Adopting and maintaining physical activity behaviours in people with severe mental illness: The importance of autonomous motivation

OBJECTIVE

Physical activity can improve the health of people with serious mental illness (SMI) but many are inactive. Adopting theoretically-based research considering the motivational processes linked to the adoption and maintenance of an active lifestyle between different diagnostic groups of people with SMI can assist in understanding physical activity in this group. Within the Self-Determination Theory (SDT) and the Trans-Theoretical Model (TTM) (stages of change) frameworks, we investigated differences in motives for physical activity between different diagnostic groups.

METHODS

All participants completed the Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2), the International Physical Activity Questionnaire (IPAQ) and the Patient-centered Assessment and Counseling for Exercise (PACE) questionnaire.

RESULTS

Overall 294 persons with SMI (190♀) (43.6 ± 13.6 years) agreed to participate. People with affective disorders had higher levels of introjected regulations than people with schizophrenia. No significant differences were found for other motivational regulations. Moreover, no significant differences were found according to gender, setting and educational level. Multivariate analyses showed significantly higher levels of amotivation and external regulations and lower levels of identified and intrinsic regulations in the earlier stages of change. Strongest correlations with the IPAQ were found for motivational regulations towards walking.

CONCLUSIONS

Our results suggest that in all people with SMI the level of identified and intrinsic motivation may play an important role in the adoption and maintenance of health promoting behaviours. The study provides a platform for future research to investigate the relationships between autonomy support, motivational regulations and physical and mental health variables within lifestyle interventions for this population.

Perceived Stress and Its Relationship With Chronic Medical Conditions and Multimorbidity Among 229,293 Community-Dwelling Adults in 44 Low- and Middle-Income Countries

In this study, we assessed the association of chronic medical conditions and multimorbidity with perceived stress among community-dwelling adults in 44 low- and middle-income countries. Data from the World Health Survey (2002-2004), including 229,293 adults, were analyzed. A perceived stress score (range, 0 (lowest stress)-100 (highest stress)) was computed on the basis of 2 questions from the Perceived Stress Scale. Eleven chronic conditions were assessed. Multivariable linear regression analyses were conducted to explore the associations. All chronic conditions were associated with significantly higher mean perceived stress scores, with the exception of edentulism. The associations were particularly strong for depression (β = 14.71, 95% confidence interval (CI): 13.68, 15.74), visual impairment (β = 10.66, 95% CI: 8.09, 13.23), and schizophrenia (β = 9.98, 95% CI: 7.71, 12.24). Compared with no chronic conditions, the β coefficients for perceived stress with the presence of 1, 2, 3, and ≥4 chronic conditions were 5.58 (95% CI: 4.94, 6.23), 9.58 (95% CI: 8.67, 10.49), 14.15 (95% CI: 12.63, 15.67), and 20.17 (95% CI: 18.29, 22.05), respectively. The associations with perceived stress were significantly stronger among the poorest individuals for arthritis, asthma, diabetes, edentulism, and ≥4 chronic conditions. Our data suggest that a range of chronic conditions and multimorbidity are associated with greatly increased perceived stress among people in low- and middle-income countries, and that the poorest persons may be a particularly vulnerable group.

Physical activity correlates in people living with HIV/AIDS: a systematic review of 45 studies

PURPOSE

Understanding barriers and facilitators of physical activity participation in persons living with HIV/AIDS is an essential first step in order to devise effective interventions. The present review provides a systematic quantitative review of the physical activity correlates in people with HIV/AIDS.

METHODS

Major electronic databases were searched till August 2016. Keywords included "physical activity" or "exercise" or "sports" and "AIDS" or "HIV".

RESULTS

Out of 55 correlates from 45 studies (N = 13,167; mean age range = 30.5-58.3 years; 63.2% male) five consistent (i.e., reported in four or more studies) correlates were identified. Lower levels of physical activity were consistently associated with older age (6/10 studies), a lower educational level (6/7), a lower number of CD4 cells/μl (7/11), exposure to antiviral therapy (4/6), and the presence of lipodystrophy (4/4). Other important barriers were the presence of bodily pain (2/2), depression (3/3), and opportunistic infections (3/4). Facilitators were a higher cardiorespiratory fitness level (3/3), a higher self-efficacy (2/2), more perceived benefits (2/2), and a better health motivation (3/3).

