Provider Management Resources

Updated: Oct 21, 2021

IMPORTANCE OF GERIATRIC DEPRESSION IDENTIFICATION:


Knowledge of psycho-social and biological risk factors of depression is essential for practitioners, but it is just as important to be aware of current effective screening tools for identifying depressive symptoms during office visits. Here are some facts:


o Depression affects more than 18 million people in the US, and of those affected, over 41,000 die by suicide (Hope for Depression, 2020). o Mental health illness is one of the costliest to United States healthcare – resulting in an expense of over $210 billion annually (Greenberg et al., 2015). o Geriatric depression (GD), in particular, is often overlooked and under-treated in primary care settings, leading to a drastically diminished quality of life for the aging population. o A percentage as high as 10% of older adults have clinically significant depression, but only about half of those are diagnosed, leading to only 1 in 5 depressed older adults receiving appropriate treatment in primary care (Park & Unutzer, 2011). o Depression is a major risk factor for suicide in the elderly, who account for approximately 24% of all completed suicides (Espinoza & Unutzer, 2019). o White men age 85 or older have the highest rate of completed suicide 55 per 100,000 (Espinoza & Unutzer, 2019). o Most elderly suicide victims were in their first episode of depression and had seen a physician within the last month of life (Espinoza & Unutzer, 2019).


 

RISK FACTORS FOR GERIATRIC DEPRESSION

o Female sex o Social isolation o Widowed, divorced, or separated marital status o Lower socioeconomic status o Comorbid general medical conditions o Uncontrolled pain o Insomnia o Functional impairment o Cognitive impairment o Nursing home residents (as many as 50%)


 

SCREENING


The Geriatric Depression Scale Screening Tool (GDS-15): The Geriatric Depression Scale (GDS) and version GDS-15 specifically is highly acclaimed in the literature for it’s ability to identify depression in the geriatric population.

FIND IT HERE: https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF

o How to interpret: 0-4 normal, 5-8 Mild depression, 9-11 Moderate depression, 12-15 Severe depression

o Next steps: In general, mild forms of GD can be managed with psychotherapy as a stand-a-lone treatment, with the addition of pharmacologic agents if necessary. For the treatment of moderate GD, antidepressant treatment is recommended. If a patient presents with severe GD, antidepressant treatment and a referral to mental health services are recommended (Blackburn et al., 2017).


How to identify depression in the COGNITIVELY IMPAIRED patient:

  • Traditional Geriatric Depression screening tools may be used in the patient with cognitive impairment, but the Cornell Scale for Depression is geared specifically to this patient population.

  • FIND IT HERE: Cornell scale for depression in dementia: https://www.michigan.gov/documents/mdch/bhs_CPG_Depression_Appendix_2_206523_7.pdf

  • The provisional diagnostic criteria for depression in Alzheimer’s disease can also be used to help identify depression in those with cognitive impairment:

(Brockman, et al., 2011)


 

Guidelines for Management of Geriatric Depression


  • SAMHSA's Practitioner's Guide for the Treatment of Depression in Older Adults:


Contents:


 

  • UpToDate Provider Management of Late-Life Unipolar Depression:

  • Treatment Outline:

  • A complete history will dictate treatment decisions

  • Determine whether the patient is using medication(s) with depressant side effects or is abusing alcohol

  • Assessment of suicidality, psychotic symptoms, hopelessness, insomnia, and malnutrition

  • Considerations of other medical conditions commonly associated with depressive symptoms (thyroid disease, diabetes, pain syndromes)

  • History of prior depressive episodes and family history

  • First line treatment of depression consists of psychotherapy and somatic therapy (medication or electroconvulsive therapy)

  • Choice of treatment depends on severity, type, and chronicity of the depressive episode, contraindications to medication, treatment access, and patient preference.

  • Several studies suggest treatment programs that offer a choice of medication and/or psychotherapy in primary care combined with patient outreach by a care manager in a collaborative care model, have significantly better outcomes than usual care.

  • Psychotherapy (cognitive behavioral therapy, interpersonal psychotherapy, problem solving psychotherapy, etc.) is useful but frequently underutilized due to lack of availability of adequately trained therapists and incomplete health insurance coverage.

  • Antidepressants are efficacious based on research.

  • Monotherapy is preferred in the elderly to minimize drug side effect and drug-drug interactions.

  • Typically take 4-6 weeks to show efficacy.

  • Start at lowest dose and follow up in 2-4 weeks to assess response.

  • The usual course of treatment for the first lifetime episode of unipolar major depression in adults is 6-12 months beyond the time of achieving full remission.

  • For older patient who experience frequent relapses or recurrences, long-term treatment may be needed.

  • Selective serotonin reuptake inhibitors (SSRIs)

  • Considered first line for treatment of depressive disorders in older adults due to better tolerability, ease of use, and general safety, especially in overdose.

  • Potential side effects of SSRIs of special concern in the elderly include Parkinsonism, akathisia, anorexia, sinus bradycardia, and hyponatremia.

