The Use of Antidepressants in Dementia in the Elderly in Nursing Homes

This research focuses on the use of antidepressants in treating depressive symptoms among elderly dementia patients in nursing homes. It includes a systematic review of studies, highlighting pharmacological and non-pharmacological interventions, nurses' knowledge and experience, and the need for additional training. The study aims to evaluate the efficacy of antidepressants and identify alternative treatments for depression in this population.

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The use of antidepressant in dementia in the elderly in Nursing homes (65&85 years)
Name of the Student
Name of the University
Author Note

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Abstract
Dementia is defined as loss of cognitive functioning – thinking, logical reasoning and
remembering. In England, approximately 676,000 people are estimated to have dementia.
Anti-depressants are one of the commonly perspective drugs that are used for the treatment of
depressive symptoms among the older adults with dementia. This research was conducted in
the form of a systematic review taking into consideration the fact that the method facilitated
adopting a systematic method for collecting secondary data. The steps were conducted by two
individual investigators, following which differences were set by partaking in group
discussions that caused modification and alteration of the search standards. This led to the
exclusion of 27 articles, and only 6 were finally incorporated in the thematic analysis. The
pharmacological therapy and the non-pharmacological therapy can be very useful in
improving the condition of the dementia patients having depression. Most of the studies
identified that the nurses had lack of knowledge regarding the condition that is dementia
along with depression. Therefore, it can be said that, nurses need more knowledge regarding
the problem as well. However, a few studies also identified that the experience of the nurses
are also very crucial. Non-pharmacological interventions can be implemented effectively for
the treatment of depressive symptoms among the older adults with dementia and nurses
required additional training in order to implement the non- pharmacological intervention as
well as training related to the person- centered care for dementia patients.

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Table of Contents
Introduction................................................................................................................................3
Literature Review.......................................................................................................................6
Association of depression and dementia among the older adults..........................................6
Person-centred care and dementia..........................................................................................8
Pharmacological and non-pharmacological interventions for depression management........9
Specified pharmacological interventions for depression management in dementia............11
Specified non-pharmacological interventions for depression management in dementia.....12
Summary of the review and gap in research........................................................................14
Rationale of the review........................................................................................................16
Methodology............................................................................................................................16
Search terms.........................................................................................................................19
Relevance assessment..........................................................................................................20
Results:.....................................................................................................................................20
Discussion................................................................................................................................32
Limitation.................................................................................................................................36
Conclusion and Recommendation:..........................................................................................37
References................................................................................................................................39
Appendix 1...............................................................................................................................46
Appendix 2...............................................................................................................................47

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Introduction
Dementia is defined as loss of cognitive functioning – thinking, logical reasoning and
remembering and other behavioural abilities to such an extent that it interferes with the ability
of a person to conduct the activities of daily living (ADLs) independently. The cognitive
functioning includes memory, visual perception, communication skills, problem solving
skills, ability of pay attention of focus and management of self. Few people suffering from
dementia fails to control their emotions leading to change in their personality. Dementia
ranges in severity starting from mildest stage to severe stage when one person becomes
completely dependent on others for executing ADLs. Signs and symptoms of dementia
surface when the neurons (nerve cells) which were once healthy lose their connection with
the other brain cells and die. Loss of function of neurons is common with the process of aging
but people suffering from dementia experience greater loss of neurons. Dementia is common
as the people grow older. Half of all people who are aged 65 years and above or between 80
to 85 years of age have dementia but it is not a process of normal aging. The cause of
dementia varies depending on the changes in the brain. Alzheimer’s disease is the most
common cause of dementia among the older adults. Other form of dementia includes Lewy
body dementia, vascular dementia, and frontotemporal disorders.
Dementia is a growing challenge in the UK. In England, approximately 676,000
people are estimated to have dementia. Dementia mainly affects the older people who are 65
years of age or older. The likelihood of developing dementia increases with age and doubles
with ever 5-year. There are around 540,000 carers of people with dementia in England. It is
estimated that one of the three nurses care for person with dementia during their professional
tenure.

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Depressive symptoms are common among the older people. However, in case of the
older adults (aged between 65 to 85 years) who are suffering from dementia, sustained and
disabling depressive episodes are more common in comparison to the age-matched controls
without dementia (Kitching 2015). The overall incidence of depression is 30% among the
patient suffering from vascular dementia and Alzheimer. The value is over 40% among the
dementia patients who are associated with Parkinson’s and Huntington disease (Kitching
2015). The symptoms and the signs of the depressive disorder among the dementia patient
cannot be differentiated with depressive symptoms of other patients. Mood of the patients
with dementia remains low and is characterised with irritability, anger, and increased level of
anxiousness. It is also associated with disturbed biological rhythms during sleep energy and
appetite. Patient mainly have negative mood along with a sense of hopelessness, guilt along
with a tendency of self-harm. The major depressive disorders develop within few weeks and
or months after the initial onset of dementia (Pema et al. 2019). Leyhe et al. (2017) are of the
opinion that the healthcare practitioners who are caring for the people suffering from
dementia must be alert about the major depressive symptoms associated with dementia, as
this will require specific management strategies.
Anti-depressants are one of the commonly perspective drugs that are used for the
treatment of depressive symptoms among the older adults with dementia. The commonly
used antidepressant includes serotonin re-uptake inhibitors (SSRI). SSRIs are regarded as
first line of drug that are used to the treatment of depression instead of tricyclics
antidepressants. Antidepressant is hypothesized to have neuro-protective effects that help in
improving the overall cognition and memory of the older adults with dementia. However,
little is known about the long term outcome of use of anti-depressants among the older adults
with dementia (Wang et al. 2016). Wang et al. (2016) are of the opinion that the older adults
with dementia between the age group of 65 to 85 years are often under-represented in the