CONCLUSIONS

The current review has elucidated that participation in physical activity by people with HIV/AIDS is associated with a range of complex factors which should be considered in rehabilitation programs. Implications for Rehabilitation Health care professionals should consider HIV-related bodily pain and feelings of depression when assisting people living with HIV in inititiating and maintaining an active lifestyle. Interventions to improve self-efficacy and motivation, and to help people living with HIV in understanding the benefits of exercise, may encourage greater participation.

Grip Strength Is Associated With Cognitive Performance in Schizophrenia and the General Population: A UK Biobank Study of 476559 Participants

Background

Handgrip strength may provide an easily-administered marker of cognitive functional status. However, further population-scale research examining relationships between grip strength and cognitive performance across multiple domains is needed. Additionally, relationships between grip strength and cognitive functioning in people with schizophrenia, who frequently experience cognitive deficits, has yet to be explored.

Methods

Baseline data from the UK Biobank (2007-2010) was analyzed; including 475397 individuals from the general population, and 1162 individuals with schizophrenia. Linear mixed models and generalized linear mixed models were used to assess the relationship between grip strength and 5 cognitive domains (visual memory, reaction time, reasoning, prospective memory, and number memory), controlling for age, gender, bodyweight, education, and geographical region.

Results

In the general population, maximal grip strength was positively and significantly related to visual memory (coefficient [coeff] = -0.1601, standard error [SE] = 0.003), reaction time (coeff = -0.0346, SE = 0.0004), reasoning (coeff = 0.2304, SE = 0.0079), number memory (coeff = 0.1616, SE = 0.0092), and prospective memory (coeff = 0.3486, SE = 0.0092: all P < .001). In the schizophrenia sample, grip strength was strongly related to visual memory (coeff = -0.155, SE = 0.042, P < .001) and reaction time (coeff = -0.049, SE = 0.009, P < .001), while prospective memory approached statistical significance (coeff = 0.233, SE = 0.132, P = .078), and no statistically significant association was found with number memory and reasoning (P > .1).

Conclusions

Grip strength is significantly associated with cognitive functioning in the general population and individuals with schizophrenia, particularly for working memory and processing speed. Future research should establish directionality, examine if grip strength also predicts functional and physical health outcomes in schizophrenia, and determine whether interventions which improve muscular strength impact on cognitive and real-world functioning.

The transcending benefits of physical activity for individuals with schizophrenia: a systematic review and meta-ethnography

A systematic review and meta-ethnographic synthesis exploring the experiences of people with schizophrenia and healthcare professionals (HCPs) towards physical activity was undertaken. Major electronic databases were searched from inception until January 2014. Studies were eligible if they considered the experiences and perceptions of people with schizophrenia or the perceptions of HCPs towards physical activity. All included studies were synthesised within a meta-ethnographic approach, including completing a methodological quality assessment. The search strategy identified 106 articles, 11 of which were included in the final analysis. Eight articles considered patients׳ experiences and perceptions, and three articles considered the experiences and perceptions of HCPs. A total of 108 patients and 65 HCPs were included. Three main themes were identified: (1) the influence of identity, culture and the environment on physical activity engagement, (2) access and barriers to participation in physical activity, and (3) the benefits of engaging in physical activity. Aspects within the built, social and political environment as well as aspects of social cognition and perceptual biases influence participation in physical activity for individuals with schizophrenia. Specific recommendations for HCPs are given to help promote physical activity in this population group.

Nutritional Deficiencies and Clinical Correlates in First-Episode Psychosis: A Systematic Review and Meta-analysis

Objective

Diet is increasingly recognized as a potentially modifiable factor influencing the onset and outcomes of psychiatric disorders. Whereas, previous research has shown long-term schizophrenia is associated with various nutritional deficiencies, this meta-analysis aimed to determine the prevalence and extent of nutritional deficits in first-episode psychosis (FEP).

