Antidepressant guidelines for long-term care residents with advanced frailty

This project was undertaken because there are a high number of long-term care (LTC) residents taking antidepressants, meaning the potential benefits and harms (e.g., risk of falls, cognitive impairment) should be considered more carefully.

Research Results

Findings: Based on our systematic review and meta-analyses, we conclude there is considerable uncertainty about the benefit of antidepressants for depression in frail, older adults with and without dementia or the neuropsychiatric symptoms of dementia compared to placebo. However, there are individual patients who might benefit from antidepressants.

Impact of findings: This review contributes to the existing dialogue of polypharmacy and appropriate prescribing in frail older adults and may lead to more judicious prescribing of antidepressants for depression and the neuropsychiatric symptoms of dementia in frail older adults with and without dementia. This could lead to a reduction in antidepressant use in the frail older adults which could reduce medication side effects, and as a result, increase quality of life. In addition, caregiver burden may be reduced if fewer medications are dispensed and there are fewer additional care needs for medication side effects.

About the Project

There are over 200,000 elderly in LTC facilities across Canada. Residents in long-term care are typically frail and commonly have multiple medical conditions, dementia and short life expectancy. However, many treatment decisions for frail elderly adults are based on standards of care using evidence developed for younger, healthier populations. This practice can lead to the inappropriate use of medications, resulting in poor outcomes and increased costs. The frequent prescribing of antidepressants for elderly residents with advanced frailty and/or dementia is of particular concern, with use in approximately 40% of residents in LTC.

The use of antidepressants in frail, older adults is an important topic due to concerns about effectiveness of the treatment of depressive symptoms for older adults who are frail.

This is why we proposed a knowledge synthesis of the available evidence and clinical expert opinion to develop practice guidelines for prescribers and a decision aid to facilitate discussions about appropriate antidepressant use for LTC residents with advanced frailty and/or dementia.

Project Team

Principal Investigators:

Laurie Mallery, MD — Dalhousie University

Constance LeBlanc, DSS, MD, CCFP, FCFP, MAEd — Dalhousie University

Co-Investigators:

Evan Bezanson

Tanya MacLeod, MSc — Dalhousie University

Knowledge Users and Partners:

Brian Steeves

Atlantic Long-Term Care Network

Canadian Coalition on Seniors Mental Health

Dalhousie CPD

Northwood Long-Term Care

RxFiles LTC Resource

Project Contact: Laurie Mallery — laurie.mallery@dal.ca

FRA 2015-A-04

Key Findings for Families

There is considerable uncertainty about the benefit of antidepressants for depression in frail, older adults with and without dementia or the neuropsychiatric symptoms of dementia, but some patients who might benefit from antidepressants
Fatigue, nausea, constipation, dizziness, and diarrhea were more common in those taking antidepressants and may be more serious side effects in the more frail
Patients started on antidepressants for depression should be reassessed after 4 to 8 weeks and 9 weeks for those using antidepressants for symptoms of agitation or psychosis in dementia

The findings of this study can provide greater awareness among clinicians, families and patients about the limited benefit of antidepressants to reduce depression in elderly adults with and without dementia or agitation/psychosis in dementia.

Greater awareness among clinicians, families and patients of the need to re-assess the elderly using antidepressants and medications stopped if there is no improvement in symptoms
A reduction in inappropriate use of antidepressants in frail elderlyadults would decrease risks of medication interactions and side effects, and as a result, increase quality of life. In addition, caregiver burden may be reduced if fewermedications are dispensed and there are fewer additional care needs for medication side effects

Why This Matters

Nearly two-thirds of Canadian seniors living in long-term care use 10 or more medications, and an estimated 40% of medications may be unnecessary. Antidepressants are the second most common medication used in long-term care, with 60% of residents using an antidepressant
Although antidepressants are widely prescribed in long-term care, diagnosis of depression in long-term care settings may be complicated by overlap in the signs and symptoms of depression, frailty, dementia and neuropsychiatric symptoms
We reviewed the evidence for the efficacy and safety of antidepressants for: (1) depression in frail older adults, (2) depression in dementia and (3) neuropsychiatric symptoms of dementia. We also reviewed the evidence for adding or switching antidepressants when the first antidepressant is not effective

