Feature Article
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On May 16, 2003, a symposium entitled “Solving the Riddle: Exploring the Comorbidity of Mood Disorders in the Older Adult” was held at the Annual Scientific Meeting of the American Geriatrics Society in Baltimore, MD. Presenters reviewed the impact of depression, dementia, and pain in the elderly, discussed case presentations, and explored treatment options for depression and comorbid painful physical symptoms in the older adult.
Educational Objectives
-Identify elderly patients with depression and painful physical symptoms.
-Distinguish between the disease states of depression and dementia.
-Discuss current research on the role of dual-action antidepressants in the treatment of depression and in the pain pathway.
Continuing Medical Education Information
Solving the Riddle: Exploring the Comorbidity of Mood Disorders in the Older Adult
This activity is made possible by an unrestricted educational grant from Eli Lilly and Company.
Target Audience
This activity is based upon a symposium offered at the 2003 American Geriatrics Society Annual Meeting in Baltimore, Maryland. It is intended for geriatricians and primary care clinicians who are interested in the treatment of mood disorders in geriatric patients.
Educational Objectives
Upon completion of this activity, participants should be able to:
• Identify elderly patients with depression and painful physical symptoms.
• Distinguish between the disease states of depression and dementia.
• Discuss current research on the role of dual-action antidepressants in the treatment of depression and in the pain pathway.
Program Completion Time
Based upon trials, the estimated time to complete this activity is 1 hour.
Accreditation
The American Geriatrics Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.
Continuing Education Hours
The American Geriatrics Society designates this continuing medical education activity for up to 1 credit hour in category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours of credit that he/she actually spent in the activity.
Obtaining Continuing Medical Education Credit
To receive credit, physicians must complete the CME Examination and Evaluation that appear at the end of this program and fax or mail to:
American Geriatrics Society
The Empire State Building
350 Fifth Ave, Suite 801
New York, NY 10118
Fax: (212) 832-8646
Attn: Dennise McAlpin
A minimum score of 70% on the Continuing Medical Education Examination is required for credit. A certificate of completion will be mailed within 4 weeks of receipt of the completed answer sheet.
Faculty Disclosure of Financial Interests
As an accredited provider of Continuing Medical Education, the American Geriatrics Society is required to ask faculty to disclose any real or apparent conflict of interest they may have as related to the content of their presentations. The existence of commercial or financial interests of faculty related to the subject matter of their presentations should not be construed as implying bias or decreasing the value of their presentations. However, disclosure should help participants form their own judgements.
All faculty were independently selected by the organizing committee for the 2003 Annual Scientific Meeting of the American Geriatrics Society upon which this supplement is based. Those faculty members who disclosed affiliations or financial interests with the commercial organizations involved with products, to which they may refer, are listed below. Where a faculty member indicates that she/he will be discussing a commercial product or an off-label or investigational use, we have indicated this below.
Dr. Eric G. Tangalos’ presentation will include a discussion of commercial products or services. He reported that he is a paid consultant for Eli Lilly and Company, Omnicare, and Ross Products Division of Abbott Laboratories. He also receives grant/research support from the National Institutes of Health. Dr. Tangalos’ presentation will not include discussion of unapproved uses of a commercial product or investigational use of a product not yet approved for this purpose.
Dr. Thomas N. Wise indicates that his presentation will include a discussion of commercial products or services. He reported that he is a member of the speakers’ bureau for Bristol-Myers Squibb Company, Eli Lilly and Company, GlaxoSmithKline, AstraZeneca, and Pfizer, Inc. He is also a paid consultant for and receives grant support from Eli Lilly, and he receives grant/research support from Pfizer, Inc. Dr. Wise’s presentation will include discussion of unapproved uses of a commercial product or investigational use of a product not yet approved for this purpose.
Disclaimer
The content and views presented in this educational activity are those of the faculty and do not necessarily reflect those of the American Geriatrics Society, Eli Lilly and Company, or MultiMedia HealthCare/Freedom, LLC. The authors have disclosed if any unlabeled use of products is mentioned in the material. Before prescribing any medicine, primary references and full prescribing information should be consulted.
