Concurrent use of polypharmacy and potentially inappropriate medications with antidepressants in older adults: A nationwide descriptive study in Denmark during 2015-2019

Ginkgo biloba L. leaf extract (EGb 761) alleviates reserpine-induced depression-like symptoms in aged rats by enhancing serotonin/norepinephrine levels and reducing oxidative/nitrosative stress

Along with accelerated aging, the prevalence of late-life depression (LLD) exacerbates. Older people are more vulnerable to the adverse effects of antidepressants than the young. Therefore, creating antidepressants from medicinal herbs that are more effective and safer is inevitable. Ginkgo biloba L. leaf extract (EGb761) is broadly applied for treating various neuronal dysfunctions. The present study aimed to evaluate the ameliorative and antidepressant effects of EGb761 against reserpine (RES)-induced depression like symptoms and associated comorbidities in aged female rats. Besides, it compared its efficacy with the antidepressant duloxetine (DULX), offering a more comprehensive understanding of therapeutic potential of EGb 761. Rats grouped into control group, EGb 761-H group, RES group, RES plus either EGb 761-L, EGb 761-H, or DULX groups. The antidepressant effects of EGb 761 were evaluated through a series of behavioral tests, measurement of depression biochemical markers, performing neuronal histopathology and immunohistochemical analyses. EGb 761 significantly attenuated behavioral deficits in the open field test and reduced immobility time in the forced swimming test. Moreover, EGb 761 exerted antidepressant-like actions by ameliorating neurotransmitter imbalances, restoring redox homeostasis in cortical region. Also, EGb 761 increased level of ATP, diminished DNA fragmentation, decreased caspase-3 immunoreactivity and increased immunoreactivity of synaptophysin in the cerebral cortex, besides it enhanced the histological architecture of this region. Overall, EGb 761 has the potential effects to manage LLD focus on the role of both serotonergic and noradrenergic systems in mediating these effects, alongside the impact on oxidative/nitrosative stress.

Influence of Ageing on the Pharmacodynamics and Pharmacokinetics of Chronically Administered Medicines in Geriatric Patients: A Review

As people age, the efficiency of various regulatory processes that ensure proper communication between cells and organs tends to decline. This deterioration can lead to difficulties in maintaining homeostasis during physiological stress. This includes but is not limited to cognitive impairments, functional difficulties, and issues related to caregivers which contribute significantly to medication errors and non-adherence. These factors can lead to higher morbidity, extended hospital stays, reduced quality of life, and even mortality. The decrease in homeostatic capacity varies among individuals, contributing to the greater variability observed in geriatric populations. Significant pharmacokinetic and pharmacodynamic alterations accompany ageing. Pharmacokinetic changes include decreased renal and hepatic clearance and an increased volume of distribution for lipid-soluble drugs, which prolong their elimination half-life. Pharmacodynamic changes typically involve increased sensitivity to various drug classes, such as anticoagulants, antidiabetic and psychotropic medications. This review examines the primary age-related physiological changes in geriatrics and their impact on the pharmacokinetics and pharmacodynamics of medications.

Patient-Related Factors Associated With the Initiation of Potentially Inappropriate Medication in Home Care: An Observational Study Based on Resident Assessment Instrument Data

BACKGROUND

The harmful outcomes of potentially inappropriate medications (PIMs) are highlighted among multimorbid older home care clients using several medicines. The aim of this study was to identify patient-related factors associated with the initiation of PIMs.

METHODS

This register-based study used Resident Assessment Instrument-Home Care (RAI-HC) assessments (n = 6176) from year 2014 to 2015. PIMs were identified according to the Beers criteria. Generalised estimating equations were used to identify factors associated with the initiation of PIMs.

FINDINGS

A total of 228 (11.3%) clients initiated PIMs during the follow-up (mean 13 months). Factors associated with higher odds to initiate PIMs were higher education (OR = 1.36, 95% CI 1.02-1.82), cognitive impairment (OR = 1.70, 1.02-2.82), reduced social interaction (OR = 1.50, 1.06-2.13), independent activity outdoors (OR = 1.72, 1.18-2.51), diabetes (OR = 1.47, 1.12-1.94), Parkinson's disease (OR = 3.42, 1.86-6.27) and longer interval between RAI assessments (OR = 1.09 per month, 1.02-1.18).

CONCLUSIONS

Incidence of PIMs among home care clients was common. The results help healthcare professionals to focus more attention on clients more susceptible to PIM prescribing. Preventing PIM use is essential, especially among older adults with cognitive impairment, to prevent further decline of health status and admission to long-term care.

