Createwriteinc.com

Depression and anxiety are prevalent Excerpt of a flipbook on
but under-recognized in residents1
anxiety in LTC residents; written for nurses in long-term care facilities Depression
•   Depression is 3.5 times more prevalent in
•   Generalized anxiety disorder (GAD) and  long-term care settings than in the general
phobias are the most common anxiety  population.2
•   In one survey, 45% of residents with symptoms  •   Almost 40% of residents have symptoms of
of depression had no treatment history for this  anxiety.5
• 60 to 90% of older adults with GAD have
concurrent case-level depression.4
“[An] untreated mental disorder
can lead to a more severe,
more difficult-to-treat illness,
prevAlenCe
and to the development of co-
occurring mental illnesses.”
ConDition
in general population
in long-term care
— National Institute of Mental Health, National  Comorbidity Survey Replication Study7 9 Challenges in recognizing depression or anxiety in
residents
•   The elderly may have symptoms that are not 
•   Residents rarely will use a term like “depressed”  typical of adult-onset depression.4 to describe symptoms. Instead, they may feel  •   Residents may complain of anxiety or “nerves”  “low,” “empty,” “lazy”—or they may not use any  when, actually, they are depressed.4 •   Many symptoms of depression and anxiety overlap.4 Depression
Irritability         Restlessness
disturbance
Concentration
problems
9 Challenges (continued)
•   Residents will more frequently present with 
•   Some medical conditions can predispose a  resident to anxiety or depression.9,11  •   Somatic symptoms* may be due to physical  ➡ Examples: chronic pain, stroke, hypothyroidism,
conditions, a mental health condition, or both.9  ➡ Example: Sleep disturbances may be caused by
disorders, some infectious diseases, sleep medications, respiratory disorders, restless leg syndrome, or depression.
•   Some medications can cause symptoms  •   Symptoms of known medical conditions can  mimicking mental health problems.12,13 mimic, overlap, mask, or distort symptoms of  ➡ Examples: heart medications, cholesterol-
lowering drugs, sedatives, some anti-parkinson ➡ Example: Differentiating depression from
neurologic disorders such as dementia, stroke, or Parkinson’s disease can be difficult. * Somatic symptoms may include, but not be limited to, unusual loss of energy, gastrointestinal disturbances, sleep disturbances, muscle aches, headaches, backaches, and hypochondria.
What depression and anxiety look and feel like14,15
Depressiona
Anxietyb
exAMples oF HoW tHis MAy
Be MAniFesteD in resiDents
Physical complaints that don’t respond to Loss of interest and pleasure in activities that were previously pleasurable (food, friends, hobbies, etc.) For example, residents may give excuses for not engaging in previously enjoy- THIS IS THE KEY INDICATOR FOR
DEPRESSION.
Sleep disturbance: difficulty falling or Early morning waking (e.g., 2 am or 4 am) staying asleep; or restless, unsatisfying Agitation: inability to sit still, hand-wringing, pulling at clothing, skin, or other objects Retardation: slowed thinking, speech, body Tension: muscle tightness or spasms, can’t relax, heart “pounds,” headache, IBS, Simple activities like getting dressed may Self-blame, overly negative self-evaluation, Difficulty concentrating or forgetfulness; “Others would be better off if I were dead.” a $ 5 of these 9 symptoms need to be present for most of the day, nearly every day, for $ 2 weeks
b $ 3 of these 6 symptoms need to be present nearly every day, all day, for $ 6 months
Information adapted from the DSM-IV-TR.
physical conditions and medications may
contribute to depression or anxiety
residents with certain medical conditions may be some medications may affect one’s mood,12
predisposed to depression11 or anxiety.16
increasing the likelihood for depressive
these conditions include:
symptoms:
•   Beta blockers and calcium channel blockers •   Hormone replacement products •   Endocrine disorders (especially thyroid  •   Brain tumors and other cancers •   Some anti-parkinson drugs  •   Neurological disorders (e.g. Alzheimer’s,  •   Autoimmune disorders (e.g. rheumatoid  •   Infectious diseases (e.g. Lyme disease, HIV/AIDS)•   Sleep disorders (obstructive sleep apnea) How do depression and anxiety affect your
residents?
