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Symptoms of depression and anxiety in elderly, medication for insomnia australia - How to DIY

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Although the prevalence of anxiety and depressive disorders among community-residing older adults is lower than in middle-aged persons, there are high rates of both in older people admitted to general hospitals, those receiving domiciliary care, and those residing in nursing homes. With increasing longevity in developed and most developing countries, both the proportion and the absolute number of older people are rising worldwide. Although anxiety and depressive disorders can usually be distinguished from one another in older people, there is substantial comorbidity between the two.
The majority of older people with anxiety and depression are seen in primary care settings. It is important to check cognitive function in older people presenting with anxiety and depressive symptoms. It is often useful to obtain a quantitative estimate of the subjective severity of anxiety or depression using rating scales specifically developed for use in older people. General medical problems become more common with advancing age and must be excluded as potential causes and complications of anxiety and depression. The excessive use of caffeine-containing beverages, including coffee and cola drinks, is associated with clinically significant anxiety symptoms in vulnerable individuals.
Many general medical conditions are associated with anxiety or depression, including ischemic heart disease, stroke, asthma, emphysema, diabetes mellitus, cancer, Alzheimer’s disease, and virus infections. There are several nonspecific interventions that are likely to assist many older people with anxiety or depressive disorders; these include psycho education, sleep hygiene, and relaxation training. Most treatments for anxiety and depression in older people can be carried out in primary care settings by appropriately trained general practitioners, clinical psychologists, and nurse practitioners.
Although benzodiazepines are in widespread use for the treatment of anxiety symptoms and anxiety disorders in adults of all ages, they have a number of disadvantages.
Antidepressants are the preferred pharmacological treatment for both anxiety and depressive disorders in older people. Combined treatment with antidepressant medication and manual- based psychotherapy (cognitive behavior therapy [CBT] or interpersonal psychotherapy [IPT]) has been shown to improve efficacy both in the acute phase and during relapse prevention in major depression. While the use of antidepressant medication is an important component of the treatment of both anxiety and depression in older people, it is often associated with adverse effects. Psychological interventions are often preferred in older people with mild to moderate anxiety or depression.
ECT is used to treat severely depressed older people and is highly effective in this context.24 It can be lifesaving in older people who are not eating and drinking, who are psychotic, or who are actively suicidal. There is no known method for the universal, population-wide prevention of anxiety or depression in older people.
There is also evidence for the selective prevention of depression in specific contexts, including macular degeneration.
Anxiety and depressive disorders are not uncommon in later life and frequently complicate the common medical problems of later life.
High rates of anxiety and depression also occur in older people with mild cognitive impairment and dementia. This likely reflects shared etiological factors, including polygenic influences, trait neuroticism, childhood adversity, adult adverse life events, physical illness, substance abuse, effects of medication, and cognitive impairment.
This appears to be due to the combined effects of reduced income, reduced tolerance to the effects of alcohol and other drugs, and social disapproval. Where this is not the case, the assessment and management of an older person should be undertaken in collaboration with his or her general practitioner (primary care physician) because of the strong nexus between mental health and physical health in older people. Although several scales are now available, the most accessible are the Geriatric Depression Scale6 and the Geriatric Anxiety Inventory.7 Both are also available in 5-item short forms8,9 for rapid screening in general medical settings.
Clinical judgment is required in ordering laboratory investigations and neuroimaging studies.
In addition, it is prudent to optimize cognitive function as part of a broader treatment plan for anxiety and depression in older people.
First of all, their efficacy has been demonstrated only in short-term studies and it is likely that they actually increase anxiety symptoms in the longer term through withdrawal effects and by limiting environmental exposure.
There is little evidence to suggest that one antidepressant is superior in efficacy to another, so choice of agent is made mainly on the basis of past history of response and expected adverse effect profile.
It is likely that the same combination would also be associated with improved efficacy in the management of late-life anxiety disorders, although no methodologically sound clinical trials of combination treatment have been published. The collaborative care program involved a depression care manager, a primary care physician, and a psychiatrist, who provided psycho education, behavioral activation, antidepressants, problem- solving therapy, and relapse-prevention strategies. However, there is some evidence for the indicated prevention of depression and anxiety in those showing early symptoms. Evidence-based psychological and pharmacological treatments are available for the treatment of anxiety and depressive disorders in older people.
This effect, in combination with cognitive aging, is likely to lead to increased rates of both anxiety and depression.
Less common anxiety disorders in late life include panic disorder, agoraphobia, social phobia, posttraumatic stress disorder, and obsessive-compulsive disorder. It also reflects to some extent an overlap in symptoms, particularly between major depressive disorder and GAD. However, those older people with substance use disorders do commonly have an anxiety and depressive disorder as well. A physical examination with special emphasis on neurological and cardiovascular function is recommended as part of the routine work-up.

