8 - Incontinence
Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.
Title: Essentials of Clinical Geriatrics, 5th Edition
Copyright 2004 McGraw-Hill
> Table of Contents > Part II - Differential Diagnosis and Management > Chapter 7 - Diagnosis and Management of Depression
Chapter 7
Diagnosis and Management of Depression
Depression is probably the most common example of the nonspecific and atypical presentation of illness in the geriatric population. The signs and symptoms of depression can be the result of a variety of treatable physical illnesses or the presenting manifestations of a major or minor depressive episode. Frequently, depression and physical illness(es) coexist in older patients. Thus, it is not surprising that treatable depressions are often overlooked in geriatric patients with physical illnesses and that treatable physical illnesses are often not managed optimally in geriatric patients diagnosed as having depression.
Sorting out the complex interrelationships between symptoms and signs of depression caused by physical illnesses and those caused primarily by an affective disorder or related psychiatric diagnosis challenges individuals caring for the geriatric population. Recognition and appropriate management of the onset or recurrence of geriatric depression are critical for improving quality of life and function, as well as for potentially preventing medical morbidity, optimizing health care use, and forestalling premature death. This chapter addresses these issues from the perspective of the nonpsychiatrist, recognizing that the optimal management of most of these patients should involve psychiatrists and psychologists experienced with and interested in the geriatric population.
AGING AND DEPRESSION
Symptoms and signs of depression are common in the geriatric population. The prevalence of major depression among community-dwelling older people is 1 to 2 percent, and an additional 2 percent suffer from dysthymia (a chronic depressive disorder characterized by functional impairment and at least 2 years of depressive symptoms). The prevalence of subsyndromal depression (i.e., symptoms of depression that do not meet standard criteria for major depression) approaches 25 percent (Lebowitz et al., 1997). The prevalence of these conditions
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is even higher among geriatric patients in acute care hospitals and nursing homes. Major depression is found in up to 22 percent and other depressive syndromes in up to 28 percent of acutely hospitalized older patients (Koenig, 1997). Among institutionalized older persons, major depression is found in close to 15 percent, with another 15 to 20 percent having depressive symptoms; incidence rates of these disorders in nursing homes are in a similar range (Rovner et al., 1991; Parmalee et al., 1992a). Depression is highly associated with mortality in the nursing home population (Rovner et al., 1991; Parmalee et al., 1992b). Suicide is disturbingly common in the geriatric population and its incidence continues to increase. Older white males have the highest rate of suicide up to six times that in the general population (Lebowitz et al., 1997). Several factors are associated with suicide in the geriatric population (Table 7-1).
TABLE 7-1 FACTORS ASSOCIATED WITH SUICIDE IN THE GERIATRIC POPULATION | ||||||||||||||||||||||||||||||||||||
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Several biological, physical, psychological, and sociological factors predispose older persons to depression (Table 7-2). Aging changes in the central nervous system, such as changes in neurotransmitter concentrations (especially catecholaminergic neurotransmitters), may play a role in the development of geriatric depression. Research is focusing on the central nervous system effects of cytokines, cortisol production, inflammation, and other immune responses, and the role these effects may play in the genesis of depression among medically ill geriatric patients (Lebowitz et al., 1997).
TABLE 7-2 FACTORS PREDISPOSING OLDER PEOPLE TO DEPRESSION | |
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The incidence of several specific diseases associated with symptoms of depression, the prevalence of chronic medical conditions, and the frequency of medication usage increase with age. Each of these factors can predispose older people to depression. Vascular disease in particular may play an important role in geriatric depression. Depressed geriatric patients often have comorbid vascular disorders accompanied by lesions in the basal ganglia and prefrontal areas of the brain. These patients commonly display motor retardation, lack of insight, and impairment of executive functions (Lebowitz et al., 1997).
Other psychosocial factors also predispose older people to depression. Losses are common in the geriatric population. Physical losses can mean a reduction in the ability for self-care, often leading to loss of independence; markedly reduced sensory capacities (especially vision and hearing) can result in isolation and sensory deprivation. Both can play a role in the development of depression. Memory loss and loss of other intellectual functions (dementia) are commonly associated with depression (see Chap. 6). Losses of job, income, and social supports (especially the death of family members and friends) increase with age and can predispose older people to bereavement and frank depression.
SYMPTOMS AND SIGNS OF DEPRESSION
Many common symptoms and signs can represent depression in geriatric patients. Several factors may make these difficult to interpret.
