Meaningful Use of Antidepressants in Long-term Care Facilities

Depression is linked with various medical conditions including cardiovascular disease, stroke, cancer, Alzheimer disease, and Parkinson disease.² Patients may also develop depression later in life due to increased medical disease burden. Late-onset depression typically presents with reduced interest in activities, more profound psychomotor retardation, and a poor and unstable response to antidepressants (ADs).¹ 

The proportion of older adults with depression may be better understood in more controlled patient populations, such as nursing home (NH) residents. About 10% to 12% of medical inpatients and 12% to 14% of NH residents have major depression, and more have less severe depressive syndromes.¹ Depression in geriatrics is concerning because it increases medical comorbidity and disability.¹ Treatments of choice for depression are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors (SNRIs), and other atypical ADs.³ SSRIs are associated with side effects of hyponatremia via the syndrome of inappropriate antidiuretic hormone secretion (SIADH), increased risk of falls, platelet dysfunction, and fractures.⁴ About 40% to 50% of older patients tend to respond favorably to medication. The remaining 50% have a better response to treatment after switching to an alternative AD or increasing the SSRI dose. The small percentage that remains tends to follow a chronic, treatment-resistant course with limited response to most ADs.² 

Another population prevalent in NHs is patients with dementia. Some 25% to 42% of patients with dementia are prescribed ADs, yet studies demonstrate little support for their effectiveness for dementia treatment.⁵ The effectiveness of ADs vs placebo for treatment of dementia is equivocal. Farina et al found citalopram seemed to improve agitation in patients with dementia, but its use was associated with significant cardiovascular side effects and cognitive impairment.⁵ ADs have also been prescribed to treat anxiety, psychosis, and apathy in patients with dementia; to improve their activities of daily living; and even to ease caregiver burden—all without significant success.⁵ Notable side effects of ADs in people with dementia include anxiety, nervousness, tremors, anorexia, and falls.⁵ Unfortunately, not all NH patients prescribed ADs receive adequate follow-up. Follow up is essential, however, as is appropriate prescribing. Other medications can interact with ADs and cause ill side effects.  

This quality improvement project identified long-term care (LTC) residents in a rural NH who were prescribed ADs to determine appropriateness of these prescriptions. The project stemmed from a concern about inappropriate AD prescribing and aims to examine AD prescribing habits. The goal was to decrease the total number of older LTC patients on ADs by 25% within 3 months of project implementation.  

Setting and Participants 

This is a quality improvement project conducted in an LTC facility in rural New York. Institutional review board approval was obtained, as well as approval from the skilled nursing facility’s quality improvement and assurance committee. Informed resident or caregiver consent was obtained. The intervention group included all residents on ADs before the start of the study on November 1, 2017. 

Procedure 

The intervention period was from November 1, 2017, to February 5, 2018. The intervention was performed via a secured phone line at the LTC facility; patient information was accessed on secured computers at the facility.  

Resident charts were reviewed for the following characteristics: (1) residents prescribed ADs for 2 years or more; (2) the indication for the AD; (3) the type of AD prescribed; and (4) the impact of attempts to wean patients off the AD over 3 months. ADs were defined as SSRIs, atypical ADs, SNRIs, serotonin modulators, SSRIs/SNRIs, and anxiolytic agents.^6-16 Inappropriate use of ADs was defined as use for a wrong clinical indication, a wrong dosage, or a lack of attempt at gradual dose reduction or discontinuation when no longer clinically indicated. 

The authors (including the medical director) and a pharmacist reviewed the patient’s chart and determined how long the patient had been taking the AD. A decision was made whether to broach the topic of weaning residents off the medication with the resident or family. The unit charge nurse was then contacted, and then each resident’s condition was discussed. The charge nurse could weigh in on the appropriateness of weaning the resident off their AD medication. If deemed appropriate, either the resident or a family member was contacted. Discussion centered on the resident’s mood, medication concerns, and the possibility of weaning them off the AD. A decision to wean, discontinue, or continue medication was made during the following conversation. The conversation also included education on depression vs dementia and length of treatment.

Education on long-term use of ADs was provided to staff, family members, and residents throughout the project. Patients and/or family members were educated verbally during the phone calls. Staff had a week of formal education in the middle of the intervention, performed by one of the authors Staff education included general overviews of depression, medications prescribed in the facility, concerning side effects, goals of the study, and a comprehensive discussion of the differences between dementia and depression. 

Data Analysis 

After LTC residents were assessed, follow-up to assess the effects of decreased or discontinued ADs was conducted 1 month later. Statistical analysis was conducted using R Core Team.¹⁷P value of ≤.05 was significant.  

