Literature Review Resources

C hanges in the mental status and functioning of older adults are common and

sometimes include dementia, which may be accompanied by depression or depressive symptoms. Sorting out which changes are associated with normal aging, dementia, and medi- cation effects is complicated by the presence of depression. A variety of medications is used to manage the complexities of dementia with depression, including selective sero-

AbstrAct As adults age, many changes in functioning occur, and de- mentia and/or depression may develop. Medications used to manage dementia and depression include selective serotonin reuptake inhibitors. The challenge for nurses is recognizing which behaviors, signs, and symptoms are the result of the dementia or depression and which are the result of the drug therapy. The purpose of this article is to present information to increase awareness of the complexities of care for older adults with dementia and/or depression and identify possible implica- tions for practicing nurses.

Roy Ann Sherrod, DSN, RN, CNE, CNL; Angela Collins, DSN, RN, CNS; Stephanie Wynn, MSN, RN; and Monika Gragg, MSN, RN

Journal of Psychosocial nursing • Vol. 48, no. 1, 2010 39

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tonin reuptake inhibitors (SSRIs). Older adults are at greater risk for unexpected sequelae when taking SSRIs (Arnold, 2004), in part, because SSRIs can cause cogni- tive impairment. To achieve our goals in this article, an individual example of a common scenario is presented.

IndIvIduAl ExAmplE Mrs. M., a 73-year-old

woman, visits a mental health nurse practitioner in an adult care center with her daughter. Her daughter reports that Mrs. M.’s husband of 53 years died 6 months ago from complications of heart disease. Mrs. M.’s initial lack of crying after the death,

inability to process and respond to simple questions, and lack of concern about her appear- ance were deemed more than the normal grief process by her four children. To maintain as much independence for Mrs. M. as possible, her children agreed she could continue to live in her home with frequent checks by her children. Her oldest daugh- ter worked in the same town as Mrs. M. and checked on her before and after work. Her old- est son lived in the same town and came by after work, stayed until she went to bed, and then went home or stayed the night, if needed.

Mrs. M. had experienced some cognitive changes, but she was able to answer the telephone, prepare meals, and

watch some television. Al- though not ideal, her function- ing seemed adequate for this ar- rangement. The mental health nurse practitioner prescribed a cholinesterase inhibitor to help preserve Mrs. M.’s cognitive per- formance. Initially, Mrs. M. was able to manage her medication with assistance from her oldest daughter.

During the next 2 months, Mrs. M. had more limited con- tact with her network of church members, family, and friends because of her inability to drive, decision to not visit, and decreasing desire and ability to use the telephone. She was ob- served by her children and other

family members to be argumen- tative, irritable, and frequently agitated. At the previous visit with the mental health nurse practitioner, Mrs. M.’s daughter reported that Mrs. M. adamant- ly stated things she believed others had said, even when they denied it. During assessment, Mrs. M. responded by saying: “I don’t know why you are asking all of these questions. I don’t know and I don’t care. Anyway, I don’t have anybody. I’m all by myself.” She had little interest in cooking anymore, despite the fact that it had always given her great pleasure. She said she often felt tired and slept most of the day.

The nurses were supportive, and additional feedback was sought from the physician. Mrs.

M. was started on an SSRI (par- oxetine, Paxil®). Within weeks, improvement was noted.

dIssEctIng dEmEntIA, dEprEssIon, And drug EffEcts

The challenge for nurses be- comes how to recognize which behaviors, signs, and symptoms are a result of dementia or depression and which are adverse effects of SSRI pharmacotherapy. Nurses are further challenged by complexi- ties related to pharmacotherapy in older adults, including changes in the ability to metabolize drugs and greater likelihood of polypharma- cy. Such changes can increase the risk for drug-drug interactions and adverse drug reactions (Murphy & Kayani, 2007).

The complexities of SSRI phar- macotherapy with older adults are numerous and include serotonin syndrome and serotonin discontin- uation syndrome (SDS). To man- age these complexities, pharma- cotherapy often involves placing patients on and then taking them off medications, using a seemingly “shot in the dark” approach to find the combination of drugs that con- trols behaviors related to both de- mentia and depression.