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clinical trials of the anti-depressants. Few of the primary studies conducted so far in order to
study the effect of use of the anti-depressants among the older adults with dementia
highlighted potentially different and complex relationships. A study conducted by Lee et al.
(2016) stated that prolong use of the anti-depressant among the older adults with dementia
increases the severity of the disease in the long run. The systematic review and meta-analysis
conducted by Moraros et al. (2017) over the older adults with dementia highlighted prolong
use of the anti-depressant among the older adults with dementia with early onset of dementia
before the age of 65 years increases the severity of the disease at the age of 70 to 75 years
leading to severe neurological impairment along with hamper in the cognitive function. On
the other hand, the systematic review of the randomised control trial conducted by Orrell
(2015) over six studies showed that use of non-pharmacological interventions like
psychological interventions is effective in reducing severity of depression and anxiety among
the older adults with dementia. The non-pharmacological interventions are found to be more
effective in comparison of the pharmacological interventions like use of anti-depressants.
However, overall systematic review of the studies conducted over the effect of the anti-
depressant among the older adults is also limited and this hampers the proper implementation
of the evidence-based practice under the setting of mental health nursing. Moreover, there are
differing opinions about the importance of the pharmacological and non-pharmacological
interventions used for the treatment of depression among the older adults with dementia.
Thus the following systematic review will be guided towards the detection of the
efficacy of the anti-depressant among the older adults with dementia. The research aims and
objectives will be designed based on the detailed analysis of the research gap done through
the conduction of a detailed literature review. The systematic review of the primary studies
conducted over the use of anti-depressant among the dementia patient will be helpful in
highlighting the pros and cons behind the administration of the anti-depressant and at the

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same time will help to evaluate any alternative treatments that are used for the treatment of
depression.
Thus the main research questions over which this systematic review will be designed
include effect of the anti-depressant among the older adults with dementia between the age
group of 65 to 85 years.
Literature Review
Dementia and depression are the two of the common psychiatric symptoms of the older adults
with dementia. Although there are approaches that help in the early identification of the
underlying causes of dementia, implementation of the proper interventions for the effective
management of the depressive symptoms of dementia remain extremely challenging. Late life
depression among the older adults with dementia is results in the cognitive impairment.
Alternatively dementia is related to an increased risk of developing depressive symptoms.
Due to the abundance, both the syndromes often co-occur among the older adults.
Association of depression and dementia among the older adults
It is estimated that in England nearly 3676.250 older people resides in 10,331
residential aged care settings and costing approximately £16 billion through direct funding
from the government. Over 30% of the people with dementia in UK reside under this setting
with £9 billion annual cost of care. In the residential aged care settings or in nursing homes,
24.6% of people are admitted with moderate dementia while 40% included severe dementia.
The behavioural symptoms are higher among the older adults with severe dementia and at
percentage amount of 87% of the total population admitted in the nursing homes. The
prescriptions of the anti-psychotic medications are also increased by 20% in the past 10 years
in order to manage the behavioural findings (Bisla et al. 2010). However, given the size of
the dementia population and the severity of the psychosis symptoms among the dementia

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patient, the basic data of prevalence and severity and the percentage use of anti-depressant
are remarkably lacking or outdated (Stewart, et al. 2014). The study also reported that
prevalence of depression or psychotic problems among the dementia patient at times are
substantially underestimated during the recorded diagnosis however, moderately
overestimated through brief screening. At the end the survey at the end sated that in spite of
over and under-estimate, one cannot ignore the significant association of depression and
behavioural problems with the dementia patient across all settings (Stewart, et al. 2014).
The study conducted by Lebedev et al. (2014) helped to get a different insight in
depression or anxiety among the older adults with dementia residing in the nursing homes
and the requirement of the antipsychotic medication in order to manage such behavioural
changes. Previous studies conducted through neuro-imaging among the dementia patient
showed that initiation of depression among the dementia patients is surface during the early
stage only and it has a significant clinical implications. The severity of depression is higher
among the people who are suffering from dementia with Lewy bodies (LBD) or Parkinson
disease dementia. With the progress in dementia there are neurochemical alterations of the
serotonin system (Fritze et al. 2011). The alternations in the serotonin system lead to greater
loss of neurons in the coeruleus along with the formation of the lesions in the concurrent
subcortical white matter. It has been suggested that enuroendocrine change and neuro-
immunological changes like formation of proinflammatory cytokines and activation of
microglia or hypercortisolemia leads to irreversible damage in the brain tissues contributing
to the development of depression among the older adults with dementia. In order to improve
the mental state and to provide a probationary relief of the older adults with dementia,
antidepressant is prescribed. Antidepressant has been reported to be associated with
decreased and increased volume of hippocampus (Fritze et al. 2011). The neuro-imaging
done by Lebedev et al. (2014) showed that among the dementia patients in the nursing homes

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there occurs cortical thinning and this increases the importance of use of antidepressant.
Lebedev et al. (2014) mainly recommended the use of the low efficacy anti-depressants for
managing cognitive impairment among the high-risk patients of dementia. However, use of
mild to moderate anti-depressant among the dementia patient is associated with the
generation of a list of adverse effects. However, exact list of the adverse effects need to be re-
evaluated.
Person-centred care and dementia
The conceptual emergence of person-centred care is dementia management was initiated by
Kitwood in the year 1997. The care plan was further developed across the other care contexts
through the help of contemporary nursing research and theory. This approach has ignited the
argument for shifting the medical mode of care towards more holistic approach. This life-
world approach is development on the biographical knowledge of effective participation and
person and family members and thereby helping to enable shared decision makings
(Edvardsson et al. 2012). Within the residential aged care settings, there is an abundance of
routine tasks and procedures that are occurring daily and that could be used in order to assist
in the process of development of person-centred relationships and other activities. This helps
in maintaining the connections of the residents in the real-life worlds. Tasks like non-
medicalized day to day activities and as forms of sharing of moment and space with the
patients/ residents help in facilitating a climate of “at-homness’ and proper well-being among
the patients with dementia (Edvardsson et al. 2012). The cross-sectional observational study
conducted over the Swedisg residential healthcare patients with dementia stated that in order
to improve the overall quality of life of the individuals suffering from dementia proper
implementation of the person-centred interventions are found to be helpful. In the domain of
the implementation of the person-centred interventions Edvardsson et al. (2014) mainly
highlighted the use of the non-pharmacological interventions that involve group activities.

