The diagnosis of depression and use of antidepressants in nursing home residents with and without dementia

Informal antidepressant strategies for nursing home residents: two group concept mapping studies

OBJECTIVES

To identify and structure potential informal antidepressant strategies that can be used in daily practice for nursing home residents alongside formal treatments.

METHODS

In a first Group Concept Mapping study, residents, relatives, and professional caregivers (N = 124) brainstormed on strategies residents could use to prevent or alleviate depression. In a second study, the same participants (N = 110) reported strategies for use by others. Furthermore, participants rated the expected effectiveness and feasibility of the suggested strategies. Simultaneously, all strategies were sorted by experts and clustered using multidimensional scaling and hierarchical cluster analysis.

RESULTS

Six clusters emerged for strategies by residents themselves and five clusters for strategies by others. For residents' strategies, the clusters Being socially connected and Participating in activities were perceived as most effective, as was the cluster Offering personal attention for strategies by others. Participants perceived Creating a healthy living environment as the most feasible cluster executed by residents. Within strategies by others, the clusters Offering personal attention, Using positive treatment/approach, and Using or adapting the physical environment were perceived as the most feasible.

CONCLUSION

The results indicated the importance of social connectedness, a personalized and positive approach by significant others, and tailored activity programs. The results also suggest that adaptations to the physical environment within nursing homes may be an easy applicable strategy to prevent or alleviate depression in residents. Although more research is needed, these findings may guide daily practice and the development of interventions that include informal strategies.

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13607863.2022.2057427 .

Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

Prevalence and correlates of major depressive disorder, bipolar disorder and schizophrenia among nursing home residents without dementia: systematic review and meta-analysis

BACKGROUND

The elderly population and numbers of nursing homes residents are growing at a rapid pace globally. Uncertainty exists regarding the actual rates of major depressive disorder (MDD), bipolar disorder and schizophrenia as previous evidence documenting high rates relies on suboptimal methodology.

AIMS

To carry out a systematic review and meta-analysis on the prevalence and correlates of MDD, bipolar disorder and schizophrenia spectrum disorder among nursing homes residents without dementia.

METHOD

Major electronic databases were systematically searched from 1980 to July 2017 for original studies reporting on the prevalence and correlates of MDD among nursing homes residents without dementia. The prevalence of MDD in this population was meta-analysed through random-effects modelling and potential sources of heterogeneity were examined through subgroup/meta-regression analyses.

RESULTS

Across 32 observational studies encompassing 13 394 nursing homes residents, 2110 people were diagnosed with MDD, resulting in a pooled prevalence rate of 18.9% (95% CI 14.8-23.8). Heterogeneity was high (I2 = 97%, P≤0.001); no evidence of publication bias was observed. Sensitivity analysis indicated the highest rates of MDD among North American residents (25.4%, 95% CI 18-34.5, P≤0.001). Prevalence of either bipolar disorder or schizophrenia spectrum disorder could not be reliably pooled because of the paucity of data.

CONCLUSIONS

MDD is highly prevalent among nursing homes residents without dementia. Efforts towards prevention, early recognition and management of MDD in this population are warranted.

Antidepressants for treating depression in dementia

BACKGROUND

The use of antidepressants in dementia accompanied by depressive symptoms is widespread, but their clinical efficacy is uncertain. This review updates an earlier version, first published in 2002.

OBJECTIVES

To determine the efficacy and safety of any type of antidepressant for patients who have been diagnosed as having dementia of any type and depression as defined by recognised criteria.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 16 August 2017. ALOIS contains information on trials retrieved from databases and from a number of trial registers and grey literature sources.

SELECTION CRITERIA

We included all relevant double-blind, randomised trials comparing any antidepressant drug with placebo, for patients diagnosed as having dementia and depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion and extracted data independently. We assessed risk of bias in the included studies using the Cochrane 'Risk of bias' tool. Where clinically appropriate, we pooled data for treatment periods up to three months and from three to nine months. We used GRADE methods to assess the overall quality of the evidence.

