The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Lakshmi Ravindran, MD, Department of Psychiatry, University of Toronto and St. Michael’s Hospital, Toronto, ON.
David Conn, MB, FRCPC, Department of Psychiatry, University of Toronto and Baycrest Centre for Geriatric Care, Toronto, ON.
Arun Ravindran, MB, PhD, FRCPC, FRCPsych, Department of Psychiatry, University of Toronto and the Centre for Addiction and Mental Health, Toronto, ON.

Depression in the older population is a condition commonly encountered by the primary care physician. However, it is frequently underdiagnosed and undertreated. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine are the first-line choice of antidepressants for the treatment of depression. Mirtazapine and bupropion are second-line agents with tricylics and monoamine oxidase inhibitors (MAOIs) being considered for refractory patients. Although equally effective, these agents exhibit varying levels of tolerability and different adverse events profiles. After remission, patients need maintenance treatment, the duration varying with the number of episodes experienced. Treatment nonresponse is often associated with the presence of concurrent medical illnesses, poor compliance, and the presence of ongoing psychosocial stressors. Partial or nonresponse to optimum doses of antidepressants will necessitate either switch augmentation or combination strategies, but caution should be exercised to prevent drug interactions. Depression in the older adult is treatable, with key goals being recognition, diagnosis, aggressive acute treatment, and planned maintenance.
Key words: depressive disorders, older adult, antidepressants, nonresponse, augmentation.

Post-Stroke Depression

Ricardo E. Jorge, MD, Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
Robert G. Robinson, MD, Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.

In most western countries, 0.2 % of the population suffer a stroke each year. One-third of them die over the next year, one- third remain permanently disabled, and the other third make a good recovery. Depression is one of the most common emotional disorders associated with cerebrovascular disease. Longitudinal studies of stroke patients have shown that about 20% of these patients will develop major depression and another 20% will develop minor depression during the first year after stroke. Depression has also been demonstrated to significantly effect clinical recovery and mortality and, more important. Post-stroke depression responds to antidepressant treatment.

Key words: stroke, mood disorders, antidepressants, cognitive disorders, disability.

Barbara Liu, MD, FRCPC, Sunnybrook &Women's College Health Sciences Centre and the Kunin-Lunenfeld Applied Research Unit, Baycrest Centre, Toronto, ON.

Falls are a common problem among older patients. Medications in general, and psychotropic drugs in particular, have been shown to increase the risk of falls. The possible mechanisms whereby psychotropic drugs increase this risk include sedation, orthostatic hypotension, arrhythmias, confusion due to anticholinergic effects, and dopaminergic effects on balance and motor control. Several epidemiological studies have identified antidepressant use--both tricyclic and selective serotonin re-uptake inhibitors--as a risk factor for falls. When treating a patient with an antidepressant, efforts should be made to reduce other modifiable risk factors for falls by optimizing intrinsic and extrinsic risk factors for falls.
Key words: falls, antidepressant, hip fracture, tricyclic antidepressant, selective serotonin re-uptake inhibitor.

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services; Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; 2002-3 Royal Canadian Legion Fellow in Care of the Elderly, Toronto, ON.

Neuropathic pain is a relatively common and challenging entity in the elderly, with a wide differential diagnosis and numerous treatments available. In general, damage to peripheral nerves via an injury or as a result of abnormal functioning is thought to trigger a cascade of events in sensory neurons that is responsible for the generation of pain. Potential treatments include tricyclic antidepressants, serotonin re-uptake inhibitors, venlafaxine, ion channel blockers, opioids, capsaicin and the Lidocaine patch. This article reviews the relative efficacy of these treatments, with specific reference to considerations in the elderly.
Key words: neuropathic pain, peripheral neuropathy, treatment, anticonvulsant, antidepressant.

Roy C. Ziegelstein, MD, Department of Medicine, Division of Cardiology, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD.