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)

  • Include venlafaxine and duloxetine

  • Second line agents

  • May be useful in patients with comorbid pain

  • There is a dose dependent risk of diastolic hypertension

  • Monitor for SEROTONIN SYNDROME – which manifests as altered mental status, myoclonus, tremors, hyperreflexia, fever, and autonomic changes among other findings.

  • Atypical antidepressants

  • Include agomelatine, bupropion, and mirtazapine.

  • Few studies exist in populations of the elderly

  • Serotonin modulators

  • Include nefazodone, trazodone, and vilazodone

  • Tricyclic and tetracyclic antidepressants

  • No longer considered first of second-line agent for treatment of depression in any age group

  • May be useful for treatment failure with other agents

  • Monoamine oxidase inhibitors (MAOIs)

  • Rarely used – except when previously initiated and tolerated or in the patient who is resistant to treatment with all other antidepressants

  • Would require special dietary and medication restrictions to prevent serotonin syndrome and hyperadrenergic crisis

  • Best prescribed by psychiatrist

  • Adjunctive medications

  • Methylphenidate

  • Aripiprazole

  • Other: Lithium and triiodothyronine

  • Quetiapine

  • Neurostimulation

  • Electroconvulsive therapy (ECT)

  • Other brain stimulation therapies

  • Exercise

  • Multiple studies indicate that physical exercise is beneficial for depressed patients 60 and older

  • Bright light therapy

  • Collaborative care

  • Among patients with major depression, the risk of death was 24% less with collaborative care than usual care

  • Home based care

  • Family support

  • Find the full article here: https://www.uptodate.com/contents/diagnosis-and-management-of-late-life-unipolar-depression?search=geriatric%20depression&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H20


Antidepressant Dosing Chart for Geriatric Use:

(Wiese, 2011)


Pharmacology Algorithm for Medication Selection:

(Mulsant et al., 2014)



Important Prescribing Notes for Antidepressants in Geriatrics:
  • SSRIs are first line treatment. The SSRIs with the best safety profile include citalopram, escitalopram, and sertraline.

  • Of the SSRIs, fluoxetine is generally not recommended for the elderly due to long half-life and prolonged side effects. Paroxetine has the greatest anticholinergic effect of all the SSRIs.

  • Common side effects with SSRIs include: nausea, dry mouth, insomnia, somnolence, agitation, diarrhea, excessive sweating, and sexual dysfunction (not as common)

  • As renal function decreases in aging, there is increased risk of hyponatremia secondary to SIADH with SSRIs.

  • MUST obtain sodium level one month after initiation SSRI tx

  • There is increased risk of GI bleed with SSRIs, especially if the patient has a history of peptic ulcer disease or taking any anti-inflammatory medication.

  • Tricyclic antidepressants are NOT considered first or second-line agents for older adults given their potential for side effects, including postural hypotension, which can contribute to falls and fractures, cardiac conduction abnormalities, and anticholinergic effects.

  • Given the side effect profile and high rates of drug-drug interactions, monoamine oxidase inhibitors (MAOIs) are not considered first- or even second-line agents for depression in the elderly (Wiese, 2011).


Notes on Antidepressant Discontinuation Syndrome:
  • About 20% of patients develop antidepressant discontinuation syndrome following an abrupt stoppage of or marked reduction in the dose of an antidepressant taken continuously for one month.

  • Symptoms are usually mild and may occur following treatment with any type of antidepressant.

  • Symptoms occur within two to four days after drug cessation and usually last one to two weeks (occasionally may persist up to one year).

  • If the same or a similar drug is started, the symptoms will resolve within one to three days.

  • Among the serotonin reuptake inhibitors, paroxetine is associated with the highest incidence of the syndrome and fluoxetine with the lowest. Because of venlafaxine's short half-life, the syndrome may occur more frequently following cessation and symptoms may be more severe.

(Gabriel & Sharma, 2017)


Medications Known to Contribute to Depressive Symptoms:

(Avasthi & Grover, 2018)


 

Nonpharmacologic Treatment Key Points:
  • Health promotion/lifestyle strategies such as nutrition, exercise, meditation

  • Lifestyle management

  • We should consider a “Lifestyle Medicine” approach for the potential prevention, promotion and management of depression.

  • While medication and psychological interventions are first-line treatments for depression, Lifestyle Medicine offers a potentially safe and low-cost option for augmenting the management of the condition.

  • While the evidence base remains patchy, many lifestyle or environmental factors are modifiable and can provide the basis of practical interventions for the management of depression.

Lifestyle Medicine for Depression Evidence Summary

(Sarris et al., 2014)

Overview of Evidence Levels (To associate with above chart)

(Lander & Balka, 2019)



 

Treatment Algorithms:

1)

(Loeb et al., 2015)



2) Formulating a Treatment Plan from the Indian Journal of Psychiatry

(Avasthi & Grover, 2018)



 

Depression in the setting of addiction: Evidence and Treatment Guidelines

Although illicit drug use typically declines after young adulthood, nearly 1 million adults aged 65 and older live with a substance use disorder (SUD) (Lehmann & Fingerhood, 2018).