Post-intervention data was collected at the end of the study period and analyzed with paired t test for differences pre- and post-intervention. Decimal places were rounded to the nearest tenth. 

Total Number of Patients on AD (Pre-intervention)  

Of 112 LTC residents, 55 residents (49.1%) were on ADs at the start of the study. Among the AD group, 29.1% were men and 70.9% were women. The age of the youngest patient was 58 years, and the oldest was 98 years. The average age of a patient on AD medication was 84 years. The majority (89.1%) of residents were prescribed 1 AD, 5 were prescribed 2 ADs, and 1 was prescribed 3 ADs.  

Regarding AD medication classes, 69.4% of prescribed ADs were SSRIs, 14.5% were atypical ADs, 6.5% were SNRIs, 4.8% were serotonin modulators, 3.2% were SSRIs/SNRIs, and 1.6% was an anxiolytic. The most commonly prescribed medications were sertraline, citalopram, mirtazapine, and escitalopram (30.9%, 20%, 14.6%, and 12.7%, respectively). Fifteen residents (27.3%) were prescribed AD medications and/or dosages considered by the manufacturer inappropriate for older patients. The manufacturers of both venlafaxine extended-release and mirtazapine recommend caution when prescribing the medications to older adults.^12,16  

Fourteen residents (25.5%) had been successfully weaned from medication in the past. The time patients were on a medication was broken up into 6-month intervals. A chart review revealed 12 residents were taking ADs for <6 months, 13 residents for >6 months, 12 residents for 1 year, 5 residents for 1.5 years, 11 residents for 2+ years, and 2 residents for an unknown period. 

Total Number of Patients on ADs (Post-intervention) 

Of the 55 LTC residents who were originally on at least one AD, 20 were unable to be weaned from the AD, 17 had dose reductions, 14 discontinued the AD, and 4 were discharged or died over the 3 months of the project. The project exceeded its goal of either reducing or eliminating ADs by 25% when 56% of the 55 residents had dosage reductions or had their prescriptions discontinued. Of the 31 LTC residents who had their AD reduced, 25 were able to remain at lower doses with no ill effect, 2 had medications restarted, 3 had further dose reductions, and 1 died from natural causes (Figure 1). 

Inappropriate Use of ADs 

ADs were prescribed for a variety of indications. The majority were used to treat depression; anxiety, insomnia, appetite issues, and inappropriate behaviors were other common reasons. Patient records suggested 3 residents were taking ADs for inappropriate indications, specifically hypersexuality/inappropriate behaviors and dementia. 

Another inappropriate use of ADs was the prescribing of medications and dosages unsafe for older adults.^8,12,16 Twelve of the 55 LTC residents taking ADs at the start of the project had been prescribed inappropriate medications or dosages. As previously mentioned, mirtazapine and venlafaxine extended-release were prescribed despite manufacturer recommendations to do so with caution in older adults.^12,16 One resident was prescribed citalopram at a dose inappropriate for older patients.⁸ 

Noted in Table 1, the average medication dose reduction was about 20.9 mg, which is significant (P=<.001). Also, the number of LTC residents able to wean off their AD increased between pre-intervention and post-intervention (14 vs 31 residents), which is also significant (P=.002) (Table 2). 

After the intervention, 7 of the 15 LTC residents originally on concerning AD medications or doses, or taking ADs for inappropriate reasons, were able to undergo reductions or discontinuations. 

Prescription Habits for ADs 

The majority of LTC residents taking ADs did so for depression, anxiety, or appetite issues. When a resident was prescribed an AD for depression by their original prescriber, most were not informed on how long it would be necessary and conditions for discontinuation. Conversations with family members and residents revealed most patients believed the prescription was for their lifetime. Most patients were not previously informed of the side effects of ADs or the negative effects of polypharmacy. When they were informed, about 46% of residents or family members were unwilling to make changes due to concerns about side effects, a belief the medication was helpful, distrust of the weaning process, or other reasons. 

In summary, the study found that some AD medications were inappropriately prescribed, and some AD dosages were too high. The project exceeded its goal of either reducing or eliminating ADs by 25% when 56% of the 55 residents had dosage reductions or had their prescriptions discontinued.  

For the majority of the LTC residents, it was difficult to determine when the AD was initially prescribed. Most residents were on ADs when they arrived. In such cases, the LTC arrival date was used as the AD start date. This underestimated the actual length of time the resident was taking the AD. 