Program Release Date: July 2003
Program Expiration Date: July 2004
Behavioral Manifestations of Dementia and Depression in the Older Adult
Eric G. Tangalos, MD, FACP, AGSF, CMD, is Professor of Medicine and Chair, Division of Community Internal Medicine, and Director, Robert and Arlene Kogod Program on Aging, Mayo Clinic, Rochester, MN.
Ten percent of elderly patients have dementia,1 70% of the elderly suffer with pain,2 and 9-18% of older adults experience late-life depression.2 In his presentation, Dr. Tangalos examined the impact of dementia, pain, and depression in combination as they affect the elderly.
The burden of illness with depression is thought to cost the United States $43.7 billion per year.3 About $23 billion of this burden is attributed to reduced productivity, $7.5 billion to depression-related suicides, and $12.4 billion to direct treatment costs.3 The socioeconomic burden of depression includes household difficulties, financial losses, social difficulties, physical limitations, increased number of days spent in bed, and limitations in job functioning.4
Symptoms of depression may be both emotional and physical. Emotional symptoms include sadness, diminished interest, feelings of worthlessness or excessive guilt, decreased ability to concentrate, recurrent thoughts of death, and anxiety.5 Physical symptoms include general body aches, headaches, gastrointestinal disturbances, joint pain, fatigue, changes in appetite resulting in weight loss or gain, and back- aches.5
Many older patients with depression tend not to consider themselves depressed and therefore complain more of physical symptoms than emotional ones.6 In fact, a study by Stewart et al7 found that multiple somatic (physical) symptoms are the best indicator of depression in elderly patients.
Pain adds substantially to the burden of depression. Thirty-four to 66% of patients with depression experience pain, and there is a strong association between pain intensity and duration, disability, and depression.8 An estimated 31-100% of patients with chronic pain suffer from depression.8
In addition, depression can cause a dementia syndrome and/or be a risk factor or prodrome for dementia. Depression and dementia often coexist, as shown in Figure 1. Depressed mood is three times more common in patients with dementia,9 and four times more likely in those suffering from reversible dementia (dementia syndrome).10
Dr. Tangalos used two case studies to discuss treatment options when caring for patients with depression, dementia, and pain.
Case 1: Dementia and Disturbed Behavior
Presentation
An 86-year-old white female moved to an assisted living facility from her home 2 years ago. Her husband was no longer able to be her primary caregiver due to health problems. The patient suffered from degenerative dementia and untreated depression. She experienced a “difficult transition” to the facility and did not like to be touched.
The patient had a peripheral edema of unclear etiology, for which she was taking triamterene with hydrochlorothiazide and furosemide. She was taking propanolol 10 mg three times a day for senile tremor and also had very poor vision. She was also taking vitamin E 400 U twice a day.
History
The patient had multiple reasons for her dementia, including meningitis in 1973. In 1994, she was diagnosed with organic brain syndrome. She had hearing loss secondary to meningitis, further adding to her sensory deprivation. As the years progressed, she also developed a multifactorial gait disturbance.
Plan of Care
The diuretic triamterene with hydrochlorothiazide was discontinued and the furosemide dose was increased to 40 mg/day. Vitamin E dosage was adjusted to 1000 U/day to reduce the number of daily doses required. An antidepressant was not indicated at the time. The patient was scheduled for follow-up in 1 month for reassessment.
Interim Visits Within One Month
Before the 1-month follow-up, the patient became verbally aggressive, especially when her husband came to visit. She yelled, screamed, struck out, and displayed the loss of frontal lobe control. She was given sertraline 25 mg/day for 1 week, and 50 mg/day thereafter.
Later that same week, the patient developed intercurrent pneumonia, with cough and crackles in both lung bases. Her chest x-ray showed bilateral infiltrates, osteopenia, and multiple vertebral compression fractures. She was given clarithromycin 500 mg twice a day for 5 days and did not require hospitalization.
Facility staff requested that the patient be transferred to a locked facility. However, both her family and the attending physician agreed that a transfer was not necessary, and she was allowed to remain at the assisted living facility. The patient was mistrustful of her caregivers and her husband at this time. Her daughter remained concerned about the peripheral edema.
After recovering from pneumonia, the patient’s lungs were clear, her heart was normal, she had significant (+3) peripheral edema, normal pulse (76 beats/min), and normal blood pressure (140/60 mmHg).
