Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-076Acute Management of Late-life DepressionVeronica Gardner and David C. SteffensDuke University Medical Center, Durham, NC, USAThe acute management of late-life depression may requirehospitalization, both for accurate diagnosis and for effectivetreatment. Ambulatory management is frequently favored becauseof rising hospital costs in a managed care environment. However,the elderly present special challenges that may require that diagnosisand/or treatment be undertaken in a hospital setting. The hospitalprovides an environment for the monitoring of symptoms foraccurate diagnosis and proper personnel for regular and accuratetreatment administration. Several factors may interfere with bothaccurate diagnosis and effective treatment on an ambulatory basis 1 ,including underlying chronic medical illness, pain, neurodegenerativechanges, dementia, adverse life events, inadequate familysupport, secret self-medication, substance abuse, bereavement,interpersonal conflicts and social isolation of the elderly patient.Actually, the elderly patient who is cognitively intact may bereliably managed on an ambulatory basis and can be instructedabout medication side effects. Similarly, the more impaired elderlypatient who has adequate social support for observation andmedication management may only need the community supportof a visiting psychiatric nurse, assuming one is available. Varyinglevels of care are also implemented in the hospital environment. Apatient may have the usual care of routine monitoring or mayhave more intense one-to-one monitoring if he/she is an imminentrisk to him/herself or others.As a general rule, the more the physical and psychiatricimpairments and fewer psychosocial resources, the greater theneed to hospitalize for accurate diagnosis and effective treatment.When deciding safe and effective management, the followingfactors favor hospitalization: poor or unstable physical health,high suicide risk, impaired judgment and reality testing, likelihoodof poor compliance, impaired cognitive functioning, lack of socialsupport, and severe anorexia and weight loss.CO-MORBIDITY OF PHYSICAL ILLNESS: THEINTERFACE OF PRIMARY CARE AND PSYCHIATRYAccurate diagnosis is a prerequisite for effective treatment. Elderlypatients with depression present to their primary care physiciansand psychiatrists in a complex manner, and signs and symptoms ofphysical illness and depression overlap. Even the normal effects ofaging may cause diagnostic difficulties and restrict treatmentoptions. Many primary care physicians diagnose and treat latelifedepression without referral. However, those patients who failtwo or three trials with antidepressants, usually selective serotoninreuptakeinhibitors (SSRIs) or newer agents, are commonly referredto a psychiatrist for further management. These patients represent atreatment challenge and may require complex medication regimensthat are more successful with hospitalization. Primary carephysicians also refer for the following reasons: suicidality, comorbiditywith substance abuse, dementia, anxiety disorder,presence of psychosis (delusions, hallucinations), catatonia,bipolar disorder, and inability to tolerate antidepressant treatment2,3 . Such patients often need to be managed in the hospital.Depression is often co-morbid with other physical diseases.Approximately 80% of older adults suffer from at least one chronichealth problem 4 . The prevalence of co-morbid depression may beup to 30% in stroke patients, 18% in myocardial infarction patients,51% in patients with hip fracture, and 50% in patients withchronic pain 1 . Existence of an undiagnosed and untreateddepression with these illnesses leads to higher disability 5 . Thediagnosis of depression with certain illnesses is complex, and thehospital environment provides the necessary monitoring andsupport staff when complicated medication changes are required.For example, a patient with cardiovascular disease may presentwith decreased energy and apathy. Determining whether this iscaused by a compromised cardiac status, a medication side effect,or is actually a symptom of depression may be difficult withouthospitalization, close monitoring and various medication trials.Formerly, hospitalization was favored for the initiation oftricyclic antidepressant therapy in elderly patients with unstablecardiac disease. First-line treatment with SSRIs is now availableand proved safe for use in cardiac disease 6 .Co-morbid neurological illness is also common in geriatricdepression. Patients with depressive symptoms following acerebrovascular accident also present a diagnostic challenge.There may be communication difficulties or other neurologicabnormalities. Depression may be diagnosed only by the report ofthe nursing staff and family, who observe apathy, irritability,tearfulness and weight loss 7 . Patients with Parkinson’s disease maydevelop an affective illness or psychosis, which may be secondaryto treatment with L-dopa. Hospitalization may be required formedication changes if outpatient support is inadequate.Severe anorexia, weight loss and refusal to eat are indicationsfor hospitalization for safe and effective treatment 8,1 . Poor oralintake commonly accompanies severe depression, but it may alsoresult from a variety of medical conditions. For example,individuals with active rheumatoid arthritis may experienceinsomnia, fatigue and poor appetite equally from their physicalillness or an associated depression 9 .SUICIDE RISK AND THE DECISION TOHOSPITALIZESuicidality is the most common reason for psychiatric hospitalization.According to Jacobson 29 , three goals for inpatient treatmentare: (a) the preservation of life and safety; (b) the elimination ofPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd