Each week we will aim to bring out a concise email that provides 4-5 key pieces of information addressing a specific issue in clinical therapeutics.
This week: Depression and Dementia
Kamran Zia, Clinical Pharmacist, Ward MM
Depression may occur in people affected by any type of dementia, and if pervasive and persistent, it should be treated. The prevalence of depression may be as high as 30% for those with vascular dementia or with Alzheimer’s disease, and may exceed 40% for those with dementia associated with Parkinson’s and Huntington’s diseases.
- Non-pharmacological and pharmacological strategies are both important in treating depression in dementia and management of these patients requires a collaborative approach.
- Some studies did not demonstrate evidence to support the use of antidepressants as a first-line treatment for people with depression in Alzheimer’s disease who are referred to aged care services: in some cases, symptoms will resolve with non-pharmacological management. A systematic review was not able to demonstrate a consistent therapeutic effect, but all of the trials were lacked sufficient power to detect differences, resulting in inconclusive findings. Issues related to the study methodology in the trials, and the influence of co-morbid appear to have confounded the findings of the review.
- In one study researchers were unable to demonstrate the efficacy of mirtazapine and sertraline relative to placebo in people with dementia and depression, but did report a greater incidence of adverse effects with the active drugs.
- Despite this, selective serotonin reuptake inhibitors are the first-line pharmacotherapy for depression in dementia. Doses should be slowly titrated while monitoring therapeutic and adverse effects, and effects on existing illnesses. The highest tolerated dose should be used. It is not appropriate to continue an ineffective low dose of an antidepressant.
- Antidepressants should be trialled for 4–6 weeks at the optimum dose before changing. If there is no benefit after six weeks, the dose should be slowly tapered and stopped.
- Tricyclic antidepressants with anticholinergic adverse effects have the potential to hasten cognitive decline due to central acetylcholine deficiency in Alzheimer’s disease and should generally be avoided.
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