Diagnosis
The patient was diagnosed as dementia with psychosis and paranoia, depression, peripheral edema, and a treated upper respira- tory tract infection.
One-Year Follow-Up
One year later, the patient returned for a multisystem examination. She wanted to maintain her independence. Her clinical condition was relatively stable. Her depression was still treated with sertraline 50 mg/day. Her peripheral edema was mild and her furosemide dose had been increased to 80 mg/day. The patient’s dementia was slowly progressive. She had gait instability due to degenerative joint disease, meningitis, and deconditioning. She also had a new mild skin rash secondary to a contact dermatitis.
Plan of Care
Many of the patient’s medications remained the same, with the exception of two new therapies—triamcinolone cream 0.1% twice daily to treat itching, and doxepin 25 mg/day at bedtime. Her other medications were furosemide 80 mg/day, acetylsalicylic acid 81 mg/day, propanolol 10 mg three times daily, calcium with vitamin D twice daily, vitamin E 1000 U/day, sertraline 50 mg/day, and one capsule of a multivitamin daily.
Interim Visit Nine Months Later
Nine months later, the patient became increasingly agitated because of a change in roommates. She had more paranoia and behavioral dyscontrol, and was shaking her fists at others. The nursing staff noticed increased weeping and tearfulness, and requested further treatment of the patient’s depression.
The patient’s vital signs were once again normal. Her weight was 160 lbs, pulse was 86 beats/minute, and blood pressure was 120/58 mmHg.
The patient was diagnosed with adjustment disorder, paranoia, behavioral dyscontrol, depression, and dementia. Doxepin was discontinued. Her attending physician was more impressed with her agitation and paranoia than with her depression. Olanzapine 2.5 mg/day was added.
Four-Month Follow-Up
Four months later, while on olanzapine, there were minimal complaints. Again, the patient’s antidepressant therapy was not changed. She was restless at night and her olanzapine dose was increased to 5 mg/day. The patient continues to do well on this treatment program.
Case 2: Ambulatory Care
Presentation
An 80-year-old elderly ambulatory female presented for an annual review and multisystem examination. She suffered from chronic pain syndrome, hypertension, and sleep disturbances, and was being treated for depression.
History
The patient had a history of old polio and multiple back operations, which led to her chronic pain syndrome. She had a history of breast cancer, abdominal operations for bowel obstruction, ovarian cysts, hysterectomy, and recurrent ankle cellulitis.
Examination
The patient was in good spirits, conversant, and well nourished. She lived independently with some help from her daughter. She wore a corset when upright and did not like to remove it. She used a walker around the house and a wheelchair when outside. She had been reluctant for years to change her medications.
She had changes in her right breast due to her prior surgery, as well as radiation scars. She had significant truncal weakness, a midline abdominal scar, weak abdominal musculature, and thoracic and lumbar scars on her back. There were no flexion contractures. The patient was able to transfer independently, although slowly. She had a healed scar from old cellulitis on the right malleolus.
The patient’s pulse was 88 beats/minute. Respiration was 18 breaths/minute. Blood pressure was 132/70 mmHg.
Treatment Regimen and Outcome
The patient’s treatment consisted of fluoxetine 20 mg twice daily, cyclobenzaprine 10 mg twice daily, hydrochlorothiazide 25 mg/day, three to four tablets of acetaminophen with codeine #3 three times daily, ranitidine 150 mg twice daily, methyldopa 250 mg twice daily, and one multivitamin tablet daily. Her narcotic use was reviewed by a psychiatrist every few years.
The patient was extremely stable, did not complain, and did not visit the doctor’s office often. However, she would tend to “creep up” her doses of cyclobenzaprine, acetaminophen with codeine, or fluoxetine, and this habit had to be kept in check.
A number of opportunities for better therapy make this an illustrative case. The patient, however, had been reluctant to all interventions. Our attention is drawn to the use of fluoxetine twice daily (which may be causing her sleep problems), the use of acetaminophen with codeine and cyclobenzaprine with fluoxetine (which can render these drugs less effective), and the use of methyldopa (now rarely used in clinical practice), which can worsen depression.
