Why Do Some Older Adults Treated With Antidepressants Progress To Dementia
Eric E. Brown, MD, MSc, FRCPCa,b Tarek K. Rajji, MD, FRCPCa,b and Benoit H. Mulsant, MD, MS, FRCPCa,b
See related article by Bartels et al
Why Do Some Older Adults Treated With Antidepressants Progress to Dementia?
The relationship between a history of depression and incident dementia is well established, yet incompletely understood. A history of remote or recent depression is associated with about a 2-fold higher risk of incident dementia.1 Despite large studies designed to elucidate the mechanism underlying this epidemiologic relationship, it is still not clear whether depression is a causal contributor to dementia, a disorder with common risk factors, or a symptom of an underlying neurodegenerative process and a prodrome of dementia.2-4 This uncertainty is due in large part to the complexity of these two clinical syndromes, each with heterogeneous etiologies, pathophysiologies, and treatments, all of which can interact with biopsychosocial factors across individuals and populations. Thus, a given individual with depression may progress from depression to dementia due to one, all, or none of the above mechanisms.
Funding/support: None.
REFERENCES
1.Byers AL, Yaffe K. Depression and risk of developing dementia. Nat Rev Neurol. 2011 7:323-331. PubMedCrossRef
2.da Silva J, Gonçalves-Pereira M, Xavier M, et al. Affective disorders and risk of developing dementia: systematic review. Br J Psychiatry. 2013 202:177-186. PubMedCrossRef
J Clin Psychiatry 2020 81:20com13559
Medications That Can Be Used To Handle Anxiety In Elderly With Dementia
One of the most difficult situations to deal with when handling a dementia patient is when they are acting anxious or agitated. These issues go beyond thinking and memory. These issues include things like:
Sleep disturbances
Disinhibited behavior, meaning the person can say or do things that are inappropriate socially speaking
Wandering and pacing
Agitation
Irrational beliefs, paranoid behaviors, and delusions
These neuropsychiatric symptoms can be hard to deal with and they are one of the most challenging things that caregivers can deal with when caring for dementia patients. There is no specific drug that can be used for the treatment of dementia, but development can be slowed down and symptoms treated.
How Antidepressants Affect The Elderly
Antidepressants affect the elderly in largely the same way that they would affect any other population.
Studies have shown that SSRIs are more effective at treating antidepressants than tricyclics. Study subjects improved 75% of the time when using tricyclics compared to 83% of the time when taking SSRIs.
Tricyclics, however, often cause more withdrawal symptoms than SSRIs.
Its important to note that elderly people often respond slower to antidepressants than younger groups. In some cases it takes up to 12 weeks before effects are pronounced.
Elderly patients may also be more prone to certain side effects such as falling. Depression related to dementia may not be treatable with common antidepressants.
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Known Risks Of Prescribing Drugs Not Approved For Dementia Treatment To Dementia Patients
None of the drug classes studied has received U.S. Food and Drug Administration approval for use in dementia, and Maust says that evidence for their off-label use is slim.
But all of the drugs are associated with special risks to people in their 60s and older, including falls or dependence that could lead to withdrawal. Most are included on the list known as the Beers criteria, which identifies medications with extra risks for all older adults, not just those with dementia.
While there is limited evidence that antidepressants help people with dementia, Maust notes that someone who had depression before they developed dementia might benefit from staying on a drug that worked for them in the past.
And while there is little evidence of benefit, all these medications have side effects. For example, some people starting a new antidepressant can experience nausea or feel a little jittery. Unfortunately, a person with dementia might have difficulty articulating such side effects to the loved one who takes care of them. Instead, they may appear more agitated leading to another prescription medication to calm them.
While the current study doesnt look at polypharmacy the use of multiple psychoactive drugs by the same patient Maust is exploring this issue further in the Medicare data.
Best Antidepressant Options For Elderly Patients
Before considering an antidepressant as an elderly person, it is important to evaluate your life. This means evaluating your condition of depression from a logical perspective. Realize that there are plenty of ways to overcome depression without meds. Obviously if your diet isnt optimal for your mental health, you dont feel socially connected , you arent getting sunlight each day, and arent getting exercise youre going to feel depressed.
In some cases, ensuring that you have a balanced life will do more for depression than any medication. However, this clearly isnt always the case some people have legitimate neurochemical imbalances that cannot be sufficiently controlled with lifestyle changes.
If this is the case, pharmaceutical medications may be needed to help treat these neurochemical imbalances. If you require a pharmaceutical treatment for depression as an elderly person, there are numerous medications to consider and discuss with an experienced psychiatrist.
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How The Research Helps Doctors Patients
George Savva, PhD, a researcher from University of East Anglias School of Health Sciences and one of the co-authors of the study, said the research can provide experts with more evidence to help them make informed decisions about whether or not to prescribe the medication.
We found that people who had been diagnosed with dementia were up to 30 percent more likely to have been prescribed specific classes of anticholinergic medications, he said in a statement. And the association with dementia increases with greater exposure to these types of medication.
However, Savva and the other researchers made clear they cant say for certain that this medication causes dementia just that its associated with increased risk.