This article presents informa- tion that can be used to differen- tiate dementia, depression, and drug effects (serotonin syndrome and serotonin discontinuation syndrome). Our goals are to fos- ter heightened awareness of the interrelatedness of these three variables; provide information to assist in differentiating these vari- ables; and present selected nurs- ing implications. These goals are grounded in the belief that the greater the ability to distinguish these variables, the greater the opportunities to choose more rel- evant, effective care that may lead to more positive outcomes for cli- ents and thereby improve their quality of life.

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The complexities of selective serotonin reuptake inhibitor (SSRI) pharmacotherapy with older adults are numerous and include serotonin syndrome and serotonin discontinuation syndrome.

dEmEntIA Dementia is a progressive de-

terioration in cognitive function- ing that may be due to a number of factors, including neurobio- logical ones (Potter & Steffens, 2007). A variety of dementias are linked to anatomical destruc- tion of brain tissue, and most are irreversible. Causes are exten- sive with the predominant form of dementia being Alzheimer’s type, which incorporates a multi- tude of severely debilitating cog- nitive deficits (Maynard, 2003). Other causes of dementia, such as hypertension, hypothyroidism, normal pressure hydrocephalus, head injury, alcoholism, HIV infection, Huntington’s disease, and Parkinson’s disease, may be lessened in severity and progres- sion with early diagnosis and treatment of the underlying con- dition.

Although awareness, alert- ness, and attention are usually unaffected, neurological damage results in a loss of abilities that have an impact on activities of daily living, resulting in poor impulse control, inability to fol- low simple directions, language disturbance, failure to identify objects, inability to think be- yond the present, and delusions. While the symptoms of the early phase of dementias may not be obvious, they become increas- ingly evident as the disease pro- gresses. Memory, reasoning, judg- ment, and personality all become impaired, often resulting in the emergence of unsafe and disrup- tive behaviors (Arnold, 2004).

dEprEssIon Depression is primarily a

mood disorder that has been re- ported in 10% to 25% of older adults (Martin & Haynes, 2000). It is often first experienced later in life at approximately age 60, and thus is more frequently char- acterized by medical comorbidi-

ties, greater apathy and cognitive impairment, and stronger asso- ciation with dementia (Martin & Haynes, 2000; Maynard, 2003; Potter & Steffens, 2007). De- pression in older adults is often difficult for clinicians to diagnose and may be in major or milder forms. Any indication of major depression should be reported immediately for consultation with a mental health specialist, such as a nurse practitioner or physician. The most critical indi- cation is suicidal intention. The risk of suicide in older adults is 50% higher than among younger adults (Maynard, 2003). Those who are taking SSRIs may be at an even higher risk. Health care

providers who suspect depres- sion in their clients should assess for thoughts of death and sui- cidal ideation, plans, or attempts (Martin & Haynes, 2000).

Older adults are more likely to have milder forms of depres- sion related to stressors such as changes in employment; living conditions; health and financial resources; and loss of a spouse, family members, friends, and physical capabilities. Signs and symptoms of a major depressive episode include depressed mood or flattened affect, loss of interest in pleasurable activities, signifi- cant change in sleeping pattern, significant change in or loss of appetite, feelings of agitation or weakness, and most important, suicidal ideation or apathy about living (American Psychiatric As-

sociation [APA], 2000). Any four of these symptoms along with de- pressed mood and loss of interest in activities indicate depression when they represent a change from the individual’s usual be- havior for more than 2 weeks. Nurses must exercise consider- able observational and listening skills to facilitate the diagnosis of depression in older adults and should consult the Diagnostic and Statistical Manual of Mental Disor- ders, fourth edition, text revision (APA, 2000), for more specific diagnostic criteria (Capriotti, 2006).

Older adults with dementia may not be able, or willing, to express when they are feeling de-

pressed and are more likely to ex- hibit symptoms that are less ob- viously related with depression. Agitation or tearfulness may be the only indicators of depres- sion (Arnold, 2004; Maynard, 2003; Pountney, 2007). Clues to depression include unexplained somatic symptoms, hopelessness, helplessness, anxiety, memory complaints with or without ob- jective signs of cognitive impair- ment, thoughts of dying, loss of pleasurable feeling, slowed movement, irritability, sleep dis- turbance, and lack of interest in personal care (e.g., poor adher- ence to medical or dietary regi- men). Poor hygiene, weight loss, and trouble following directions may also be clues (Arnold, 2004). The defining difference may be that depressed older adults will

Increased use of SSRIs has led to a greater likelihood of adverse reactions. These adverse responses are potentially life altering for older patients, who have decreased physiological reserves.

