Medication Management of Opioids, Antipsychotic Use in Older Adults

Elderly man's hands
Old man with big problems
Experts examine medication management in older adults, including the use of antidepressants for patients with Alzheimer disease and the dangers of opioid prescribing.

Every month, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that impacts geriatric practice. This month, Natalie R. Baker, DNP, ANP-BC, GNP-BC, CNE, GS-C, FAANP, president-elect of GAPNA, discusses medication management in older adults, including the use of antidepressants for patients with Alzheimer disease, transitional care when discharging patients from skilled nursing facilities to home, and the dangers of opioid prescribing in this age group.

Antidepressant use and progression of mild to moderate Alzheimer disease: results from the European ICTUS cohort

J Am Med Dir Assoc. 2021;22(2):433-439.

A team of researchers investigated the potential long-term associations between antidepressant exposure and functional and cognitive progression in patients with mild to moderate Alzheimer disease at 29 memory clinics throughout Europe.1 The researchers found that antidepressant exposure (ie, prescription for a minimum of 6 months) was not associated with a faster rate of cognitive or functional decline in patients with mild to moderate Alzheimer disease. In contrast, antipsychotic exposure at baseline was linked to a greater functional decline in activities of daily living score. Antidepressants might be appropriate alternatives to antipsychotics in the management of neuropsychiatric symptoms in patients with mild to moderate disease, the authors concluded.

Commentary by Dr. Baker:

Patients diagnosed with Alzheimer disease (AD) frequently experience neuropsychiatric symptoms that impact their quality of life. Neuropsychiatric symptomology includes depression, anxiety, aggression, agitation, and/or apathy. For years, the accepted solution for neuropsychiatric symptom management was antipsychotic medications. Research has shown increased mortality in older adults receiving antipsychotic medications and safety warnings against selection of antipsychotics have prompted providers to increase the use of antidepressants in this patient population.

This study evaluates cognitive and functional measurements of patients diagnosed with AD who were prescribed antidepressants for at least 6 months. The 2-year prospective study involved participants from 29 memory clinics located in 12 European countries who were enrolled in the Impact of Cholinergic Treatment USe (ICTUS) study. Cognitive measurement tools included the Folstein Mini-Mental State Examination (MMSE) and the Alzheimer Disease Assessment Scale-Cognitive Subscale (ADAS-Cog). The Katz Activities of Daily Living scale was used for functional measurement.

Patients prescribed antidepressants for at least 6 months were assigned to the exposed group (n=212; mean age, 75 years; median MMSE=22), those who were never prescribed antidepressants were assigned to the nonexposed group (n=375; mean age, 76.1 years; MMSE=21).

Antidepressant prescribing was not associated with cognitive decline (P =.19) or functional decline (P =.48) at 2-year follow-up. Antipsychotic prescribing at baseline yielded greater functional decline (P <.01) at the end of 2 years. These findings suggest that antidepressant use might be a safer alternative than antipsychotics when treating neuropsychiatric symptoms in patients with AD.

Health care providers should also consider nonpharmacologic interventions when treating patients with AD.

This article originally appeared on Clinical Advisor