Depressed mood is common after a myocardial infarction and is associated with increased mortality risk. Although mild forms of depression often resolve without specific treatment, moderate to severe depression is typically longer lasting. Depression is particularly unlikely to resolve spontaneously in those who are socially isolated, a common problem in older individuals. Patients may be screened for depression using one of several short and valid instruments. If antidepressant treatment is indicated, a selective serotonin reuptake inhibitor is preferred and should be combined with efforts to improve social support, to address medication adherence issues and to encourage participation in a cardiac rehabilitation program.
Key words: depression, myocardial infarction, screening, social support, antidepressants.

Kiran Rabheru, MD, CCFP, FRCP, ABPN, Physician Leader, Geriatric Psychiatry Program, Regional Mental Health Care and Chair, Division of Geriatric Psychiatry, Associate Professor of Psychiatry, University of Western Ontario, London, ON.

Depression is the most common psychiatric disease in the elderly. Over 30% of community-dwelling elderly suffer from subsyndromal depression and over 10% of hospitalized elderly have syndromal major depressive disorder (MDD). Depression is frequently a persistent and recurrent disorder leading to increased morbidity and mortality, as well as poor quality of life.

Early antidepressant medications, tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were discovered through astute clinical observations. These first-generation medications are effective because they enhance serotonergic and/or noradrenergic function. Unfortunately, the TCAs also block histaminic, cholinergic and alpha-1 adrenergic receptor sites, causing unwanted side effects such as weight gain, dry mouth, constipation, urinary retention, confusion, drowsiness and dizziness. MAOIs interact with tyramine to cause potentially lethal hypertension and cause dangerous interactions with a number of prescribed and over-the-counter medications.¹

A major goal of antidepressant development is to improve on preceding drug classes for greater specificity, fewer unwanted side effects and more rapid onset of action.

Monica Lee, BSc (Phm), MSc
Research Pharmacist
Baycrest Centre for Geriatric Care,
Toronto, ON.

Julie Dergal, MSc
Kunin-Lunenfeld Applied Research Unit
Baycrest Centre for Geriatric Care,
Toronto, ON.

Introduction
Older people often take multiple drug therapies for the treatment of various, concomitant chronic conditions. As a result, older adults are at increased risk of developing adverse drug events. It is important for physicians to regularly review the drug regimen of any older patient, and to discontinue any drug therapies that are no longer required or indicated. Physicians may also have to discontinue a particular drug therapy for other reasons including: if the drug therapy is ineffective; if it causes intolerable adverse effects; if newer and safer alternative drug therapies become available; or if the patient refuses to continue the treatment. It is important that physicians know how to appropriately discontinue or switch an older person's drug therapy in order to avoid adverse events.

There are currently limited practice guidelines available for discontinuing or switching psychotropic drug therapies. When discontinuing a medication, physicians need to consider whether it can be withdrawn abruptly or gradually tapered.

Thomas Tsirakis, BA

The use of selective serotonin reuptake inhibitors (SSRI) as a first-line of treatment for depression in the elderly has become the standard of choice in clinical practice. The widespread preference of initiating treatment with an SSRI versus the more traditional tricyclic antidepressants (TCA) has been largely due to the belief that SSRIs have a safer profile, are better tolerated, and have a lower drop-out rate than TCAs. An accumulating number of studies published in the last few years, however, have begun to question this rationale, and have demonstrated that SSRIs are neither as advantageous, nor as safe as previously believed.

There are four SSRIs currently available [fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox)], each possessing both similar and unique side-effect profiles. Though SSRIs have been the main-stay of first-line treatment in recent years, it is important to be aware that they are not without risk. The belief that SSRIs exhibit fewer side-effects than TCAs is misleading in that TCAs have been studied far more extensively than SSRIs, and nearly every study comparing an SSRI with a TCA has used one of the most poorly tolerated TCAs in the comparison, thus making the SSRIs look remarkably tolerable.