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

Reporting heterogeneity and health measurement bias in older adults: nationwide cross-sectional study

PURPOSE

To examine reporting heterogeneity in self-rated health (SRH) among middle-aged and older adults using anchoring vignettes, and evaluate the impact of reporting heterogeneity on further measures of health inequalities.

METHODS

Data on a sample of 13,323 respondents aged 45 years and over from the China Family Panel Studies (CFPS) were used. An ordered probit model and the hierarchical ordered probit (HOPIT) model were used to compare the estimated differences in pre- and post-adjusted SRH, and the concentration index was applied to measure health inequalities.

RESULTS

After correcting for reporting heterogeneity, the health advantage of these middle-aged and older adults was further expanded to varying degrees, and those living in urban areas had better health compared to those living in rural areas (β = 0.057, P = 0.046). In addition, respondents with a high school education or higher and in urban areas use a lower cut-off point when rating a given health condition as poor and a higher cut-off point when rating a given health condition as good. Significant increases in the inequalities in SRH between urban and rural areas and across regions after adjustment for reporting heterogeneity. In comparison to urban areas, the trend that higher SRH was more concentrated among the better educated is more pronounced in rural areas.

CONCLUSION

These findings highlight the importance of addressing reporting heterogeneity in SRH to ensure equitable healthcare interventions and resource allocation, particularly to underserved regions and populations.

Acute periapical abscesses in patients using selective serotonin reuptake inhibitors

AIMS

Depression and anxiety are severe health problems affecting millions of individuals worldwide. Consequently, the use of antidepressants has constantly been on a rise. Selective serotonin reuptake inhibitors (SSRIs) antidepressant are now commonly used due to fewer side effects as compared to other types of antidepressants. The aim of this study was to assess the prevalence of periapical abscesses (PAs)in patients using SSRIs.

METHODS AND RESULTS

Integrated data of hospital patients was used. Data from the corresponding diagnosis codes for SSRIs and acute PAs was retrieved by searching the appropriate query in the database. The different diagnoses were coded using the international coding systems ICD 10. Diagnosis was made by calibrated dentists in a hospital setting based on clinical examination and imaging data. The odds ratio (OR) for the prevalence of acute PAs and its association with the use of SSRIs were calculated and analyzed statistically. It was found that the prevalence of acute PAs was significantly higher in patients using SSRIs as compared to the other hospital patient population. The OR was 2.8 and the difference between patients using SSRIs and patients who do not was statistically significant (p < .0001).

CONCLUSION

Under the conditions of this study, it appears that the prevalence of acute PAs is higher in patients using SSRIs.

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.

Falls prediction using the nursing home minimum dataset

OBJECTIVE

The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.

MATERIALS AND METHODS

The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.

RESULTS

The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.

DISCUSSION

Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.

CONCLUSION

The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

Prevalence, progress, and subgroup disparities in pharmacological antidepressant treatment of those who screen positive for depressive symptoms: A repetitive cross-sectional study in 19 European countries

Background

The European Mental Health Action Plan (EMHAP) 2013–2020 promoted community-based mental health services. One potential success indicator is the provision of antidepressant medication to those needing it.

Methods

Public data from two surveys (Health Survey for England, UK; Survey of Health, Ageing and Retirement in Europe) covered 19 European countries across EMHAP phases one (2011–2015) and two (2015–2018). People screening positive for depressive symptoms by self-report were included. The primary outcome was antidepressant use: using country-specific weighted regression models, we estimated temporal trends and subgroup disparities in antidepressant receipt, with secondary analysis by country-level measures including healthcare expenditure.

Findings

Across 37,250 participants, after controlling for age, sex, wealth, and physical disability, antidepressant use (amongst those screening positive) increased significantly in 14/19 countries, with the smallest increase being in Slovenia (adjusted OR[AOR] for trend=1.68[1.20–2.36]) and the highest increase being in Germany (AOR for trend=10.07[7.54–13.46]) and Austria (AOR for trend=10.07[7.32–13.74]). The overall proportion using antidepressants was positively associated with national health expenditure (coefficient=5.43[1.62–9.25]), but not with gross national income per capita or the number of psychiatrists, general practitioners, or psychiatric hospital beds. In 15/19 countries, antidepressants were used less by ≥65-year-olds than 50–64-year-olds, with the smallest differential reported in Luxembourg (AOR=0.70[0.49, 0.98]) and the highest in Germany (AOR=0.28[0.21, 0.37]); this disparity widened in 12/15 countries. Men used antidepressants less than women in 8/19 countries, across phases. In 13/19 countries, people with physical disability were more likely to receive antidepressants, with the smallest gap in Italy (AOR=1.42[1.12–1.80]) and the largest in Israel (AOR=2.34[1.46–3.74]); this disparity narrowed in 5/13 countries. Disparity by wealth was found in 8/19 countries, but its temporal trend varied.

Interpretation

Usage of antidepressants by those with depressive symptoms has increased, with wide variation between countries and subgroups. Disparities across age, sex, and disability should prompt further research.

Funding

Medical Research Council (grants MC_PC_17213 and MR/W014386/1), UK National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) East of England, NIHR Cambridge Biomedical Research Centre (BRC-1215-20014).