Efficacy and safety of antidepressants for pain in older adults: A systematic review and meta-analysis

AIMS

In many countries, pain is the most common indication for use of antidepressants in older adults. We reviewed the evidence from randomized controlled trials on the efficacy and safety of antidepressants, compared to all alternatives for pain in older adults (aged ≥65 years).

METHODS

Trials published from inception to 1 February 2024, were retrieved from 13 databases. Two independent reviewers extracted data on study and participant characteristics, primary efficacy (pain scores, converted to 0-100 scale) and harms. Estimates for efficacy were pooled using a random effects model and reported as difference in means and 95% CI. Quality of included trials was assessed using the Cochrane risk of bias tool.

RESULTS

Fifteen studies (n = 1369 participants) met the inclusion criteria. The most frequently studied antidepressants were duloxetine and amitriptyline (6/15 studies each). Pain related to knee osteoarthritis was the most studied (6/15 studies). For knee osteoarthritis, antidepressants did not provide a statistically significant effect for the immediate term (0-2 weeks), (-5.6, 95% confidence interval [CI]: -11.5 to 0.3), but duloxetine provided a statistically significant, albeit a very small effect in the intermediate term, (≥6 weeks and <12 months), (-9.1, 95% CI: -11.8 to -6.4). Almost half (7/15) of the studies reported increased withdrawal of participants in the antidepressant treatment group vs. the comparator group due to adverse events.

CONCLUSIONS

For most chronic painful conditions, the benefits and harms of antidepressant medicines are unclear. This evidence is predominantly from trials with sample sizes of <100, have disclosed industry ties and classified as having unclear or high risk of bias.

Depression Treatment Trajectories and Associated Social Determinants: A Three-Year Follow-Up Study in 66,540 Older Adults Undergoing First-Time Depression Treatment in Denmark

OBJECTIVE

This study aimed to describe depression treatment patterns, identify unique trajectory groups using a group-based trajectory approach, and explore associated social determinants in older adults undergoing first-time depression treatment during a 3-year follow-up.

METHODS

This Danish register-based cohort study included all adults aged ≥ 65 who initiated depression treatment by redeeming first-time antidepressant prescriptions (no prescriptions in the last 10 years) between 2006 and 2015. The outcome of interest during the 2-year follow-up was depression treatment, assessed as antidepressant prescriptions redemptions and psychiatric hospital contacts for depression. Latent class growth analyses were applied to model treatment trajectories during 3 years. Multinomial logistic regression analyses were used to analyze adjusted associations between social determinates and trajectory group membership.

RESULTS

Among the 66,540 older adults (55.2% females, mean age: 77.3 years), we identified three distinct groups with unique patterns of depression treatment trajectories: 'brief-treatment' where individuals stopped depression treatment within 6 months (33.7%); 'gradual-withdrawal' (26.5%) where treatment was gradually stopped over 2 years; and 'persistent-treatment' where individuals continued depression treatment for the entire 3 years (39.8%). Females, single-person households, and residents of less-urbanized regions were associated with higher odds of membership in the 'persistent-treatment' group, while older age, widowhood or separation, and non-Danish ethnicities were associated with lower odds.

CONCLUSIONS

Three distinct patterns of depression treatment trajectories were identified in older adults, indicating differential clinical courses of depression-potentially influenced by social determinants, including sex, marital status, urban residence, and ethnicity. Early patient stratification and targeted interventions are crucial in depression care for older adults.

Depressive symptoms in the entire spectrum of cognitive ageing in Greece: evidence from the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD)

OBJECTIVES

To study (i) the prevalence of mild and moderate-to-severe depressive symptoms in the entire spectrum of cognitive ageing in Greece and (ii) the relationship between these symptoms and demographic and clinical data.

METHODS

The study was based on the randomly selected cohort of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD). Depressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale. Participants also received a comprehensive neuropsychological assessment, while the clinical diagnoses of dementia and mild cognitive impairment were established according to international diagnostic criteria. Statistical analyses relied on comparison tests and a logistic (proportional odds) ordinal regression model.

RESULTS

Depressive symptoms were detected in 19.5% of the 1936 study participants, while 11.3% of both people with MCI and dementia had moderate-to-severe depressive symptoms. The regression model revealed that older adults with more severe depressive symptoms were more likely female, cognitively impaired, less educated, were treated with psychotropic medication and lived in Attica versus Thessaly.

