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Avoiding Drug-Induced Depression in Nursing Home Residents

October 1, 2004
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Creating residents' depression is the last thing you need-and it's highly avoidable by Brian Garavaglia, PhD

Many individuals are admitted to acute, subacute, and long-term care facilities each year suffering from a depression that may never be recognized as a treatable illness by physicians, nurses, or other clinical practitioners. For some residents, however, depression can be created by clinical intervention. This article examines both occurrences of depression in nursing home residents.

Although the Epidemiologic Catchment Area Survey found that incidence of depression in the older adult general population was actually lower than for other age groups,1 this may be an underestimate and have little bearing on long-term care facilities. Katz and Parmelee have estimated that the rates of depression within nursing home residents may dramatically exceed those found in the general population, involving some 30 to 50% of the nursing home population.2

In the general population it has been estimated that the older adult takes approximately four medications daily. Those within the long-term care setting take double that number, averaging approximately eight medications, with a large number of them strongly affecting the central nervous system.3 What does this have to do with depression in the older adult? Possibly more than we'd like to think.

Before addressing pharmacogenesis of depression, however, consider another factor: Depression in the older adult is often more difficult to diagnose than in younger people. One reason is a prevailing misconception within general society, and even within the professional community, that older adults are supposed to be depressed, that it is a natural part of getting older. In fact, an older adult's functional status, or level of impairment thereof, is often more influential than mere aging in shaping a person's mood.4,5 The residents of nursing homes usually have significant levels of debilitation, often arising from numerous chronic conditions. The complex nature of these conditions often frustrates physicians and treatment staff, often leading residents to have a sense of sadness or depression.6,7

We know, however, that improving the functional status of the individual, even through palliative measures, can often improve mood. This could include measures as simple as providing proper-fitting dentures to improve dietary intake, providing a mattress that enables the resident to rest and sleep better, or establishing and maintaining proper therapy or rehabilitative nursing to help the resident with maintaining movement and flexibility.

Nevertheless, one major problem underlies all of the frustrations with helping older adults in nursing homes: The nursing home is an institutional environment that has become medicalized. Nursing homes are viewed as an extension of the acute-care industry, in which treatment means medical treatment, especially through the use of polypharmaceutical interventions. In fact, residents, family, and staff have come to believe that this is what skilled nursing facilities should be predicated on. Although some nursing facilities have tried recently to move beyond the medical model and adopt a more psychosocial environment (e.g., The Eden AlternativeÖ), most continue to exist as "institutions" firmly entrenched in the medical model.8 These are environments that are exogenously conducive toward depression.9

Even with the modern emphasis on creating a more "homelike" environment, nursing facilities continue to exist as de facto extensions of the acute care medical industry, caring for those who are usually quite ill and severely compromised, with the paramount response being medical intervention. This is a sad and somber setting at best, making it all the more difficult to identify true depression in a resident. Think of how difficult it is for many on your staff to accurately code the section of the MDS differentiating depression from a sad or somber affect.

I have already mentioned that most older adults in nursing facilities are on approximately eight medications. Approximately half these medications are likely to have a depressant effect.10 It has also been estimated that adverse drug reactions occur in 15 to 25% of older adults, with adverse reactions from psychoactive medications being implicated in 23% of nursing home residents.11,12 Many of the medications residents use can cause or mimic symptomatology of depression. For example, antihypertensive/cardiac drugs, such as calcium channel blockers, beta blockers, digitalis, and the cardiac glycosides, can cause depression yet may never be considered for this. Levodopa for Parkinson's disease and corticosteroids for inflammation are also associated with depression. Antineoplastics, such as Arimidex and tamoxifen, and even certain antibiotics, such as Bactrim, Flagyl, and Cipro, can induce depression or depressive-like symptoms.13