Background & study purpose

1. Prevalence of Predictors of Antidepressant Prescribing in Nursing Home Residents in the United StatesSwapna U. Karkare, MS, SandipanBhattacharjee, MS, PravinKamble, MSThe American Journal or Geriatric Pharmacotherapy; april 2011, vol 9, No. 2Priyank DevtaPharm D candidate 2012

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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