References
1. Alzheimer’s Association. Facts about Alzheimer’s Disease. Available at: http://www.alz.org/ResourceCenter/FactSheets/FsAlzheimerDisease.pdf. Accessed June 13, 2003.
2. Geerlings SW, Twisk JW, Beekman AT, et al. Longitudinal relationship between pain and depression in older adults: Sex, age and physical disability. Soc Psychiatry Psychiatr Epidemiol 2002;37:23-30.
3. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. Depression: A neglected major illness. J Clin Psychiatry 1993;54:419-424.
4. Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry 1996;153:1411-1417.
5. Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC: American Psychiatric Association; 2000.
6. Mulsant BH, Ganguli M. Epidemiology and diagnosis of depression in late life. J Clin Psychiatry 1999;60(suppl 20):9-15.
7. Stewart RB, Blashfield R, Hale WE, et al. Correlates of Beck Depression Inventory scores in an ambulatory elderly population: Symptoms, disease, laboratory values, and medications. J Fam Pract 1991;32:497-452.
8. Meana M, Stewart DE. Pain: Adding to the affective burden. In: Steiner et al, eds. Pain and Mood Disorders in Women. London, England: Martin Dunitz; 2000: 269-284.
9. Devanand DP, Sano M, Tang MX, et al. Depressed mood and the incidence of Alzheimer’s disease in the elderly living in the community. Arch Gen Psychiatry 1996;53:175-182.
10. Alexopoulos GS, Meyers BS, Young RC, et al. The course of geriatric depression with “reversible dementia”: A controlled study. Am J Psychiatry 1993;150:1693-1699.
Treatment of Depression and Comorbid Painful Physical Symptoms in the Older Adult
Thomas N. Wise, MD, is Chairman, Department of Psychiatry, Inova Fairfax Hospital, and Medical Director, Behavior Sciences, Inova Health Systems, Falls Church, VA. He is also Professor, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, and Vice-Chairman, Department of Psychiatry, Georgetown University School of Medicine, Washington, DC.
Dr. Wise discussed the impact and treatment of depression and comorbid painful physical symptoms in the older adult.
Patients with depression have a threefold increased chance of developing painful symptoms. Conversely, at least 20% of patients experiencing pain also have a psychological diagnosis. Thirty percent or more of patients with chronic pain are depressed.1 Painful symptoms and depression certainly overlap; however, they can be two discrete categories. Depression in patients experiencing pain from multiple illnesses should not be dismissed as simply an understandable reaction.
In a study by Ohayon and Schatzberg,2 19,000 subjects in five Western European countries were followed to determine, among other things, the prevalence of pain in different age groups. Not surprisingly, the older the people were, the more complaints of pain they had. “This empirically documented in a very large survey that older patients are at greater risk for having chronic complaints,” said Dr. Wise.
In this study, there was a striking increase in the prevalence of pain in subjects who experienced feelings of sadness, depression, hopelessness, or loss of interest (Table).2 Two screening questions—“Do you feel sad or depressed?” and “Have you noticed a loss of interest in usual activities, or a loss of pleasure in what you like to do?”—have been associated with an 88-90% sensitivity for possible depressive disorder.3 One-third of people with pain in the Ohayon/Schatzberg2 study answered “yes” to the first question, and 26% responded “yes” to the second question. The authors concluded that patients seeking consultation for chronic painful physical conditions should be systematically evaluated for depression.2
Denninger et al4 demonstrated that the degree of physical symptom improvement correlates with the ability to achieve remission of depression. “This makes sense, since it is more difficult to treat a patient who is depressed if they have a comorbid chronic pain condition. Nevertheless, the study results mandate that we need to treat both conditions,” said Dr. Wise.
Recognizing the Symptoms of Pain
Pain evaluation should be included in the measurement of vital signs.5 However, the symptoms of pain are not always easily recognized. People with cognitive limitations who are suffering from dementia often do not initially complain about pain. Instead, they may exhibit agitated or aggressive behavior. Other signs of pain include crying, frustration, changes in sleep patterns or eating habits, and withdrawal from friends, family, or usual activities. “If someone likes to play an instrument, volunteers in a symphony, goes to church on a regular basis, and actively withdraws from this, the reason may be due to pain that is not the overt first complaint,” said Dr. Wise.