General practitioners' perspectives on discontinuation of long-term antidepressants in nursing homes

Background

Long-term use of antidepressant drugs (AD), much longer than recommended by guidelines, in nursing homes (NH) is common. NH home residents may have a relatively higher risk of adverse events. Moreover, in an NH setting nursing staff and relatives are intensively involved in the decision-making process. In many countries, General Practitioners’ (GPs) provide care for residents in NHs. Little is known about GPs’ perspectives on discontinuation of long-term AD in NH residents.

Objectives

To explore GPs’ views of discontinuing long-term AD in NH residents.

Methods

An exploratory qualitative study, with semi-structured interviews, was conducted with a purposive sample of 20 Belgian GPs. Interviews, conducted over six months in 2019, were analysed by thematic analysis.

Results

Twenty interviews were conducted until data saturation. The first theme, ‘reluctance to rock the boat: not worth taking the risk’, describes that GPs perceive discontinuation as an unpredictable risk without clear benefits. GPs’ main concern was the risk of destabilising the fragile balance in an older patient. Second, ‘it takes at least three to tango’, captures the unspoken alliance between GPs, nursing staff and relatives and suggests that agreement of at least these three partners is required. The third, ‘Opening the door: triggers to discontinue’, points to severe health problems and dementia as strong facilitators for discontinuation.

Conclusion

Discontinuation of long-term AD in NHs is a complex process for GPs. More evidence and attention to the role nursing staff and relatives play are needed to better guide the discontinuation of AD in older NH patients.

Quality of Care and Outcomes Among a Diverse Group of Long-Term Care Residents With Alzheimer's Disease and Related Dementias

ObjectivesThis article assessed whether disparities among ADRD Medicare beneficiaries existed in five different long-stay quality measures. Methods: We linked individual-level data and facility-level characteristics. The main quality outcomes included whether residents: 1) were assessed/appropriately given the seasonal influenza vaccine; 2) received an antipsychotic medication; 3) experienced one/more falls with major injury; 4) were physically restrained; and 5) lost too much weight. Results: In 2016, there were 1,005,781 Medicare Advantage and fee-for-service long-term residents. About 78% were White, 13% Black, 2% Asian/Pacific Islander (Asian/PI), 6% Hispanic, and 0.4% American Indian/Alaska Native (AI/AN). Whites reported higher use of antipsychotic medications along with Hispanics and AI/AN (28%, 28%, and 27%, respectively). Similarly, Whites and AIs/ANs reported having one/more falls compared to the other groups (9% and 8%, respectively). Discussion: Efforts to understand disparities in access and quality of care among American Indians/Alaska Natives are needed, especially post-pandemic.

Depression, antidepressants and fall risk: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarize the existing knowledge on fall risk associated with antidepressant use in older adults, describe underlying mechanisms, and assist clinicians in decision-making with regard to (de-) prescribing antidepressants in older persons.

METHODOLOGY

We comprehensively examined the literature based on a literature search in Pubmed and Google Scholar, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in depression in geriatric patients. We discuss use of antidepressants, potential fall-related side effects, and deprescribing of antidepressants in older persons.

RESULTS

Untreated depression and antidepressant use both contribute to fall risk. Antidepressants are equally effective, but differ in fall-related side effect profile. They contribute to (or cause) falling through orthostatic hypotension, sedation/impaired attention, hyponatremia, movement disorder and cardiac toxicity. Falling is an important driver of morbidity and mortality and, therefore, requires prevention. If clinical condition allows, withdrawal of antidepressants is recommended in fall-prone elderly persons. An important barrier is reluctance of prescribers to deprescribe antidepressants resulting from fear of withdrawal symptoms or disease relapse/recurrence, and the level of complexity of deprescribing antidepressants in older persons with multiple comorbidities and medications. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antidepressants.

CONCLUSIONS

(De-) prescribing antidepressants in fall-prone older adults is often challenging, but detailed insight in fall-related side effect profile of the different antidepressants and a recently developed expert-based decision aid STOPPFalls assists prescribers in clinical decision-making.

Factors Associated with Hyponatremia in Patients Newly Prescribed Citalopram: A Retrospective Observational Study

Background

Hyponatremia is a common and under-recognized adverse drug reaction of selective serotonin re-uptake inhibitor (SSRI) antidepressants. Despite its clinical importance, there are few large-scale studies on the factors associated with hyponatremia.

Objective

The aim of this study was to determine the incidence of hyponatremia and to identify patient factors associated with hyponatremia in a large, population-based cohort initiating new prescriptions for citalopram.

Methods

We included all patients with a new prescription for citalopram during 2010–2017, inclusive, with baseline and post-initiation serum sodium values available. Data were obtained from an Alberta Health Pharmacy database to identify new citalopram prescriptions. Laboratory values for patients with new prescriptions were obtained from linked Calgary Laboratory Services data. Incident hyponatremia was defined as serum sodium level < 135 mmol/L, following prescription initiation. Associations were determined by performing Cox regression with time-varying covariate analysis, with the development of hyponatremia as the dependent variable.