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Aging changes, as well as several common medical conditions, can lead to the physical appearance of depression, even when depression is not present.
Nonspecific physical symptoms (such as fatigue, weakness, anorexia, diffuse pain) may represent a variety of treatable medical illnesses as well as depression.
Specific physical symptoms, relating to every major organ system, can represent depression as well as physical illness in geriatric patients.
Depression can exacerbate symptoms of coexisting physical illnesses.
The physical appearance of older patients suspected of being depressed should be interpreted cautiously. Aging changes such as graying and loss of hair, wrinkled skin, loss of teeth (with altered facial architecture), stooped posture, and slowed gait can present an image of depression. Several medical conditions can further emphasize the physical appearance of depression. Parkinson's disease, which manifests itself by masked facies, bradykinesia, and stooped posture, can be misinterpreted as depression. Patients with presbycusis may appear withdrawn and disinterested simply because they cannot hear enough of normal conversation to participate actively; therefore they withdraw out of frustration. The psychomotor
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retardation of hypothyroidism may offer the physical appearance of depression. Systemic illnesses such as disseminated tuberculosis, malignancy, and malnutrition (alone or resulting from a medical condition) can produce a depressed appearance. Moreover, true depression commonly accompanies many of these medical conditions in geriatric patients (Small et al., 1996; Koenig, 1997).
Symptoms must also be interpreted very cautiously. Many different symptoms can represent depression, physical illness, or a combination of both. Table 7-3 lists several examples of somatic symptoms that may actually represent, or be exacerbated by, depression in older patients. Depression presenting primarily with physical symptoms, which as been termed masked depression, is especially common in the geriatric population for several reasons. Many of today's older generation were
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raised in an atmosphere that inhibited the expression of emotion. Finding direct expression of feelings of sadness, guilt, and anger difficult, they may somaticize these emotions and complain of physical symptoms. In addition, many older persons with diminished sensory input from losses of vision, hearing, or touch may overrespond to internal cues (such as their heartbeat and gastrointestinal motility) and focus on these concerns when they are feeling anxious and depressed.
TABLE 7-3 EXAMPLES OF PHYSICAL SYMPTOMS THAT CAN REPRESENT DEPRESSION | ||||||||||||||
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Insomnia is an example of a very common yet nonspecific symptom in the geriatric population. Although it is one of the key symptoms in diagnosing different forms of depression, a variety of factors may underlie this complaint (Table 7-4).
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Persistent complaints of sleep disturbance are, in fact, associated with depression among community-dwelling older people. In addition to depression, insomnia may be caused by other psychiatric disorders as well as several types of medical problems. For example, orthopnea and nocturia caused by congestive heart failure, abdominal discomfort from reflux esophagitis, or anxiety and restlessness from hyperthyroidism can underlie the complaint of insomnia. A careful history should help identify these and other medical conditions that might be contributing to the problem. Insomnia can also be caused by the effects of (or withdrawal from) several types of drugs and alcohol. As more older patients with sleep disturbances have undergone detailed analysis (including continuous observation during sleep and monitoring by polysomnography), other conditions have been detected, including sleep apnea and periodic leg movements. As much as one-third of the geriatric population may have a specific sleep disorder. Obstructive sleep apnea is the most common of these disorders and results not only in complaints of insomnia but also in nighttime hypoxia with associated risks for cardiac arrhythmias and myocardial and cerebral infarction. Specific symptoms, which are often elicited from the bed partner, should prompt consideration for referral to a sleep center, because hypnotics may exacerbate the conditions. Other more specific treatments are available, including continuous positive airway pressure, dental appliances, and uvulopalatopharyngoplasty. Aging itself is associated with changes in sleep patterns, such as daytime naps, early bedtime, increased time until onset of sleep, decreases in the absolute and relative amounts of the deeper stages of sleep, and increased periods of wakefulness, which could contribute to the complaint of insomnia. Thus there is a lengthy differential diagnosis of insomnia in the older patient; the complaint should not be attributed simply to aging or depression and treated with a sedating antidepressant or hypnotic before other potential causes are considered.
TABLE 7-4 KEY FACTORS IN EVALUATING THE COMPLAINT OF INSOMNIA | |
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DEPRESSION ASSOCIATED WITH MEDICAL CONDITIONS
Symptoms and signs of depression are associated with medical conditions in the geriatric population in several ways.