Journal of Psychosocial nursing • Vol. 48, no. 1, 2010 41

be concerned about these chang- es, whereas older adults with de- mentia are apathetic about them. Another key differentiation may be greater fluctuation in the in- tensity of symptoms, such as in the evenings as daylight fades for people with dementia (Capriotti, 2006; Pountney, 2007).

drug thErApy EffEcts Data from 2002 indicate that

approximately 8.5% of people in the United States are taking an- tidepressant agents, and evidence suggests this percentage will

continue to increase (Stagnitti, 2005). For example, between 1997 and 2002, antidepressant medication use among those age 65 and older increased from 9.3% to 13.2% (Agency for Healthcare Research and Quality, 2005).

SSRIs are among the most widely prescribed antidepressant agents. Every medication var- ies in risks, benefits, and adverse effects. Due to increased use of these medications to modify mood, reduce pain, and decrease symptoms associated with depres- sion and obsessive-compulsive

disorders, greater numbers of ad- verse events are being noted in clinical practice. Adverse drug reactions are reported voluntarily in the postmarketing phase of a medication’s approval, and main- taining awareness of problems that occur rarely or in particular populations (e.g., older adults) is challenging for health care pro- viders (Aronson, 2007).

Historically, adverse responses to SSRIs were thought to occur infrequently (Boyer & Shannon, 2005). However, increased use of SSRIs has led to a greater likeli-

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tAblE

sIgns And symptoms to fAcIlItAtE dIffErEntIAtIon of dEmEntIA, dEprEssIon, sErotonIn syndromE, And sErotonIn dIscontInuAtIon syndromE

Sign/Symptom Dementia Depression Serotonin Syndrome

Serotonin Discontinuation

Syndrome Onset Gradual onset over

months and years Onset occurs over a period of weeks (may be accelerated if related to overwhelming loss)

Sudden, acute onset (may include hyperthermia, high blood pressure, manic behavior)

Onset after decrease in or discontinuation of an SSRI (within 24 to 48 hours)

Duration Chronic Can be chronic or acute

Acute phase should terminate in 24 hours

1 to 2 weeks

Mental status Losses in cognition, language, and function; inability to complete simple tasks

Delayed responses to questions

Manic, flight of ideas Slow to process thoughts and instructions, inability to complete activities

Orientation Impaired as disease progresses

Usually not impaired N/A N/A

Sleep-wake cycle Day and night reversed

Inability to maintain sleep

Difficulty initiating sleep Lethargic, inability to maintain sleep

Appetite/ gastrointestinal issues

Variable periods of increased and decreased appetite

Increased or decreased appetite

Nausea, heartburn Increased or decreased appetite

Memory Recent memory impairment

Slower recall N/A N/A

Communication Difficulty finding words

Slow speech and thought

Rapid speech Slow speech

Activity level Variable, may be agitated or lethargic

Variable, may be agitated or lethargic

Excessive physical activity

Fatigue, slow response time

Note. N/A = Not a differentiating sign or symptom; SSRI = selective serotonin reuptake inhibitor.

hood of adverse reactions. These adverse responses are potentially life altering for older patients, who have decreased physiologi- cal reserves. Howland (2007) presented a clinically relevant discussion of the research asso- ciated with the adverse reaction of completed suicide and the use of all antidepressant agents. Ad- verse medication responses relat- ed to psychopharmotherapy for dementia and depression include serotonin syndrome and SDS. Nurses need to identify those older patients at highest risk, as- sess for these adverse drug reac- tions, and intervene to minimize negative outcomes.

IndIvIduAl ExAmplE, contInuEd

Since her last visit with the mental health nurse practitioner 6 weeks ago, Mrs. M. continued to be prescribed paroxetine. Mrs. M.’s daughter now needed to check on her before work and at lunchtime; she also fixed break- fast and brought lunch because her mother would not do so. Mrs. M. no longer bathed daily on her own and was resistant to her daughters’ encouragement to do so. Often, she responded, “I just had a bath” or “I will get one later.” Her daughter continu- ously noticed perspiration on her mother, and Mrs. M. repeatedly said, “My heart is running.”