It could be that these medications are being prescribed for very early symptoms indicating the onset of dementia, Savva said. But because our research shows that the link goes back up to 15 or 20 years before someone is eventually diagnosed with dementia, it suggests that reverse causation, or confounding with early dementia symptoms, probably isnt the case.
Dr. Malaz Boustani, MPH, a Regenstrief Institute and Indiana University Center for Aging Research investigator, said in a statement that physicians should think twice about ordering prescriptions for these medications.
Experts already knew that using these drugs could affect cognition and shouldnt be used in older, frail patients, according to the study authors.
What Does Current Guidance Say On This Issue
The NICE guideline published in June 2018 on the assessment and management of dementia has a section on managing non-cognitive symptoms. It suggests considering psychological treatments for people with mild to moderate dementia who have mild to moderate depression. It says that antidepressants should not be routinely offered unless they are indicated for a pre-existing severe mental health problem.
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Additional Adverse Side Effects From High Dosage
When the dose of the antipsychotic drug is high, the following additional adverse side effects can occur:
- Increased risk of a fall
- Diminished cognitive function
- High risk of stroke and death
- Movement disorders known as extrapyramidal symptoms can mimic symptoms like that of Parkinsons disease
The pros and cons of Alzheimers medications include the fact that antipsychotics may decrease psychotic symptoms, such as paranoia, hallucinations, or delusions, but it is rare for them to completely correct these symptoms in AD patients. Antipsychotic drugs are best started at the lowest dose possible and gradually increased until a response is seen. They take about 2-4 weeks to fully work and have to be continued as long as the symptoms last.
How Can Caregivers Best Help
Scheduling pleasant activities, helping a loved one structure their day in a meaningful way, and problem-solving around issues contributing to distress may all help improve mood and decrease anxiety. In addition, it is important to help your loved one keep their brain sharp by eating a healthy Mediterranean diet, engaging in physical activity, and yes, continuing the weekly bridge games.
About the Author
Stephanie Collier, MD, MPH, Contributor
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A Better Approach To Treatment
Recently, researchers at Weill Cornell Institute of Geriatric Psychiatry in New York studied the effectiveness of a new home-delivered therapy called Problem Adaptation Therapy, or PATH, in participants with depression and dementia or mild cognitive impairment.
In the PATH intervention, therapists meet with the participants in 12 weekly sessions to teach them how to solve problems contributing to sadness, through a personalized approach often involving caregivers. The therapist and patient develop a plan, which includes avoiding negatively charged situations and identifying stimuli that trigger positive emotions, such as scheduling pleasurable activities.
Therapists also help participants develop compensatory strategies, such as the use of calendars and checklists, to bypass functional limitations due to memory impairment. When compared to a control therapy, in which participants received 12 weeks of supportive therapy , participants treated with the PATH approach experienced a greater decrease in depressive symptoms and disability at week 12.
Although research on psychosocial interventions is still sparse, this new research is encouraging, as nonmedication treatments are desperately needed. Research is also emerging on psychosocial interventions to in people with cognitive disorders.
Widely Prescribed Antidepressant Not Beneficial In Treating Agitation In Dementia Patients Study Finds
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The antidepressant mirtazapine offers no benefit in the treatment of agitation in patients with dementia and could increase the risk of mortality, according to a study published in the Lancet.
The study, published on 21 October 2021, described mirtazapine as one of the most widely prescribed antidepressants in older people.
As part of the Study of mirtazapine for agitated behaviours in dementia trial a double-blind, placebo-controlled trial researchers recruited 204 participants from 26 NHS clinical centres in the UK.
Each participant had probable or possible Alzheimers disease exhibited agitation that was unresponsive to non-drug treatment and had a Cohen-Mansfield Agitation Inventory score of 45 or more .
The CMAI is a 29-item questionnaire used by a patients carer to systematically assess levels of agitation. The authors said that their rationale for using the measurement was because it is the most commonly used instrument in trials for agitation in dementia, with robust psychometric properties including responsiveness to change.
Participants were randomly assigned to receive either mirtazapine or a placebo, with an aim to measure whether participants experienced a reduction in their CMAI score after 12 weeks.
The researchers found that, although there was a reduction in both sets of scores after 12 weeks, the mean CMAI scores were not significantly different between participants in either group .
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Preventing Alzheimers Disease With Antidepressants
A recent study by the University of Pennsylvania and Washington University Medical School found that the antidepressant citalopram lowered the production of beta amyloid proteins in both mice and in healthy humans. Results were published in the Science Translational Medicine journal. The antidepressant, commonly known as Celexa, reduced the production of beta-amyloid proteins by 38% over a 28 day regimen.
This study could potentially be groundbreaking when it comes to preventing Alzheimers. The good news for those at risk for the disease is that Celexa is:
- Widely used and accessible
What Drugs Are Used To Calm Dementia Patients
Many different drugs are used to calm individuals with dementia and their symptoms, with medication regimens based on the type of dementia each individual has. Some of the most common include painkillers like buprenorphine, antipsychotic medications and benzodiazepines.
