Non-pharmacologic Treatments may be more Effective for Psychiatric Symptoms of Dementia

Summary: A systematic review and meta-analysis suggests outdoor activities were more clinically effective than anti-psychotic medication for treating physical aggression in patients with dementia. For patients with physical agitation, massage and touch therapy were more efficacious than usual care or caregiver support.

For patients with dementia who have symptoms of aggression and agitation, interventions such as outdoor activities, massage and touch therapy may be more effective treatments than medication in some cases, suggests a study publishing Oct. 14 in Annals of Internal Medicine.

The systematic review and meta-analysis, led by St. Michael’s Hospital of Unity Health Toronto and the University of Calgary, suggest outdoor activities were more clinically effective than anti-psychotic medication for treating physical aggression in patients with dementia. For patients with physical agitation, massage and touch therapy were more efficacious than usual care or caregiver support.

“Dementia affects 50 million people worldwide and as many as three quarters of those living with the disease have reported neuropsychiatric symptoms including aggression, agitation and anxiety,” said Dr. Jennifer Watt, a researcher at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

“Unfortunately, our understanding of the comparative efficacy of medication versus non-medicine interventions for treating psychiatric symptoms has been limited due to a lack of head-to-head randomized controlled trials of the two routes.”

To address this gap, researchers led by Dr. Watt, who is also a geriatrician; Dr. Sharon Straus, director of the Knowledge Translation Program at St. Michael’s; and Dr. Zahra Goodarzi, a geriatrician and researcher at the University of Calgary, worked with 12 dementia care partners to select study outcomes based on commonly reported neuropsychiatric symptoms of the disease. They identified reports of improvement in aggression and agitation to be the main two outcomes to focus on in the analysis and review.

The study’s findings are based on an analysis of 163 randomized controlled trials involving 23,143 people with dementia and the study of pharmacologic or non-pharmacologic interventions to treat aggression and agitation.

Though the study allows for the comparison of the two types of interventions, the researchers point out that neuropsychiatric symptoms of dementia do not have a one-size-fits-all solution.

“Treatment should be tailored to the patient and their specific experience,” said Dr. Straus, who is also a geriatrician at St. Michael’s. “This study, however, does shed light on the opportunity to consider prioritizing different types of interventions for aggression and agitation when appropriate.”

Further research, Dr. Watt said, will aim to understand the influence of individual patient characteristics on their response to interventions. The researchers also note the need for an analysis of the differences in cost between pharmacologic and non-pharmacologic interventions to treat aggression and agitation in patients with dementia.

“This study shows us that multidisciplinary care is efficacious, and that is consistent with a person-centred approach to care,” Dr. Watt said. “It points to evidence of the benefit of supporting multidisciplinary teams providing care to patients in the community and nursing home settings.”

Antidepressants for Seniors Have Doubled in Two Decades

Depression is common in older adults, occurring in 2% of those aged 55 years and older and rising with increasing age. Many more — from 10% to 15% — struggle with depressive symptoms, although they may not have been diagnosed with major depression.1

That being said, there’s been a major rise in the number of antidepressants being prescribed for older adults over the last two decades, without a similarly sharp increase in the number depressed, according to a study published in The British Journal of Psychiatry.2

The findings suggest seniors may be being overprescribed antidepressant drugs, which could have serious implications for their health, although the researchers weren’t willing to state this, noting instead, “we can’t infer that older patients are prescribed antidepressants unnecessarily.”3

Antidepressant Use More Than Doubles Among Seniors

In order to investigate whether the prevalence of depression and antidepressant drug use changed from 1990 to 2011 in people aged 65 and over, researchers used data from two English population-based cohort studies involving 15,397 people. The studies took place from 1991 to 1993 and between 2008 and 2011.

In the first study group, 4.2% of the adults were taking antidepressants, but this jumped to 10.7% in the later study. During this time, the prevalence of depression decreased, but only slightly, from 7.9% to 6.8%.4 Also noteworthy, among older adults living in care homes, the prevalence of depression was unchanged but the use of antidepressants rose from 7.4% to 29.2%.5

There were a few suggestions offered for why antidepressant prescribing rates increased so steeply without a similar increase in depression, including overdiagnosis or prescribing the drugs for conditions other than depression. However, most of those prescribed antidepressants had not been diagnosed with depression.

Lead study author Antony Arthur, Ph.D. of the University of East Anglia, Norwich, United Kingdom, told Medscape, “Sometimes treatment is given for mild depression which falls outside of our definition of depression ― much of the evidence for the effectiveness of antidepressants is for people with moderate or severe depression. Antidepressants are also used to treat other conditions, for example, neuropathic pain and sleep disorders.”6

He added that opportunities to deprescribe antidepressants should not be overlooked.7 “Whatever the explanation, substantial increases in prescribing has not reduced the prevalence of depression in the over-65 population. The causes of depression in older people, the factors that perpetuate it, and the best ways to manage it remain poorly understood and merit more attention,” he stated.8

A separate study, published in World Psychiatry in 2017, reviewed data collected from 1990 to 2015 from Australia, Canada, England and the U.S. It similarly found that “the prevalence of mood and anxiety disorders and symptoms has not decreased, despite substantial increases in the provision of treatment, particularly antidepressants.”

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