In addition, cognitive screening tests, other than the Informant Questionnaire for COgnitive Decline in the Elderly (IQCODE),4 do not establish the extent of cognitive change over time. However, the following blood tests are commonly requested: full blood examination, serum electrolytes, serum glucose, serum urea and creatinine, liver enzymes, thyroid stimulating hormone, serum vitamin B12, red cell folate and serum vitamin D. In addition, excessive alcohol consumption is often associated with depressive symptoms, and withdrawal from alcohol is often associated with both anxiety and depressive symptoms. Evidence from adult populations indicates that combination treatment with antidepressant medication and a psychological intervention works best, both during acute treatment and for relapse prevention.
Secondly, they are associated with falls, amnesia, disruption of sleep architecture, and confusion.
Some antidepressants are more activating whereas others are more sedating and these properties enable them to be tailored to treat patients with psychomotor retardation or agitation, respectively. Other augmentation strategies for major depression include the use of mood stabilizers, such as lithium carbonate, sodium valproate, or an atypical antipsychotic. A large UK clinical trial has suggested that antidepressants might not be effective for the treatment of major depression in the context of dementia.17 However, this study did have methodological limitations, including the inclusion criterion of a score of 8 or more on the Cornell Scale for Depression in Dementia, rather than a formal diagnosis of major depression based on a diagnostic interview.
The IMPACT intervention was found to be superior to usual depression care at 12-month, 18-month, and 24-month follow up.23 The findings from this study suggest that a multimodal, stepped-care approach can be effective for the management of depression in older people. Unfortunately, ECT remains a highly stigmatized treatment modality and it can be difficult to access in some places. Problem-solving treatment was associated with a 50% reduction in incident depression at 2-month follow-up. Personality in adulthood: a six-year longitudinal study of self-reports and spouse ratings on the NEO Personality Inventory. Performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening test for dementia. Development and validation of a geriatric depression screening scale: a preliminary report. Development and validation of a short form of the Geriatric Anxiety Inventory – the GAI-SF. Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicenter, double-blind, placebocontrolled trial.
Interpersonal psychotherapy (IPT) for late-life depression in general practice: uptake and satisfaction by patients, therapists and physicians.
A controlled evaluation of monthly maintenance interpersonal psychotherapy in late-life depression with varying levels of cognitive function. Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment.
Randomised controlled trial of interpersonal psychotherapy and cognitive-behavioural therapy for depression.
Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. Cost-effectiveness of a stepped care intervention to prevent depression and anxiety in late life: randomised trial.
Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study.
These two treatment modalities show approximately equivalent efficacy, although drug treatments are generally preferred for older people with more severe depression and psychological treatments are generally preferred for older people with mild to moderate anxiety. However, in most national epidemiological studies, anxiety and depression fall in prevalence among community-residing individuals after the age of about 50 years (see Figure 1 page 340).1 The full explanation for this observation is yet to be elucidated, although selective mortality of people with anxiety and depressive disorders and changes in personality with advancing age are likely to contribute.
It has been proposed that the sympathetic nervous system becomes less responsive in old age, making panic attacks and panicky feelings less likely.
This is particularly true for abuse and dependence syndromes involving alcohol and prescribed hypnosedatives. Magnetic resonance imaging is generally considered the neuroimaging study of choice in older people because of its ability to reveal the extent of white matter ischemic changes, although it is often more expensive and less accessible than computer tomographic brain imaging. As a consequence, the initial management of depression or anxiety in older people should include consideration of their caffeine and alcohol intake. Sympathomimetic agents, including those used in treatment of asthma and chronic obstructive lung disease, commonly lead to anxiety symptoms. Because benzodiazepines and related medications also have significant amnestic effects, their use should be minimized in older people. It is beyond the scope of this article to discuss the management of individual anxiety disorders. Thus, if benzodiazepines are to be used, they should be reserved for short-term use, while initiating antidepressant therapy and planning psychological treatment.
The selective serotonin reuptake inhibitors (SSRIs) are first-line treatments for both anxiety and depressive disorders in older people. Hence, the findings should not be taken as the last word on the treatment of depression in dementia.

Both interpersonal psychotherapy and cognitive behavioral therapy are effective in older people, although the latter is in more widespread use. Although personality is relatively stable over the adult lifespan, older adults do have lower neuroticism in comparison with younger adults.2 As neuroticism is the character trait most relevant for the development of anxiety and depression, it makes intuitive sense for the prevalence of these two disorders to decrease in late life. Anxiety and depressive symptoms also occur commonly in older people with general medical conditions, including chronic obstructive lung disease, ischemic heart disease, and stroke. Use of amphetamines, cocaine, and narcotics is much less prevalent in most older populations, but is still worth considering in selected cases.