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Few of the group activities that were studies in this cross-sectional observational study
include making coffee, or cleaning the table, watering the plants, outdoor walks, parlour
games and church visits. The results showed that participants who took active part in the
group based activities are more likely to have an improved quality of life during the
progression of dementia. However, the study also highlighted few contrasting points like
even through participation in the group based activities help to improve the overall quality of
life of the older adults with dementia; the pro-active approach of the participants in the taking
part in the group based activities is poor. High prevalence of the cognitive impairment among
the patients with dementia, lack of positive initiatives from the nursing professionals to
motivate the residents to take part in the activity and lack of organizational flexibility are few
of the reasons found responsible for decreased in active participation of the residents in
group-based non-pharmacological activities. Edvardsson et al. (2014) also stressed over the
importance of the person-centred interventions improving the depressive symptoms among
the older adults with dementia. However, Rokstad et al. (2012) stated that group based non-
pharmacological interventions are not directly the part of the person-centred care approach.
Thus, creating a gap in understanding the importance of the person-centred approach towards
improving the dementia care among the older adults under the aged care setting.
Pharmacological and non-pharmacological interventions for depression management
The behavioural and the psychological symptoms associated with dementia among the
older adults mainly include increased state of agitation, depressive symptoms along with the
development of apathy, psychosis, repetitive behaviour, questionings, development of
aggression, sleep problems and unnecessary wondering and showcase of inappropriate
behaviour. Development of one or more than one of these behaviours affect the quality of life
of the older adults with dementia and at the same time make it difficult for the nursing
professional to handle the patients under the nursing home settings. Alternatively

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development of complex behavioural or psychological symptoms are regarded as few of the
most complex, stressful and costly aspects of the care process and lead to the development of
myriad of negative health related outcome of the patients, increase in the cost of care, stress
development among the family care givers, unmet needs of the patients. The complexity of
the entire scenario indicate that there no one step solution for the problem. Tailored
approaches are recommended in order to promote faster recovery from the scenario (Kales,
Gitlin and Lyketsos 2015). Kales, Gitlin and Lyketsos (2015) recommended the use of the
non-pharmacological approaches in order to meet the complex behavioural and the
psychological need of the patients suffering from dementia. Kales, Gitlin and Lyketsos
(2015) also referred the use of the pharmacological interventions like the use of anti-
psychotic medications or the use of anti-depressant but failed to resolve the benefit to risk
ration. Finally Kales, Gitlin and Lyketsos (2015) stated that the shift in the paradigm is
required to be fully estimated for the generation of person-centred interventions for the older
adults the family members suffering from dementia under the nursing home settings. Kogan,
Wilber and Mosqueda (2016) helped in understanding the importance of the person-centred
approach under the dementia setting. Kogan, Wilber and Mosqueda (2016) stated that person-
centeredness has a substantial uptake in the academic literature on care of older adults with
dementia. However, challenges exist in interpreting and then synthesizing the evidence of the
effects of providing the person-centred care as the person-centred components of few
intervention related studies are unclear. The quasi-experimental study conducted by
Edvardsson, Sandman and Borell (2014) with a one month of follow-up aimed towards
exploring the effect of interventions on the person-centeredness of care and the overall
environment under the aged care settings. The results indicated that an interactive yet
stepwise research intervention for the transition of knowledge help in designing of the
person-centred care plan for the people with dementia. Moreover, the study also showed that

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implementation of the person-centred care plan is effective for improving the overall quality
of life of the older adults with dementia (Edvardsson, Sandman and Borell 2014).
Specified pharmacological interventions for depression management in dementia
In the domain of pharmacological interventions for the treatment of the behavioural
and the psychological symptoms associated with dementia, National Institute for Health and
Care Excellence (2012) stated that drugs are mainly preferred over the non-pharmacological
strategies. The reason behind this is lack of proper training of the nursing professionals in
giving non-pharmacological interventions. AGS Choosing Wisely Workgroup (2013) also
accused non-pharmacological interventions to be lengthy and time consuming and there are
no documented guidelines for the reimbursement in such approaches. No drugs have yet been
approved by Food and Drug Administration (FDA) for treating behavioural and
psychological symptoms associated with dementia. Thus majority of the drugs used for the
treatment of dementia under the nursing home settings (Kales, Gitlin and Lyketsos 2015). In
the group of anti-depressant, tricyclic anti-depressant has been shown to have restricted
benefits along with potential risk factors associated with the treatment of dementia (Kales,
Gitlin and Lyketsos 2015). As per the systematic review and meta-analysis conducted by
Kales et al. (2012) from four randomised control trial studies, selective serotonin reuptake
inhibitors (SSRIs) have high level of tolerability along with favourable response. This
methodologically sound study though having inadequate sample size showed that there is a
good treatment response towards sertraline (helps in reducing depression). However, the
recent meta-analysis conducted by Sepehry et al. (2012) based on five randomised control
trials (RCTs) showed that lack of clear benefit of sertraline for the effective management of
depression and anxiety among the dementia patients. The difference in the reported outcome
of sertraline in the management of depression among the dementia patients is attributed to

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different depression diagnostic criteria used for the diagnosis of depression in the different
studies. The process of outcome measurements, controls and the confounding factors are also
different in different studies. Kales, Gitlin and Lyketsos (2015) are of the opinion that
antidepressant are often used for the reduction of agitation and psychosis associated with
dementia among the older adults in nursing homes. The review of the trials conducted by
Zivin et al. (2013) revealed that administration of sertraline and citalopram helps to reduce
agitation in comparison to the placebo. Seitz set al. (2011) studied the effect Citalopram for
Agitation in Alzheimer Disease over 186 people of dementia having clinically significant
agitation effect. The study showed that the combination of the psychological interventions
along with the implementation of the citalopram helps to reduce agitation within 9 weeks in
comparison to the placebo. Kales, Gitlin and Lyketsos (2015) recommended that more trials
must be conducted in order to understand the actual dosing of citalopram among the patients
with dementia and to compare the efficacy of citalopram with other atypical antipsychotic
drugs that belong to the category of SSRIs. There are several adverse effects associated with
the use of the anti-depressant among the older adults with dementia. The use of the tricyclic
antidepressants is associated with the development of hypotension or orthostatic hypotension,
generation of seizures, deregulation in the glucose metabolism and synthesis and formation of
anticholinergic effects (urine retention, dry mouth, confusion, delirium and constipation). The
prolong use of antidepressants also cause development of prolonged AT, gain in weight,
sexual dysfunction (Kales, Gitlin and Lyketsos 2015). Kales, Gitlin and Lyketsos (2015) are
of the opinion that although safety and other considerations are taken, the adverse effects are
associated with the use of anti-depressive medication.
Specified non-pharmacological interventions for depression management in dementia
The non-pharmacological interventions under the nursing settings also do not have
any definite guidelines for the therapy implementation. It also lacks proper strategy, dosing,