Some diseases can result in the physical appearance of depression, even when depression is not present (e.g., Parkinson's disease).
Many diseases can either directly cause depression or elicit a reaction of depression. The latter is especially true of conditions that cause or produce fear of chronic pain, disability, and dependence.
Drugs used to treat medical conditions can cause symptoms and signs of depression.
The environment (factors such as isolation, sensory deprivation, forced dependency) in which medical conditions are treated can predispose to depression.
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Depression among older patients with medical illnesses is associated with high levels of functional impairment (Covinsky et al., 1997) and health care costs (Unutzer et al., 1997). A wide variety of physical illnesses can present with or be accompanied by symptoms and signs of depression (Table 7-5). Any medical condition associated with systemic involvement and metabolic disturbances can have profound effects on mental function and affect. The most common among these are fever, dehydration, decreased cardiac output, electrolyte disturbances, and hypoxia. Hyponatremia (whether from disease process or drugs) and hypercalcemia (associated especially with malignancy) may also cause older patients to appear depressed. Systemic diseases, especially malignancies and endocrine disorders, are often associated with symptoms of depression. Depression accompanied by anorexia, weight loss, and back pain is commonly present in patients with cancer of the pancreas. Among the endocrine disorders, thyroid and parathyroid conditions are most commonly accompanied by symptoms of depression. Most hypothyroid patients manifest psychomotor retardation, irritability, or depression. Hyperthyroidism may also present as withdrawal and depression in older patients so-called apathetic thyrotoxicosis. Hyperparathyroidism, with attendant hypercalcemia, can simulate depression and is often manifest by apathy, fatigue, bone pain, and constipation. Other systemic physical conditions such as infectious diseases, anemia, and nutritional deficiencies can also have prominent manifestations of depression in the geriatric population.
TABLE 7-5 MEDICAL ILLNESSES ASSOCIATED WITH DEPRESSION | ||
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Because cardiovascular and nervous system diseases are among the most threatening and potentially disabling, they can precipitate symptoms of depression. Myocardial infarction, with attendant fear of shortened life span and restricted lifestyle, commonly precipitates depression. Stroke is often accompanied by depression, but the depression may not always correlate with the extent of physical disability. Patients in whom stroke has produced substantial disability (e.g., hemiparesis, aphasia) can become depressed in response to their loss of function; others whose stroke has produced only minor degrees of physical disability (but in theory may have affected areas of the brain controlling emotion) can also become depressed. Other causes of brain damage, especially in the frontal lobes, such as tumors and subdural hematomas, can also be associated with depression. Older individuals with dementia, both Alzheimer's and multiinfarct dementia, may have prominent symptoms of depression (see Chap. 6). Patients with Parkinson's disease also have a high incidence of clinically diagnosed depression. Depression that develops in response to the chronic pain, loss of function and self-esteem, dependence, and fear of death that accompany physical illness can become severe. Many older individuals who commit suicide have an active physical illness at the time of death.
Symptoms of depression are often caused not only by physical illness but also by the treatment of medical conditions. A variety of psychological responses to hospitalization (including depression) have been observed in older
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patients. Isolation, sensory deprivation, and immobilization, common in hospitalized patients with physical illness, can cause or contribute to depressive symptoms. Iatrogenic complications such as fecal impaction and urinary retention or incontinence can also cause psychological symptoms, including those of depression. Drugs are the most common cause of treatment-induced symptoms and signs of depression. Although a wide variety of pharmacologic agents can produce symptoms of depression (Table 7-6), antihypertensive agents and sedatives are probably the most common drugs that cause symptoms and signs of depression in the geriatric population (Medical Letter, 2002). The mechanisms by which various drugs cause these effects differ and are poorly understood in many instances. Some drugs such as alcohol, sedatives, antipsychotics, and antihypertensives have direct effects on the central nervous system. Thus, depressive symptoms, especially new symptoms, should raise a high index of suspicion about the role of drug and/or alcohol abuse. Whenever possible, drugs that can potentially produce these symptoms should be discontinued.
TABLE 7-6 DRUGS THAT CAN CAUSE SYMPTOMS OF DEPRESSION | ||||||||||||||||||||||||||||||||||||||
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DIAGNOSING DEPRESSION
In view of the prevalence of symptoms and signs of depression in the geriatric population; aging changes that may complicate the diagnosis; and the interrelationship between depression and its signs and symptoms, medical illnesses, and treatment effects how is the diagnosis of depression made?
