Antidepressant prescribing in nursing homes: is there a place for tricyclics?

Depressive symptoms in neurodegenerative diseases

Depressive symptoms are very common in chronic conditions. This is true so for neurodegenerative diseases. A number of patients with cognitive decline and dementia due to Alzheimer’s disease and related conditions like Parkinson’s disease, Lewy body disease, vascular dementia, frontotemporal degeneration amongst other entities, experience depressive symptoms in greater or lesser grade at some point during the course of the illness. Depressive symptoms have a particular significance in neurological disorders, specially in neurodegenerative diseases, because brain, mind, behavior and mood relationship. A number of patients may develop depressive symptoms in early stages of the neurologic disease, occurring without clear presence of cognitive decline with only mild cognitive deterioration. Classically, depression constitutes a reliable diagnostic challenge in this setting. However, actually we can recognize and evaluate depressive, cognitive or motor symptoms of neurodegenerative disease in order to establish their clinical significance and to plan some therapeutic strategies. Depressive symptoms can appear also lately, when the neurodegenerative disease is fully developed. The presence of depression and other neuropsychiatric symptoms have a negative impact on the quality-of-life of patients and caregivers. Besides, patients with depressive symptoms also tend to further decrease function and reduce cognitive abilities and also uses to present more affected clinical status, compared with patients without depression. Depressive symptoms are treatable. Early detection of depressive symptoms is very important in patients with neurodegenerative disorders, in order to initiate the most adequate treatment. We review in this paper the main neurodegenerative diseases, focusing in depressive symptoms of each other entities and current recommendations of management and treatment.

Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States

BACKGROUND

Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents.

OBJECTIVES

The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents.

METHODS

The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson's behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use.

RESULTS

According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16-47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12-32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22-5.09), SNRIs (2.78%; 95% CI, 2.45-3.12), TCAs (2.34%; 95% CI, 2.03-2.65), and MAOIs (0.01%; 95% CI, 0.00-0.03). Citalopram (12.92%; 95% CI, 12.21-13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55-10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety.

CONCLUSION

Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents.

Antidepressant use in Alzheimer's disease patients: results of the REAL.FR cohort

BACKGROUND

Psychotropic medication is widely prescribed in clinical practice for the management of behavioral and psychological symptoms of dementia (BPSD) in Alzheimer's disease (AD). However, there have been few pharmaco-epidemiological studies or studies conducted in a natural setting on the real use of antidepressants in AD. The aim of this survey was to assess the prevalence of antidepressant use in AD and to identify the clinical factors associated with antidepressant prescription.

METHODS

REAL.FR is a four-year, prospective, multi-center study. Baseline data including demographic characteristics, clinical variables and drug intake were obtained. Depressive symptoms were determined using the Neuropsychiatric Inventory (NPI).

RESULTS

A total of 686 AD patients were included. Antidepressant treatment was prescribed for 34.8% of patients. Clinically significant depressive symptoms (NPI >or= 4) were observed in 20.5% of the total population. Although depressed subjects were significantly more likely to be treated with antidepressants than non-depressed subjects (p<0.0001), only 60% of depressed subjects overall were prescribed an antidepressant. In multivariate analysis, clinically significant depressive symptoms were associated with antidepressant prescription although this result was only observed in subjects without a previous history of depression.

CONCLUSIONS

The available data on antidepressant efficacy in BPSD other than depression (in particular, agitation, aggression and, occasionally, psychotic symptoms) do not influence prescription choices. Depressive symptoms may be taken more seriously in the absence of a previous history of depression, leading to increased antidepressant prescription rates in individuals presenting with depression for the first time.

Antidepressant use in nonmajor depression: secondary analysis of a program to encourage active, rewarding lives for seniors (PEARLS), a randomized controlled trial in older adults from 2000 to 2003

BACKGROUND

It is estimated that major depressive disorder affects 0.9% of community-dwelling older adults in the United States. However, as many as 18% of older US adults reportedly suffer from depressive symptoms that do not necessarily fit the criteria for major depressive disorder (eg, dysthmia, minor depression).

OBJECTIVES

The goals of this study were to describe patterns of antidepressant medication use in older adults with dysthymia or minor depression and to examine factors associated with the use of antidepressants at baseline.

METHODS

This was a secondary analysis using cross-sectional data collected during a randomized controlled trial conducted from 2000 through 2003. It involved community senior service agencies and in-home visits in Seattle, Washington. Adults aged >or=60 years who had minor depression or dysthymia and were receiving services through community senior service agencies or living in senior public housing were included. Study participants were classified as users or nonusers of antidepressants. Prescription medication use in the past 2 weeks was assessed at baseline and 6 and 12 months. Medication name, dose, and directions were recorded from the medication label. Logistic regression was used to examine variables associated with baseline antidepressant use.

RESULTS

A total of 138 patients (mean age, 73.00 years) were included; the majority of study participants were female (779.00%). Overall, 42.33% were nonwhite (34.3% black, 4.4% Asian, 1.5% American Indian/Alaskan Native, 0.7% Hispanic, and 1.5% other). At baseline, 36.2% of study participants (n = 50) were using antidepressants. Selective serotonin reuptake inhibitors were the most common class of antidepressants, used by 62.00%, 70.22%, and 71.11% of antidepressant users at baseline, 6, and 12 months, respectively. However, nortriptyline was the most common antidepressant at baseline, taken by 20.00% of antidepressant users. Use of other prescription medications was associated with antidepressant use at baseline.

CONCLUSIONS

We found antidepressant use to be low in these relatively poor, community-dwelling, ethnically diverse older adults with dysthymia and minor depression in 2000 through 2003, with 36.22% of participants using antidepressants at baseline. Antidepressant users were more likely to be taking other prescription medications than nonusers.