Prevalence of Predictors of Antidepressant Prescribing in Nursing Home Residents in the United States Swapna U. Karkare, MS, Sandipan Bhattacharjee, MS, Pravin Kamble, MS The American Journal or Geriatric Pharmacotherapy; april 2011, vol 9, No. 2 Priyank Devta Pharm D candidate 2012

Background & study purpose No funding was received for this study Late life depression is a common psychiatric disorder associated with increased morbidity and mortality Depression is often under detected and undertreated in elderly nursing home residents Depression increases mortality and negatively affects daily activities Prevalence of depression is 3-5 times higher in nursing home residents compared with residents community Potential to cause serious adverse events is the main issue of antidepressant use in the elderly population Objective: examine the prevalence of antidepressant prescribing and to identify need, predisposing, and enabling factors associated with the use of antidepressants

design The analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS) Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents Multiple logistic regression analysis within the conceptual framework of Anderson’s behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use

Setting/study population Study sample included a nationally representative sample of nursing home residents aged ≥ 65 years The data was obtained from the national Nursing Home Survey (NNHS) which provided information on two facets of nursing homes: service providers and care recipients Trained interviewers collected the information by conferring with designated staff having knowledge about the residents and their care There was no direct interaction between interviewers and residents for data collection SSRI, SNRI, MAOIs, TCAs, serotonin modulators were included as antidepressants for the analysis

Predictor variables The conceptual behavioral model by Anderson and Newman was used to examine the predisposing, enabling, and need factors associated with antidepressant agents – Predisposing – age, gender, ethnicity, race, martial status – Enabling – sources of payment and facility characteristics – Need – behavioral characteristics (decision-making ability, depressed mood indicators, behavioral symptoms), functional characteristics (activities of daily life, out of bed mobility, history of falls/fractures), diagnoses (dementia, anxiety, stroke, depression, agitation, parkinsonism), total number of medications

Statistical analysis SAS version 9.2 statistical software was used to extract and analyze the survey data P value of 0.05 was considered to be statistically significant

results 1.32 million elderly residents in nursing homes 74.4% female, 51.2% ≥85 yrs old, 96.7% non hispanic, 87.4% white 0.60 million residents received antidepressant medications (46.22%) 31.09% received SSRI (12.92% received citalopram) 49.7% of users were ≥85 yrs old, 75.7% female, 91.1% white Likelihood of receiving antidepressant was lower for those ≥85 yrs old; odds for receiving antidepressants were greater for white people and married people Enabling factors such as medicaid were positively associated with antidepressant prescription – May be due to better coverage of psychotropic medications People diagnosed with anxiety were less likely to receive antidepressants Presence of depressed mood indicators and a history of falls and fractures increased the likelihood of an antidepressant prescription

discussion Study conducted from 1976 – 1985 showed 5% prevalence of antidepressant Study from 1996 – 2006 showed increase from 21.9% in 1996 to 47.5% in 2006 Increased use may be attributed to federal regulations, greater recognition of depressive symptoms, or the introduction of agents that are safer and more efficacious compared SSRI are the most commonly used Mirtazapine can be used to treat patients who do not respond to or tolerate SSRI or TCAs – Effective in improving appetite and may help with sleep Increased use may be attributed to federal regulations, greater recognition of depressive symptoms, or introduction of safer and efficacious agents

limitations The prevalence obtained was a single point prevalence, which may change over time Findings are limited to elderly nursing home residents in 2004 and cannot be generalized to other settings or years Use of secondary database makes it difficult to assess accuracy due to possible errors in data collection, editing

conclusion Antidepressants were prescribed to 46% of elderly nursing home residents in the United States according to 2004 NNHS data Most frequently prescribed antidepressants were SSRIs Greater understanding of the role of predisposing factors and enabling factors can be vital to optimizing pharmacotherapy with antidepressants in elderly