Dementia clients are being placed on antidepressants although the treatment might do more damage than great, professionals have actually cautioned.
Near to one million Britons are coping with the neurological disease, which triggers gradually aggravating issues with memory and motion – and approximately one in 4 are recommended the tablets to fight low state of mind, agitation and stress and anxiety, which are likewise typical signs.
Yet while the drugs are shown to be reliable in clients without dementia, a current series of research studies recommend they offer little or no advantage to those with the condition.
One expert cautioned the practice of providing the tablets to this group was ‘hazardous and useless’. Recently drugs guard dog the National Institute for Health and Care Quality (NICE) upgraded its assistance on antidepressant prescribing – encouraging that clients ought to be thoroughly weaned off the drugs over lots of weeks to prevent withdrawal signs.
REMAINING ACTIVE: Dementia client Tracey Lane, aged 56
Near to one million Britons are coping with dementia, which triggers gradually aggravating issues with memory and motion – and approximately one in 4 are recommended antidepressants – however a current series of research studies recommend they offer little or no advantage to those with the condition
However professionals state the drugs have particular threats in dementia patients: they trigger sedation, increasing the threat of falls and dehydration, which can have severe and possibly deadly effects.
‘Sedation threatens if you have dementia,’ states Dr Robert Howard, Teacher of Old Age Psychiatry at University College London. ‘While antidepressants work for dealing with anxiety in the basic population, the proof reveals they do not operate in dementia clients.’
And speaking on The Mail on Sunday’s Medical Minefield podcast today, Teacher Sube Banerjee, a dementia expert at the University of Plymouth, included: ‘The negative effects [of antidepressants] are even worse in dementia clients since of the frailty that originates from the dementia itself, triggering queasiness and lightheadedness.’
good alerts versus regularly recommending antidepressants for non-severe anxiety in dementia clients, unless the mental disorder existed prior to the dementia.
Other psychiatric drugs, such as antipsychotics, ought to be provided just when mental alternatives, such as treatment or altering environment, have not worked, and the client is suffering deceptions, hallucinations or extreme agitation. However according to Prof Howard, these guidelines are not followed.
Typically, he states, dementia clients are provided a more recent kind of antidepressant, called mirtazapine, which some research studies recommend has a relaxing impact in those with the condition.
Older types, consisting of selective serotonin reuptake inhibitors (SSRIs) such as citalopram, are likewise routinely recommended.
Antidepressants, consisting of selective serotonin reuptake inhibitors (SSRIs) such as citalopram (imagined), are routinely recommended to dementia clients
A 2014 research study discovered that citalopram activated a sedative impact in clients with Alzheimer’s, the most typical type of dementia, increasing the threat of falls. Prof Howard states lots of clinicians understand that antidepressants do more damage than great however provide them anyhow.
‘Typically clinicians may feel they need to recommend the drug if they’re fretted a relatively depressed and upset client may hurt somebody else, particularly in a care house or medical facility setting,’ he states.
‘In reality, the very best treatment in this case would be investing more individually time with an expert nurse, who is trained to soothe clients down – however that is pricey.’
Teacher June Andrews, among Britain’s prominent professionals in dementia care, states GPs are frequently drawn by a ‘temptation to provide something instead of absolutely nothing’. Nevertheless, she includes: ‘If you actually understood what older individuals with dementia requirement, you’d beware about recommending any psychedelic drug’.
The concerns follow the publication of a major review into the safety and effectiveness of antidepressants in dementia patients, by researchers at University College London. The experts concluded that the pills, taken by 8.3 million British adults, ‘do not work in depression in dementia’.
The paper echoes the findings of a 2018 analysis by the medical research body Cochrane, which looked at three of the most common types of antidepressants. It concluded there was little or no effect on Alzheimer’s patients.
It warned that dementia patients taking any type of antidepressant, including SSRIs, were more likely to suffer dizziness, dry mouth and other serious side effects than those who don’t take them.
Other studies have shown that mirtazapine increases the risk of stroke by at least a third in elderly people, while those on citalopram and another SSRI, sertraline, were roughly 60 per cent more likely to suffer a bone fracture – usually caused by a fall or trip.
About a third of dementia patients develop symptoms of depression, according to studies. The problem can be present at any point during the beginning and middle of the illness, but is most common in the early stages.
In people without dementia, trials show that common antidepressants improve symptoms in between half and two-thirds of patients – compared to about a fifth of people in a placebo group.
Professor Sube Banerjee (pictured), a dementia specialist at the University of Plymouth, said: ‘The side effects [of antidepressants] are worse in dementia patients because of the frailty that comes from the dementia itself, causing nausea and dizziness’
But intriguingly, in dementia sufferers, studies show no difference between the two groups. In other words, the drugs don’t make patients feel happier. Experts believe this is because depression in dementia is an altogether different syndrome.