Mrs. M.’s daughter also no- ticed the thermostat was fre- quently at 95°F, with Mrs. M. wearing multiple layers of cloth- ing. When asked, Mrs. M. would angrily say, “I don’t know who did that. You calling me a liar?” Mrs. M. would not sit or lay still; she constantly walked from one end of the house to the other, changed positions, picked up objects, folded socks one into another, and placed objects in the socks. Her blood pressure had been elevated, her skin was

diaphoretic, and her pupils were sometimes slightly dilated.

During this time, Mrs. M. and her daughter made many visits to the adult care center, and Mrs. M.’s treatment regimen was changed and adjusted. However, increas- ingly negative cognitive and be- havior changes were observed. For example, Mrs. M.’s daughter noted that Mrs. M. had found the medicine bag used to prepare her weekly medication dosages and the new bottle of paroxetine was missing more than one third of the pills when only 5 days’ worth should have been gone. She also noticed that Mrs. M. mixed up dosages in the weekly pack but de- nied making any mistakes in tak- ing her medicine. It was clear that therapeutic dosages to manage Mrs. M.’s symptoms would not be obtained if she were responsible for taking her medicine, and thus her oldest son and daughter de- cided to administer their mother’s medicine. They also made home safety adjustments, such as remov- ing knives, placing some cabinet door latches, and installing door safety locks.

Although Mrs. M.’s daughters were in consultation with the adult center’s RN, mental health nurse practitioner, and physi- cian, who had been seeing Mrs. M. every other day during the past month, her children decided that some changes needed to be made. Mrs. M. was referred to a local program providing geropsy- chiatric care and daily activity.

sErotonIn syndromE Serotonin syndrome related

to SSRIs is currently a hot topic of discussion in journals read by members of multiple health disci- plines and in a variety of health care environments (Boyer & Shannon, 2005; Capriotti, 2006; Rusyniak & Sprague, 2005). However, there is a paucity of in- formation in the literature regard-

ing its relationship to dementia and depression. Several central issues are relevant to serotonin syndrome that health care prac- titioners need to be aware of in clinical practice.

First, intentional SSRI over- dose often results in serotonin syndrome; this fact needs to be disseminated to first responders to suicide attempts, emergency de- partment staff, and poison control center personnel. Prompt inter- vention is required to manage au- tonomic cardiovascular instability and decrease hyperthermia. Sec- ond, approximately 14% to 16% of people who overdose on SSRIs exhibit the classic constellation of signs and symptoms, which include hypertension, tremor, increased peristalsis, diaphore- sis, pupil dilation, hyperthermia, and agitation (Boyer & Shannon, 2005). It should be noted, how- ever, that even one dosage of an SSRI can precipitate serotonin syndrome in individuals with a genetic abnormality related to metabolism, such as those who are poor metabolizers of CYP2D6 and CYP2CIP (Pestka, Hale, Johnson, Lee, & Poppe, 2007).

IndIvIduAl ExAmplE, contInuEd

Mrs. M. attended her gero- psychiatric and daily activity program visits during the next 9 weeks. Staff reported that Mrs. M. sometimes participated in activities and displayed inappro- priate behavior and communica- tion. They also had difficulty get- ting her to take and swallow her medicine, no matter how it was given. Medication nonadherence was an increased concern be- cause program staff reported Mrs. M. sometimes stated she had “a racing heart,” showed mild signs of sweating, had low grade fever and chills, and constantly wiped her nose and sniffed. On several occasions, Mrs. M. was taken

Journal of Psychosocial nursing • Vol. 48, no. 1, 2010 43

to the hospital and observed, but nothing significant was noted.

During the next 2 weeks, Mrs. M.’s children noted that she had begun to complain of a persistent headache and say that her husband (deceased) came to tell her he was going to take her money. Her anxi- ety was increasing, and she was not

sleeping much at night. Concerns grew with her worsened behaviors, and Mrs. M. no longer wanted to go to the geropsychiatric and daily activity program. She was referred to a geropsychiatrist in the next county who hospitalized her for evaluation and development of a treatment plan.

sErotonIn dIscontInuAtIon syndromE

The likelihood of nonadher- ence issues with older adults who have limited cognitive function and assistance is great. When SSRIs are discontinued or the client is intermittently noncom-

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IntErvEntIons for nursEs or fAmIly mEmbErs And cArEgIvErs rElAtEd to dEmEntIA, dEprEssIon, And drug EffEcts

Dementia

• Keep things the same as much as possible. Familiarity, a structured routine, reinforcement with repetition, and a familiar environment can help with behaviors (Arnold, 2004). • Maintain sameness related to medication administration. Consistency in how medication is given, what it looks like, and when it is administered is important. • Give dosages precisely and monitor for signs of toxicity. Older adults metabolize antipsychotic drugs slowly. Metabolites can accumulate and cause lethargy (Abrams, Pennington, & Lammon, 2007).

