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Addressing Comorbid Geriatric Syndromes in Dementia
Orlando—The management of comorbid geriatric syndromes in patients with early dementia is complex. During a symposium at the American Geriatrics Society 2014 Annual Scientific Meeting, Dimitry S. Davydow, MD, MPH, and Noll Campbell, PharmD, BCPP, discussed the prevalence and outcomes of depression superimposed on dementia, and outlined the management challenges and treatment strategies.
Major depression is one of the most common neuropsychiatric syndromes in patients with dementia, affecting 25% of patients with Alzheimer’s disease and 20% to 30% of patients with subsyndromal depression. Depression is also a risk factor for progression from mild cognitive impairment to dementia, according to Dr. Davydow.
Patients with depression in dementia may exhibit the following signs and symptoms:
• Agitation
• Anhedonia
• Anxiety
• Apathy
• Depressed mood
• Irritability
• Personality change
• Poor appetite
• Psychomotor changes
• Sleep disturbance
• Suicidal ideation
• Worsened cognition
There are also 4 validated assessment scales for diagnosis:
- Geriatric Depression Scale
- Cornell Scale for Depression in Dementia
- Neuropsychiatric Inventory
- Patient Health Questionnaire-2
Dr. Davydow noted adverse outcomes related to depression in dementia. For example, a study published by Dr. Davydow and colleagues in Journal of General Medicine in 2014 found that depression, cognitive impairment without dementia, and/or depression were independently associated with increased risks of potentially preventable rehospitalization within 30 days after hospitalization for pneumonia, congestive heart failure, or acute myocardial infarction. Other studies have shown that depression in dementia is associated with greater caregiver burden, increased risk of institutionalization, and increased risk of mortality.
He also discussed the findings of 4 randomized, controlled trials regarding the role of antidepressants in the management of depression in dementia. A study published in 2003 in Archives of General Psychiatry found that the selective serotonin reuptake inhibitor sertraline was superior to placebo in the treatment of depression in dementia in a single-center, randomized, controlled trial. However, a multicenter, randomized, controlled trial published in American Journal of Geriatric Psychiatry in 2010 found no difference between sertraline and placebo. Sertraline and mirtazapine, a tetracyclic antidepressant, are the 2 most commonly prescribed drugs for dementia. A study published in Lancet in 2012 found no difference between sertraline and mirtazapine versus placebo. In a multicenter, randomized, controlled trial of patients in Norwegian nursing homes, researchers sought to determine the effect of discontinuing antidepressant treatment in patients with dementia and neuropsychiatric symptoms. The results reported in British Medical Journal in 2012 found that discontinuation of antidepressant treatment in patients with dementia and neuropsychiatric symptoms led to an increase in depressive symptoms compared with those patients who continued with treatment.
When prescribing antidepressants for depression in dementia, clinicians should factor in the risk–benefit ratio of the medication, target problematic signs/symptoms such as insomnia and/or poor appetite and agitation, and consider medications that have fewer CYP450 interactions such as venlafaxine, citalopram, escitalopram, and mirtazapine, said Dr. Davydow. He also spoke to evidence-based nonpharmacologic interventions for depression in dementia. Interventions include exercise and physical activity and psychotherapy (eg, basic cognitive-behavioral therapy, supportive and interpersonal therapies, and problem-solving therapy).
Dr. Campbell continued the symposium with an overview of the adverse cognitive effects of medications in older adults with dementia and potential medication adherence interventions in this patient population.
He began with statistics on medication complexity in older adults. Ambulatory adults use an average of 11 medications per day, and 74% report combining prescription and nonprescription medications. Furthermore, as many as 60% use a medication that is associated with adverse cognitive effects. According to the updated 2012 American Geriatrics Society Beers Criteria, 3 classes of drugs have been identified with adverse cognitive effects—benzodiazepines (including benzodiazepine receptor agonists), anticholinergics, and histamine-2 receptor antagonists.
Because of the adverse cognitive effects of medications associated with polypharmacy and inappropriate medication use in older patients, Dr. Campbell noted that clinicians should consider discontinuation of multiple medications, if appropriate. He highlighted a study published in Archives of Internal Medicine in 2010 that applied the Good Palliative-Geriatric Practice algorithm for drug discontinuation to a cohort of 70 community-dwelling older patients. The results found that 91% of patients were eligible for discontinuation of at least 1 medication, 58% of all medications used were eligible for discontinuation, 81% of medications were discontinued successfully, and 88% of patients reported global improvement in health.
When addressing medication changes, Dr. Campbell recommended that clinicians:
- Educate patient and caregivers on potential adverse cognitive effects of medications
- Determine treatment goals of adverse cognitive effect medications from a patient perspective
- Try nonpharmcologic treatment approaches
- Consider alternative medications as necessary in replacement of adverse cognitive effect medications
- Apply taper schedules when necessary for narrow therapeutic medications or chronically used psychotropic medications
Dr. Campbell concluded with a discussion on potential medication adherence interventions in older adults with a diagnosis of dementia.
Adherence interventions for dementia include:
• Activate adherence assistant for each patient (eg, support communication with and among the healthcare system)
• Activate resources within the healthcare team (eg, pharmacist to identify trends and provide medication education)
• Address concerns regarding adverse effects
• Conduct drug regimen review to minimize polypharmacy
• Identify all barriers to medication adherence
• Minimize dosing frequency (eg, no more than twice daily)
• Provide reminder aids within the patient’s daily routine
“Interventions must be comprehensive and personalized,” said Dr. Campbell. —Eileen Koutnik-Fotopoulos