Physicians should watch for “pained” expressions, body movements, or vocalizations, and changes in interpersonal interactions. “We observe as well as we hear,” said Dr. Wise. “Often the data from collateral sources is very important—information from the patient’s family, or pharmacist, and mental changes as well.” Visual analogue scales (VAS) are helpful when assessing pain and can be used to follow patients on an ongoing basis.
Barriers to proper pain recognition include cognitive and sensory impairment, where the patient cannot discretely report pain and instead presents with agitation, demoralization, or discouragement. Other barriers include fear of addiction, depression, lack of education regarding treatment options, a hopeless feeling that nothing can be done about the pain, and reluctance to report pain. Coexisting medical conditions can overshadow reports of pain, and multiple medications can obscure the need for pain control or a diagnosis of depression.
Some of the more common nonmalignant pain-related conditions seen in the elderly are diabetic neuropathy, osteoporosis, and postherpetic neuralgia. Postherpetic neuralgia is not only common, but it is also very demoralizing to patients because it can limit their activities and cause them to lose pleasure in common hobbies such as playing a musical instrument. Other common ailments include lower back pain and myofascial pain. In fact, lower back pain was a predictor of depressive disorder in the Ohayon/Schatzberg study.2
The consequences of persistent pain are very important. Loss of appetite and sleep disturbances caused by chronic pain throughout the night are common, as is decreased ambulation, which can lead to many other problems. Persistent pain in the elderly can lead to comorbid depression. It can foster anxiety and agitation, and decrease socialization to the point where the patient does not want to be around his or her usual colleagues and friends.
Depression and Pain: Association of Serotonin and Norepinephrine
Depression and pain perception are closely associated with the serotonin and norepinephrine systems. The serotonin system is involved with impulsivity, aggression, appetite, and sex. The norepinephrine system is associated with vigilance and motivation. Both systems have an effect on anxiety, irritability, aches, cognitive function, mood, and emotion.
Both the serotonin and norepinephrine systems are key modulatory neurotransmitters in the ascending mood pathways and the descending inhibitory pain pathway. Dysregulation of these systems may explain the frequent presence of painful physical symptoms in depressed patients.
Antidepressants are often used to treat both depression and pain. Dual-acting tricyclic antidepressants affect both the serotonin and norephinephrine systems, while selective serotonin reuptake inhibitors (SSRIs) affect only the serotonin system.
Antidepressants in the Treatment of Depression
Dual-acting antidepressants have demonstrated greater response rates than some SSRIs in the treatment of depression. Clomipramine, for example, has shown significantly greater efficacy than certain SSRIs.6
However, the goal of treating depression is not just response (which is often defined as a 50% decrease in a rating scale), but full remission. “A response fosters a likelihood of relapse,” said Dr. Wise. For example, Lynch7 found that 76% of compliant patients with lingering symptoms of depression relapsed within 10 months. Therefore, more recent studies are focusing on the effect of dual-acting antidepressants on remission.
Beginning with European studies from the Danish University Antidepressant Group (DUAG), there have been suggestions that dual-acting antidepressants offer more robust efficacy.6 In order to better assess the role of newer agents, both Thase et al8 and Smith et al9 separately compared double-blind, randomized trials of venlafaxine, a dual-acting antidepressant that inhibits both noradrenergic and serotonergic inhibition. Utilizing pooled analysis, Thase et al8 compared remission rates of venlafaxine (n = 851) versus SSRIs (fluoxetine, paroxetine, and fluvoxamine; n = 748) from eight comparable randomized, double-blind studies of major depressive disorder. Venlafaxine had a significantly increased remission rate compared to full baseline criteria over fluoxetine. The conclusions must be tempered by problems in any meta-analytic study because only available studies were included, the subjects within the meta-analysis may have differed in that they might have been treated shortly prior to entering the study, and the time of the studies varied. Furthermore, the study with fluvoxamine only included 34 subjects, and the one study with sertraline did not reveal a significant difference. Smith et al9 utilized a different statistical method to review 20 studies and also found venlafaxine to be superior to fluoxetine. Again dosages differed between studies. Although these studies have methodologic shortcomings inherent in comparing multiple clinical trials, they may suggest dual-action antidepressants to be more efficacious than selected SSRIs. The average remission rate for venlafaxine was 45%, while that of the SSRIs was 35%, and the difference between venlafaxine and SSRIs became significant at week 2.
