementia in a nursing home setting, therapeutic biking with a “wheelchair bicycle” was found to be effective in treating depression, with gains maintained at 10-week follow-up.
      • Buettner L.L.
      • Fitzsimmons S.
      AD-venture program: Therapeutic biking for the treatment of depression in long-term care residents with dementia.

       Psychological Treatments

      Use of psychotherapy in treatment of depression in the elderly is supported by evidence for many forms of therapy including cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and bibliotherapy.
      • Thompson L.W.
      • Gallagher D.
      • Breckenridge J.S.
      Comparative effectiveness of psychotherapies for depressed elders.
      • Reynolds C.
      • Frank E.
      • Perel J.
      • et al.
      Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years.
      • Scogin F.
      • Hamblin D.
      • Beutler L.
      Bibliotherapy for depressed older adults: A self-help alternative.
      In long-term care in particular, there are relatively few studies of psychological treatments,
      • Bharucha A.J.
      • Dew M.A.
      • Miller M.D.
      • Borson S.
      • Reynolds 3rd, C.
      Psychotherapy in long-term care: A review.
      most reporting short-term and sometimes long-term benefits of therapy on instruments measuring depression, hopelessness, self-esteem, perceived control, and other psychological variables. Many limitations of these studies include small sample sizes, variable study entry criteria, short duration of trials, heterogeneous outcome assessment methods, and lack of detail on intervention methods. More studies of nonpharmacologic approaches that can be efficiently delivered in long-term care settings are urgently needed.

      Prevention of Depression in Nursing Homes

      Given the high prevalence of depression in nursing homes, it would be reasonable to ask if primary prevention measures can be implemented in this high-risk population. Unfortunately, we could not identify data to support this. There are emerging primary prevention studies for depression in high-risk older adults such as those with medical comorbidities,
      • Rybarczyk B.
      • De Marco G.
      • DeLa Cruz M.
      • Lapidos S.
      Comparing mind-body wellness interventions for older adults with chronic illness: Classroom versus home instruction.
      and future research would do well to focus on institutionalized adults, another high-risk group that is rapidly expanding.
      In conclusion, depression is widely prevalent in nursing home populations, and it is often under diagnosed and under treated. There are validated diagnostic tools, as well as an expanding evidence base for both biological and psychological treatments of depression in this population, even in those depressed patients with comorbid dementia. A challenge for the field is to implement the existing knowledge to improve outcomes, and to consider the possibility of group-based primary prevention initiatives.

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