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and timings and is associated with perceived lack of efficacy in comparison to the use of
drugs like anti-depressants. Concerns regarding the efficacy are secondary in comparison to
the heterogeneity of the behavioural interventions encompassing all starting from the
aromatherapy and body massage to supportive interventions for the care givers (Gitlin et al.
2014). The nursing providers are not sure about which non-pharmacological interventions
will be effective and how to select them and implement them simultaneously. Lack of
documented efficacy in experimental trials and lack of methodological rigour hampers the
comprehensive implementation of the non-pharmacological interventions under the nursing
home settings (Cohen-Mansfield et al. 2013). The study conducted by Gitlin, Kales and
Lyketsos (2012) also reported similar findings. The study showed that although a variety of
tools and scales are present to document and describe the depressive symptoms among
dementia patients, they are rarely employed under the real world settings to guide the
management. Kales et al. (2014) argued that in non-pharmacological management of
depressive symptoms of dementia, mindfulness based therapy is found to produce better
results in comparison to the drug treatments. However, the uses of drugs for the treatment of
depressive symptoms are employed when the level of depression is severe and the person is
undertaking homicidal tendencies. Gitlin, Kales and Lyketsos (2012) stated that evidence
based standardised approach is important for detecting and managing depressive symptoms
of dementia with the help of non-pharmacological interventions. In some cases DICE
approach is used for the analysis of the severity of the depressive symptoms among the
dementia patients and followed by proper implementation of the non-pharmacological
interventions. In the DICE approach, D stands for Describe that is contextualizing and
characterising the behaviours of the patients through discussion and followed by determining
the immediate concerns in risk or safety. If risks are found like self-harming attitude, then use
of psychotropic drug is taken under consideration. If self-harming risks are not detected then

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Investigation (I) is conducted. Under this stage the examination of the possible caused of
typical behaviour is done by considering patients factors, care giver factors, and
environmental contribution. If safety issues are found then again pharmacological
interventions are used (Gitlin, Kales and Lyketsos 2012). In case of no safety risks are
highlighted then step three is used that is Create (C). Under this stage collaboration with the
care givers and the treatment team helps to create and implement person-centred treatment
plan for managing distressing symptoms. The key interventions are targeted to the care givers
and the patients Lang with the environment. If the care giver reports that there are tendency
of aggression and depression among the older adults with dementia then again administration
of psychotropic drug is given importance as the first line of strategy. This is followed by
Evaluation (E) of the interventions. If psychotropic drugs are used then adverse effects are
evaluated and if psychotropic drugs are not used then the monitoring of the new behaviour is
done. Kales et al. (2014) are of the opinion that the DICE framework mainly gives
preferences for the use of the antipsychotic medications or the anti-depressive pills for the
treatment of depressive symptoms of dementia apart from the use of the non-pharmacological
interventions. Moreover, the overall process is lengthy and involves active participations of
the family care givers in the intervention planning. The importance of the presence of the
family members is only feasible under the residential healthcare setting and not under the
aged care settings. Moreover, the since of the overall process is extremely time consuming, it
becomes difficult for the healthcare professional to implement the same under the aged care
settings. The nursing professionals at time lack the required proficiency to analyse the
severity of the symptoms and to implement the required interventions accordingly.
Summary of the review and gap in research
Thus from above discussion, it can be stated that people who are suffering from
dementia suffers from late life depression and this is followed by cognitive impairment. In

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order to manage the depressive symptoms among the older adults with dementia, there are
range of interventions like non-pharmacological interventions and non-pharmacological
interventions. Here the review presented both current state of evidences and future
perspectives regarding the integration and value of the both pharmacological and non-
pharmacological interventions used for the management of the depressive symptoms
associated with dementia among the older adults. The review helped in understanding the
importance and the drawbacks of the pharmacotherapy and psychotherapy for depression
among the demented patients. The draw backs of the pharmacological interventions include
several side effects like the hypertension and hypotension, obesity and arthritis. In the domain
of implementation of the non-pharmacological interventions the drawbacks include lack of
expertise of the nursing professionals in designing person-centred care plan and lack of
effectiveness of the non-pharmacological interventions in the management of severe
depressive symptoms that invite in suicidal or self-harming risks. The studies reviewed
mainly considered the older adults with dementia as a whole. None of the studies conducted
so fare helped to highlight the older adults with dementia between the age group of 65 to 85
years. Moreover, there is a lack of significant review highlighting the importance of the use
of anti-depressant over the use of non-pharmacological interventions or vise-versa. The gap
in research also exists in the domain of how proper skills or nursing expertise help in
designing of the person-centred approach for giving care for the depressive older adults with
dementia. In order words, it can be said that summary and well-controlled studies and
systematic reviews and meta-analysis failed to highlight the efficacy of antidepressants over
non-pharmacological interventions or vise-versa in the treatment of the depressive symptoms
of dementia among the older adults with self-harming attitude.
Thus the objectives of the systematic review will include

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 To test the efficacy of anti-depressant versus non-pharmacological interventions in
improving the depressive symptoms among the older adults with dementia (65 to 85
years of age)
 To study the nursing expertise required to implement and observe the person-centred
interventions for the management of depression among the older adults with dementia
 To recommend the strategies in order to bring further refinement in the healthcare
intervention planning for improving the quality of life of the people with dementia
and suffering from depressive symptoms
Rationale of the review
There is an urgent need for evaluation of the anti-depressants and role of non-
pharmacological interventions for the management of dementia among the older adults. This
will help in assessing how any one or both the interventions implemented together help in
improving the overall quality of life of the older adults with dementia. Improvement in the
quality of life of the older adults with dementia is the main aim of care for the nursing
professionals who are caring for the dementia patients under the aged care settings. The
analysis of the efficacy of the anti-depressants and making a comparison with the non-
pharmacological interventions will help in the development of the person-centred
intervention and thereby helping to procure a holistic are approach. The devising of the
person-centred approach for the treatment of depression among the older adults with
dementia will help in improving the outcome of care. It will also help the nursing
professional to understand the required expertise important for the development of the
person-centred interventions and to monitor the targeted improvements.