“Many behavioral therapies and medications have been successful in treating substance use disorders in older adults. Little is known about the best models of care, but research shows that older patients have better results with longer durations of care. Ideal models include diagnosis and management of other chronic conditions, re-building support networks, improving access to medical services, improved case management, and staff training in evidence-based strategies for this age group (Lehman & Fingerhood, 2018).”



 

When to Refer to the Emergency Department:

(Avasthi & Grover, 2018)



 

How to include spouse/caregiver in plan of care:

 

Coding

  • ICD 10 Codes

  • 10F33.0 - Major depressive disorder, recurrent, mild

  • 10F33.1 - Major depressive disorder, recurrent, moderate

  • 10F33.2 - Major depressive disorder, recurrent severe without psychotic features

  • 10F33.3 - Major depressive disorder, recurrent, severe with psychotic symptom

  • CPT Codes

  • CPT Code 96127 (brief emotional /behavioral assessment) can be billed for a variety of screening tools, including the PHQ-9 for depression, as well as other standardized screens for ADHD, anxiety, substance abuse, eating disorders, suicide risk. For depression, use in conjunction with the ICD-10 diagnosis code Z13 (Encounter for screening for other diseases and disorders).


 


References


Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian Journal of Psychiatry, 60 (Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474


Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. British Columbia Medial Journal, 59(3), 171–177. Retrieved from: https://bcmj.org/articles/depression-older-adults-diagnosis-and-management


Brockman, S., Jayawardena, B., & Starkstein, S. (2011). The diagnosis of depression in Alzheimer’s disease: Review of the current literature. Neuropsychiatry, 1(4), 377–384. https://doi.org/10.2217/npy.11.39


Espinoza, R., & Unützer, J. (2019). Diagnosis and management of late-life unipolar depression. UpToDate. https://www.uptodate.com/contents/diagnosis-and-management-of-late-life-unipolar-depression?search=geriatric%20depression&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H20


Gabriel, M., & Sharma, V. (2017). Antidepressant discontinuation syndrome. CMAJ : Canadian Medical Association Journal, 189(21), E747. https://doi.org/10.1503/cmaj.160991


Greenberg, P. E., Fournier, A.-A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The Economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry, 76(02), 155–162. https://doi.org/10.4088/JCP.14m09298


Hope for Depression Research Foundation. (2020). Facts about Depression. Retrieved July 21, 2020, from https://www.hopefordepression.org/depression-facts/


Lander, B., & Balka, E. (2019). Exploring how evidence is used in care through an organizational ethnography of two teaching hospitals. Journal of Medical Internet Research, 21(3), e10769. https://doi.org/10.2196/10769


Lehmann, S. W., & Fingerhood, M. (2018). Substance-Use Disorders in Later Life. New England Journal of Medicine, 379(24), 2351–2360. https://doi.org/10.1056/NEJMra1805981


Loeb, D., Sieja, A., Corral, J., Zehnder, N. G., Guiton, G., & Nease, D. E. (2015). Evaluation of the role of training in the implementation of a depression screening and treatment protocol in 2 academic outpatient internal medicine clinics utilizing the electronic medical record. American Journal of Medical Quality : The Official Journal of the American College of Medical Quality, 30(4), 359–366. https://doi.org/10.1177/1062860614532681


Mulsant, B. H., Blumberger, D. M., Ismail, Z., Rabheru, K., & Rapoport, M. J. (2014). A systematic approach to the pharmacotherapy of geriatric major depression. Clinics in Geriatric Medicine, 30(3), 517–534. https://doi.org/10.1016/j.cger.2014.05.002


Park, M., & Unützer, J. (2011). Geriatric Depression in Primary Care. Psychiatric Clinics of North America, 34(2), 469–487. https://doi.org/10.1016/j.psc.2011.02.009


Sarris, J., O’Neil, A., Coulson, C. E., Schweitzer, I., & Berk, M. (2014). Lifestyle medicine for depression. BMC Psychiatry, 14(1), 107. https://doi.org/10.1186/1471-244X-14-107


Sepehry, A. A., Lee, P. E., Hsiung, G.-Y. R., Beattie, B. L., Feldman, H. H., & Jacova, C. (2017). The 2002 NIMH Provisional Diagnostic Criteria for Depression of Alzheimer’s Disease (PDC-dAD): Gauging their Validity over a Decade Later. Journal of Alzheimer’s Disease, 58(2), 449–462. https://doi.org/10.3233/JAD-161061


Wiese, B. S. (2011). Geriatric depression: The use of antidepressants in the elderly. British Columbia Medial Journal, 53(7). https://bcmj.org/sites/default/files/BCMJ_53_Vol7_depression.pdf

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