Results

A total of 19,679 patients with new prescriptions were identified; 12,842 females and 6837 males. The mean age was 55.48 years (SD 21.35). Of these patients, 3250 (16.5%) developed hyponatremia, 1996 (15.5% of) females and 1254 (18.3% of) males (p = 0.002). Cox regression showed significant associations of hyponatremia with lower baseline sodium (HR 0.788), older age (HR 1.029), thiazide diuretic use (HR 1.141), and male sex (HR 1.168). Pharmaceutical manufacturer or strength of citalopram did not have significant effects on the development of hyponatremia.

Conclusion

This study provides additional data on the predictors of hyponatremia among patients initiating citalopram therapy. We report a 16.5% incidence of hyponatremia after starting citalopram treatment, and significant new findings include a higher incidence in males. This is the first published incidence of hyponatremia following the initiation of citalopram treatment across all ages in Canada.

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Use of antidepressant medications among older adults in European long-term care facilities: a cross-sectional analysis from the SHELTER study

Background

Late-life depression is common among older adults living in nursing homes (NHs). Over the last 30 years there has been an increase in the rates of prescription of antidepressant medications across all ages, with the largest rise reported in older adults. This study aimed to describe the pattern of antidepressant medication use among NH residents from 7 European countries and Israel and to examine patient and facilities characteristics that may account for it.

Methods

We conducted a cross-sectional analysis of data from the SHELTER study, an observational longitudinal cohort study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument in 7 European Countries and Israel.

Descriptive statistics were used to examine sample characteristics. Potential correlates of antidepressant medication use were identified using multiple logistic regression modeling.

Results

Among 4023 residents entering the study, 32% had depressive symptoms and nearly half of these individuals used antidepressants. Antidepressant medication use varied by country, with a prevalence in the overall sample of 35.6% (n = 1431). Among antidepressant users, 59.9% were receiving selective serotonin reuptake inhibitors (SSRI). The strongest correlates of antidepressant use included reported diagnosis of anxiety, depression, bipolar disorder, pain, falls and high level of social engagement. Age over 85 years, living in facilities located in rural areas and a diagnosis of schizophrenia reduced the likelihood of being prescribed with an antidepressant.

Conclusions

A large proportion of residents in European long-term care facilities receive antidepressant medications. The decision to prescribe antidepressants to NH residents seems to be influenced by both patient and facility characteristics. Future longitudinal studies should evaluate the efficacy and safety of antidepressant use in NHs thus providing evidence for recommendations for clinical practice.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

BACKGROUND

Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated.

RESULTS

A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%).

CONCLUSION

The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.

All-cause mortality with current and past use of antidepressants or benzodiazepines after major osteoporotic and hip fracture

In the first year, after an osteoporotic fracture of a hip, forearm, upper arm, or spine, the dispensing rates of antidepressants and benzodiazepines increased significantly. After those fractures, recent and past use of antidepressants and benzodiazepines was associated with increased all-cause mortality; current use was not associated with mortality risk.

INTRODUCTION

It remains unclear to what extent use of antidepressants and benzodiazepines is associated with mortality risk after a major osteoporotic fracture (MOF). We aimed to study the cumulative use of antidepressants and benzodiazepines during the year after MOF or hip fracture (HF) and whether the use was associated with mortality.

METHODS

A cohort study was performed within the Dutch PHARMO Database Network including all patients aged 65+ with a first record of MOF (hip, humerus, forearm, and clinical vertebral fracture) between 2002 and 2011. Data were analyzed using Cox regression models, adjusted for comorbidities, and concomitant medication use and broken down to index fracture type.

RESULTS

A total of 4854 patients sustained a first MOF, of whom 1766 patients sustained a HF. Mean follow-up was 4.6 years, divided in 30-day periods. The cumulative antidepressant and benzodiazepine use during the first year after MOF increased from 10.6 to 14.7% and from 24.0 to 31.4%, respectively. Recent (31-92 days before each follow-up period) and past use (> 92 days before) of antidepressants and benzodiazepines after MOF or HF was associated with an increased all-cause mortality risk but current use (< 30 days before) was not.

CONCLUSION

There is a considerable increase in dispensing rate of antidepressants and benzodiazepines in the first year after a MOF. Recent and past use of these medications was associated with all-cause mortality. The finding that current use was not associated with mortality should be further explored and may probably be explained by the healthy survivor's bias.

Medication burden attributable to chronic co-morbid conditions in the very old and vulnerable

OBJECTIVE

Polypharmacy is common in older patients but relationships between polypharmacy and common co-morbid conditions have not been elucidated. Our goal was to determine relationships between daily oral medication use and common co-morbid disease dyads and triads using comprehensive medication and diagnostic data from a national sample of nursing homes (NH).

DESIGN

Retrospective, cross-sectional study.

SETTING

Nationally representative sample of U.S. Nursing Homes.

PARTICIPANTS

Nationally representative sample of long-term stay residents (n = 11734, 75% women) aged 65 years or older.

MEASUREMENTS

Diagnosis and medication data were analyzed. Proportion of daily oral medication intake attributed to treatment of common two-(dyads) and three-disease (triad) combinations and "health maintenance" agents (vitamins, dietary supplements, stool softeners without related diagnoses) was determined.