Thus, the management of anxiety and depression in older people should include consideration of any comorbid general medical disorders and any prescribed medication. Commencement of SSRI treatment is commonly associated with an initial increase in jitteriness, anxiety or insomnia.
Lithium carbonate can be used as an augmentation agent in the acute treatment of major depression as well as in relapse prevention, including following a course of electroconvulsive therapy (ECT). Because the use of antidepressants and other drugs to treat anxiety and depression in later life is often associated with dose-limiting adverse effects and modest efficacy, there may be a role in the future for pharmacogenomic assessment to help with the selection of antidepressant medication and dose range.
These have been described in detail in specialist texts.18 Common modifications include increasing the font size in manuals to allow for visual impairment, increasing the number of sessions to allow for more summary and review work, and incorporating explicit learning and memory aids. These methods include trans-cranial magnetic stimulation (TMS), vagal nerve stimulation, and deep brain stimulation. Rational drug treatment of anxiety and depression in older people mainly involves the use of antidepressant medication, particularly the selective serotonin reuptake inhibitors. Despite these general observations, the trend toward lower rates of anxiety and depression in community-residing older people masks much higher rates of anxiety and depression among hospitalized older people, among those receiving domiciliary nursing care and those living in nursing homes. Suicide rates are increased in older people with anxiety and depressive disorders and in many countries this is particularly true for older men. Because most anxiety and depressive disorders develop before middle age, older persons developing anxiety or depression for the first time in later life must be investigated for an underlying general medical condition.
This early worsening can be managed with a combination of psycho education and the short-term use of a benzodiazepine, such as oxazepam. The evidence base for combinations of antidepressants as an augmentation strategy is less secure in older people and best avoided. At present, vagal nerve stimulation and deep brain stimulation are generally reserved for those with severe treatment- resistant disorders unresponsive to multiple courses of treatment, including ECT. Stepped care consisted of 3- month cycles of watchful waiting, bibliotherapy, problem-solving treatment, and antidepressant medication provided over a 12-month period. At present, it is unclear whether antidepressant medication is effective in patients with both dementia and depression. The prevalence of cognitive problems, including mild cognitive impairment and dementia, rises exponentially with advancing age.
While generally safer than tricyclic antidepressants and monoamine oxidase inhibitors, the SSRIs are associated with an increased risk of bleeding, hyponatremia, and falls in older people.10 Hyponatremia appears to occur more commonly in women and those on thiazide diuretics. TMS is in more widespread use and has the advantage over ECT that no general anesthetic is required. The intervention halved the 12-month incidence of depressive and anxiety disorders with a number-needed- to-treat of 8.3 and at a cost (in 2007 euros) of €4297 per depression- and anxiety-free year.
Electroconvulsive therapy remains an appropriate option for older depressed patients who have stopped eating or drinking, have psychotic symptoms, or are actively suicidal. Both mild cognitive impairment and dementia are associated with high rates of anxiety and depressive symptoms and disorders. Citalopram and escitalopram have been reported to be associated with prolongation of the electrocardiogram corrected QT (QTc) interval and cardiac arrhythmias in older people. Relaxation techniques, behavioral activation, pleasant event scheduling, and exposure are well worth pursuing.
Combination treatment with antidepressant medication and one of the psychological treatments is recommended although there is only limited supporting evidence in older people. As a consequence, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended that citalopram be used in doses no greater than 20 mg daily and that escitalopram be used in doses no greater than 10 mg daily in people aged 65 years and over.11 By convention, older patients with insomnia as part of their anxiety or depression have been treated with more sedating antidepressants such as fluvoxamine or mirtazapine, which rely on antihistaminic properties to assist with sleep. Critical to the success of most behavioral interventions for anxiety disorders in older people is the use of explicit measures to overcome avoidance behavior. Newer brain stimulation treatments such as transcranial magnetic stimulation are being trialed in older people with anxiety and depression, but in many places their use remains investigational.
However, newer drugs such as agomelatine, which work on the melatonergic and 5-HT2C systems, might offer an advantage in this situation.12 In older people with cognitive impairment, urinary hesitancy, or narrow-angle glaucoma, it is prudent to avoid antidepressants with significant anticholinergic effects, such as paroxetine, the older tricyclics, and monoamine oxidase inhibitors. CBT and IPT are generally more effective when administered on an individual rather than a group basis. Prevention of both anxiety and depression in older people does seem feasible and a stepped-care program has shown promising results. However, if a tricyclic antidepressant is to be used to treat an anxiety or depressive disorder in late life, it is often preferable to use nortriptyline, as it seems to be associated with the best safety profile in older people.
Low-potency antipsychotic medications, such as quetiapine, have sometimes been used in the management of anxiety symptoms.

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