MAIN RESULTS

We included ten studies with a total of 1592 patients. Eight included studies reported sufficiently detailed results to enter into analyses related to antidepressant efficacy. We split one study which included two different antidepressants and therefore had nine groups of patients treated with antidepressants compared with nine groups receiving placebo treatment. Information needed to make 'Risk of bias' judgements was often missing.We found high-quality evidence of little or no difference in scores on depression symptom rating scales between the antidepressant and placebo treated groups after 6 to 13 weeks (standardised mean difference (SMD) -0.10, 95% confidence interval (CI) -0.26 to 0.06; 614 participants; 8 studies). There was probably also little or no difference between groups after six to nine months (mean difference (MD) 0.59 point, 95% CI -1.12 to 2.3, 357 participants; 2 studies; moderate-quality evidence). The evidence on response rates at 12 weeks was of low quality, and imprecision in the result meant we were uncertain of any effect of antidepressants (antidepressant: 49.1%, placebo: 37.7%; odds ratio (OR) 1.71, 95% CI 0.80 to 3.67; 116 participants; 3 studies). However, the remission rate was probably higher in the antidepressant group than the placebo group (antidepressant: 40%, placebo: 21.7%; OR 2.57, 95% CI 1.44 to 4.59; 240 participants; 4 studies; moderate-quality evidence). The largest of these studies continued for another 12 weeks, but because of imprecision of the result we could not be sure of any effect of antidepressants on remission rates after 24 weeks. There was evidence of no effect of antidepressants on performance of activities of daily living at weeks 6 to 13 (SMD -0.05, 95% CI -0.36 to 0.25; 173 participants; 4 studies; high-quality evidence) and probably also little or no effect on cognition (MD 0.33 point on the Mini-Mental State Examination, 95% CI -1.31 to 1.96; 194 participants; 6 studies; moderate-quality evidence).Participants on antidepressants were probably more likely to drop out of treatment than those on placebo over 6 to 13 weeks (OR 1.51, 95% CI 1.07 to 2.14; 836 participants; 9 studies). The meta-analysis of the number of participants suffering at least one adverse event showed a significant difference in favour of placebo (antidepressant: 49.2%, placebo: 38.4%; OR 1.55, 95% CI 1.21 to 1.98, 1073 participants; 3 studies), as did the analyses for participants suffering one event of dry mouth (antidepressant: 19.6%, placebo: 13.3%; OR 1.80, 95% CI 1.23 to 2.63, 1044 participants; 5 studies), and one event of dizziness (antidepressant: 19.2%, placebo: 12.5%; OR 2.00, 95% CI 1.34 to 2.98, 1044 participants; 5 studies). Heterogeneity in the way adverse events were reported in studies presented a major difficulty for meta-analysis, but there was some evidence that antidepressant treatment causes more adverse effects than placebo treatment does.

AUTHORS' CONCLUSIONS

The available evidence is of variable quality and does not provide strong support for the efficacy of antidepressants for treating depression in dementia, especially beyond 12 weeks. On the only measure of efficacy for which we had high-quality evidence (depression rating scale scores), antidepressants showed little or no effect. The evidence on remission rates favoured antidepressants but was of moderate quality, so future research may find a different result. There was insufficient evidence to draw conclusions about individual antidepressant drugs or about subtypes of dementia or depression. There is some evidence that antidepressant treatment may cause adverse events.

Provision and perceived quality of mental health services for older care home residents in England: a national survey

OBJECTIVE

This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents.

METHODS

A postal survey was sent to all CMHTsOP in England. Information was collected about teams' staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers' rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-squared tests of association and ordinal regression.

RESULTS

Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP.

CONCLUSION

The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP. Copyright © 2017 John Wiley & Sons, Ltd.

Evolution of the Antidepressant Prescribing in Alzheimer's Disease and Related Disorders Between 2010 and 2014: Results from the French National Database on Alzheimer's Disease (BNA)

BACKGROUND

Safety warnings from health authorities are currently intended to limit the use of psychotropic agents in dementia-related conditions. Evidence concerning the use of antidepressants in dementia is, however, scarce and contradictory.

OBJECTIVE

To evaluate antidepressant use among individuals with Alzheimer's disease (AD) and related disorders in the French population between 2010 and 2014.

METHOD

Antidepressant prescriptions in individuals with AD, mixed dementia (MD), and vascular dementia (VaD) in the French National Alzheimer Database between 2010 and 2014 were analyzed (N = 199,544).