When the quality improvement project began, 49.1% of LTC residents were taking at least one AD. A 2009 study found, on average, about 14% of all NH residents taking ADs are aged 65 or older.¹ The percentage at the LTC facility in this study was significantly higher. A possible reason is that after older patients were prescribed an AD, no consideration was made to reevaluate their condition later. Physicians may have been hesitant to change medications prescribed by other providers or were unsure when medications could be discontinued. Another reason for higher-than-average use was that the age of the patients on ADs fell outside statistical age range. Those taking ADs at the LTC facility were between age 58 and 98, with the youngest being the only resident taking 3 ADs. 

The medical director and pharmacist were essential in this project. They identified residents with inappropriate AD use and notified providers about decreasing medications. They identified practice patterns and offered education on appropriate use of ADs to facility staff (ie, physicians, nurse practitioners, and nurses). They also helped troubleshoot problems that arose during AD weaning. 

For each of the 55 LTC residents on ADs, a decision was made whether to broach the topic of weaning residents off the medication with the resident or family, as noted above. If deemed appropriate, either the resident or a family member was contacted. Concerns included the loss of mental stability if the medication was withdrawn, distrust of the weaning process, and that the resident had a worsening mood that necessitated medication. Some reasons why residents or caregivers did not want the medication discontinued were: (1) the resident had been taking the AD for a long time and was doing well; and (2) no attempts had been made in the past to wean the patient off the AD, so why now?  

Occasionally, someone would mention a symptom that better fit into the dementia aspect of patient care rather than depression, and education on the difference between the 2 conditions was provided. If either the nurse, resident, or family member did not support changes to the resident’s medications, none were made. Over half the residents approached were willing to have medication changes made. In those cases, residents were monitored for side effects and withdrawal symptoms. Medication changes were stopped by 2 residents for reasons not well understood. Their lack of participation in the formal week of education may have played a role. 

Inappropriate AD prescribing targeted hypersexuality/inappropriate behaviors and dementia. Hypersexuality and inappropriate behaviors are common traits of dementia. While AD and other medications have been used in attempts to treat such behaviors, they are not manufactured to do so. These medications need to be used carefully in NHs, since the patient population is older, and residents have higher rates of side effects due to polypharmacy and decreased clearance of the medication from the liver and kidneys. Dementia should be treated with medications to help maintain mentation, not ADs. One resident was taking a dose of citalopram that was listed as being too high for the older population due to clearance issues.⁸ Success was obtained in decreasing the amount of AD medication that residents were on by 20.9 mg. 

Two of the medications, venlafaxine extended-release and mirtazapine, are not recommended for older patients. However, these medications are used frequently to treat mood disorders. 

Venlafaxine and mirtazapine are on the Beers list as potentially inappropriate in patients aged 65 years and older due to their potential to cause or exacerbate SIADH or hyponatremia.^12,16 SIADH is more common when the older patient is volume depleted and/or is using diuretics concurrently. Mirtazapine requires caution in older adults because of their decreased ability to clear the drug through the kidneys and liver.¹² Mirtazapine may be used off-label for weight gain.¹²  

AD discontinuation is beneficial from both medical and nursing views. Dose reduction or discontinuation of redundant prescriptions leads to fewer drug-disease and drug-drug interactions, as well as fewer adverse medication reactions or effects. Medication distribution and monitoring requires time and staff; thus, reducing or discontinuing inappropriate medications frees time for other resident care.  

Nursing education was provided to standardize our approach to ADs. About 25% of nursing staff was present for the discussion. This led some staff to believe nurses were, by design, excluded from the project. Due to the low compliance rate of nurses in the education process, funding was made available for mandatory staff education. Moving forward, we are attempting to foster a culture of nonpharmacological approach first, rather than medication first, in patient care. 

Due to the success of this study, future quality improvement projects are planned for this LTC facility. Psychoactive medication or opioid prescribing may be addressed. Through this safe, step-wise manner of reducing medications and monitoring for side effects, other institutions can implement similar programs to alleviate the overmedication of the older adults. The most important part of the process is to gain staff support in the project through education. 

Authors: Alicia Harbison, DO; Joseph Mwesige, MD, MPH, CMD, FACP

Affiliations:
Guthrie Robert Packer Hospital, Sayre, PA

Disclosures:
The authors report no relevant financial relationships.

Address correspondence to:
Alicia Harbison, DO
Family Medicine, Guthrie Robert Packer Hospital
1 Guthrie Square Sayre, PA 18845
Phone: (603) 459-5715
Fax: (570) 887-2807
Email: alicia.harbison@guthrie.org