A new dual-action antidepressant is awaiting final approval from the FDA. It is “balanced” in its reuptake inhibition of both serotonin and norepinephrine, which clinically means less dosage titration. Early studies find it to be both safe and efficacious in elderly patients. One 9-week study presented by Nelson et al10 examined the efficacy of this drug in a subpopulation of elderly patients with depression who were given either duloxetine 60 mg every day (n = 46) or placebo (n = 42). The response rate of duloxetine was 52.8%, compared with 28% for placebo. The remission rate of duloxetine was significantly higher (44.1%) than that for placebo (16.1%).
Antidepressants in the Treatment of Pain
Treatment options for pain vary widely and include acetaminophen, nonsteroidal anti-inflammatory agents, cyclooxygenase-2 inhibitors, antidepressants, anticonvulsants, corticosteroids, and opioids. Antidepressants are often used as adjunctive if not primary treatment for chronic pain complaints.
Tricyclic antidepressants have proven efficacy in the treatment of chronic pain.11 Amitriptyline, for example, provides an excellent response to chronic pain. However, drugs like amitriptyline have many side effects, ranging from anticholinergic effects that foster confusion to hypotensive effects, sedation, and dry mouth. SSRIs, on the other hand, have fewer side effects than tricyclic antidepressants, but have questionable efficacy in the treatment of pain.7
“Dual-acting tricyclic antidepressants, such as venlafaxine and duloxetine, seem to be quite effective at modifying and improving pain tolerance and perception,” said Dr. Wise. A number of studies have been conducted to determine the effect of these drugs on pain.
Fishbain12 reviewed a number of individual placebo-controlled studies for the treatment of specific chronic pain syndromes. This informal meta-analysis concluded that serotonergic-noradrenergic antidepressants had a more consistent analgesic effect than did the serotonergic antidepressants, and were significantly more effective in treating headaches and fibromyalgia (Figure 2).12
Kunz et al13 examined the efficacy of venlafaxine in the treatment of pain associated with diabetic neuropathy. In this double-blind, 6-week study, nonelderly patients were given either venlafaxine extended-release 75 mg/day or 150-225 mg/day, or placebo. The high dose of venlafaxine was significantly more effective at treating the pain associated with diabetic neuropathy. Unfortunately, the commonly used dose of venlafaxine is much lower than 150 mg, where the effect on pain is minimal. “When a drug like venlafaxine is used [to treat pain], a significant dose titration is required,” said Dr. Wise.
Nelson et al10 also investigated the efficacy of duloxetine in the treatment of painful physical symptoms in the elderly. Over the 9-week study period, patients taking duloxetine had reduced VAS back pain severity scores, which separated from placebo at 1 week.10 Duloxetine also significantly reduced VAS scores for overall pain, pain while awake, pain during daily activities, and shoulder and head pain.10
Conclusion
In summary, physical complaints and depression are commonly associated with one another. “Effective and safe potentiation of both the serotonin and norepinephrine systems can relieve both physical and emotional symptoms,” said Dr. Wise. “There is a growing belief that the dual-acting antidepressants [such as duloxetine] offer an improved advantage over SSRIs in the treatment of both depression and pain.”
References
1. Meana M, Stewart DE. Pain: Adding to the affective burden. In: Steiner M et al, eds. Pain and Mood Disorders in Women. London, England: Martin Dunitz; 2000: 269-284.
2. Ohayon MM, Schatzberg AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry 2003;60:39-47.
3. Brody DS, Hahn SR, Spitzer RL, et al. Identifying patients with depression in the primary care setting: A more efficient method. Arch Intern Med 1998;158(22):2469-2475.
4. Denninger JW, Mahal Y, Merens W, et al. The relationship between somatic symptoms and depression. Presented at: 155th Annual Meeting of the American Psychiatric Association; May 18-23, 2002; Philadelphia, PA.
5. American Society of Consultant Pharmacists. Guidelines for Recognition and Assessment of Pain in Older Adults. Available at: http://www.ascp.com/public/pr/guidelines/painrecognition/. Accessed June 16, 2003.