RESULTS

Multivariate analysis showed an annual significant increase (p < 0.001) in the prescription rate of antidepressants from 26% (2010) to 31% (2014), and identified female gender, younger age, higher education, living in long-term facilities, more severe cognitive decline, and presence of vascular signs (VaD and MD) as associated factors for antidepressant prescribing.

CONCLUSION

The annual increase of antidepressant prescribing among individuals with AD, MD, and VaD in French specialized settings may be partially related to the lack of current valuable medications for dementia-related behavioral symptoms.

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

METHODS

This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

RESULTS

Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

CONCLUSIONS

This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Persistent use of psychotropic drugs in nursing home residents in Norway

Background

The prevalence of psychotropic drug (PTD) use in NH residents is high, but few have explored prevalence and persistency in PTD in NH residents and factors associated with persistency. This at the same time as we know that risk of side events may be higher with long- term use in older adults. Thus, the aim of this study was to describe the prevalence and persistence in use of PTD and to explore factors associated with persistence in use of PTD at two consecutive time points in nursing home (NH) residents.

Methods

We included 1163 NH residents in a 72-month longitudinal study with five assessments. Use of PTD, neuropsychiatric symptoms (NPS), severity of dementia and physical health were assessed each time.

Results

The prevalence over time and persistent use of antipsychotic drugs, antidepressants, anxiolytics and sedatives at two consecutive time points were high in residents with and without dementia. There was an association between greater NPS at the first time point, and persistent use of these drugs, but changes in NPS between time points, did not explain such use. A longer NH stay increased the odds for persistent use of antipsychotics.

Conclusion

Psychotropic drugs are frequently used as a long-term treatment among NH residents and are associated with severity of neuropsychiatric symptoms, but not with severity of dementia. Closer attention should be paid to follow-up of psychotropic drug treatment, and especially for long –term use of antipsychotics, since the duration of such treatment should be as short as possible.

Association of psychological distress late in life and dementia-related mortality

OBJECTIVE

It is not fully understood how subjective feelings of psychological distress prognosticate dementia. Our aim was to investigate the association between self-reported psychological distress and risk of dementia-related mortality.

METHOD

We included 31,043 eligible individuals between the ages of 60 and 80 years, at time of examination, from the CONOR (Cohort of Norway) database. They were followed for a period of 17.4 years (mean 11.5 years). The CONOR Mental Health Index, a seven-item self-report scale was used. A cut-off score equal to or above 2.15 on the scale denoted psychological distress. Cox regression was used to assess the association between psychological distress and risk of dementia-related mortality.

RESULTS

Total number of registered deaths was 11,762 and 1118 (9.5%) were classified as cases of dementia-related mortality. We found that 2501 individuals (8.1%) had psychological distress, of these, 119 (10.6%) had concomitant dementia-related mortality. Individuals with psychological distress had an increased risk of dementia-related mortality HR = 1.52 (95% confidence interval (CI) 1.25-1.85) after adjusting for age, gender and education. The association remained significant although attenuated when implemented in a full adjusted model, including general health status, smoking, obesity, hypertension, diabetes and history of cardiovascular disease; hazard ratio, HR = 1.30 (95% CI 1.06-1.59).

CONCLUSION

Our results indicate that psychological distress in elderly individuals is associated with increased risk of dementia-related mortality. Individuals at increased risk of dementia may benefit from treatments or interventions that lessen psychological distress, but this needs to be confirmed in future clinical studies.

Factors associated with antidepressant use in residents with and without dementia in Australian aged care facilities

OBJECTIVE

Depressive symptoms are highly prevalent in residential aged care facilities (RACFs). The prevalence of antidepressant use is increasing but the effectiveness of antidepressants in people with dementia is uncertain. The objective of the study was to investigate factors associated with antidepressant use in residents with and without dementia.

METHODS

This was a prospective cross-sectional study of 383 residents in six Australian RACFs. Data on health status, medications and demographics were collected by trained study nurses from April to August 2014. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with antidepressant use. Analyses were stratified by dementia and depression.

RESULTS

Overall, 183 (47.8%) residents used antidepressants. The prevalence of antidepressant use was similar among residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use in the main analysis (AOR = 0.56, 95% CI = 0.32-0.99) and in subanalyses for residents with documented depression (AOR = 0.51, 95% CI = 0.27-0.96). In residents with dementia, moderate quality of life was associated with a lower odds of antidepressant use compared with poor quality of life (AOR = 0.35, 95% C I= 0.13-0.95). In residents without dementia, analgesic use was associated with antidepressant use (AOR = 2.34, 95% CI = 1.07-5.18).