RESULTS

Older NH residents received slightly >8 oral medications/day with the number related to number of medical diagnoses (p < .0001). One third of chronic oral medication intake/day (excluding health maintenance agents) could be attributed to dyad combinations and about half to triad combinations despite an average of 5 other diagnoses. Triads were comprised of hypertension +/- arthritis +/- vascular disease, +/-depression, +/- osteoporosis +/- gastroesophageal reflux disease and +/- diabetes. Health maintenance agents accounted for 15-17% of daily oral medication intake (1.4 medications) such that almost two-thirds of daily oral medications were attributable to disease triads plus health maintenance. Fewer medications were prescribed for NH residents over age 85 (decreased ACE inhibitor and HMG CoA reductase inhibitor USE (p < .001)) while use of Alzheimer medications was higher (p < .01).

CONCLUSIONS

A large fraction of daily oral medications were attributed to management of common co-morbid disease dyads and triads. Efforts to reduce polypharmacy and unwanted medication interactions could focus on regimens for common co-morbid dyads and triads in varying populations.

The relationship of SSRI and SNRI usage with interstitial lung disease and bronchiectasis in an elderly population: a case-control study

Background

The association between interstitial lung disease (ILD) and selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors (SSRI/SNRI) has been previously described in published case reports. However, its prevalence may be more common than expected. We examined the association between SSRI/SNRI usage and presence of ILD and or bronchiectasis (ILD/B) in an elderly population.

Methods

We conducted a retrospective case series and case–control study involving all 296 eligible elderly patients in one primary care geriatric practice in Victoria, BC, Canada. Cases required the presence of ILD/B on computed tomography (CT) or chest X-ray (CXR). Cases were excluded if they had other causes for ILD/B on CXR or CT such as exposure to known pneumotoxic drugs, metastatic cancer, rheumatoid lung disease, sarcoidosis, previous pulmonary tuberculosis, or pneumoconiosis. Data were abstracted from the patients’ medical record. The exposure variable was standardized cumulative person-month (p-m) dose of SSRI/SNRI. The study was approved by the Clinical Research Ethics Board of University of British Columbia with a waiver of informed consent.

Results

A total of 12 cases and 273 controls were identified. Their mean ages were 89.0 and 88.7 years, respectively (p=0.862). A total of 10/12 cases and 99/273 controls were exposed to SSRI/SNRI. The odds ratio was 8.79, 95% confidence interval 2.40–32.23 (p=0.001). The median p-m exposure to SSRI/SNRI was 110.0 months for cases and 29.5 for controls (p=0.003).

Conclusion

SSRIs and SNRIs were significantly associated with the risk of ILD/B in this elderly population. Because of their widespread usage, further studies should be done to validate these findings. Prescribers should cautiously monitor patients for development of insidious pulmonary symptoms when these drugs are used.

The correlates of anxiety among older adults in nursing homes and other residential aged care facilities: a systematic review

OBJECTIVE

To synthesize and summarize the studies examining the correlates and predictors of anxiety in older adults living in residential aged care.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, five electronic databases were searched using key terms and subject headings, as well as reference lists of relevant papers. The search was limited to peer-reviewed literature published in English. Eligible studies examined the association between at least one correlate/factor and anxiety disorders or symptoms in aged care residents aged 50+ years.

RESULTS

A total of 3741 articles were identified, of which 34 studies (with a total of 1 543 554 participants) were included in this review. Correlates associated with anxiety included pain, use of anti-depressants/lithium, depression, and lower perceived quality of life. Less consistent and/or less studied variables included younger age, female gender, higher educational level, functional dependence, subjective health status, more prescribed medications, impaired vision, insomnia, external locus of control, fear of falling, attachment, hope, meaning in life, and the influence of social, environmental, and staff/policy correlates.

CONCLUSIONS

While several variables were found to have strong associations with anxiety in aged care residents, a number of factors have been examined by only one or two studies. Further research (preferably prospective studies) is therefore needed to reliably confirm findings and to help plan and develop preventative and intervention strategies. Copyright © 2016 John Wiley & Sons, Ltd.

Risk of Cognitive Decline Associated With Paroxetine Use in Elderly Nursing Home Patients With Depression

OBJECTIVE

This study evaluated the risk of cognitive decline associated with paroxetine use in elderly nursing home patients with depression.

METHODS

A retrospective cohort study was conducted using the 2007 to 2010 Medicare Part D claims and minimum data set (MDS) data involving new users of paroxetine and other selective serotonin reuptake inhibitors (SSRIs). The primary outcome was MDS Cognition Scale. The repeated-measures mixed model was used to examine the effect of paroxetine on cognition after controlling for other factors.

RESULTS

The baseline MDS Cognition Scale measures for paroxetine (n = 63) and other SSRI users (n =1018) were 2.02 (±1.85) and 2.50 (±2.39), respectively. The repeated-measures mixed model did not find statistically significant difference in cognition with the use of paroxetine (β = 0.02, 95% CI: -0.16 to 0.21]) when compared to other SSRIs.

CONCLUSIONS

There was no differential effect of paroxetine on cognition when compared to other SSRIs.