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Methodology
The literature review discussed in the previous section illustrated that older adults
who are diagnosed with dementia commonly report signs and symptoms of depression at a
later stage in their life, which is concomitant with a decline of cognitive functioning. Hence,
it becomes imperative for healthcare professionals to manage the presenting complaints of
depression, in addition to dementia, in order to enhance the health-realted quality of life of
the patients, by enhancing their health outcomes. This chapter will discuss the methodology
employed for retrieving articles that have been included in thematic analysis.
This research was conducted in the form of a systematic review taking into
consideration the fact that the method facilitated adopting a systematic method for collecting
secondary data. This was soon followed by critically analysing the research findings, and
correlating them with the phenomenon under investigation. The reason behind conducting a
systematic review can be accredited to the fact that it facilitated the generation of narrow and
specific research objective and also provided a detailed summary of evidences that were
pertinent to the topic (ten Ham-Baloyi and Jordan 2016). The advantages of conducting a
systematic review can be associated with the fact that the method creates the provision for
finding and selecting appropriate studies, thereby reducing bias, and also increases the
likelihood of obtaining accurate and reliable conclusions (de Vries et al. 2018). In addition,
this process was also selected as summary of information from different primary scholarly
evidences allowed easy understanding and comprehension of the collected information.
The process is less costly to perform, when compared to collecting information from
study subjects in real-time settings. In addition, the process also created the provision for
generalisation and extrapolation of the results to the wider population, thus acting as an
evidence-based source of information. The first step in conducting the review encompassed
development of a structured questions for that guided the review (Boland, Cherry and

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Dickson 2017). This this warranted a complete examination and investigation of prevailing
data. The PICO mnemonic was used for framing the research question (Speckman. and
Friedly 2019). The table provided below categorises the different elements of the research
question, corresponding to the components of the mnemonic.
P (Population) Dementia patients aged 65-85 years
I (Intervention) Antidepressants
C (Comparison) Usual care
O (Outcome) Enhanced cognitive functioning
Table 1- PICO format
A systematic review was conducted based on non-biased research technique, which in
turn prohibited inclusion or exclusion of articles, based on bias of the researchers. Following
development of an agreeable research question, the second step encompassed selection of
articles that were able to match the inclusion and exclusion criteria. The eligibility criteria
formulated for the systematic review helped in highlighting the resource limits. Though it has
often been suggested that grey literature is important for inclusion in a systematic review, due
to time constraint, they were not incorporated in the review. The inclusion and exclusion
criteria for the review is provided below:
Inclusion criteria Exclusion criteria
Articles published in English Articles published in foreign languages
Articles published on or after 2012 Articles published prior to 2012
Articles that focus on dementia and
antidepressants
Articles that focus on dementia and other
medications

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Articles that contain information on study
subjects who were aged between 65-85 years
Manuscripts, abstracts, and unpublished articles,
Primary research articles (cohort, RCT,
observational)
Case series and clinical guidelines
Peer reviewed articles
Table 2- Inclusion and exclusion criteria for the proposed literature review
Search terms
The third stage of conducting the systematic review encompassed selection of definite
search terms, based on the background study and articles that had been discussed in the
literature review section. At the time of formulating appropriate search terms that facilitated
the extraction of pertinent primary articles, in relation to the pre-determined research
question, the guideline proposed by Centre for Reviews and Dissemination’s (CRD) in the
year 2009, was taken into consideration. This acted in the form of a framework for consulting
the major research question (Zeng et al. 2015). Based on the recommendations present in the
guidelines, spelling variance, abbreviations, and synonyms were also taken into consideration
at the time of article extraction. Three electronic databases namely, CINAHL, MEDLINE,
and PsycINFO were comprehensively investigated for retrieving the scholarly evidences.
This was followed by conducting a manual search of the articles that were considered
appropriate.
Snowballing procedure thus helped in gaining access to articles that might have been
missed if the search was limited to the electronic databases only. The search terms used for
article extraction were namely, “antidepressants”, “antidepressant medication”,“ssri”,
“selective serotonin reuptake inhibitors”, “dementia”, “Alzheimer’s”, “cognitive
impairment”, “memory loss”, “65 years”, “older”, “elderly”, “aged” , and “geriatric”. These

21
DISSERTATION
search terms were combined with the use of boolean operators ‘OR’ and ‘AND’ (McGowan
et al. 2016). While ‘OR’ broadened the search results by finding articles that even contained
synonyms of the search terms, use of the operator ‘AND’ helped in narrowing down the hits.
It restricted the search history to articles that contained all the search terms that were
incorporated in the database.
Relevance assessment
After retrieving a total of 253 articles from the three electronic databases, the
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was
employed for assessing the applicability and significance of the articles to the research
question, during completion of the search process. The retrieved articles were assessed in a
three-stage procedure by evaluating them against their eligibility criteria. Firstly the titles of
the acquired hits were assessed. This step provided the advantage of excluding scholarly
evidences that were not able to meet the rational of the envisioned investigation, within a
moderately short time. Articles that contained limited information on the use of
antidepressants among elderly people, diagnosed with dementia, were also included in the
list.
The steps were conducted by two individual investigators, following which
differences were set by partaking in group discussions that caused modification and alteration
of the search standards (Booth, Sutton and Papaioannou 2016). The initial hits of 253 articles
were decreased to 129 after removing duplicate articles. The abstracts of the 129 articles were
analysed against the criteria. This reduced the number to 33 articles, which were then
evaluated for their full-text eligibility. This led to the exclusion of 27 articles, and only 6
were finally incorporated in the thematic analysis.

22
DISSERTATION
Results:
All total six articles were selected and the details of them are presented below.
Name of the
Authors
Aims and
Objective
Methodology Results Critique
Chen et al.
(2014)
The main aim of
this study is to
investigate the
effectiveness of
non-
pharmacological
interventions
on the
psychological
and behavioural
symptoms of
dementia
patients.
In this study,a
perspective
cohort study
method was used
that included 104
older men
suffering from
dementia in two
veteran homes in
Taiwan. As a part
of the
intervention,
orientation
program, music
therapy
intervention,
physical activities
were performed.
All the
participants were
examined by
The study result
showed that, the
intervention
group had
relatively lesser
score in the NPI
scale while
comparing with
the non-
intervention
group of the
study. From the
score of the
Multivariate
analysis, it was
reported that,
the non-
pharmacological
therapy is
associated with
the reduced
From the study,
it was clearly
mentioned that,
the study
population was
clearly
mentioned and
after the study
complete
outcome of the
patients were
analysed in a
well manner.
However, the
study only
represented the
male
population, so it
could not be the
representative
of the whole