Depression11 and anxiety4 affect their physical health and quality of life.
•   Untreated depression11 and anxiety17 adversely
•   Untreated anxiety causes greater disability,
affect health outcomes, resulting in:
more functional limitations, and poorer quality
➡ Longer recovery from surgeries, acute illnesses, of life than chronic illnesses such as diabetes
and congestive heart failure.18
•   Generalized anxiety that co-occurs with late-
life depression adversely affects treatment
➡ Impaired management of chronic conditions response and long-term outcomes.4
How to advocate for your residents
Knowing how to recognize anxiety and depression can help you develop the best care regimen  
for your residents.
•   remember that clinical depression and
• if you see changes, first rule out the obvious:
anxiety are not a normal part of aging.19,20
➡ Drug interactions: was the resident started  ➡ Know the symptoms of both.
•   employ “watchful awareness.”
➡ New medical conditions: simple issues (like  ➡ Look for changes over time (weeks or  a urinary tract infection) can trigger odd  •   Be concerned about sustained changes that
➡ Dehydration: causes loss of energy and  are severe enough to interfere with your
other symptoms mimicking depression.24 resident’s life.14
•   if depression or anxiety is suspected:
➡ Loss and bereavement are “normal.” In  ➡ Perform assessments and add these results  contrast, a depressive disorder makes a  person feel worthless, helpless, hopeless.13 ➡ Notify a qualified physician or other  ➡ Situational anxiety and worrying are  prescriber if assessment results exceed  “normal.” In contrast, an anxiety disorder is  threshold values or you feel the resident’s  exaggerated, almost constant worry that the  references
1. AGS Position Statement Psychotherapeutic Medications in the Nursing Home. American Geriatrics Society. January 1997. Available at: http://www.americangeriatrics.org/products/positionpapers/psychot.
shtml. Accessed December 6, 2007. 2. Mulsant BH, Ganguli M. Epidemiology and diagnosis of depression in late life. J Clin Psychiatry. 1999;60(suppl 20):S9-S15. 3. Burrows AB, Satlin A, Salzman C, et
al. Depression in a long-term care facility: clinical features and discordance between nursing and patient interviews. J Am Geriatr Soc. 1995;43(10):1118-1122. 4. Flint AJ. Generalised Anxiety Disorders in
Elderly Patients: Epidemiology, Diagnosis and Treatment Options. Drugs Aging. 2005;22(2):101-114. 5. Smalbrugge M., Pot AM, Jongenelis K, et al. Prevalence and correlates of anxiety among nursing
home patients. J Affect Disord. 2005;88(2):145-153. 6. Mental Health: A Surgeon General’s Report. Chapter 2. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec2_1.html.
Accessed October 17, 2007. 7. National Institute of Mental Health web site. http://www.nimh.nih.gov/healthinformation/ncs-r.cfm. Accessed Aug 29, 2007. 8. Shapiro AM, Roberts JE, Beck JG.
Differentiating Symptoms of Anxiety and Depression in Older Adults: Distinct Cognitive and Affective Profiles? Cognitive Therapy and Research. 1999;23(1):53-74. 9. Atai-Otong D. Is your patient
depressed? Nursing2004. December:55-60. 10. American Association for Geriatric Psychiatry web site. http://www.aagpgpa.org/prof/facts_mh.asp. Accessed Aug 29, 2007. 11. Ranga K, Krishnan R, Delong
M, et al. Comorbidity of depression with other medical diseases in the elderly. Biol Psychiatry. 2002:52(6);559-588. 12. Medicinenet web site. Medicines that Cause Depression. http://www.medicinenet.
com/script/main/art.asp?articlekey=55169. Accessed October 18, 2007. 13. National Institute of Mental Health. Depression. National Institutes of Health; US Department of Health and Human Services.