Depression

• Monitor closely for deliberate self-destructive behaviorsa (Martin & Haynes, 2000). • Encourage expression of feelings, while providing attention and therapeutic listening (Martin & Haynes, 2000). • Monitor initiation of drug therapy. Dosages of selective serotonin reuptake inhibitors (SSRIs) should be increased graduallya (Arnold, 2004).

Drug Effects: Serotonin Syndrome

• Discontinue the drug intake. • Observe for new or increased intensity of any signs and symptoms. View new complaints as side effects of medications (Murphy, 2007). • Assess for the sequelae of a drug-drug interaction or a drug-herbal supplement interaction. The U.S. Food and Drug Administration (2009) has issued a public health advisory related to the high occurrence of serotonin syndrome with concurrent use of medication class of triptans, which are indicated for treatment of migraine headaches. However, the list of medications and herbal supplements that have triggered serotonin syndrome when added to an SSRI is diversea (Boyer & Shannon, 2005). • Aggressively correct hyperthermiaa (Boyer & Shannon, 2005). • Address tremorsa (Boyer & Shannon, 2005). • When any medication is added to an SSRI, review the literature for case reports relevant to possible interactions that may result in serotonin syndrome. Clients taking SSRIs need aggressive medication-specific education so they avoid adding over-the-counter medications and herbal products that can be problematic. For example, Tramadol (Ultram®), a medication commonly used for pain in older adults, can trigger severe serotonin syndromea (Boyer & Shannon, 2005).

Drug Effects: Serotonin Discontinuation Syndrome

• Remove all alcohol from medicinesa and diet until syndrome clears because alcohol can worsen the symptoms (Ditto, 2003). • Avoid abrupt discontinuation of SSRIs (Ditto, 2003). • Rule out other causes of symptomsa (Warner, Bobo, Warner, Reid, & Rachal, 2006). • Restart the medication at a lower dosage with a gradual decrease plana (Warner et al., 2006). The decision to restart should be based on the severity of symptoms and whether or not an antidepressant agent is still needed.

a Indicates interventions limited to nurses or other appropriately licensed health care professionals.

pliant, clusters of symptoms oc- cur that neither the client nor provider may connect to medica- tion withdrawal. Symptoms are nonspecific, and only a correla- tion of symptoms with a history of stopping the medication can result in an accurate diagnosis (Ditto, 2003). The most common symptoms are flu-like symptoms, including rhinorrhea, dizziness, irritability, loss of appetite, in- somnia, and sensory disturbances (Martin & Haynes, 2000). On- set of symptoms is medication specific: The longer the medica- tion remains metabolically active (half-life), the later the onset of SDS symptoms.

Separating discontinuation reactions from an acceleration of psychiatric symptoms is difficult. Anxiety, headaches, mood li- ability, vivid dreams, and tremors can be associated with either an increase in depression symptoms or SDS. An in-depth history is the key to making the appropri- ate diagnosis (Ditto, 2003).

nursIng ImplIcAtIons The implications for nurses

when dealing with dementia, depression, and drug effects such as serotonin syndrome and/or SDS are numerous and challeng- ing, and a complete discussion of them all is beyond the scope of this article. Our goal is to provide information to primarily enhance awareness, rather than be strictly prescriptive regarding care im- plications. Enhancing awareness entails setting aside any precon- ceived notions of these variables; doing so will result in improved care for the clients experiencing them (Maynard, 2003).

Nurses need to be aware of some common key implications for all three variables. These impli- cations should lead nurses to rule out normal aging (Arnold, 2004; Maynard, 2003; Potter & Steffens, 2007); know the characteristics,

signs, and symptoms of the three variables; be aware of the expected outcomes, reactions, and interac- tions; and assess and document the condition or symptom the medica- tion is intended to treat (Murphy & Kayani, 2007).