About This Study

The topic of antidepressants was selected among a list of 32 other medications by members of a health professional and researcher network. The members of this network have an interest in reducing inappropriate medication use in the frail elderly
The evidence review was completed by a team of clinical and academic professionals in geriatrics, medicine, pharmacy and research
Due to the lack of available research on antidepressants in frail elderly adults, we reviewed studies of patients 65 years of age or older and/or with chronic illness (i.e., Post-Stroke Depression, Parkinson’s Disease, Heart Failure)
We reviewed meta-analyses, systematic reviews and randomized controlled trials, representing 29 clinical trials and 4,365 patients. The goal of the review was to assess efficacy and safety of antidepressants for clinically meaningful improvement in depression/neuropsychiatric symptom scores
We analyzed the combined data from the trials with and without tricyclic antidepressants (TCAs) due to the low use of TCAs in the elderly and because they are listed on several guidelines as potentially inappropriate drugs in the elderly (i.e., Beers list, STOPP/START)
To our knowledge, this is the most up-to-date review of antidepressants for depression in the frail elderly with and without dementia and agitation or psychosis in dementia

Key Findings for Policy

Based on our systematic review and meta-analyses, we conclude there is considerable uncertainty about the benefit of antidepressants for depression in frail, older adults with and without dementia or the neuropsychiatric symptoms of dementia compared to placebo. However, there are individual patients who might benefit from antidepressants
Fatigue, nausea, constipation, dizziness, and diarrhea were significantly more frequent in those taking antidepressants and may be burdensome side effects in advanced frailty
Patients started on antidepressants for depression should be reassessed after 4 to 8 weeks and 9 weeks for those using antidepressants for neuropsychiatric symptoms

The findings of these studies can inform current health policies to support the appropriate prescribing of antidepressants to frail elderly adults. This could lead to cost savings, due to a decrease in the purchasing and administration of these medications.

Support for staff education and resources for non-pharmacological interventions for depression and neuropsychiatric symptoms of dementia in long-term care
Support for patient and family engagement and educationalinitiatives about the harms of polypharmacy and the potential for inappropriate medication use

Why This Study was Needed

Nearly two-thirds of Canadian seniors living in long-term care use 10 or more prescription medications, and an estimated 40% of medications may be unnecessary. Antidepressants are the second most common medication used in long-term care, with 60% of residents using an antidepressant (36% SSRIs)
Although antidepressants are widely prescribed in long-term care, diagnosis of depression in long-term care settings may be complicated by significant overlap in the signs and symptoms of depression, frailty, dementia and neuropsychiatric symptoms
We reviewed the evidence for the efficacy and safety of antidepressants for: (1) depression in frail older adults, (2) depression in dementia, and (3) neuropsychiatric symptoms of dementia. We also reviewed the evidence for augmentation and switching of antidepressants when the first antidepressant is not effective

Study Summary

A network of stakeholders with an interest in reducing polypharmacy in the frail elderly used a Delphi process to select antidepressants among a list of 32 other medications as a priority topic for an evidence review
The evidence review was completed by a team of clinical and academic professionals in geriatrics, medicine, pharmacy and research. These multidisciplinary collaborations had a positive impact on the rigour and quality of the review
Due to the lack of available research on antidepressants in frail elderly adults, we reviewed studies of patients 65 years of age or older and/or with chronic illness (e.g., Post-Stroke Depression, Parkinson’s disease, Heart Failure)
We reviewed meta-analyses, systematic reviews and randomized controlled trials, representing 29 clinical trials and 4365 patients. The goal of the review was to assess efficacy and safety of antidepressants for clinically meaningful improvement in depression/neuropsychiatric symptom scores
We conducted meta-analyses with and without tricyclic antidepressants (TCAs) due to the declining use of TCAs in elderly populations and because they are listed on several guidelines as potentially inappropriate drugs in the elderly (e.g., Beers list, STOPP/START)
To our knowledge, this is most up-to-datereview of the efficacy and safety ofantidepressants for depression in the frail elderly with and without dementia and neuropsychiatricsymptoms in dementia. We anticipate that the results from this review will contribute to Canada’svisibility and reputation for international leadership in the field of polypharmacy and appropriateprescribing in the frail elderly

Key Findings for Researchers

Based on our systematic review and meta-analyses, we conclude there is considerable uncertainty about the benefit of antidepressants for depression in frail, older adults with and without dementia or the neuropsychiatric symptoms of dementia compared to placebo. However, there are individual patients who might benefit from antidepressants
Fatigue, nausea, constipation, dizziness and diarrhea were significantly more frequent in those taking antidepressants and may be burdensome side effects in advanced frailty
Patients started on antidepressants for depression should be reassessed after four to eight weeks, and nine weeks for those using antidepressants for neuropsychiatric symptoms

This study provides guidance for the management of older adults with depression, with and without dementia.