Several general principles are helpful.
Questions that screen for depressive symptoms, or the use of a depression scale, may be helpful in identifying depressed geriatric patients. However, somatic components of many depression scales are less useful in older patients because of the high prevalence of physical symptoms and medical illnesses.
Nonspecific or multiple somatic symptoms that are suggestive of depression should not be diagnosed as such until physical illnesses have been excluded.
Somatic symptoms unexplained by physical findings or diagnostic studies, especially those of relatively sudden onset in an older person who is not usually hypochondriacal, should raise the suspicion of depression.
Drugs used to treat medical illnesses (see Table 7-6), sedatives, hypnotics, and alcohol abuse should be considered as potential causes for symptoms and signs of depression.
Standard diagnostic criteria should be the basis for diagnosing various forms of depression in the geriatric population, but several differences may distinguish depression in older, as opposed to younger, patients.
Major depressive episodes should be differentiated from other diagnoses such as uncomplicated bereavement, bipolar disorder, dysthymic disorder, minor depression, and adjustment disorders with a depressed mood.
Consultation with experienced geriatric psychiatrists and/or psychologists should be obtained whenever possible to help diagnose and manage depressive disorders.
Whenever there is uncertainty about the diagnosis, a judicious (but adequate) therapeutic trial of an antidepressant can be very helpful.
Several differences in the presentation of depression can make the diagnosis much more challenging and difficult in older people, as compared to younger people (Table 7-7). The most common clinical problem is differentiating major depressive episodes from other forms of depression. Table 7-8 outlines the criteria for major depression. Table 7-9 lists some of the key features that can aid in distinguishing major depression from other conditions. In addition, as much as 25 percent of community-dwelling and 50 percent of medically ill older patients and nursing home residents suffer from minor or subsyndromal depression. While the depressive symptoms may not be as
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severe as in major depression, they are associated with the development of major depression, physical disability, and heavy use of health services (Lebowitz et al., 1997).
TABLE 7-7 SOME DIFFERENCES IN THE PRESENTATION OF DEPRESSION IN THE OLDER POPULATION, AS COMPARED WITH THE YOUNGER POPULATION | |
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TABLE 7-8 SUMMARY CRITERIA FOR MAJOR DEPRESSIVE EPISODE | ||||
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TABLE 7-9 MAJOR DEPRESSION VERSUS OTHER FORMS OF DEPRESSION | ||||||||||||
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Like the early stages of dementia, depression may go unrecognized unless specific questions are asked. Many older patients who commit suicide have been seen by their physicians within the previous few weeks. At a minimum, all geriatric patients should periodically be asked such a screening question. Specific questions about other common depressive symptoms can also be added to the system review (e.g., sleep disturbance, appetite changes, trouble concentrating, lack of energy, loss of interest). Positive responses should be followed up by further questioning, especially about suicidal ideation. Table 7-10 provides examples of screening questions. A commonly used depression scale is provided in the Appendix.
TABLE 7-10 EXAMPLES OF SCREENING QUESTIONS FOR DEPRESSION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Because of the overlap of symptoms and signs of depression and physical illness and the close association between many medical conditions and depression, older patients presenting with what appears to be a depression should have physical illnesses carefully excluded.
This can almost always be accomplished by a thorough history, physical examination, and basic laboratory studies (Table 7-11). Other diagnostic studies can provide helpful objective data in patients with persistent somatic symptoms that are difficult to distinguish from psychosomatic complaints (e.g., masked depression). For example, echocardiography and radionuclide cardiac scans can help rule out organic heart disease as a basis for chest pain, fatigue, and dyspnea. Pulmonary function tests can exclude intrinsic lung disease as a cause for chronic shortness of breath. A new complaint of constipation may be related to
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depression but may also be caused by hypothyroidism or colonic disease; thus a test for occult blood in the stool, barium enema or colonoscopy, and thyroid function tests can be helpful in the evaluation of this symptom.