23
DISSERTATION
using the
neuropsychiatric
inventory (NPI),
Barthel Index,
Instrumental
Activities of
Daily Living,
defined daily
dose of
psychotropic
drug use, Mini-
Mental State
Examination,
Tinetti balance
score, Geriatric
Depression Scale
and Tinetti gait
score.
cases of
hallucination
and agitation
among the
patient of
dementia in
older adults.
population of
the cohort.
Fereshtehnejad,
Johnell and
Eriksdotter
(2014)
The main aim of
this study is to
examine the
efficacy of anti-
dementia drugs
associated with
the depression
In this study, a
cross sectional
analysis method
was used to
analyze the data.
The data of 5907
diseased patients
The study result
showed that, the
most of the
patients were in
the mild stages
of their disease.
As a part of the
From the study,
it is reported
that, the study
addressed the
issue in a clear
manner and
authors clearly

24
DISSERTATION
that is
cholinesterase
inhibitors
(ChEIs) and
NMDA
antagonists.
Simultaneously
this study also
investigate the
co-medication
and IDU in the
out patient
department
patients with
dementia.
were collected
from the Swedish
Dementia Quality
Registry
(SveDem). Use
of less than 3
psychotropic
drugs and
polypharmacy
based on the anti-
depression
treatment of the
patients were
used to evaluate
the condition of
the patient
subjects of the
study. Cognitive
evaluation was
measured by
using the Mini-
Mental
State
Examination
(MMSE) score of
pharmacoogical
therapy. the
patients were
given ChEI and
NMDA
antagonists
indiv9idually.
However, a few
patients were
reported to have
both of the
drugs and on the
contrary a few
patients were
not given any
kind of drugs at
all. The drugs
used for
reducing
depression
among the
dementia
patients that is
ChEIs were
very effective in
described the
study type as
well. All the
data collection
method was
clearly
mentiond in the
study and data
were collected
from the data
bank of
Swedish
research centre.
Moreover, more
numbers of
participants of
this study
enhanced the
reliability of the
study as well.

25
DISSERTATION
the patients. reducing the
symptoms. It
was concluded
that, the patients
having ChEIs
needed less
amount of
pharmacological
drugs.
Scerri & Scerri
(2013)
The primary
aim of this
study is to
examine the
knowledge and
behaviour of the
nursing students
towards patients
suffering from
dementia. Along
with this, the
level of
education
among the
nurses were
In this study, the
students of the
nursing college
of Malta was
enrolled and they
were in the first,
second and third
year of their
courses. The
overall
population
consisted of 305
nursing full time
diploma students
and 136 full time
The study result
showed that, the
study
participants had
adequete
knowldge and
they showed a
positive
behaviour
towards the
dementia
patients.
Moreover, it
was also
reported that,
From the study,
it was quite
evident that, the
study
population was
well defined
and the study
clearly
examined the
goal of the
study as well.
Moreover, this
study is
successful in
identifying the

26
DISSERTATION
examined. degree course
students and 16
students were
enrolled in the
mental health
nursing
programme.
Alzheimer's
Disease
Knowledge Scale
(ADKS) and
Dementia
Attitudes
Scale (DAS)
were used to
collect the data as
self-administred
questionnaires.
The AKDS scale
focuses on
diffeent seven
factors related to
dementia and the
DAS is 7 point
likert scale of 20
the Age,
training,
academic year,
and previous
care of dementia
patients during
their clinical
placement were
also associated
with the
attitudes and
knowledge of
the nurses.
levels of
knowledge and
behaviour of the
nurses towards
the dementia
patients.

27
DISSERTATION
questions. The
data was
analyzed by
using the PASW
statics software.
For analysing the
parametric data
normal ANOVA
and for the non
parametric data
Kruskal Wallis
ANOVA were
used.
Ballard et al.
(2018)
This study aims
to evaluate the
effectiveness of
psychosocial
intervention and
person centred
care approach
for the dementia
patients in the
nursing homes
In this study, a
randomized
control trial
method was used
and this was
conducted in
between the
January 2013 to
September 2015
which compared
the WHELD
intervention with
The study result
showed that,
there was no
significance
difference
between
WHELD and
TAU for the
outcomes . The
use of
antipsychotic
drugs was less
The study
followed the
criteria of the
randomized
control trial and
the subjects
were randomly
allocated to
either group of
the study. The
large sample
size enhanced

28
DISSERTATION
treatment as
usual (TAU). The
patients were
admitted in the
69 hospitals in
UK. During the
study, all the
nursing homes
were provided
trained nurses
having adequate
knowledge of
person centred
care and other
education
regarding the
antipsychotic
pharmacotherapy.
The primary
outcomes were
measured by
using the QoL
parameters and
the secondary
outcomes were
in case of both
the groups.
the quality of
the study.
However,
subjects were
collected from
the hospitals
and so it could
not be the
representative
of whole
population.

29
DISSERTATION
measured by
using the
parameters like
Agitation
(CohenMansfield
Agitation
Inventory
[CMAI]),
antipsychotic use,
quality of
interactions
(Quality of
Interactions Scale
[QUIS]) global
deterioration
(Clinical
Dementia
Rating), mood
(Cornell Scale for
Depression in
Dementia), pain
(Abbey Pain
Scale), unmet
needs
(Camberwell

30
DISSERTATION
Assessment of
Need for the
Elderly),
neuropsychiatric
symptoms
(Neuropsychiatri
c Inventory–
Nursing Home
Version [NPI-
NH]), mortality,
quality of
interactions
(Quality of
Interactions Scale
[QUIS]). Almost
847 patients were
randomized to
the study and 553
patients
completed the
study for 9
months.
Lin, Hsieh &
Lin (2012)
The main aim of
this study is to
In this study, 124
nurses were
The study result
showed that, the
The large
sample size of

31
DISSERTATION
examine the
hospital nurses’
knowledge and
attitudes of the
nurses toward
dementia care.
given a
questionnaire
with 16 items
related to
dementia care
knowledge.
Again a 13 item
questionnaire was
used to assess
their approach
related to person
centred care or
reality oriented
care.
most of the
nurses were
confused about
the symptoms of
dementia with
delirium.
Moreover, it
was reported
that, the nurses
who had more
experience, they
had better
knowledge
regarding
dementia care
knowledge.
the study was
associated with
the higher
reliability of the
study and the
study clearly
identified the
subject
population. The
aims of the
study was
related to the
study findings
as well.
Jhonell, Religa
& Eriksdotter
(2013)
The study aimed
to examine the
associations of
dementia
disorders and
use of the
antipsychotics
for depression
and anti-
The data was
collected from
the national
Swedish
Dementia
Registry
(SveDem) 2007–
2010 and sample
size was 7570 (n
The study
result showed
that, the almost
80% of AD
patients and
86% of
dementia with
Lewy bodies
patients used
The study
succeded to
address the
research
question and the
required other
parameters were
also considered
during the

32
DISSERTATION
dementia drugs
among the
dementia
patients.
= 7,570).
Multivariate
logistic
regression
analysis was used
to find the
association
between
antidepressant
drugs,
antidementia
drugs and
dementia patients
after adjustment
for age,
residential
setting, living
alone, sex, ,
MMSE score and
number of other
drugs (a proxy
for overall co-
morbidity).
anti dementia
drugs.
Moreover,
almost 6% of
patients used
antidepressant
drugs. A high
MMSE score
was associated
with the use of
ChEIs and it
was associated
with NMDA
receptors
antagonists and
antidepressant
in a negative
manner.
analysis of the
study result as
well.