Comparative risk of hip fractures in elderly nursing home patients with depression using paroxetine and other selective serotonin reuptake inhibitors

AIM

To evaluate comparative safety of paroxetine and other selective serotonin reuptake inhibitors (SSRIs) for the risk of hip fractures.

PATIENTS & METHODS

A propensity score-matched retrospective cohort study was conducted using 2007-2010 Minimum Data Set linked Medicare data. Robust Cox proportional hazards model was used to evaluate the risk of hip fractures in depressed elderly nursing home residents.

RESULTS

Cox analysis did not find any significant difference in the risk of hip fractures for the paroxetine users (hazard ratio: 1.09; 95% CI: 0.91-1.32) when compared with other SSRIs. Results from the sensitivity analysis supported the main findings.

CONCLUSION

There was no differential risk of hip fractures between paroxetine and other SSRIs. Future studies are needed to evaluate other anticholinergic effects of paroxetine.

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.

Comparative Cognitive Profile of Second-Generation Antidepressants in Elderly Nursing Home Residents With Depression

BACKGROUND

Past literature suggests that the use of second-generation antidepressants improves cognition in depressed elderly patients.

OBJECTIVE

This study assessed the comparative cognitive profile of commonly used second-generation antidepressant classes in elderly residents with depression.

METHODS

A multiple propensity score adjusted retrospective cohort study was conducted using 2007-2010 Medicare Part D claims and Minimum Data Set (MDS). Elderly nursing home residents (65 years or older) with depression using a new prescription of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tetracyclics constituted the study cohort. The outcome of interest was cognition, measured using the MDS Cognition Scale. Cognition was measured at each quarterly assessment after antidepressant initiation for a maximum of 1 year. The propensity score-adjusted repeated-measures mixed model was used to evaluate the comparative profile of SSRIs, SNRIs, and tetracyclics with respect to cognition.

RESULTS

The study cohort comprised 1518 elderly nursing home residents. Of these, 1081 received SSRIs (71.21%), 320 received tetracyclics (21.08%), and 117 received SNRIs (7.71%). The propensity score-adjusted repeated-measures mixed model did not show any statistically significant difference in cognition with the use of SSRIs (β = -0.14; 95% CI = -0.53, 0.25) or tetracyclics (β = -0.36; 95% CI = -0.80, 0.08) when compared with SNRIs, after controlling for other factors.

CONCLUSIONS

The cognitive effect of SSRIs, SNRIs, and tetracyclics was similar in elderly nursing home residents with depression. Further studies are needed to evaluate the long-term cognitive effects of second-generation antidepressants in this vulnerable population.

Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Characteristics of antidepressant medication users in a cohort of mid-age and older Australians

OBJECTIVES

We aimed to investigate antidepressant use, including the class of antidepressant, in mid-age and older Australians according to sociodemographic, lifestyle and physical and mental health-related factors.

METHODS

Baseline questionnaire data on 111,705 concession card holders aged ⩾45 years from the 45 and Up Study-a population-based cohort study from New South Wales, Australia-were linked to administrative pharmaceutical data. Current- and any-antidepressant users were those dispensed medications with Anatomical Therapeutic Chemical classification codes beginning N06A, within ⩽6 months and ⩽19 months before baseline, respectively; non-users had no antidepressants dispensed ⩽19 months before baseline. Multinomial logistic regression was used to calculate adjusted relative risk ratios (aRRRs) for predominantly self-reported factors in relation to antidepressant use.

RESULTS

Some 19% of the study population (15% of males and 23% of females) were dispensed at least one antidepressant during the study period; 40% of participants used selective serotonin reuptake inhibitors (SSRIs) only and 32% used tricyclic antidepressants (TCAs) only. Current antidepressant use was markedly higher in those reporting: severe versus no physical impairment (aRRR 3.86(95%CI 3.67-4.06)); fair/poor versus excellent/very good self-rated health (4.04(3.83-4.25)); high/very high versus low psychological distress (7.22(6.81-7.66)); ever- versus never-diagnosis of depression by a doctor (18.85(17.95-19.79)); low-dose antipsychotic use versus no antipsychotic use (12.26(9.85-15.27)); and dispensing of ⩾10 versus <5 other medications (5.97(5.62-6.34)). Sociodemographic and lifestyle factors were also associated with use, although to a lesser extent. Females, older people, those with lower education and those with poorer health were more likely to be current antidepressant users than non-users and were also more likely to use TCAs-only versus SSRIs-only.

CONCLUSIONS

Use of antidepressants is substantially higher in those with physical ill-health and in those reporting a range of adverse mental health measures. In addition, sociodemographic factors, including sex, age and education were also associated with antidepressant use and the class of antidepressant used.

The use of antidepressants in Belgian nursing homes: focus on indications and dosages in the PHEBE study

BACKGROUND

Since antidepressants are prescribed for multiple indications, the use of an antidepressant cannot be equated with a diagnosis of depression.

OBJECTIVE

The objective of this study was to examine the quality of antidepressant prescribing in Belgian nursing homes, with a critical evaluation of indications and dosages, to see whether depression was appropriately treated in terms of drug choice, the indications for which antidepressants were being prescribed and whether there was underdosing.