6. Citalopram: Clinical effect profile in comparison with clomipramine: A controlled multicenter study. Danish University Antidepressant Group. Psychopharmacology (Berl) 1986;90:131-138.
7. Lynch ME. Antidepressants as analgesics: A review of randomized controlled trials. J Psychiatry Neurosci 2001;26:30-36.
8. Thase ME, Entsuah AR, Rudolph RL. Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. Br J Psychiatry 2001;178:234-241.
9. Smith D, Dempster C, Glanville J, et al. Efficacy and tolerability of venlafaxine compared with selective serotonin reuptake inhibitors and other antidepressants: A meta-analysis. Br J Psychiatry 2002;180:396-484.
10. Nelson JC, Kennedy JS, Mallinckrodt CH, et al. Duloxetine for the treatment of major depressive disorder in patients age > 55. Presented at: Annual Meeting of the International College of Geriatric Psychoneuropharmacology; October 10-12, 2002; Barcelona, Spain.
11. Magni C, Moreschi C, Rigatti-Luchini S, Merskey H. Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain. Pain 1994;56:289-297.
12. Fishbain DA. Evidence-based data on pain relief with antidepressants. Ann Med 2000;32:305-316.
13. Kunz NR, Goli V, Entsuah AR, Rudolph RL. Diabetic neuropathic pain management with venlafaxine extended release. Eur Neuropsychopharmacol 2000;10:S389.
CME Examination & Evaluation
Solving the Riddle: Exploring the Comorbidity of Mood Disorders in the Older Adult
To receive a certificate of completion, please complete the following CME Examination and Evaluation and fax or mail to:
American Geriatrics Society
The Empire State Building
350 Fifth Ave, Suite 801
New York, NY 10118
Fax: (212) 832-8646
Attn: Dennise McAlpin
Please allow 4 weeks for processing. Program expiration is July 2004. Please phone (212) 308-1414 with any questions.
cme Examination Please circle the correct answer.
1. There is a strong association between pain intensity and duration, disability, and depression.
True False
2. Physical symptoms of depression may include:
a. Headaches
b. Gastrointestinal disturbances
c. Fatigue
d. Any of the above
3. The degree of physical symptom improvement does not correlate with the ability to achieve remission of depression.
True False
4. Which of the following statements is incorrect?
a. Dual-acting tricyclic antidepressants affect only the serotonin system.
b. The serotonin and norepinephrine systems are key modulatory neurotransmitters in the ascending pathway.
c. The serotonin and norepinephrine systems are key modulatory neurotransmitters in the descending inhibitory pain pathway.
d. The serotonin and norepinephrine systems are both closely associated with depression and pain perception.
5. Lower back pain was not a predictor of depressive disorder in the Ohayon and Schatzberg study.
True False
6. Emotional symptoms of pain in the elderly include:
a. Agitation or aggression
b. Crying
c. Withdrawal from friends or usual activities
d. All of the above
7. Selective serotonin reuptake inhibitors have more side effects than tricyclic antidepressants and have questionable efficacy in the treatment of pain.
True False
8. Tricyclic antidepressants, particularly the dual-acting tricyclics, have proven efficacy in the treatment of chronic pain.
True False
9. Dual-acting antidepressants show greater efficacy than selective serotonin reuptake inhibitors in the treatment of depression.
True False
CME evaluation
Please circle the number that best reflects your opinions on the following statements, using the following rating scale:
1 = Strongly Agree; 2 = Agree; 3 = Disagree; 4 = Strongly Disagree.
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2. The program content was useful. 1 2 3 4
3. The program content was relevant. 1 2 3 4
4. The program was educational. 1 2 3 4
5. The program was not promotional. 1 2 3 4
Additional Comments:
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This special report was sponsored by the American Geriatrics Society and produced by MultiMedia HealthCare/Freedom, LLC, under an unrestricted educational grant from Eli Lilly and Company. The views expressed in this publication are not necessarily those of the American Geriatrics Society, Eli Lilly, or the publishers. This publication may not be reproduced in whole or in part without the express written permission of MultiMedia HealthCare/Freedom, LLC.
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