CONCLUSIONS

Since depressive symptoms were detected in almost one in five older adults, healthcare professionals in Greece should safeguard the timely detection and effective treatment of such symptoms and the post-diagnostic care of older adults with depression.

Comparative effectiveness of selective serotonin reuptake inhibitors (SSRIs) for depression in 43,061 older adults with chronic somatic diseases: A Danish target trial emulation study

OBJECTIVE

To investigate the comparative effectiveness of commonly used selective serotonin reuptake inhibitors (SSRIs) for comorbid depression in older adults with chronic somatic diseases by applying a target-trial-emulation framework.

METHODS

Danish target-trial-emulation study including 43,061 individuals aged ≥65 years (54.1% females, mean age 77.8 years) with a first redeemed prescription for depression with sertraline (n = 6673), escitalopram (n = 7104) or citalopram (n = 29,284) in 2006-2017. Individuals had cancer, cardiovascular diseases (CVD), chronic-obstructive-pulmonary-disease (COPD)/asthma, diabetes, neurodegenerative disorders, or osteoporosis. Outcomes were treatment switching, combination/augmentation, psychiatric hospital contact for depression, and any psychiatric in-patient care. Follow-up was one year and adjusted Cox regression analyses calculated hazard rate ratios (HRR) within each somatic disease.

RESULTS

Across all six disease groups and four outcomes, we found that citalopram use, compared with sertraline, was associated with lower risks in several analyses, with statistically significant results in cancer, CVD, COPD/asthma, and diabetes (e.g., HRRs for psychiatric hospital contacts for depression/any psychiatric in-patient care ranging between 0.47 and 0.61). For escitalopram, compared with sertraline, some analyses indicated poorer outcomes with significantly higher risks for combination/augmentation treatment (HRRs ranging between 1.15 and 1.40).

CONCLUSIONS

Although observational studies are prone to confounding, these findings indicate clinically relevant differences between the SSRIs, with better outcomes in citalopram users and poorer outcomes in escitalopram users than sertraline, urging the need for clinical studies in this vulnerable patient population.

Mental Health Polypharmacy in "Non-Coded" Primary Care Patients: The Effect of Deprescribing

Background: Mental health (MH) polypharmacy, defined as prescribing multiple mental health medications for the same condition, presents significant challenges in clinical practice. With varying prevalence rates and an increasing trend, particularly in the UK, this deprescribing prospective quality improvement project aimed to address the complexities and risks associated with MH polypharmacy. Patients and Methods: A large primary care centre in London was selected for this project. Electronic records of 667 patients (non-coded in mental health lists) were analysed as a result of the absence of a Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for mental health. Seventy-two non-coded patients exhibiting "same-class" as well as "adjunctive" and "augmentation" polypharmacy were identified. Their demographic and health data, including MH diagnoses, physical status, and lifestyle habits, were evaluated. This deprescribing prospective project included 68 patients and employed a model inspired by the Plan-Do-Study-Act (PDSA) cycle, focusing on reducing psychotropic, adjunctive, and augmentative medications while monitoring mental health control through face-to-face consultations using the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder Assessment-7 (GAD-7) scores, alongside physical health parameters. Results: The project revealed a significant decrease in the average number of psychotropic and adjunct medications from initial consultations to the end of the 18-month period. Additionally, a marked reduction in reported side effects and drug interactions was observed. Improvements in mental health control, as evidenced by PHQ-9 and GAD-7 scores, were noted. Physical health parameters, including BMI, blood pressure, heart rate, HbA1c, and cholesterol levels, also showed significant improvements. Educational initiatives for patients and clinicians were successfully implemented, contributing to these positive outcomes. Discussion: The project faced challenges like balancing medication reduction with mental health stability, patient apprehension, and the absence of standardised protocols. However, the successful reduction in medication numbers and the improvement in health outcomes highlight the effectiveness of the model. This project underscores the necessity of a tailored approach to MH polypharmacy, emphasising continuous education, clinical titration, and adherence to guidelines. Future research is needed to develop clear guidelines for medication combination in mental health care and to understand the long-term effects of polypharmacy in mental health populations. Conclusions: This project demonstrates the potential for significant improvements in the management of MH polypharmacy. By carefully managing medication reductions and employing a comprehensive care approach, including patient education and clinician training, the project achieved improvements in both mental and physical health outcomes. These findings suggest a promising direction for future practices in MH polypharmacy management.