There is no cure for dementia and, as a progressive disease, it gets worse over time, often resulting in mood swings, anxiety, anger or other emotions that are hard for individuals and their families to deal with.
But that doesnt mean you have to deal with frustration and other difficult emotions without help. There are many ways to calm individuals with dementia and help them find the support they need for a happy, productive life and ease the stress on their family and friends.
Medication is just one of those techniques, and its often combined with other tools, such as music therapy, to create a calm, positive environment.
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Description Of The Intervention
Drugs licensed as antidepressants are a heterogeneous group. They are commonly described as falling into a number of classes with different mechanisms of action, although the various classes are generally reported to be of similar efficacy . However, different drugs or classes of drugs may vary in their efficacy or safety in the depression of dementia, or may be preferentially effective in particular subtypes of dementia.
Best Antidepressants For The Elderly
Assuming youve done your due diligence and experimented with various natural cures for depression, but havent found any relief, there are some other good antidepressants that elderly people can consider. The first couple I recommend are NOT medication, but have been shown to be just as effective as medication.
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Best Anti Anxiety Medication For Elderly With Dementia
People with dementia can be upset or get anxious quite easily. It is also normal for people with such a condition to be rather restless and have issues sleeping. This is why you find them pacing up and down.
Anxiety is an issue that makes such elderly patients not be able to handle the daily routines and they can become very harmful to their loved ones or their caregivers. The best anti-anxiety medication for elderly with dementia should be administered to help them cope.
One of the greatest triggers of anxiety in such patients is change. It may be because the routine changes, or she /he is in new surroundings, or that he/she is surrounded by new faces.
It may also be because of fatigue or fear. Anxiety can also be because of infections or other underlying medical issues. If such a thing happens to a loved one and you are not able to point out the reason for the issue, you should seek help from a doctor to establish the real cause.
Cholinesterase Inhibitors And Other Drugs
The new generation of cholinesterase inhibitor drugs were originally developed to improve memory and the ability to carry out day-to-day living activities in people with Alzheimers disease.
Evidence suggests that these drugs also have slight beneficial effects on behavioural symptoms, particularly apathy , mood and confidence, delusions and hallucinations. Taking cholinesterase inhibitor drugs may therefore reduce the need for other forms of medication. However, in higher doses these cholinesterase inhibitor drugs may occasionally increase agitation and produce insomnia with nightmares.
Memantine is the most recent antidementia drug to be developed. It works in a different way to the anticholinesterase drugs and is the first drug approved for those in the middle to later stages of Alzheimers disease.
There is some evidence that memantine has a positive effect on mood, behaviour and agitation.
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Calming Medication For Individuals With Dementia
If you are working with a relative or friend with dementia whos using medication to handle their condition, what medication should you expect to come into contact with? What drugs are used to calm dementia patients? Most of the medications used to fall into a few categories:
- Medications that help with pain or constipation
- Medication that helps with seizures
- Anti-depressants
- Medications designed to help with memory and clouded thoughts
Whether youre caring for someone with Alzheimers disease or another dementia diagnosis, medication can help keep individuals calm and reduce their stress and anxiety. Lets take a closer look at the different types of drugs that are used in Alzheimers care and other dementia cases.
Antidepressants And Neurogenesis In Humans
Antidepressants may have neuroprotective effects in humans as well and protect against hippocampal volume loss associated with cumulative episodes of depression. Evidence indicates that normalizing 5-HT activity in depression may have specific beneficial effects on cognition. Studies have shown that SSRIs may reduce the risk of AD in depressed individuals. A retrospective study of over 1.4 million individuals over a decade suggested that depressed individuals who were treated with an antidepressant only once or for a short period of time, had a greater risk of AD than those with chronic antidepressant treatment. Continued long-term antidepressant treatment was associated with a reduction in the rate of dementia, however, not to the same level as the rate for the general population,.
It has also been suggested that treatment with an SSRI may improve cognitive function and daily living in MCI and AD patients. Randomized, placebo-controlled trials evaluating the effect of SSRIs on cognition in MCI patients and in AD reported a favorable and enhancing effect of Fluoxetine on memory and cognition in MCI patients and Sertraline in AD patients,.
Therefore, long-term continued treatment with antidepressants might promote neurogenesis in the human hippocampus, thereby decrease the risk of developing dementia in cognitively healthy individuals and decelerate progression to dementia in MCI patients.
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So What Is The Best Antidepressant For Elderly People
- SSRIs. As mentioned, SSRIs are the most popular antidepressants. They are least likely to cause serious side effects and are generally very effective. SSRIs may be stimulating or relaxing depending on the brand.
- SNRIs. These drugs work similar to SNRIs but also affect our adrenaline levels. As such they may be more stimulating.
- MAOIs. MAOIs interact often with other medications and supplements. Your doctor may avoid them if you are prescribed other medications.
- Tricyclics. Tricyclic antidepressants are often very effective. However, they have a higher side effect profile compared to other medications. Your doctor may recommend them if other medications dont seem to work.
The best option is to explain your symptoms and situation to your doctor. They will help you decide on the best medication.