2007. NIH Publication No. 07-3561. 14. Diagnostic and Statistical Manual of Mental Disorders. 4th edition (Text Revision). American Psychiatric Association. 2000. 15. Psychiatry Online. http://www.
psychiatryonline.com/resourceTOC.aspx?resourceID=1. Accessed Aug 29, 2007. 16. Healthyplace web site. www.healthyplace.com/Communities/Anxiety/medical_conditions.asp. Accessed January 17,
2008. 17. Murphy K. Anxiety: When is it Too Much? Nursing made Incredibly Easy! 2005. September/October:22-33. 18. Wetherell JL, Thorp SR, Patterson TL, Goshan S, Jeste DV, Gatz M. Quality of life
in generalized anxiety disorder: a preliminary investigation. J Psych Research. 2004;38:305-312. 19. Geriatric Mental Health Foundation web site. Depression in Late Life: Not A Natural Part Of Aging.
www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html. Accessed January 15, 2008. 20. Psychology Today web site. Generalized Anxiety Disorder. http://psychologytoday.com/conditions/
gad.html. Accessed January 15, 2008. 21. National Institute of Mental Health. Anxiety Disorders. National Institutes of Health; US Department of Health and Human Services. 2006. NIH Publication No. 06-
3879. 22. FDA Consumer Magazine. September-October 1997. Revised September 2003. Publication No. 03-1315C. Available at: www.fda.gov/FDAC/features/1997/697_old.html. Accessed January 16,
2008. 23. Merck Manual Online. Depressive Disorders. Available at: www.merck.com/mmpe/sec15/ch200/ch200b.html. Accessed January 16, 2008. 24. Aging Parents and Elder Care web site. http://www.
aging-parents-and-elder-care.com/pages/signs_of_Dehydration.html. Accessed January 16, 2008. 25. Stanford University web site. www.stanford.edu/~yesavage/GDS.english.short.score.html. Accessed Aug
8, 2007. 26. Kurlowicz L, Greenburg, SA. The Geriatric Depression Scale. Try This: Best Practices in Nursing Care to Older Adults. Issue Number 4, Revised 2007. 27. Pachana NA, Byrne GJ, Siddle H, et
al. Geriatric Anxiety Inventory. University of Queensland. 2000. 28. Alexopoulos GS. The Cornell Scale for Depression in Dementia. Cornell Institute of Geriatric Psychiatry. Weill Medical College of
Cornell University. Dec 2002. 29. Flint AJ. Choosing appropriate antidepressant therapy in the elderly: a risk-benefit assessment of available agents. Drugs Aging. 1998;13(4):269-280. 30. Kehoe WA. Factors
affecting the use and selection of antidepressants in the elderly. Expert Rev Neurotherapeutics. 2002;2(1):35-43. 31. Mendelson D, Ramchand R, Abramson R, et al. Prescription Drugs in Nursing Homes:
Managing Costs and Quality in a Complex Environment. NHPF Issue Brief, No. 784. November 12, 2002. 32. Neligan P. Basic Pharmacology, Part 1: Pharmacokinetics. Online tutorial. Available at: http://
www.4um.com/tutorial/science/pharmak.htm. Accessed July 25, 2007. 33. Lieberman J. Managing Anticholinergic Side Effects: Primary Care Companion. J Clin Psychiatry. 2004;6(suppl 2):S20-S23. 34.
Celexa [package insert]. St Louis, MO: Forest Pharmaceuticals, Inc.; 2007. 35. Lexapro [package insert]. St Louis, MO: Forest Pharmaceuticals, Inc.; 2007. 36. Prozac [package insert]. Indianapolis, IN: Eli
Lilly and Company; 2007. 37. Paxil CR [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2007. 38. Zoloft [package insert]. New York, NY: Roerig, a division of Pfizer, Inc.; 2007. 39.
Cymbalta [package insert]. Indianapolis, IN: Eli Lilly and Company; 2007. 40. Effexor XR [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals Inc.; 2007. 41. Lam RW, Andersen HF. The Influence of
Baseline Severity on Efficacy of Escilatopram and Citalopram in the Treatment of Major Depressive Disorder: An Extended Analysis. Pharmacopsychiatry. 2006;39:180-184. 42. Ninan PT, Wang J, Ventura
D. Escitalopram is effective and well tolerated in the treatment of severe depression. Presented at the 156th Annual Meeting of the American Psychiatric Association; May 17-22, 2003, San Francisco, CA.
