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Contemporary Issues in the Diagnosis and Treatment of Late-Life Depression

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Identifying Depression

It has become commonplace to suggest that diagnosis of depression in the elderly is quite difficult, because of the overlap of symptoms between chronic illness and major depressive disorder. But Dr. Katz said the difficulty has probably been overstated, noting that “depression can be reliably assessed, even in the very old, and even in those with multiple chronic illnesses.”

His foundation for treating patients is a model developed and presented by an expert consensus panel on the treatment of

Depression Takes a Toll

Patients who have been admitted to a nursing home are likely to develop a self-limiting adjustment disorder that resolves as they become more familiar with their surroundings. But, said Dr. Katz, a patient who remains significantly depressed several weeks after admission deserves an evaluation for depressive disorder, mainly because the disorder is associated with major morbidity (Table 1). Depressive disorder is associated with disability, not simply because disability leads to depression;

Importance of Monitoring

Although older drugs such as nortriptyline are effective in elderly patients, it turns out that they may have unacceptable risks. Dr. Katz has explored alternatives, including sertraline.

Sertraline, although safer than older antidepressants, does not produce a high response rate at 100 mg/day. In one study, only 15 to 20% of patients treated at this level experienced remission of symptoms. Increasing the dose to 200 mg/day yields a response, but 30 to 35% of patients taking this dosage must

Isoenzyme Specificity

Dr. Pollock said that the key to anticipating the potential for drug interactions is understanding isoenzyme specificity. A large proportion of medications are metabolized by the CYP3A4 enzyme, which is the most prevalent enzyme in the liver and is also found in the intestine. Approximately 65% of prescribed drugs are metabolized by this “high-clearance, heavy-duty” enzyme.

An intriguing bit of history, explained Dr. Pollock, is that this enzyme alerted researchers to the whole area of enzyme

Costs of Treating Depression in Long-Term-Care Facilities

Certainly, the increase in the number of patients being treated for depression in long-term-care facilities has had an economic impact. Robert Valuck, PhD, RPh, an associate professor in the Department of Pharmacy Practice at the University of Colorado Health Sciences Center in Denver, looked at the cost, benefits, and cost effectiveness of using antidepressant medications—an undertaking that involved making a coherent picture out of numerous studies that have been carried out using different

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Cited by (6)

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    The Activities of Daily Living (ADL) index explores the possibilities of self care (dressing, bathing, eating…) [21] whereas the Instrumental Activities Daily Living index explores the ability to use public transportation, telephone, to drive, to go shopping, to do own checking. Depression is often underestimated in the elderly and should be adequately assessed through specific questionnaires [22]. Denutrition is also frequent in elderly patients due to various reasons: dental problems, low income, beginning of dementia [23].

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Contemporary Issues in the Diagnosis and Treatment of Late-Life Depression was sponsored by the College of Physicians and Surgeons of Columbia University and supported by an unrestricted educational grant from Forest Pharmaceuticals.

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