Management of Depression in Adults 65 Years and Older

Version / 1
Name of responsible (ratifying) committee / Formulary and Medication
Dementia Steering Group
Date ratified / 19th September 2014
Document Manager (job title) / Dr Cath Charlton (Consultant Geriatrician)
Date issued / 2ndOctober 2014
Review date / 1stOctober 2016
Electronic location / Clinical Guidelines
Related Procedural Documents
Key Words (to aid with searching) / Diagnosis, depression, antidepressant, Older Persons Mental Health, OPMH

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author

CONTENTS

  1. Introduction
  1. Status
  1. Purpose
  1. Scope
  1. Clinical Process

APPENDICES

  1. Flow chart for managing depression in Portsmouth Hospitals Trust and Referral Criteria to Older Persons Mental Health (OPMH) Psychiatric Liaison

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document

  1. Chronic physical health problems are associated with an increased incidence of depression.
  1. Prompt diagnosis and treatment of depression has the potential to increase quality of life and life expectancy.
  1. Delirium should always be excluded in patients who are being assessed for symptoms that suggest depression.
  1. Always check for suicidal ideation in patients with depressed mood. Where you identify a risk of suicide, refer the patient to the appropriate psychiatry team.
  1. Assess and document mental capacity when prescribing new medication.
  1. When prescribing medication for depression, consider interactions with other medications the patient is taking.
  1. If you make a diagnosis of depression record this in the discharge summary and hand over to the GP for follow up.

1.INTRODUCTION

Depression is characterised by low mood and / or loss of pleasure and interest in most activities. Chronic physical health problems are associated with an increased incidence of depression (2-3 times more common) and depression can worsen the pain and distress in people with physical illness and adversely affect outcomes. Good management of depression has the potential to increase their quality of life and life expectancy.

2.PURPOSE

This is a clinical guideline to guide hospital medical teams in the diagnosis and management of depression in the over 65s. It also provides the criteria for referral to Older Person’s Mental Health Psychiatric Liaison Service.

3.SCOPE

This guideline applies to all staff involved in the direct care of patients. It should be used for guidance only.

4.CLINICAL PROCESS

4.1 Diagnosing depression

To diagnose depression, symptoms should be present at sufficient severity for most of every day. The guidelines here are based on the ICD-10 criteria.

In typical depression episodes, the individual usually suffers from depressed mood, loss of interest and enjoyment and reduced energy levels, leading to increased fatigability and diminished activity. Marked tiredness after only slight effort is common. In some cases, anxiety, distress and motor agitation may be more prominent at times than the depression, and the mood change may also be masked by added features such as irritability, excessive consumption of alcohol, histrionic behaviour and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations. Symptoms should be present for 2 weeks or more. “Somatic” symptoms are: loss of interest or pleasure in activities that are usually enjoyable; lack of emotional reactivity to normally pleasurable surroundings and events; waking in the morning 2 hours or more before the usual time; depression worse in the morning; objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people); marked loss of appetite; weight loss (often defined as 5% or more of body weight in the past month); marked loss of libido.

Other common symptoms are:

a)reduced concentration and attention

b)reduced self-esteem and self-confidence

c)ideas of guilt and unworthiness (even in a mild type of episode)

d)bleak and pessimistic views of the future

e)ideas or acts of self-harm or suicide

f) disturbed sleep

g)diminished appetite

Mild depressive episode

At least two of: depressed mood, loss of interest and enjoyment, and increased fatigability, plus at least two of the other symptoms a-g above

Moderate depressive episode

At least two of: depressed mood, loss of interest and enjoyment, plus at least three (and preferably four) of the other symptoms a-g above.

An individual with a moderately severe depressive episode will usually have considerable difficulty in continuing with social, work or domestic activities

Severe depressive episode

All three of depressed mood, loss of interest and enjoyment, and increased fatigability should be present, plus at least four other symptoms a-g as above, some of which should be of severe intensity.

During a severe depressive episode it is very unlikely that the sufferer will be able to continue with social, work or domestic activities, except to a very limited extent.

Pitfalls in diagnosis

  • Be aware that the symptoms of delirium include mood symptoms, so always consider delirium in someone who appears to be depressed. In particular, hypoactive delirium shares a number of characteristics with depression (withdrawal, apathy, psychomotor retardation, low mood, poor appetite) and therefore can be easily confused. The treatment for delirium is quite different to the treatment of depression, principally identifying the underlying cause, and should be ruled out in inpatients.
  • Remember to assess and document mental capacity when you are prescribing a new medication (see Mental Capacity Act Guidelines on intranet: Mental Capacity Act (MCA). Where a patient lacks capacity to consent to an antidepressant, it is important to assess and document their best interests. This will usually include talking to their relatives or carers.
  • Elderly people and some chronically physically unwell people usually need lower doses of antidepressants than working age adults. For example, citalopram is usually started at 10mg and should not exceed 20mg. Some antidepressants are not recommended in elderly people: fluoxetine should be avoided as it can be agitating, and tricyclic antidepressants should not usually be prescribed as they are anticholinergic and therefore can worsen confusion, cardiac disorders and constipation, among other things.
  • When a patient has glaucoma, be careful to find out if this is the open or closed angle variety. In closed angle glaucoma, caution is needed as many antidepressants can exacerbate the condition.
  • ALWAYS check for suicidal ideation and plans in a patient with depressed mood and anxiety – enquiring about suicidal ideation does not increase the risk of suicide. Where you identify a risk of suicide, refer the patient to the Older Persons Mental Health Liaison Psychiatry Team.
  • Make sure you record depression as a diagnosis on the discharge summary and hand over the diagnosis and their treatment to their GP when they are discharged, requesting follow up.
  • Sometimes depression can be harder to diagnose in patients with physical illness, as there is an overlap of symptoms (e.g. anorexia, poor sleep, lack of energy, lack of interest) – a rating scale such as the Hospital Anxiety and Depression Scale can be useful in this situation to identify depression (Link to HAD Scale)
  • When prescribing antidepressants for patients with physical health problems, remember to consider their effects on the particular disorder (e.g. lofepramine can be hepatotoxic in liver disease, SSRIs can exacerbate hyponatraemia) and interactions with the other medications that the patient may be taking.