43. Gorwood P, Weiller E, Lemming O, Katona C. Escitalopram Prevents Relapse in Older Patients with Major Depressive Disorder. Am J Geriatr Psychiatry. 2007;15(7):581-593. 44. McIntyre RS, Konarski
JZ, Mancini DA, et al. Improving outcomes in depression: A focus on somatic symptoms. J Psychosom Res. 2006;60(3):279-282. 45. Pigott TA, Prakash A, Arnold LM, et al. Duloxetine versus escitalopram
and placebo: an 8-month, double-blind trial in patients with major depressive disorder. Cur Med Res Opin. 2007;23(6):1303-1318. 46. Llorca PM, Azorin JM, Despiegel N, Verpillat P. Efficacy of
escitalopram in patients with severe depression: a pooled analysis. Int J Clin Pract. 2005;59(3):268-275. 47. The Hamilton Rating Scale for Depression. GlaxoWellcome Inc. Feb 1997. 48. Lader M, Andersen
HF, Bækdal, T. The effect of escitalopram on sleep problems in depressed patients. Hum Psychopharmacol Clin Exp. 2005;20:349–354. 49. Bose A, Saikali KG, Gandhi C, Chen, S. Escitalopram in the Acute
Treatment of Depressed Patients Aged 60 Years or Older. Presented at the 19th Annual Meeting of the American Association for Geriatric Psychiatry, March 10-13, 2006; San Juan, Puerto Rico. 50. Kasper S,
de Swart H, Andersen HF. Escitalopram in the Treatment of Depressed Elderly Patients. Am J Geriatr Psychiatry. 13:10, October 2005;13(10):884-891. 51. American Medical Directors Association.
Depression Clinical Practice Guideline. Columbia, MD: AMDA; 2005. 52. Wade A, Gembert K, Florea I. A comparative study of the efficacy of acute and continuation treatment with escitalopram versus
duloxetine in patients with major depressive disorder. Cur Med Res Opin. 2007;23(7):1605-1614. 53. Kaup BA, Loreck D, Gruber-Baldini AL, et al. Depression and its relationship to function and medical
status, by dementia status, in nursing home admissions. Am J Geriatr Psychiatry. 2007;15(5):438-442. 54. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin
Psychopharmacol. 1996;11(suppl 3):89-95. 55. Baldwin DS , Huusom AKT, Mæhlum E. Escitalopram and paroxetine in the treatment of generalized anxiety disorder. British Journal of Psychiatry.
2006;189:264-272. 56. Bielski RJ, Ventura D, Chang C-C. A double-blind comparison of escitalopram and venlafaxine extended release in the treatment of major depressive disorder. J Clin Psychiatry.
2004;65:1190-1196. 57. Centers for Medicare and Medicaid. Revised Facility Guide for the MDS QI/QM Reports. Baltimore, MD; Department of Health and Human Services: 2005. http://www.
nursinghomehelp.org/edmat.html. Accessed Aug 29, 2007. 58. Gorman JM, Korotzer A, Su G. Efficacy comparison of escitalopram and citalopram in the treatment of major depressive disorder: pooled
analysis of placebo-controlled trials. CNS Spectr. 2002;7(suppl 1):40-44. 59. Goodman, WK, Bose A, Wang Q. Treatment of generalized anxiety disorder with escitalopram: Pooled results from double-blind,
placebo-controlled trials. J Affect Disord. 2005;87:161-167. 60. Khan A, Bose A, Alexopoulos GS, Gommoll C, Li D, Gandhi C. Double-blind comparison of escitalopram and duloxetine in the acute
treatment of major depressive disorder. Clin Drug Invest. 2007;27:481-492. 61. Bielski RJ, Bose A, Chang CC. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of
Generalized Anxiety Disorder. Ann Clin Psychiatry. 2005;17(2):65-69. 62. Boulenger J-P, Huusom AKT, Florea I, Báekdal T, Sarchiapone M. A comparative study of the efficacy of long-term treatment with
escitalopram and paroxetine in severely depressed patients. Curr Med Res Opin. 2006;22(7):1331-1341. 63. Burke WJ, Rothschild T, de Swart H. Safety Experience with Escitalopram in the Treatment of
Elderly Patients. Presented at the 16th Annual Meeting of the American Association for Geriatric Psychiatry; March 1-4, 2003; Honolulu, HI. 64. Owens MJ, Knight DL, Nemeroff CB. Second-generation
SSRIs: human monoamine transporter binding profile of escitalopram and R-fluoxetine. Biol Psychiatry. 2001;50:345-350. 65. Sánchez C, Bergqvist PBF, Brennum LT, et al. Escitalopram, the S-(+)-
enantiomer of citalopram, is a selective serotonin reuptake inhibitor with potent effects in animal models predictive of antidepressant and anxiolytic activities. Psychopharmacology. 2003;167:353-362. 66.