33
DISSERTATION
From the above findings it can be easily stated that, the pharmacological therapy and
the non-pharmacological therapy can be very useful in improving the condition of the
dementia patients having depression. Moreover, in various studies, it was also reported that,
the use of ChEIs among the patients with dementia is associated with the less amount of
antidepressant among the patients suffering from dementia. However, it is very crucial to
have adequate knowledge about the disease so that they can use appropriate approach during
the delivery of care. Most of the studies identified that the nurses had lack of knowledge
regarding the condition that is dementia along with depression. So, it can be said that, nurses
need more knowledge regarding the problem as well. However, a few studies also identified
that the experience of the nurses are also very crucial. In studies, it was reported that more
experience nurses are capable of providing better care to the patients suffering from
dementia. So, it can be said that, in order to provide better care to the patients the nurses
should be given proper training regarding the care process that is person centred care,
symptoms of the disease and such initiatives may improve the condition as well (Edwards,
Voss and Iliffe 2013). Along with the pharmacological therapy, the patients should also be
given various type of non-pharmacological therapy such as music therapy intervention, social
interaction (Vink et al. 2013). Therefore, such non-pharmacological therapies should be
recommended more in order to have better results regarding the treatment outcomes of the
patients with dementia and depression under the age group of 65 to 85 years. As, it can be
easily said that, the pharmacological therapies may have various adverse effect and so more
non-pharmacological therapies should be used in the treatment process to avoid the adverse
events (Pellegrino et al. 2013).

34
DISSERTATION
Discussion
From the discussion in the above section it can be said that the dementia has become
very much prevalent in the world wide health sector. United Kingdom is also very much
affected by the dementia as well and it has become growing burden on the health care system
of the United Kingdom. It has been reported that the more than 500, 000 people aged between
the 65 to 85 years old has been affected by the dementia in the United Kingdom in the recent
years (Lewis et al. 2014). Dementia is a kind of disease which severely affects the activities
of the daily living among the sufferer of the dementia patients. One of the major way of
treating the dementia patients is to the provision of antidepressant drug among the patients
suffering from dementia. However, studies have shown that these drug does not have out and
out efficacy in comparison with the other treatment method (Lewis et al. 2014). On top of
that these drugs have very severe adverse side effects which impacts and exacerbated the
conditions and challenges even more faced by the dementia patients. One primary and
prevalent co- morbidity of the dementia is depression and majority of the patients has
admitted or diagnosed to be suffering from depression. Pharmacological intervention is one
of the intervention method which generally implemented for this symptoms, although studies
have shown that non- pharmacological intervention is similarly effective without the adverse
side effects (Cooper et al. 2012). There are many non- pharmacological interventions are
available for the treatment of the dementia which is similarly effective but lacks adverse side
effects. However, lack of proper training among the nurses is one of the obstacle for the
implementation of the non- pharmacological interventions as well proper research related to
the standard guidelines related to this procedures and implementation. It has been well
evidenced that the anti- depressants have severe adverse side effects (Livingston et al. 2014).
Hence, this investigation was designed to study the difference between the efficacies of the
anti-depressant versus non-pharmacological interventions in improving the depressive

35
DISSERTATION
symptoms among the older adults with dementia (65 to 85 years of age). In order to do that, a
systematic review has been performed in this investigation in the search databases like
Medline, CINAHL etc. Inclusion and exclusion criteria were used while selecting the articles.
Articles published before 2012 were not selected to maintain the relevancy of the information
related to the objectives of this investigation. From the systematic search, six articles were
selected and the outcomes of them were discussed in detail manner in the above section.
From the result section presented above, it can be seen that the non- pharmacological
intervention has managed control the symptoms of the dementia effectively among the older
patients suffering from dementia. In respect to that Chen et al. (2014), have performed a
cohort study in Taiwan. In their research investigation, they have shown that the non-
pharmacological interventions have significant treating the symptoms of the dementia
patients. They have shown that the non- pharmacological intervention effectively tackled and
had a positive effect on the outward symptoms of the dementia like agitation. Not only that, it
has also effectively managed the intrinsic symptoms like delusion and hallucination among
the older patients suffering from dementia. Another study has also shown the similar effect
while administrating non- pharmacological treatment approach for treatment of the dementia-
suffering patients (Takeda et al. 2012). On the other hand, Fereshtehnejad, Johnell and
Eriksdotter (2014), have studied the effect of the cholinesterase inhibitors (ChEIs) among the
dementia patients. They have shown that cholinesterase inhibitors (ChEIs) have a significant
effect the patients for the reduced use of the anxiolytics and antipsychotics. The uses of
anxiolytics and antipsychotics have significantly higher among the patients who are not
taking cholinesterase inhibitors (ChEIs). From their study, it can be stated that the
cholinesterase inhibitors (ChEIs) have significant impact on the reduction of the use of
anxiolytics and antipsychotics, however, the findings are not conclusive enough, and the
authors have suggested further investigation to be sure about the effect of the cholinesterase