Patient information leaflets

When you identify depression in a patient, they should be offered appropriate information leaflets, such as those found on the Royal College of Psychiatrists website (Depression in Older Adults)

4.2 Medication

Sertraline and citalopram are generally the first choice for most people, as they have few effects on cardiac and renal function and relatively few drug interactions. In some cases the ‘side effects’ of some antidepressants can be useful. Mirtazapine for example can promote appetite and sleep, as well as having mild anti-emetic effects.

Choice of anti-depressants in certain physical disorders

Renal impairment: sertraline and citalopram

Epilepsy: Selective Serotonin Reuptake Inhibitor (SSRI)

Hepatic impairment: imipramine, paroxetine or citalopram (start at 10mg if severe hepatic impairment) and titrate slowly

Cardiac disease: SSRI or mirtazapine

Important interactions between antidepressants and physical health medications

The table below is not exhaustive and interactions should be checked in the BNF/SPC (Specification of Product Characteristics)

Medication for chronic physical health problem / Recommended antidepressant(s)
Non-steroidal anti-inflammatory drugs (NSAIDs) /
  • Do not normally offer SSRIs – but if no suitable alternatives can be identified, offer gastroprotective medicines (for example, proton pump inhibitors) together with the SSRI
  • Consider mirtazapine or trazodone

Warfarin and heparin /
  • Caution with SSRIs
  • Consider mirtazapine
  • Check the INR in 5-7 days when starting or stopping any drug

Aspirin /
  • Use SSRIs with caution – if no suitable alternatives can be identified, offer gastroprotective medicines together with the SSRI
  • When aspirin is used as a single agent, consider trazodone or mirtazapine

‘Triptan’ drugs for migraine /
  • Do not offer SSRIs
  • Offer mirtazapine or trazodone

MAO-B inhibitors (for example, selegiline and rasagiline) /
  • Do not normally offer SSRIs
  • Offer mirtazapine or trazodone

Theophylline, clozapine, methadone or tizamidine /
  • Offer sertraline or citalopram

Flecainide or propafenone /
  • Offer sertraline as the preferred antidepressant
  • Mirtazapine may also be used

Atomoxetine /
  • Do not offer fluoxetine or paroxetine
  • Offer a different SSRI

Swapping and stopping antidepressants

If you need to stop an antidepressant that a patient has been taking for a prolonged period (six weeks or longer), discontinuation symptoms can occur if the medication is stopped suddenly. If possible therefore, it is a good idea to gradually taper off the dose over four weeks. Certain medications, for example paroxetine and venlafaxine, may be more likely to cause discontinuation symptoms, but stopping any antidepressant has the potential to cause them.

When considering swapping from one antidepressant to another, advice from a pharmacist or psychiatrist should be sought about how to do this.

5.TRAINING REQUIREMENTS

There are no specific training requirements associated with this Clinical Guideline

6.REFERENCES AND ASSOCIATED DOCUMENTATION

NICE Clinical Guideline 90, Identification, Treatment and Management of Depression in Adults aged 18 years and older. October 2009

NICE Clinical Guideline 9, Depression in Adults with Chronic Physical Health Problems, Treatment and Management. October 2009.

Southern Health Policies, Guidelines and Shared Care Guidelines: Management of Depression in Adults and Older People.

APPENDIX A


7.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly.

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

No waste

This policy should be read and implemented with the Trust Values in mind at all times.

Management of Depression in Adults 65 Years and Older: Issue 1 Number Issue Date 02/10/2014 (Review date: 01/10/2016 (unless requirements change)

8.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations
Audit of awareness of guidelines amongst junior doctors / Dr Cath Charlton / In development / Annual / Policy audit report to:
  • MOPRS CSC
/ Dr Cath Charlton
Policy audit report to:
Policy audit report to:

The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.

The details of the monitoring to be considered include:

  • The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
  • The lead for ensuring the audit is undertaken
  • The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
  • Frequency of the monitoring e.g. quarterly, annually;
  • The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required. In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
  • The lead(s) for acting on any recommendations necessary.

Management of Depression in Adults 65 Years and Older: Issue 1 Number Issue Date 02/10/2014 (Review date: 01/10/2016 (unless requirements change)