Greenblatt DJ, von Moltke LL, Hesse LM, Giancarlo GM, Harmatz JS, Shader RI. The S-Enantiomer of Citalopram: Cytochromes P450 Mediating Metabolism and Cytochrome Inhibitory Effects. Presented
at the Society of Biological Psychiatry Annual Meeting; May 3-5, 2001; New Orleans, LA. 67. Dywer SP. Nursing Spectrum Drug Handbook. New York, NY: McGraw-Hill; 2007. 68. Drug interaction
database. http://www.drugdigest.org/DD/Interaction/ChooseDrugs/1,4109,,00.html. Accessed July 17, 2007. 69. Aricept [package insert]. Woodcliff Lake, NJ: Eisai Inc.; 2006. 70. Lopressor [package insert].
East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2006. 71. Remeron [package insert]. Roseland, NJ: Organon USA Inc.; 2007. 72. Protonix [package insert]. Philadelphia, PA: Wyeth
Pharmaceuticals Inc.; 2007. 73. Gorman, JM. Comorbid depression and anxiety spectrum disorders. Depress Anxiety. 1997;4(4):160-168. 74. Lydiard RB. Effects of Escalitopram on Anxiety Symptoms in
Depression. Presented at the Annual Meeting of the American Psychiatric Association; May 5-10, 2001; New Orleans, LA. 75. Porter RS, Kaplan JL, Beers MH. The Merck Manuals Online Medical Library.
The Merck Manual of Medical Information, Second Home Edition. 2007. Available at: http://www.merck.com/mmhe/print/sec02/ch014/ch014a.html. Accessed December 7, 2007. 76. Geriatric Mental Health
Foundation web site. http://www.gmhfonline.org/gmhf/consumer/late_life_depression_trtmn.html. Accessed Aug 8, 2007. 77. Drug Treatment for Depression. Primary Care Practice Toolkit. Developed by the
Practicing Physician Education Project. AGS Foundation for Health in Aging. Available at: www.americangeriatrics.org/education/depression.shtml. Accessed December 19, 2007. 78. Owens MJ. Selectivity
of Antidepressants: From the Monamine Hypothesis of Depression to the SSRI Revolution and Beyond. J Clin Psychiatry. 2004;65(suppl 4):S5-S10. 79. Nierenberg AA, Greist JH, Mallinckrodt CH, et al.
Duloxetine versus escitalopram and placebo in the treatment of patients with major depressive disorder: onset of antidepressant action, a non-inferiority study. Cur Med Res Opin. 2007;23(2):401-406. 80.
Data on file. Forest Laboratories, Inc. 81. IMS National Prescription Audit. Twelve-month rolling average. November 2006. 82. Ventura D, Armstrong EP, Skrepnek GH, Erder MH. Escitalopram versus
sertraline in the treatment of major depressive disorder: a randomized clinical trial. Cur Med Res Opin. 2007;23(2):245-250. 83. Möller H-J. Anxiety associated with comorbid depression. J Clin Psychiatry.
2002;63(suppl 14):S22-S26. 84. Burke WJ, Gergel I, Bose A. Fixed-dose trial of the single isomer SSRI escitalopram in depressed outpatients. J Clin Psychiatry. 2002;63:331-336. 85. Moore N, Verdoux H,
Fantino B. Prospective, multicentre, randomized, double-blind study of the efficacy of escitalopram versus citalopram in outpatient treatment of major depressive disorder. Int Clin Psychopharmacol.
2005;20:131-137. 86. Rapaport MH, Bose A, Zheng H. Escitalopram continuation treatment prevents relapse of depressive episodes. J Clin Psychiatry. 2004;65:44-49.

Source: http://createwriteinc.com/pdfs/Quick%20Reference%20Guides/Jan%202008%20flipbook%20excerpt.pdf