TABLE 7-11 DIAGNOSTIC STUDIES HELPFUL IN EVALUATING APPARENTLY DEPRESSED GERIATRIC PATIENTS WITH SOMATIC SYMPTOMS | ||||||||||||||||||||
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MANAGEMENT
General Considerations
Several treatment modalities are available to manage depression in older persons (Table 7-12). Both pharmacological treatment and psychotherapy have some effectiveness in mild to moderate depression in the outpatient geriatric population (McCusker et al., 1998). A randomized controlled trial has documented the effectiveness of a depression treatment program that includes both nonpharmacological and pharmacological treatment coordinated by a care manager with the support of mental health expertise (Unutzer et al., 2002). The choice of treatment(s) for an individual patient depends on many factors, including the primary disorder causing the depression, the severity of symptoms, the availability and
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practicality of the various treatment modalities, and underlying conditions that might contraindicate a specific form of treatment (e.g., disorders of vision and hearing that make psychotherapy difficult or severe cardiovascular disease that precludes the use of certain antidepressants).
TABLE 7-12 TREATMENT MODALITIES FOR GERIATRIC DEPRESSION | |
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When a specific active medical condition or drug is suspected as the cause of or contributor to the symptoms and signs of depression, these factors should be attended to before other therapies are initiated unless the depression is severe enough to warrant immediate treatment (e.g., the patient is delusional or suicidal). Treatment of the medical condition should be optimized and all drugs that could be worsening the depression should be discontinued if medically feasible.
Nonpharmacological Management
Supportive measures, such as those listed in Table 7-12, and psychotherapy are often ignored, but they can be very helpful in managing depressed patients; they may also be useful adjuncts to other treatments for patients with more severe depressions. Standard approaches to psychotherapy, such as cognitive behavioral therapy and interpersonal therapy, are effective in depressed geriatric patients. However, no single approach appears to be more effective than others. Geriatric patients with depressions caused by uncomplicated bereavement, adjustment disorders
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related to a psychosocial stress (retirement, family conflicts, etc.) or physical conditions (myocardial infarction, stroke, hip fracture, etc.), dysthymic disorder, and minor depression may respond well to supportive measures and psychotherapeutic approaches.
Many depressed patients have hearing impairments, other physical disabilities, or cognitive impairment that can make group and individual psychotherapy difficult. Behavioral treatment may be effective in some dementia patients who are depressed (Teri et al., 1997). Outpatient psychiatric partial hospitalization programs are available in many communities and may be especially helpful in managing frail depressed patients who are isolated during the day.
If pharmacological treatment is contraindicated by medical conditions or fails, or if rapid relief from depression is desired (as might be the case in delusional, suicidal, or extremely vegetative patients), electroconvulsive therapy (ECT) should be considered. ECT is relatively safe and can be highly effective in the geriatric population. Certain added precautions are necessary in older patients with hypertension and cardiac arrhythmias (such as close cardiac monitoring and diminished doses of pretreatment atropine), and cardiology consultation is advisable in these situations. Adequate pretreatment muscle relaxation will help avoid musculoskeletal complications, which are of special concern in those patients with osteoporosis. Posttreatment confusion and memory loss is usually mild and improves as the depression subsides.
Pharmacological Treatment
When symptoms and signs of depression are of sufficient severity and duration to meet the criteria for major depression (see Table 7-8), or if the depression is producing marked functional disability or interfering with recovery from other illnesses, drug treatment should be considered.
When pharmacological treatment is initially considered, the patient and family should be educated to understand that an adequate therapeutic trial may take at least 4 to 6 weeks. If this is not discussed, patients may become discouraged by a lack of a rapid response to therapy.
Several types of drugs are available to treat depression in the geriatric population (Table 7-13). While many antidepressants have been studied in these patients, limitations in study designs, outcome measures, patient characteristics, and sample sizes make the clinical utility of several of these agents difficult to assess (Rigler et al., 1998). Experts recommend at least 6 months of therapy beyond recovery for patients with their first onset of depression in late life, and at least 12 months for those with recurrent depression. Some older patients with recurrent depression may need to be treated indefinitely (Lebowitz et al., 1997).