Real-World Evidence on Clinical Outcomes of Commonly Used Antidepressants in Older Adults Initiating Antidepressants for Depression: A Nationwide Cohort Study in Denmark

OBJECTIVE

The authors investigated the clinical outcomes of commonly used antidepressants among older adults who initiated first-time antidepressants for depression by analyzing the 1-year risk of selected clinically relevant outcomes.

METHODS

This cohort study used nationwide Danish registry data and included all older adults who redeemed a first-time (since 1995) antidepressant prescription with an indication of depression between 2006 and 2017. Only the 10 most frequently redeemed antidepressants were included in the analyses. Outcomes included discontinuation, switching, augmentation, psychiatric hospital contacts, suicide attempt or self-harm, fall-related injuries, cardiovascular events, and all-cause mortality. Incidence rate ratios (IRRs) and 95% confidence intervals were estimated using Poisson regression models, controlling for potential confounders.

RESULTS

The study sample included 93,883 older adults (mean age, 78.0 years, SD=7.5 years; 56% female). The most frequently prescribed antidepressants were selective serotonin reuptake inhibitors (citalopram, 47.04%; escitalopram, 11.81%; fluoxetine, 0.55%; paroxetine, 0.52%; sertraline, 11.17%), serotonin-norepinephrine reuptake inhibitors (duloxetine, 0.71%; venlafaxine, 1.54%), a tricyclic antidepressant (amitriptyline, 1.86%), and two atypical antidepressants (mianserin, 1.93%; mirtazapine, 22.87%). Compared with users of sertraline (the reference drug in this analysis, as Danish guidelines recommend it as the first-choice treatment for depression), users of most of the other nine antidepressants had a significantly higher risk of discontinuation (e.g., mirtazapine: IRR=1.55, 95% CI=1.50-1.61; venlafaxine: IRR=1.22, 95% CI=1.12-1.32), switching (amitriptyline: IRR=1.45, 95% CI=1.15-1.81; venlafaxine: IRR=1.47, 95% CI=1.20-1.80), augmentation, cardiovascular events, and mortality. Overall, mirtazapine and venlafaxine users had the most adverse outcomes compared with sertraline users. These results remained consistent in analyses stratified by sex and age (≤75 years vs. >75 years).

CONCLUSIONS

This real-world evidence suggests that clinical outcomes may vary among initiators of commonly used antidepressants in older adults, which may inform benefit-risk evaluation at treatment initiation, and highlights the importance of careful selection of antidepressant treatment.

Prevalence and predictors of inappropriate prescribing in outpatients with severe mental illness

Background

Potentially inappropriate prescribing (PIP) is frequent in geriatrics and results in an increased risk for adverse effects, morbidity, mortality and reduced quality of life. Research on PIP in psychiatry has mainly focused on elderly patients and inpatients.

Objectives

To determine the prevalence and the predictors of PIP of psychotropic medication in outpatients with severe mental illness.

Design

This study is part of the Muva study, a pragmatic open Stepped Wedge Cluster Randomized Trial of a physical activity intervention for patients (age ⩾ 16 years) with severe mental illness.

Methods

A structured medication interview, questionnaires on social functioning, quality of life and psychiatric symptoms, and BMI and waist circumference measurements were performed followed by a structured medication review. Patients were divided into groups: PIP versus no PIP. Between-group differences were calculated and a multivariate binary logistic regression was performed to examine predictors for PIP. A receiver operating characteristics analysis was performed to determine the area under the curve (AUC).

Results

In 75 patients, an average of 5.2 medications of which 2.5 psychotropic medication was used. 35 (46.7%) patients were identified with PIP. Unindicated long-term benzodiazepine use was the most frequently occurring PIP (34.1%). Predictors of PIP were female gender [odds ratio (OR) = 4.88, confidence interval (CI) = 1.16-20.58, p = 0.03], number of medications (OR = 1.41, CI = 1.07-1.86, p = 0.02) and lower social functioning (OR = 1.42, CI = 1.01-2.00, p = 0.05). The AUC was 0.88 for the combined prediction model.

Conclusion

The prevalence of PIP of psychotropic medication in outpatients with severe mental illness is high. It is therefore important to identify, and where possible, resolve PIP by frequently performing a medication review with specific attention to females, patients with a higher number of medications and patients with lower social functioning.

Trial registration

This trial was registered in The Netherlands Trial Register (NTR) as NTR NL9163 on 20 December 2020 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163).

Optimizing treatment for older adults with depression

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.