Heuristic comparison of sertraline with nortriptyline for the treatment of depression in frail elderly patients.

Studies have demonstrated that the selective serotonin reuptake inhibitor antidepressants have similar efficacy to other agents, such as tricyclic antidepressants. However, data are limited for direct comparisons with other antidepressants. The authors conducted a contemporaneous comparison of nursing home residents treated with open-label sertraline in doses up to 100 mg/day with nursing home residents treated in a double-blind randomized study of low vs. regular doses of nortriptyline. There were 97 patients enrolled in the study (28 treated with sertraline), with an average treatment duration of 55 days. There were no differences in the tolerability of sertraline vs. nortriptyline. However, in this group of frail older adults, sertraline was not as effective as nortriptyline for the treatment of depression.

Drug treatment of depression in frail elderly nursing home residents.

The authors conducted a randomized, double-blind, 10-week clinical trial of two doses of nortriptyline in eight nursing homes. Sixty-nine patients, average age 79.5 years, were randomized to receive regular doses (60 mg-80 mg/day) vs. low doses (10 mg-13 mg/day) of nortriptyline. Among the more cognitively intact patients, there was a significant quadratic relationship defining a "therapeutic window" for nortriptyline plasma levels and clinical improvement. There were also significant differences in plasma level-response relationships between depressed patients who were cognitively impaired and those who were more cognitively intact. Depression remains a syndrome that responds to specific treatment, even in frail nursing home patients, and those depressions that occur in patients with significant dementia may represent a treatment-relevant condition with a different plasma level-response relationship than in depression alone.

Measuring depression in hospitalized, medically ill, older adults.

Studies have consistently shown high prevalence rates of depression associated with negative medical, functional, and psychosocial outcomes in hospitalized, medically ill, older adults. Several issues pose challenges to measurement of depression in this population. In particular, symptoms simultaneously attributable to both medical illness and psychiatric problems may confound measurement of depression, and there is no distinct boundary between normal and abnormal symptoms. This article critiques prevalence research methods used to measure depression in hospitalized, medically ill, older adults and makes recommendations regarding future measurement approaches in both research and clinical practice. Through the identification of appropriate methods for measurement of depression in this population, psychiatric nurses can make a valuable contribution in this area of research as well as enhance effective case-finding and evaluation of depression in older, hospitalized, medically ill patients in the clinical setting.

Lessons from geriatric psychiatry in the long-term care setting.

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society.

OBJECTIVE: A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research? PARTICIPANTS: Consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy. EVIDENCE: The expert presenters summarized data from the world scientific literature on the questions posed to the panel. CONSENSUS PROCESS: The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached. CONCLUSIONS: Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.

Alcohol abuse: a source of reversible functional disability among residents of a VA nursing home.

The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly.

Case studies from purgatory: maladaptive behavior within geriatrics health care teams.

The practice of geriatrics frequently involves the services of an interdisciplinary team. Behavior of team members exists on a functional continuum, from adaptive to maladaptive. Health professionals readily identify maladaptive behaviors in patients, but may ignore or avoid such behavior in colleagues. Ignoring these behaviors precludes influencing the affected team member to seek help, and can cause members to leave the team. Team members with maladaptive behavior, and persons colluding with this behavior, can negatively influence care. Using case vignettes, this article categorizes common maladaptive behavior patterns within teams and suggests intervention strategies from an individual, team, and organizational perspective.

Federal regulations and the care of patients with dementia in the nursing home.

More than half of the people residing in nursing homes in the United States have dementia. A long history of basic contradictions in the conceptualization of nursing home care in the United States has resulted in a serious mismatch between the needs of residents with dementia and the resources of nursing homes to care for these residents. Concern for this discrepancy, and the resultant inadequate and inappropriate care, provided a major impetus for nursing home reform. OBRA 87 was a broad public policy initiative intended to improve the quality of life of nursing home residents. The spirit of the legislation is embodied in federal regulations that explicitly recognize the importance of psychological and social domains of the lives of nursing home residents; restrict the use of psychotropic drugs and physical restraints; and advocate for activities and services to attain or maintain patients' highest practicable physical, mental, and psychosocial well-being. Although the impact of OBRA 87 on the quality of life of residents with dementia is unknown, the federal regulations constitute a major step in the movement for nursing home reform and toward improved quality of care.

The dying elderly patient.

Care of the dying elderly patient is commonly regarded as a hopeless endeavor, but the patient and the family can be helped to face death. The physician must become skilled at recognizing obstacles to care and understanding the concerns of the patient and the family. With proper intervention, it is possible to diminish fears and change maladaptive behavior. Positive strategies can reduce the patient's suffering, isolation and loss of autonomy.