METHODS

This analysis was based on data obtained in the Prescribing in Homes for the Elderly in Belgium (PHEBE) study, a cross-sectional, descriptive study of a representative, stratified, random sample of 1,730 residents from 76 Belgian nursing homes. The PHEBE study investigated overall drug utilization in Belgian nursing homes in 2006. Clinical and medication data for the present study were obtained from this study. A 28-item checklist of clinical conditions was designed ad hoc for the PHEBE study and sent to the residents' general practitioners (GPs) to collect clinical information. We copied the residents' medication charts, classified the drugs using the Anatomical Therapeutic Chemical (ATC) classification system codes and transferred the drug names and dosages into a database. Information on indications was retrospectively obtained from the GPs, so that we could link the indication to each medication. Minimum effective doses (MEDs) of antidepressants to treat major depression were obtained from the literature to assess underdosing.

RESULTS

The overall use of antidepressants in nursing homes was 39.5 % (95 % CI 37.2, 41.8). The physicians classified 34.2 % (95 % CI 32.0, 36.4) of the residents as having depression, and 80.9 % of these patients were treated with an antidepressant. Indications among the single antidepressant users (n = 551) were depression (66.2 %), insomnia (13.4 %), anxiety (6.2 %) and neuropathic pain (1.6 %). In the indication of depression, 74.8 % used a selective serotonin reuptake inhibitor (SSRI), predominantly citalopram, sertraline and escitalopram. Venlafaxine was used by 10.7 % of the residents. Dosages for these antidepressants were equal to or higher than the MED. But when trazodone, amitriptyline or mirtazapine were used to treat depression, respectively, 92.3, 55.5 and 44.5 % of prescribed dosages were below the MED. In the indication of insomnia, most of the time, trazodone (90.5 %) or mirtazapine (5.4 %) were used, and in lower dosages than those required for depression treatment (<MED). Tricyclic antidepressants were predominantly used for the treatment of neuropathic pain and were also used at lower dosages. Of all the residents receiving a medication for anxiety, only 13.9 % received an antidepressant (mostly an SSRI), and the remaining received a benzodiazepine.

CONCLUSIONS

The number one indication for the use of an antidepressant was depression. Within this indication, mostly the recommended SSRIs were used, in dosages equal to or higher than the MED. Furthermore, we noticed that there was substantial use of sedative antidepressants for insomnia and that the physicians preferred to prescribe benzodiazepines over the recommended SSRIs to treat anxiety chronically.

Medicare Part D plan generosity and medication use among dual-eligible nursing home residents

BACKGROUND

In 2006, dual-eligible nursing home residents were randomly assigned to a Medicare Part D prescription drug plan (PDP). Subsequently, residents not enrolled in qualified plans at the start of the next year were rerandomized. PDPs vary in generosity through differences in medication coverage and utilization management. Therefore, residents' assigned plans may be relatively more or less generous for their particular drugs. The impact of generosity on residents' medication use and health outcomes is unknown.

METHODS

Using data from 2005 to 2008, we estimated logistic regression models of the impact of coverage and utilization management on the risk for medication changes and gaps in use, hospitalizations, and death among elderly nursing home residents using 1 of 6 selected drug classes, adjusting for patient characteristics.

RESULTS

Few current medication users faced noncoverage of their drug (0.4% to 8.7%) or prior authorization or step therapy requirements if the drug was covered (1.1% to 37.4%). After adjusting for individual-level covariates, residents with noncovered drugs were more likely than residents with covered drugs to change medications in most classes studied (eg, for 2006 angiotensin receptor blocker users, the adjusted average probability of medication change was 0.35 when uncovered vs. 0.11 when covered). Those subjected to prior authorization or step therapy were more likely to change in a subset of classes. There were no statistically significant differences in the rates of hospitalization or death after correcting for multiple comparisons.

CONCLUSIONS

The Part D benefit's special protections for nursing home residents may have ameliorated the health impact of coverage limits on this frail elderly population.

Trends in psychotropic drug prescribing in Norwegian nursing homes from 1997 to 2009: a comparison of six cohorts

BACKGROUND

Psychotropic drugs are extensively prescribed for the treatment of neuropsychiatric symptoms, despite modest efficacy and severe side effects.

AIMS

We examined trends in psychotropic drug prescribing in Norwegian nursing homes from 1997 to 2009, in order to gain insight in practice development.

METHODS

The study is a secondary data analysis of six cross-sectional nursing home studies conducted between 1997 and 2009. Patients aged >65 years were included. We compared the prevalence of psychotropic drugs (antipsychotics, anxiolytics, hypnotics, and antidepressants). Associations between prescription of psychotropics, and patients' age, gender, type of ward, and year of data collection were examined by univariate analysis and logistic regression.

RESULTS

Altogether, 7 661 patients (mean age 85.2 years, 72.6% women) were included. Prevalence of all psychotropic drugs combined increased from 57.6% to 70.5%, anxiolytics from 14.9% to 21.9%, hypnotics from 14.5% to 22.9%, and antidepressants from 31.5% to 50.9%. Prevalence of antipsychotics varied between extremes 21.1% and 25.6%. Less prescribing of older drugs was exceeded by an increase in newer drug types. Concomitant prescribing of two or more psychotropic drugs increased from 21% to 33%. Predictors of psychotropic drugs were female gender (except antipsychotics), as well as age <80 years, and residency in special care units (except hypnotics).