36
DISSERTATION
inhibitors (ChEIs) on the reduction use of anxiolytics and antipsychotics. Investigation on the
similar area by other academics has also presented similar findings (Canevelli et al. 2014).
On the contrast, Scerri and Scerri (2013), have delved in to different perspective of the
problem studied how the care giving process can be improved among the dementia patients.
The quality of life severely affected by the dementia among the patients suffering from it due
to the cognitive impairment. Hence, it is paramount that the patients suffering from it
required special and personalised care while managing their daily requirement. In their
research investigation, Scerri and Scerri (2013), have shown that the current procedure and
nursing care giving approach is not beyond reproach and it can be further enhanced by the
provision of knowledge and information about dementia care training among the nurses and
care givers. Other studies are also agree with this kind of approach and stated that the person
centred care giving process is requires for the provision of highest quality of service for the
improvement of their quality of life (Rokstad et al. 2015). Ballard et al. (2018) have also
reported similar findings with the findings presented by the Scerri and Scerri (2013).
However, they have stressed on the provision of the person centred care. Every patient
suffering from dementia is has different symptoms with different intensity. Hence, they have
suggested and reported that person- centred care will be particularly effective in this regard.
They have implemented WHELD intervention method among the patients and shown that the
person- centred care is particularly effective for the handling of the outward and intrinsic
symptoms of the dementia patients. Lin, Hsieh and Lin (2012), have delved in to the required
knowledge and care giving technique among the nurses for the care dementia patients. They
have reported in their study that the nurses should be much more competent in recognising
difference between the deliriums from dementia. They have suggested that the more training
is required in this area so that the nurses can better distinguished between them and provide
better quality of service to the dementia patients. Johnell, Religa and Eriksdotter (2013), have

37
DISSERTATION
investigated on the used anti- dementia drugs for the treatment of the dementia patients. They
have showed that the anti- dementia drugs have managed to treat the dementia patients and
within the standard guidelines of the Swedish government. However, they have also reported
and suggested that patients using anti- dementia are very much susceptible to antipsychotics.
In a nutshell, it can be stated that the pharmacological and non- pharmacological
interventions both can be implemented for the treatment of the dementia patients. However, it
is well evident that the pharmacological interventions have adverse side effects. Hence, non-
pharmacological interventions has been suggested by the researchers for the treatment of the
dementia. It has been also evident that the person- centered care by the care givers and nurses
are required to provide better care to the dementia patients. One of the obstacle is the limited
knowledge of the nurses which can be overcome by providing adequate, evidence based
training to the nurses. One of the objective of this investigation was to test the efficacy of
anti-depressant versus non-pharmacological interventions in improving the depressive
symptoms among the older adults with dementia (65 to 85 years of age). From the above
discussion, it is evident that the non-pharmacological interventions can be implemented
effectively for the treatment of depressive symptoms among the older adults with dementia.
Another objective was to study the nursing expertise required to implement and observe the
person- centered interventions for the management of depression among the older adults with
dementia. Above discussion suggests that the nurses required additional training in order to
implement the non- pharmacological intervention as well as training related to the person-
centred care for dementia patients.
Limitation
The study design that was adapted for this research investigation was systematic
review. Being a systematic review it has some limitation as well. The first limitation was that

38
DISSERTATION
no meta- analysis was performed in this research investigation. As no meta- analysis was
performed in this research investigation, quantitative data cannot be produced for this
research investigation. Owing to this reason, the findings of this research investigation cannot
be compared numerically with other (Morrison et al. 2012). Only thematic analysis can be
conducted and hence, only thematic analysis has been conducted for this study. In addition to
this, statistical analysis cannot be conducted of the outcomes and findings from research
paper presented in this research investigation. Therefore, the findings cannot be stated with
confidence that they are statistically significant. Thence, this is one of the major limitation of
this research investigation. Another limitation of this study design is that the sample size,
intervention methods, and intervention settings are different for each extracted articles
(Morrison et al. 2012). Therefore, the findings of this studies cannot be compared with each
other due to the variable sample size, intervention methods, and intervention settings. Hence,
the correlation and difference of the findings of the different studies might not similar due to
their differences. Another, main limitation of this study design is the presence of the selection
bias and judgemental bias while selecting the articles. However, measures were taken to
reduce the selection bias, but the selection bias might still be present among the findings.
Several inclusion and exclusion criteria were introduced during the selection of the articles.
One of them was that the articles published with English language will be selected only. Due
to this criteria, important and relevant articles might be missed out which were published in
the language other than English (Morrison et al. 2012). No articles were selected which were
published before the year of 2012. Owing to this inclusion and exclusion criteria, articles with
relevance information might be omitted or not selected. Therefore, these are the additional
limitation of this study design.
Few measures can be taken to minimise these limitation presence in this study design.
One of them would be to perform meta- analysis among the extracted and selected articles.

39
DISSERTATION
By conducting meta- analysis, the data can be compared numerically as well as statistical
analysis can be conducted on the findings of this investigation. Another measure that can be
taken in this research investigation is that to reduce the selection while selecting articles.
Conclusion and Recommendation:
Dementia is a growing challenge in the UK. . Dementia mainly affects the older
people who are 65 years of age or older. The likelihood of developing dementia increases
with age and doubles with ever 5-year. Anti-depressants are one of the commonly perspective
drugs that are used for the treatment of depressive symptoms among the older adults with
dementia. The behavioural and the psychological symptoms associated with dementia among
the older adults mainly include increased state of agitation, depressive symptoms along with
the development of apathy, psychosis, repetitive behaviour, questionings, development of
aggression, sleep problems and unnecessary wondering and showcase of inappropriate
behaviour. The pharmacological therapy and the non-pharmacological therapy can be very
useful in improving the condition of the dementia patients having depression. In order to
provide better care to the patients the nurses should be given proper training regarding the
care process that is person centred care, symptoms of the disease and such initiatives may
improve the condition as well. Additionally, the patients should also be given various type of
non-pharmacological therapy such as music therapy intervention, social interaction.
Non-pharmacological therapies should be recommended more in order to have better
results regarding the treatment outcomes of the patients with dementia and depression under
the age group of 65 to 85 years. As, it can be easily said that, the pharmacological therapies
may have various adverse effect and so more non-pharmacological therapies should be used
in the treatment process to avoid the adverse events. The nurses required additional training

40
DISSERTATION
in order to implement the non- pharmacological intervention as well as training related to the
person- centered care for dementia patients.

41
DISSERTATION
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PRISMA 2009 Flow Diagram
–
Records identified through
database searching
(n = 253)
PsychINFO- 167; MEDLINE-
48; CINAHL- 38
ScreeningIncluded Eligibility Identification
Additional records identified
through other sources
(n = 0)
Records after duplicates removed
(n = 129)
Records screened
(n = 129)
Records excluded
(n = 90)
Full-text articles
assessed for eligibility
(n = 33)
Full-text articles
excluded, with reasons
(n = 27)
Studies included in
qualitative synthesis
(n = 6)
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Appendix 1
Figure 1- PRISMA flowchart for the systematic review

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Appendix 2
Figure 2- CINAHL database search
Figure 2- MEDLINE database search

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Figure 3- PsychINFO database search