CONCLUSIONS

The prevalence of antidepressant use was similar in residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use but there was no association between self-reported pain and antidepressant use.

Impact of care settings on residents' functional and psychosocial status, physical activity and adverse events

BACKGROUND

Internationally, as the number of older adults increases, different types of care settings are evolving to address the care needs of this growing group of individuals.

AIMS AND OBJECTIVES

The purpose of this study was to describe and compare clinical outcomes of residents with moderate to severe cognitive impairment living in residential care facilities (RCFs) and nursing homes (NHs).

DESIGN

This was a secondary data analysis that included data from two studies testing a Function-Focused Care for Cognitively Impaired (FFC-CI) Intervention.

METHODS

A total of 96 participants were from RCFs and 103 were from NHs. Change scores over a 6-month period in RCF and NH residents were evaluated using a multivariate analysis of variance.

RESULTS

Residential care facilities residents had more agitation, better function and engaged in approximately twice as much physical activity as those in NH settings at baseline. Controlling for treatment status and baseline differences, over 6 months, RCF residents showed a decrease of -22.77 ± 41.47 kilocalories used in 24 hours while those in NHs increased to a mean of 10.49 ± 33.65 kilocalories used. With regard to function, residents in RCFs declined 10.97 ± 18.35 points on the Barthel Index, while those in NHs increased 10.18 ± 19.56 points.

CONCLUSIONS

In this sample, NH residents were more likely to be African American, had more comorbidities, less cognitive impairment, engaged in less physical activity, were more impaired functionally and had less agitation than those in RCFs. Controlling for treatment group status and baseline differences in comorbidities, cognitive status and race, residents in RCFs declined more in terms of functional and physical activity over a 6-month period.

IMPLICATIONS FOR PRACTICE

Ongoing research and clinical work is needed to understand the impact of care settings on clinical outcomes.

Depressive symptomatology in severe dementia in a European sample: prevalence, associated factors and prescription rate of antidepressants

BACKGROUND

Depression is a common comorbid disorder of dementia. This study explores the prevalence of and factors associated with depressive symptomatology, and antidepressant prescription rates in severe dementia across eight European countries.

METHODS

In total, 414 people with severe dementia completed measures of cognition and quality of life (QoL), whilst carers completed proxy measures of activities of daily living (ADLs), depression, neuropsychiatric symptoms, QoL and comorbidity.

RESULTS

Findings indicated that 30% of the sample had depression, whilst the highest and lowest prevalence of depression was reported in Germany and Finland, respectively. Lower QoL, the presence of pain and more frequent neuropsychiatric symptoms were associated with depressive symptomatology, whilst no significant relationship between impairment of ADLs, comorbidity, and depression emerged. Spain and Estonia had the highest and lowest rates of antidepressant prescribing, respectively, whilst Germany had the highest discrepancy between depressive symptomatology and prescription.

CONCLUSIONS

The study highlights variations across countries in the prevalence of depressive symptomatology in severe dementia and prescription of antidepressants. Information about factors associated with depressive symptomatology may help to better identify and manage depression.

Prevalence of depression among recently admitted long-term care patients in Norwegian nursing homes: associations with diagnostic workup and use of antidepressants

AIMS

We aimed to establish the prevalence of depression among recently admitted long-term care patients and to examine associations with diagnostic initiatives and treatment as recorded in patients' medical records.

MATERIALS AND METHODS

Eighty-eight long-term care patients were included. Depression was diagnosed according to the ICD-10 criteria; patients were screened for depression using the Cornell Scale for Depression in Dementia (CSDD) and for dementia with the Clinical Dementia Rating (CDR) scale.

RESULTS

Depression was found in 25% of the patients according to the ICD-10 criteria and in 31% according to a CSDD sum score of ≥ 8. Diagnostic initiatives were documented in the medical records of half of the patients with depression. Forty-four percent of the patients were prescribed antidepressants and 23% actually received them for the treatment of depression.

CONCLUSION

Depression was prevalent among recently admitted long-term care patients, but diagnostic initiatives were too rarely used. Antidepressants were commonly prescribed, but depression was the indication for treatment in only half of the cases. Screening for depression should be mandatory on admission.