Are your oldest patients getting risky drugs?
Are your oldest patients getting risky drugs?
Experts say SSRIs offer benefits over tricyclics
Elderly nursing home patients are at high risk for depression, and leading researchers speaking at the recent American Association for Geriatric Psychiatry (AAGP) annual meeting in Miami suggest that some commonly prescribed antidepressants may cause potentially deadly complications for the oldest of those patients.
Available data suggest that older, less expensive, generic antidepressant drugs may increase the risk of mortality in people with heart disease, yet those tricyclic antidepressants are still commonly prescribed in nursing homes nationwide, notes Soo Borson, MD, immediate past president of AAGP and professor of psychiatry and behavioral sciences and director of geriatric psychiatry services at the University of Washington Medical Center in Seattle. "Newer antidepressants, including selective serotonin reuptake inhibitors [SSRIs], though more expensive, have lower risk of cardiovascular side effects, which makes them a good choice for elderly nursing home patients."
Although there is no evidence in the literature that the use of low-dose tricyclics is harmful, low doses do not treat clinical depression adequately, she says. "It takes a big dose of a tricyclic to treat depression, and higher doses come with side effects that are especially risky for the elderly."
Those side effects include sedation, constipation, orthostatic hypotension, mental confusion, blurred vision, dry mouth, urinary hesitancy, and urinary obstruction.
"Urinary hesitancy and urinary obstruction are particularly troubling in older men with large prostates," notes Borson. "In low doses, tricyclics are effective for pain relief and sleep disturbances in the elderly, but for treating depression, my first choice is now an SSRI. These drugs appear to be safer and have fewer side effects than tricyclics. Unfortunately, we have little clinical evidence about the use of SSRIs in the very old."
To clarify issues surrounding appropriate therapies for treating depression in the very old, researchers at the University of Pittsburgh are participating in a landmark study to evaluate SSRI antidepressant therapy in people ages 75 and older. The study includes 200 depressed patients in that age group, making it the largest study of depression in people 75 and older. Previously, only five studies on the treatment of depression in that age group, involving a total of 52 patients, have been published.
"Coexisting medical illnesses such as heart disease increase one’s risk for depression, and depression worsens outcomes for medical illness," says Bruce Pollock, MD, PhD, FRCP(C), professor of psychiatry and pharmacology at the University of Pittsburgh Medical Center. "Given the substantial medical burden in people aged 75 and older, we need to know more about treating depression effectively in this group."
He notes that the few studies published to date on antidepressant therapy for the very old indicate that SSRIs and tricyclics are equally effective for treating depression, but SSRIs have far fewer side effects. "If the drugs work the same, but one type has fewer dangerous side effects, why are the riskier drugs more commonly used? Are treatment decisions about depression in nursing homes being made based on what is best for the patient or the bottom line?"
Studies in younger patients indicate that even though SSRIs are more expensive than tricyclics, the comparative costs of the two therapies are about even over time due to the need for fewer physician office visits to address side effects for patients treated with SSRIs, notes Borson. "The problem is we don’t have any evidence about cost benefits of the two therapies in the elderly."
Several factors are working simultaneously to heighten the urgency to learn more about and do more to treat depression adequately in the elderly, adds Borson. "People are living to older ages and are surviving longer with cardiovascular disease and other serious medical conditions. Treatment regimens for these conditions are more complex than ever before. Medical illnesses are one of the two most potent causes of depression in late life. As a result, we face a rising tide of mental illness in older adults and greater potential risks of therapies."
To complicate the issue further, Borson notes, depression often goes unrecognized in nursing home residents. "On average, older patients who are depressed are more anxious, lose weight, and have sleep disturbances. They may not cry but are often apathetic and withdrawn. They may lose interest or desire to participate in any activities. Depression is often not even suspected or investigated in nursing home situations," she says.
Risk factors for late-life depression AAGP urges case managers to watch for include a previous history, social isolation, family history, female gender, recent bereavement, financial strain, chronic illness, and disability/disabling illness.
Depression in the elderly often coexists with chronic disability or illness, says Borson. "The relationship between depression and heart disease is particularly troubling. Depression can be a risk factor for heart disease as well as an outcome of it. Cardiovascular disease may cause depression in the elderly and, at the same time, patients with depression are more likely to develop cardiac events, such as strokes, and die of heart disease than patients who are not depressed."
Many physicians and case managers question whether it’s even possible, in the presence of co-morbidities, to diagnose depression accurately in the oldest of the old, she says. "It’s true that nursing home patients have a considerable amount of co-morbidities and often a degree of dementia. There’s legitimate lingering concern that with so much medical illness it’s not possible to distinguish whether elderly patients are really depressed. A good geriatric psychiatrist can help case managers and nursing home staff do this."
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