CONCLUSIONS

Prescribing of psychotropic drugs in nursing homes has increased considerably, especially regarding antidepressants. Explanations for this trend need to be further explored.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Serotonin-norepinephrine reuptake inhibitor therapy in late-life depression is associated with increased marker of bone resorption

Antidepressants are associated with bone loss and fractures in older adults. We treated depressed older adults with an antidepressant and examined its effects on bone turnover by comparing blood samples before and after treatment. Bone resorption increased after antidepressant treatment, which may increase fracture risk.

INTRODUCTION

Antidepressants have been associated with increased bone loss and fractures in older adults in observational studies, but the mechanism is unclear. We examined the effects of a serotonin-norepinephrine reuptake inhibitor, venlafaxine, on biomarkers of bone turnover in a prospective treatment study of late-life depression.

METHODS

Seventy-six individuals aged 60 years and older with current major depressive disorder received a 12-week course of venlafaxine XR 150-300 mg daily. We measured serum C-terminal cross-linking telopeptide of type I collagen (β-CTX) and N-terminal propeptide of type I procollagen (P1NP), measures of bone resorption and formation, respectively, before and after treatment. We then analyzed the change in β-CTX and P1NP within each participant. Venlafaxine levels were measured at the end of the study. We assessed depression severity at baseline and remission status after treatment.

RESULTS

After 12 weeks of venlafaxine, β-CTX increased significantly, whereas P1NP did not significantly change. The increase in β-CTX was significant only in participants whose depression did not remit (increase by 10 % in non-remitters vs. 4 % in remitters). Change in β-CTX was not correlated with serum levels of venlafaxine or norvenlafaxine.

CONCLUSION

Our findings suggest that the primary effect of serotonergic antidepressants is to increase bone resorption. However, such an increase in bone resorption seemed to depend on whether or not participants' depression remitted. Our results are in agreement with prior observational studies reporting increased bone loss in older adults taking serotonergic antidepressants. These negative effects on bone homeostasis could potentially contribute to increased fracture risk in older adults.

The complex interplay of depression and falls in older adults: a clinical review

Depression and falls have a significant bidirectional relationship. Excessive fear of falling, which is frequently associated with depression, also increases the risk of falls. Both depression and fear of falling are associated with impairment of gait and balance, an association that is mediated through cognitive, sensory, and motor pathways. The management of depression in fall-prone individuals is challenging, since antidepressant medications can increase the risk of falls, selective serotonin reuptake inhibitors may increase the risk of fragility fractures, and data are lacking about the effect of fall rehabilitation programs on clinically significant depression. Based on the current state of knowledge, exercise (particularly Tai Chi) and cognitive-behavioral therapy should be considered for the first-line treatment of mild depression in older fallers. Antidepressant medications are indicated to treat moderate to severe depression in fall-prone individuals, but with appropriate precautions including low starting dose and slow dose titration, use of psychotropic monotherapy whenever possible, and monitoring for orthostatic hypotension and hyponatremia. To date, there have been no recommendations for osteoporosis monitoring and treatment in individuals prescribed antidepressant medications, beyond the usual clinical guidelines. However, treatment of the older depressed person who is at risk of falls provides the opportunity to inquire about his or her adherence with osteoporosis and fracture prevention guidelines.

Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents

Psychotropic medications are commonly prescribed for older adults living in long-term care settings. Use of these medications has been associated with negative functional outcomes. The purpose of this study was to describe the prevalence of psychotropic medication use among nursing home residents, and to explore the relationship of psychotropic medication use on physical and psychosocial outcomes. A secondary data analysis was done using baseline measures from the Res-Care Intervention Study. The sample included 419 residents from 12 nursing homes. There were 288 participants (69%) who were prescribed at least one psychotropic medication, with 81 participants (19%) receiving antipsychotics, 248 (59%) receiving antidepressants, 50 (12%) receiving anxiolytics and 37 (9%) receiving sedative/hypnotics. Controlling for gender, age and cognition, physical outcomes were significantly lower in residents receiving psychotropic medications (F= 3.2, P= 0.01) compared to those not receiving psychotropic medications. Psychosocial outcomes were significantly lower in those residents receiving psychotropic mediations (F= 2.0, P= 0.04). The findings from this study provide additional support for the prevalence of psychotropic medication use among nursing home residents and suggest that residents receiving psychotropic medications may be less likely to engage in functional activities and experience decreased quality of life.

Inhibitory metabolic drug interactions with newer psychotropic drugs: inclusion in package inserts and influences of concurrence in drug interaction screening software

BACKGROUND

Food and Drug Administration (FDA) regulations mandate that package inserts (PIs) include observed or predicted clinically significant drug-drug interactions (DDIs), as well as the results of pharmacokinetic studies that establish the absence of effect.

OBJECTIVE

To quantify how frequently observed metabolic inhibition DDIs affecting US-marketed psychotropics are present in FDA-approved PIs and what influence the source of DDI information has on agreement between 3 DDI screening programs.