The challenge for nurses is dif- ferentiating behaviors, signs, and symptoms of dementia, depression, serotonin syndrome, or SDS—all of which are issues nurses will likely face with older clients. Addi- tional implications for assessment, intervention, and evaluation are discussed below to facilitate efforts to provide optimal care.

Assessment The first and most critical step

in differentiation is assessment. Maynard (2003) suggested that a vital component of this process is to set aside any assumptions that depression, dementia, and adverse drug effects are comor- bid certainties with older adults. According to Arnold (2004), “An older adult with depression may deny feeling sad or having psychological symptoms but may report vague, unexplained so- matic complaints” (p. 41). Fam- ily members may also deny signs and symptoms because they may be unwilling to acknowledge that their loved one is no longer the person he or she used to be.

Tools to assess for these vari- ables are varied. Key to assess- ment for all are skill in inter- viewing, clarity in observation, thoroughness in history tak- ing, and possession of excellent physical assessment skills. Nurses should perform a thorough men- tal health assessment, physical examination, and client history, including onset of symptoms, past mental illness, and current activities. Nurses should also observe the client’s appearance, affect, and behavior during the interview (Arnold, 2004; May- nard, 2003).

In addition to the specific as- sessment information for each of the variables, it is important to note that diagnostic tests (e.g., laboratory tests, computed to- mography, magnetic resonance imaging) are also needed to rule out infections, anemia, metabolic disorders, tumors, hydrocephalus, and strokes, particularly when looking at dementia and depres- sion (Maynard, 2003). In addi- tion, nurses should assess for sui- cidal ideation, plans, or attempts (Martin & Haynes, 2000; May- nard, 2003) and adherence to the prescribed medication regimen. All assessments should include observations for the signs and symptoms indicative of dementia, depression, and drug effects.

Dementia. In addition to gen- eral assessments, Thibault and Steiner (2004) noted screening tools used for dementia that in- clude the Mini-Mental State Ex- amination, Clock Drawing Test, Katz Index of Independence in Activities of Daily Living scale, and the Instrumental Activi- ties of Daily Living scale. Nurses need to have appropriate training and skills to use these tools, but the instruments are designed for easy use and are specific for older adults. For individuals with de- mentia, use of these tools might be limited because of diminished cognitive ability and the fact that some functional assessments depend on caregiver observa- tion, yet not all individuals have caregivers (Thibault & Steiner, 2004).

Depression. Every health care provider must be aware of the se- riousness of assessing and screen- ing for depression, as well as be- ing aware of systems for follow up and treatment. Nurses can assess for depression by primarily ob- serving for behaviors, and if quali- fied, by using tools recommended by Thibault and Steiner (2004) such as the Geriatric Depression

Journal of Psychosocial nursing • Vol. 48, no. 1, 2010 45

Scale, Center for Epidemiologic Studies Depression Scale, and Patient Health Questionnaire-2 and -9. The Patient Health Ques- tionnaire-2 would be used for initial screening and the Pa- tient Health Questionnaire-9 for confirmation of diagnosis or for monitoring (Thibault & Steiner, 2004). As noted above, assessing for suicidal ideation is critical, with immediate action taken if it is present (Arnold, 2004).

Drug Therapy Effects: Sero- tonin Syndrome. Tools to assess serotonin syndrome need to be incorporated into mental health practice so even mild symp- toms of serotonin side effects are monitored and documented. No laboratory tests are available for serotonin syndrome, so nurses must depend on adequate assess- ment for differentiation (Finfgeld, 2004). Subtle signs and symptoms are better assessed by the Sero- tonin Syndrome Scale (Hegerl et al., 1998). However, severe cases are characterized by serious sympathetic symptoms, as noted above.

Drug Therapy Effects: SDS. Be- cause symptoms are not specific, there are no particular tools to assess SDS. Assessment should include and focus on an in-depth

medication history. Challenges with clients who have dementia are their lack of recall and that they may have several caregivers at different times, who may have some or all of the information needed. The Table contains ad- ditional information about signs and symptoms to assist in differ- entiation of dementia, depression, serotonin syndrome, and SDS.

