How Pharmacists Can Identify Late-Life Depression Risk Factors and Monitor Effects of Medication

How Pharmacists Can Identify Late-Life Depression Risk Factors and Monitor Effects of Medication

Late-Life Depression Risk Factors and Effects of MedicationThe holiday season often heralds loneliness and sadness for elderly patients, adding yet another layer of risk to the other struggles responsible for late-life depression, such as comorbid disease and chronic pain. Pharmacists should make an extra effort to reach out to older patients over the holidays. If a brief conversation reveals signs of depression, encourage them to seek help. You can make a meaningful difference by gently reminding them that depression is not a part of normal aging and it can be treated.

Characteristics of Late-Life Depression

The CDC reports that about 15 percent of adults aged 65 and over are affected by depression and 1 to 5 percent of community-dwelling elderly adults meet the criteria for major depression.1 You’ll see some variation in prevalence data, depending on the population. For example, 13.5 percent of those who require home health care are depressed. The number jumps to 50 percent of adults in long-term care facilities.2 But all of the data leads to one conclusion: Depression is a significant concern for older adults.

The holidays may trigger depression, but elderly adults face risk factors throughout the year that often lead to misdiagnosis. Health care providers may not treat depression because they think it’s a temporary reaction to a life event. On the flip side, patients often view depression as a natural part of getting older, so they don’t seek treatment. Some of the common factors include:

  • Chronic disease – Depression is more common in people with other illnesses; 80 percent of older adults have at least one chronic health condition and half of them have two or more.3 Stroke, rheumatoid arthritis, Alzheimer’s disease, cancer, myocardial infarction and Parkinson’s disease are all associated with depression prevalence higher than 15 percent.
  • Functional limitations – Whether due to arthritis, another illness, or chronic pain from any cause, the inability to fulfill normal activities of daily living increases the risk for depression.
  • Significant life events – Those over the age of 65 are more likely to grieve the death of friends and loved ones or experience stressful events such as lower income and hospitalization.

Pharmacist Assessment for Depression

The latest version of the Diagnostic and Statistical Manual of Mental Disorders—DSM-5—includes eight types of depressive disorders, which differ in duration, timing, and etiology. However, they all share this common definition: “sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.”4

The primary symptoms of depression include loss of interest in daily activities, feelings of hopelessness and worthlessness, change in appetite, psychomotor agitation or retardation, and suicidality. In older adults with late-life depression, the key risk factors are narrowed down to:

  • Sleep problems
  • Disability and loss of function
  • Grief – lasting more than two months or severe enough to impair function or cause suicidal ideation
  • Previous history of depression
  • Female sex

You can easily assess most of these characteristics without being intrusive or seeming like you’re giving a formal evaluation. By virtue of being the pharmacist, you already know whether the patient receives medications to treat health conditions that may increase the risk for depression. And if you’ve ever dispensed antidepressants, you know they have a history of depression. Beyond information based on medications, all you need to do is ask a few conversational questions, such as:

  • How are you doing – are you keeping up with holiday activities?
  • You look tired, are you getting enough sleep?
  • You seem a little sad today, is everything ok?
  • Is your medication taking care of the pain or do you still have trouble walking?

At the very least, such questions let patients know they’re not alone, while demonstrating your concern for their health. If the patient’s demeanor and reply hint at depression, you can take it a step further to talk about depression.

Some people may immediately shrug off the suggestion that they’re depressed—they may take it more seriously if you tie it into their physical health. This tie-in could be through existing conditions known to cause depression or you could tell them about depression’s impact on their health. In addition to affecting sleep and appetite, leading to weight changes and fatigue, it often causes headaches and muscle pain. All of these factors need to be taken seriously because they contribute to age-related frailty, which in turn increases the risk for progressive disability and cognitive decline.

The bottom line is to let patients know that depression is not a normal part of aging, that it can have physical consequences, and that it is treatable. When you suspect late-life depression, encourage patients to see their regular physician—they may be more motivated to act when they know that treatment can be started without seeing a psychiatrist.

Monitor Adverse Effects of Antidepressants

When you dispense antidepressants to patients with late-life depression, be sure they know that a full response could take 4 to 12 weeks. Advise them to be patient and call you or their doctor before they stop taking the medication.  In addition to the usual adverse effects—and the risk for serotonin syndrome in those taking other medications and OTC products—elderly patients may be more susceptible to the following problems with particular medications:

  • Selective serotonin reuptake inhibitors – May double the risk of clinical fragility fracture, and suicide risk in men older than 66 years is 5-fold higher in the first month of treatment.
  • Serotonin–norepinephrine reuptake inhibitors – Should be avoided in patients with uncontrolled hypertension; may cause tachycardia or urinary retention.
  • Tricyclic antidepressants – TCAs are generally avoided in the elderly population and should not be used in those with urinary retention, benign prostatic hyperplasia, arrhythmias, cardiac conduction abnormalities or narrow-angle glaucoma. Elderly patients are especially vulnerable to orthostasis, dry mouth, constipation, urinary retention, blurred vision and confusion caused by TCAs.
  • Monoamine oxidase inhibitors – Like TCAs, MAOIs are not first-line treatments for late-life depression, but may be used when patients don’t respond to other agents. When delivered via a transdermal patch at the lowest dose, elderly patients may be less likely to experience weight gain or hypotension.

Pharmacist Intervention Improves Health Outcomes

Of all the reasons to encourage patients with late-life depression to seek treatment, here are two of the most compelling: Late-life depression can lead to irreversible dementia and increase the risk of all-cause death.5 With their accessibility to the community, pharmacists are often the only health care professionals able to reach out, so keep a watchful eye over your older patients this holiday season and throughout the year.

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Show 5 footnotes

  1. “CDC Promotes Public Health Approach to Address Depression Among Older Adults,” accessed November 2016, http://www.cdc.gov/aging/pdf/CIB_mental_health.pdf
  2. “Depression in the Elderly: A Pharmacist’s Perspective,” December 2013, http://formularyjournal.modernmedicine.com/formulary-journal/content/tags/alzheimers-disease/depression-elderly-pharmacist-s-perspective
  3. “Depression is Not a Normal Part of Growing Older,” March 2015, http://www.cdc.gov/aging/mentalhealth/depression.htm
  4. “Depressive Disorders,” accessed November 2016, http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm04
  5. “What Are the Causes of Late-Life Depression?” October 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4084923/
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