METHODS

The scientific literature and PIs were reviewed to determine all drug pairs for which there was rigorous evidence of a metabolic inhibition interaction or noninteraction. The DDIs were tabulated noting the source of evidence and the strength of agreement over chance. Descriptive statistics were used to examine the influence of source of DDI information on agreement among 3 DDI screening tools. Logistic regression was used to assess the influence of drug class, indication, generic status, regulatory approval date, and magnitude of effect on agreement between the literature and PI as well as agreement among the DDI screening tools.

RESULTS

Thirty percent (13/44) of the metabolic inhibition DDIs affecting newer psychotropics were not mentioned in PIs. Drug class, indication, regulatory approval date, generic status, or magnitude of effect did not appear to be associated with more complete DDI information in PIs. DDIs found exclusively in PIs were 3.25 times more likely to be agreed upon by all 3 DDI screening tools than were those found exclusively in the literature. Generic status was inversely associated with agreement among the DDI screening tools (odds ratio 0.11; 95% CI 0.01 to 0.89).

CONCLUSIONS

The presence in PIs of DDI information for newer psychotropics appears to have a strong influence on agreement among DDI screening tools. Users of DDI screening software should consult more than 1 source when considering interactions involving generic psychotropics.

Opportunities for reversible inhibitors of monoamine oxidase-A (RIMAs) in the treatment of depression

Treatment-resistant depression (TRD) may be implicated in 33–57% of depression cases. The currently available effective treatments include electroconvulsive therapy (ECT) or augmentation of serotonin selective reuptake inhibitors (SSRIs) with antipsychotics. ECT and antipsychotics are both associated with safety and tolerability concerns. Depression is hypothesized to result from a dysregulation of monoamine neurotransmitters, although the source of the dysregulation has been unclear. However, recent studies have revealed that an enzyme that degrades the neurotransmitters, known as monamine oxidase-A (MAO-A), may be overactive in patients with depression. Thus, treatments for depression that modulate MAO-A could act upstream relative to current antidepressant treatments. Monoamine oxidase inhibitors (MAOIs) can be highly effective therapeutic agents for depression and some anxiety disorders. Some evidence suggests that MAOIs may act by reversing excessive neurotransmitter depletion within the neuron and the synapse. MAOIs tend to be underutilized in clinical practice, due in part to misinformation and mythology about their dietary and drug interactions. The new class of reversible monoamine oxidase inhibitors (RIMAs) has shown efficacy in depression, with safety and tolerability comparable to SSRIs. This article discusses recent progress in RIMAs toward the treatment of TRD. Dietary and drug interactions of MAOIs will be covered, as well as guidelines for integrating these agents into clinical practice.

A review of the effectiveness of antidepressant medications for depressed nursing home residents

BACKGROUND

Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population.

OBJECTIVE

To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents.

METHODS

The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimer's disease.

RESULTS

A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group.

CONCLUSIONS

The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.

Antidepressant prescribing patterns in the nursing home: second-generation issues revisited

INTRODUCTION

The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.

DESIGN

Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.

SETTING

Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).

PARTICIPANTS

Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).

MEASUREMENTS

Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.

RESULTS

Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.

CONCLUSION

Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

Age and sex variation in prevalence of chronic medical conditions in older residents of U.S. nursing homes

OBJECTIVES

To investigate patterns in prevalences of chronic medical conditions over the age span of long-term stay nursing home residents and between the sexes with data from the 2004 National Nursing Home Survey (NNHS).

DESIGN

Retrospective, cross-sectional study.

SETTING

U.S. nursing homes.

PARTICIPANTS

Nationally representative sample comprising 11,788 long-term stay residents (3,003 (25%) men, 8,785 (75%) women) aged 65 and older.

MEASUREMENTS

Clinical Classifications Software was used to group International Classification of Diseases, Ninth Revision, codes to identify the 20 most-prevalent chronic medical conditions. SAS survey procedures were used to account for design effects of stratification and clustering to generate nationally representative estimates of prevalences of medical conditions.

RESULTS

Average age was 84, with women older than men (85 vs 81, P = .02) and 67% of women aged 80 to 95. Women required more assistance with activities of daily living. The most frequent chronic medical conditions were hypertension (men 53%, women 56%), dementia (men 45%, women 52%), depression (men 31%, women 37%), arthritis (men 26%, women 35%), diabetes mellitus (men 26%, women 23%), gastroesophageal reflux disease (GERD) (men 23%, women 23%), atherosclerosis (men 24%, women 20%), congestive heart failure (CHF) (men 18%, women 21%), cerebrovascular disease (CVD) (men 24%, women 19%), and anemia (men 17%, women 20%). Sex differences in prevalences existed for all but constipation, GERD, and hypertension. Diabetes mellitus, CVD, and lipid disorders decreased with age in men and women. Atrial fibrillation, anemia, arthritis, CHF, dementia, and thyroid disease increased with age in men and women. Age-related patterns differed between the sexes for diabetes mellitus, hypertension, and Parkinson's disease.

CONCLUSION

The profile of chronic medical conditions varies over the age span of nursing home residents and differs between men and women. This knowledge should guide educational and care efforts in long-term care.