TABLE 7-13 CHARACTERISTICS OF SELECTED ANTIDEPRESSANTS FOR GERIATRIC PATIENTS | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclics as the first-line drug treatment for geriatric depression. Studies suggest that these agents are useful in treating depressed older people, but they have not been well studied in frail and medically ill geriatric patients. In one randomized, placebo-controlled trial, paroxetine was beneficial in older patients with dysthymia and more severely impaired patients with minor depression (Williams et al., 2000). All SSRIs are metabolized by the liver and excreted by the kidney. Fluoxetine and its partially active metabolite have especially long half-lives. In addition, fluoxetine and paroxetine are potent inhibitors of the hepatic cytochrome P450 microsomal enzyme system. Toxicity can occur when these drugs are used concurrently with drugs that are metabolized by this system. Elevated levels or toxicity can occur with several drugs used relatively commonly in the geriatric population, including:
Antiarrhythmics (type 1C)
Anticonvulsants
Antipsychotics
Astemizole
Benzodiazepines
Beta blockers
Calcium-channel blockers
Carbamazepine
Cisapride
Codeine
Erythromycin
Oral hypoglycemics
Terfenadine
Theophylline
Tricyclics
Warfarin
The major side effects of SSRIs include gastrointestinal symptoms (nausea, vomiting, diarrhea), agitation, weight loss, sexual dysfunction, akathisia, and parkinsonian effects. These agents are also associated with the syndrome of inappropriate antidiuretic hormone (SIADH) and may thus cause or contribute to hyponatremia.
Tricyclic antidepressants may be effective, but they have anticholinergic and potential cardiovascular side effects. These include dry mouth, constipation, gastroesophageal reflux, blurred vision, cognitive impairment, tachycardia, and postural hypotension. Tricyclics and SSRIs are associated with falls and hip fracture (Thapa et al., 1998). In one study of older depressed patients with ischemic heart disease, paroxetine was associated with significantly fewer adverse cardiac events (2 percent) than was nortriptyline (18 percent) (Roose et al., 1998). Postural hypotension is a special
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concern in frail geriatric patients already at risk for falls. Tricyclics, like SSRIs, are associated with SIADH.
Other antidepressants such as venlafaxine, bupropion, mirtazapine, and nefazodone are available (see Table 7-13). Experience with these drugs suggest that they may be useful in geriatric depression. Both venlafaxine and mirtazapine should be used carefully in patients with underlying hypertension. Nefazodone may be useful in depressed older patients with prominent anxiety. This drug cannot, however, be used in conjunction with cisapride or the antihistamines terfenadine and astemizole, as it inhibits their metabolism and may thereby lead to life-threatening ventricular arrhythmias.
Methylphenidate (Ritalin) in small doses (10 mg one to three times a day) has been effective and safe in some geriatric patients with retarded depressions and cardiovascular disease. Its effects may diminish over time, and anorexia can be a side effect. Monoamine oxidase inhibitors (such as isocarboxazid, phenelzine, and tranylcypromine) have been used in geriatric patients, but necessitate a relatively strict diet (avoidance of tyramine-rich foods) and can cause prominent hypotension. SSRIs must be discontinued 2 weeks (6 weeks for fluoxetine) before initiating treatment with one of these drugs.
For patients with bipolar disorder, lithium is useful in treating the manic phase of the illness and in preventing recurrent depression. It may also enhance the effects of other antidepressants in treating unipolar depression. Lithium has a very narrow therapeutic:toxic ratio and must be used very carefully in the geriatric population. Its renal clearance is diminished, and blood levels can be influenced by diuretics and angiotensin-converting enzyme (ACE) inhibitors. Blood levels should be monitored once or twice weekly until a stable dosage is achieved and then at least monthly. Dosages of 150 to 300 mg three times a day generally yield adequate blood levels in the elderly (0.3 to 0.6 mEq/L for maintenance). Older patients are particularly susceptible to lithium toxicity, especially tremor and delirium. Hypothyroidism can occur in patients on lithium, and thyroid function tests should be monitored periodically in patients on chronic therapy.
Depressed geriatric patients with psychotic features (paranoid and other types of delusions, hallucinations) may also require antipsychotic drug treatment. These drugs, as well as sedative and hypnotic agents (which are also useful in some depressed older patients with prominent anxiety or psychomotor agitation), are discussed in Chap. 14.
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Suggested Readings
Finkel SI: Efficacy and tolerability of antidepressant therapy in the old-old. J Clin Psychiatry 57:23 28, 1996.
Hay DP, Rodriguez MM, Franson KL: Treatment of depression in late life. Clin Geriatr Med 14:33 46, 1998.
Kelly KG, Zisselman M: Update on electroconvulsive therapy (ECT) in older adults. J Am Geriatr Soc 48:560 566, 2000.
Kennedy GJE: Suicide and Depression in Late Life: Critical Issues in Treatment, Research, and Public Policy. New York, Wiley, 1996.
Martin LM, Fleming KC, Evans JM: Recognition and management of anxiety and depression in elderly patients. Mayo Clin Proc 70:999 1006, 1995.
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