Interventions Although a number of inter-

ventions to address the signs and symptoms inherent in dementia, depression, serotonin syndrome, and SDS exist, to address all of them is beyond the scope of this article. The focus of the interven- tions presented here is primarily related to differentiating dementia, depression, and drug effects, ex- cept in critical or life-threatening situations. Interventions should be based on the results of the assess- ment. Because nurses are involved in deciding which nursing inter- ventions are appropriate for older clients with cognitive changes, it is helpful to note that some inter- ventions are appropriate for clients regardless of which condition the client is experiencing (Martin & Haynes, 2000), such as interven- tions related to patient safety (Ar-

nold, 2004). Strategies related to pharmacotherapy, such as the use of one pharmacy to fill prescrip- tions, pill boxes, a trusted caregiver to help with filling and monitoring pill boxes, automatic medication dispensers with a voice-activated message, and telephone reminders, can be applied to clients with any of these conditions. Use of these interventions depends on whether the client’s mental status is such that these options are viable.

Nurses should also discuss ex- pected outcomes and potential side effects with clients and/or their caregivers. It is helpful to provide written instructions and telephone follow up for those who are cogni- tively impaired or lack social sup- port (Murphy & Kayani, 2007). Nurses can help the prescribing clinician (e.g., nurse practitioner, physician) minimize polyphar- macy, particularly regarding sero- tonin-enhancing drugs, which can affect cognitive functioning.

Other general interventions in- clude providing support and educa- tion for family and caregivers and monitoring details of the client’s medication history and adherence (Arnold, 2004). The person who implements specific interventions will vary by client and the nature of the intervention. Sometimes the nursing intervention will be to teach family members or other caregivers how to perform the in- tervention because the client may not be in a hospital, nursing home, or clinic setting. Key interventions for nurses or family members and caregivers related to dementia, de- pression, and drug effects are pro- vided in the Sidebar on page 44.

Evaluation Evaluation is primarily related

to analysis of the impact of vari- ous interventions on the older client’s behavioral, physiological, and cognitive function. Specific evaluation for each of the three variables should focus first on

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1. Sorting out which changes in the mental status and functioning of older adults are associated with normal aging, dementia, and medication effects is complicated by the presence of depression.

2. The complexities of SSRI pharmacotherapy with older adults are numerous and include serotonin syndrome and serotonin discontinuation syndrome.

3. Older adults with dementia may not be able, or willing, to express when they are feeling depressed and are more likely to exhibit symptoms that are less obviously related with depression.

4. The first and most critical step in differentiation is assessment. Key to assessment are nurses’ skill in interviewing, clarity in observation, thoroughness in history taking, and possession of excellent physical assessment skills.

Do you agree with this article? Disagree? Have a comment or questions? Send an e-mail to the Journal, at [email protected].

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K E y p o I n t s

the most critical adverse effects, provide direction for additional interventions, and highlight any additional implications.

IndIvIduAl ExAmplE, conclusIon

Despite three more inpatient hospitalizations and multiple medication adjustments to com- bat SDS, dementia, and depres- sion over the next 3 years, Mrs. M. continued to decline. Her signs and symptoms were relieved only temporarily by some medi- cations and interventions. Her children were required to spend increased time and energy at her home caring for her. Due to their mental and physical exhaustion but with much guilt and remorse, Mrs. M.’s children placed her in a group home located close to one of the children. Mrs. M.’s behav- ior and condition stabilized for ap- proximately 4 months, but it did not last, and her children decided to bring her home again after find- ing a qualified full-time, live-in helper. After additional hospital- izations and increased combative behavior, potential for self-harm, and skilled nursing care needs, Mrs. M.’s children decided they had no choice but to seek care for her in a skilled nursing facility.

conclusIon Each person is a unique

blend of DNA, culture, gender, and environment, and find- ing an appropriate match of these factors and drug therapy may require some experimen- tation. This match is compli- cated further when the person is older and has dementia and depression. Older adults are at increased risk for adverse reac- tions when taking SSRIs for de- mentia and depression. When differentiating dementia, de- pression, and drug effects of se- rotonin syndrome and SDS in older clients, it may be helpful

to remember Goldilocks’ story: For each person, it is an experi- ment to find the medication, dosage, and therapeutic effect that is “just right.”

rEfErEncEs Abrams, A.C., Pennington, S.S., & Lam-

mon, C.B. (2007). Clinical drug therapy: Rationales for nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins.