More judicious prescribing of antidepressants for depression in frail older adults with and without dementia and for the neuropsychiatric symptoms of dementia
- Enhanced conversations with families, patients and caregivers about the limited potential of antidepressants for depression and/or the neuropsychiatric symptoms of dementia, including potential adverse effects from antidepressants
A reduction in the use of antidepressants in frail elderly adults could decrease risks of polypharmacy and medication side effects, and as a result, increase quality of life. In addition, caregiver burden may be reduced if fewer medications are dispensed and there are fewer additional care needs for medication side effects

Why This Study was Needed

Diagnosis of depression in long-term care settings may be complicated by overlap in the signs and symptoms of depression, frailty, dementia and the neuropsychiatric symptoms of dementia
Polypharmacy, the use of more medications than is clinically necessary, is a significant problem among the frail elderly in long-term care and antidepressants are the second most common medication used in long-term care, with 60% of residents using an antidepressant (36% SSRIs)
To provide greater clarity around the evidence for the efficacy and safety of antidepressants for: (1) depression in frail older adults, (2) depression in dementia and (3) neuropsychiatric symptoms of dementia, we synthesized the existing evidence. We also reviewed the evidence for augmentation and switching of antidepressants when the first antidepressant is not effective

How This Study Addresses the Gap

A network of stakeholders with an interest in reducing polypharmacy in the frail elderly used a Delphi process to select antidepressants among a list of 32 other medications as a priority topic for an evidence review
The evidence review was completed by a team of clinical and academic professionals in geriatrics, medicine, pharmacy and research. These multidisciplinary collaborations had a positive impact on the rigour and quality of the review
Due to the lack of available research on antidepressants in frail elderly adults, we reviewed studies of patients 65 years of age or older and/or with chronic illness (i.e., Post-Stroke Depression, Parkinson’s disease, Heart Failure)
We reviewed meta-analyses, systematic reviews and randomized controlled trials, representing 29 clinical trials and 4,365 patients. The goal of the review was to assess efficacy and safety of antidepressants for clinically meaningful improvement in depression/neuropsychiatric symptom scores
We conducted meta-analyses with and without tricyclic antidepressants (TCAs) due to the declining use of TCAs in elderly populations and because they are listed on several guidelines as potentially inappropriate drugs in the elderly (i.e., Beers list, STOPP/START)

Future Research

The efficacy and safety of pharmacological and non-pharmacological interventions for depression and neuropsychiatric symptoms in frail, older adults with and without dementia needs further study
There is a need for validated tools/approaches to differentiate the symptoms of depression from those of dementia, frailty and neuropsychiatric symptoms of dementia

Presentations

MacLeod, T., Mallery, L., Bezanson, E., Moorhouse, P., Steeves, B., LeBlanc, C. (September 2015). Antidepressant review poster. 3rd annual TVN Scientific Meeting. Toronto, ON

Rationale, Hypothesis, Objectives & Research Plan

Rationale: Frail individuals often have multiple chronic illnesses that not only impair physiologic resilience, but put them at high risk for adverse events from polypharmacy.

Hypothesis: The inappropriate use of antidepressant medications may add to existing polypharmacy.

Objectives: This study focused on investigating the following questions: (1) What is the efficacy and safety of antidepressants for depression in frail older adults? (2) What is the efficacy and safety of antidepressants for depression in the elderly with dementia? (3) What is the efficacy and safety of antidepressants for the neuropsychiatric symptoms in the elderly with dementia?

Research plan: Our review of the evidence involved a rigorous appraisal of double-blind, randomized, placebo controlled trials for the efficacy and safety of antidepressants for frail older adults: (1) with depression (> 65 y/o), (2) with depression and dementia and (3) with the neuropsychiatric symptoms of dementia.

Webinars

CFN Webinar (February 1, 2017): Antidepressant guidelines for long-term care residents with advanced frailty