‘A key element of depression is feeling guilty and shameful about yourself, as well as thoughts about life not being worth living,’ says Dr Lindsey Sinclair, a psychiatrist and dementia researcher at the University of Bristol. ‘But in dementia patients it’s different. They are very tearful and feel apathetic towards doing anything they used to enjoy. Or they are anxious and agitated by things that never used to bother them before.’
Prof Howard says: ‘Dementia not only causes deterioration in brain areas with memory and learning, but also in sections important for regulating mood. The result is depression-like symptoms.’
But this, he says, is why antidepressants such as SSRIs, which work by altering the balance of brain chemicals involved in feelings of happiness, have little effect. ‘For some dementia patients, the depression may be the result of feeling despondent and concerned about being diagnosed with the condition, and SSRIs may help. But that’s usually only true in the earliest stages.’
Prof Andrews says: ‘What a lot of people don’t realise about these drugs is they make patients even less able to tell loved ones and nurses when something is wrong.’
Over the past few decades, campaigners have rallied against the unnecessary and widespread use of powerful antipsychotic drugs in dementia care – the so-called ‘chemical cosh’.
Research has shown that these medicines can double the risk of early death in dementia sufferers and accelerate cognitive decline, due to their sedative effect.
In 2008, Ministers launched a review into the practice, and as a result ordered a crackdown on the use of antipsychotic medication in care homes.
Antidepressants ought to be treated with similar caution, the experts say. So, what should clinicians do instead?
‘In the very early stages, low mood can be to do with withdrawing from your normal life because you’re afraid you won’t be able to do the same things you used to,’ says Prof Howard, adding that simply encouraging patients to continue engaging in these activities can help ‘cheer them up’.
IT’S A FACT
Studies show that people with a history of depression are two times more likely to develop dementia in later life.
Many may also benefit from a newly developed psychological treatment called problem adaptation therapy. This involves working with a GP, nurse or psychologist to adapt a patient’s daily routine to suit their condition.
‘The key is about making practical plans that mean the patient can still do the things they enjoy, albeit in a slightly different way,’ says Prof Howard.
Early trials have found the therapy to be effective for reducing depressive symptoms in mild to moderate dementia.
‘You can train nurses and GPs to lead the therapy in a 30-minute session,’ includes Prof Howard.
Even in the later stages of dementia, drugs might not be the answer, according to Prof Andrews.
‘Enhancing the mood is not about giving medication,’ she says. ‘It is much more to do with identifying elements in their environment that are causing distress – often it’s something simple, like the sound of an alarm or even a particular TV programme. I often see cases where the patient is very agitated in a hospital ward or nursing home, and then they are moved to a specialist dementia unit and suddenly they are much calmer.
‘Some dementia services are designed in a way that minimises unpleasant noises or colours, and staff are trained to spot common triggers.’
For 56-year-old Tracey Lane, who was diagnosed with frontotemporal dementia in 2015, antidepressants have proven unhelpful.
The psychiatric medication was first prescribed to the former school secretary shortly before her diagnosis, when doctors assumed her illness was depression. ‘I went to see the GP because I was feeling like something just wasn’t right,’ says the mother of two from Somerset.
‘I was having problems recognising individuals’s faces and being able to cope with simple tasks at work – and it started to get me down.
‘I’d also started having strange thoughts, like I’d be driving to work and thinking about turning the car over and killing myself.’
Tracey’s GP told her she had anxiety, most likely triggered by the menopause, and prescribed the SSRI citalopram.
Tracey Lane (pictured with husband Mike) was diagnosed with frontotemporal dementia in 2015 and said that antidepressants have proven unhelpful
Tracey’s GP told her she had depression, most likely triggered by the menopause, and prescribed the SSRI citalopram
She says: ‘It didn’t help at all. I became more and more confused, frustrated and felt like I couldn’t cope. I started to do strange things like go into rooms at work and forget why I was there. I had to write to my boss to explain that I was struggling.’
Tracey spent two years going back and forth to her GP, seeking help for increasing memory problems. Eventually, she was referred for cognitive tests and brain scans. Results showed the tell-tale damage to areas in the front and sides of the brain that indicate frontotemporal dementia – a less typical form of the disease.
Specialists took Tracey off citalopram but offered another SSRI a year later to help with continued bouts of low mood.
She is still taking the highest possible daily dose of the drug, escitalopram.
‘I don’t think it’s made much difference, to be honest’ she says. ‘I still have a lot of low days when I think, ‘What’s the point in being in the world?’ The difficulty is I am on the highest dose, so there’s not much more doctors can do about it.’
Thankfully, she hasn’t suffered any unpleasant negative effects. ‘I find that the more active I am, the better I feel, that’s what makes a real difference. I have actually a whiteboard in the kitchen where I compose what I’m preparing to do.
‘Often it’s singing classes or dementia support system, other times it’s seeing my good friends.
‘Our boys live 10 minutes down the roadway, which assists. It’s constantly a delight to see them. I understand that I’m assisting myself if I attempt my finest to do something every day.’