Agency for Healthcare Research and Qual- ity. (2005). AHRQ news and numbers: Trends in antidepressant use. Retrieved from http://www.ahrq.gov/news/nn/ nn051605.htm

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/ appi.books.9780890423349

Arnold, E. (2004). Sorting out the 3 D’s: Delirium, dementia, and depression. Nursing 2004, 34(6), 36-42.

Aronson, J.K. (2007). Adverse drug reac- tions—No farewell to harms. British Journal of Clinical Pharmacology, 63, 131-135.

Boyer, E.W., & Shannon, M. (2005). The serotonin syndrome. New England Jour- nal of Medicine, 352, 1112-1120.

Capriotti, T. (2006). Update on depression and antidepressant medications. Med- surg Nursing, 15, 241-246, 222.

Ditto, K.E. (2003). SSRI discontinuation syndrome. Awareness as an approach to prevention. Postgraduate Medicine, 114(2), 79-84.

Finfgeld, D.L. (2004). Serotonin syn- drome and the use of SSRIs. Journal of Psychosocial Nursing and Mental Health Services, 42(2), 16-20.

Hegerl, U., Bottlender, R., Gallinat, J., Kuss, H.J., Ackenheil, M., & Möller, H.J. (1998). The Serotonin Syndrome Scale: First results on validity. Euro- pean Archives of Psychiatry and Clinical Neuroscience, 248, 96-103.

Howland, R.H. (2007). Antidepressants and suicide: Putting the risk in per- spective. Journal of Psychosocial Nurs- ing and Mental Health Services, 45(7), 15-19.

Martin, J.H., & Haynes, L.C. (2000). De- pression, delirium, and dementia in the elderly patient. AORN Journal, 72, 209-217.

Maynard, C.K. (2003). Differentiate de- pression from dementia. The Nurse Practitioner, 28(3), 18-19, 23-27.

Murphy, D.P., & Kayani, N. (2007). Strategies for optimal care of the elderly: Polypharmacy in elderly pa- tients: Practical tips to avoid adverse

effect and interactions. Consultant, 47, 1172.

Pestka, E.L., Hale, A.M., Johnson, B.L., Lee, J.L., & Poppe, K.A. (2007). Cyto- chrome P450 testing for better psychi- atric care. Journal of Psychosocial Nurs- ing and Mental Health Services, 45(10), 15-18.

Potter, G.G., & Steffens, D.C. (2007). Depression and cognitive impair- ment in older adults. Psychiatric Times, 24(13). Retrieved from http://www. psychiatrictimes.com/depression/ article/10168/54436

Pountney, D. (2007). Dementia, delirium, or depression? Nursing Older People, 19(5), 12-14.

Rusyniak, D.E., & Sprague, J.E. (2005). Toxin-induced hyperthermic syn- dromes. Medical Clinics of North Amer- ica, 89, 1277-1296.

Stagnitti, M.N. (2005). Statistical brief #77: Antidepressant use in the U.S. civilian noninstitutionalized population, 2002. Retrieved from the Agency for Healthcare Research and Qual- ity website: http://www.meps.ahrq. gov/mepsweb/data_files/publications/ st77/stat77.pdf

Thibault, J.M., & Steiner, R.W. (2004). Efficient identification of adults with depression and dementia. American Family Physician, 70, 1101-1110.

U.S. Food and Drug Administration. (2009). Public health advisory—Com- bined use of 5-hydroxytryptamine recep- tor agonists (triptans), selective serotonin reuptake inhibitors (SSRIS) or selective serotonin/norepinephrine reuptake inhib- itors (SNRIS) may result in life-threat- ening serotonin syndrome. Retrieved from http://www.fda.gov/Drugs/ DrugSafety/PublicHealthAdvisories/ ucm124349.htm

Warner, C.H., Bobo, W., Warner, C. Reid, S., & Rachal, J. (2006). Antidepres- sant discontinuation syndrome. Ameri- can Family Physician, 74, 449-456.

Dr. Sherrod is Professor of Nursing, Dr. Collins is Clinical Professor, and Ms. Wynn and Ms. Gragg are Instructors, The University of Alabama, Capstone College of Nursing, Tuscaloosa, Alabama.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Roy Ann Sherrod, DSN, RN, CNE, CNL, Professor of Nursing, The University of Alabama, Capstone College of Nursing, Box 870358, Tuscaloosa, AL 35487-0358; e-mail: [email protected]. doi:10.3928/02793695-20091204-01

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