Method

A search of electronic databases conducted in July 2017 identified 28 eligible studies, examining blood levels of 6 vitamins and 10 minerals across 2612 individuals: 1221 individuals with FEP and 1391 control subjects. Meta-analyses compared nutrient levels in FEP to nonpsychiatric controls. Clinical correlates of nutritional status in patient samples were systematically reviewed.

Results

Significantly lower blood levels of folate (N = 6, n = 827, g = -0.624, 95% confidence interval [CI] = -1.176 to -0.072, P = .027) and vitamin D (N = 7, n = 906, g = -1.055, 95% CI = -1.99 to -0.119, P = .027) were found in FEP compared to healthy controls. Synthesis of clinical correlates found both folate and vitamin D held significant inverse relationships with psychiatric symptoms in FEP. There was also limited evidence for serum level reductions of vitamin C (N = 2, n = 96, g = -2.207, 95% CI = -3.71 to -0.71, P = .004). No differences were found for other vitamins or minerals.

Conclusions

Deficits in vitamin D and folate previously observed in long-term schizophrenia appear to exist from illness onset, and are associated with worse symptomology. Further research must examine the direction and nature of these relationships (ie, mediator, moderator, or marker) with clinical status in FEP. Future trials assessing efficacy of nutrient supplementation in FEP samples should consider targeting and stratifying for baseline deficiency.

Negative symptoms are associated with lower autonomous motivation towards physical activity in people with schizophrenia

OBJECTIVE

This cross-sectional study examined the association between psychiatric symptoms and motivation for physical activity within the self-determination theory (SDT) framework in people with schizophrenia.

METHOD

Over a 4-month period, 55 (17♀) inpatients with a DSM-V diagnosis of schizophrenia were assessed with the Psychosis Evaluation tool for Common use by Caregivers (PECC) and the Behavioural Regulation in Exercise Questionnaire (BREQ-2), that provided separate scores for amotivation, external, introjected and autonomous regulation. Spearman correlation coefficients were examined between these motivation scores and symptom ratings.

RESULTS

The BREQ-2 score for autonomous regulations (2.6±1.1) was significantly correlated with the PECC negative symptoms score (10.3±4.1) (r=-0.34, p=0.011). No other significant correlations between BREQ-2 and PECC scores were found. The BREQ-2 score for external regulations (0.7±0.9) was associated with older age (35.2±11.3years) (r=-0.30, p=0.024).

CONCLUSIONS

These findings provide evidence that negative symptoms are associated with lower autonomous motivation towards physical activity in inpatients with schizophrenia. Future longitudinal research should confirm the current findings. Such research will guide physical activity approaches aimed at facilitating enhanced physical and mental health outcomes in individuals with schizophrenia.

Association Between Muscular Strength and Cognition in People With Major Depression or Bipolar Disorder and Healthy Controls

IMPORTANCE

Objective physical fitness measures, such as handgrip strength, are associated with physical, mental, and cognitive outcomes in the general population. Although people with mental illness experience reduced physical fitness and cognitive impairment, the association between muscular strength and cognition has not been examined to date.

OBJECTIVE

To determine associations between maximal handgrip strength and cognitive performance in people with major depression or bipolar disorder and in healthy controls.

DESIGN, SETTING, AND PARTICIPANTS

In a multicenter, population-based study conducted between February 13, 2005, and October 1, 2010, in the United Kingdom, cross-sectional analysis was conducted of baseline data from 110 067 participants in the UK Biobank. Data analysis was performed between August 3 and August 18, 2017. Invitations were mailed to approximately 9.2 million UK homes, recruiting 502 664 adults, all aged 37 to 73 years. Clinically validated measures were used to identify individuals with major recurrent depression (moderate or severe) or bipolar disorder (type I or type II) and healthy controls (those with no indication of present or previous mood disorders).

MAIN OUTCOMES AND MEASURES

Handgrip dynamometry was used to measure muscular function. Cognitive functioning was assessed using computerized tasks of reaction time, visual memory, number memory, reasoning, and prospective memory. Generalized linear mixed models assessed the association between handgrip strength and cognitive performance, controlling for age, educational level, sex, body weight, and geographic region.

RESULTS

Of the 110 067 participants, analyses included 22 699 individuals with major depression (mean [95% range] age, 55.5 [41-68] years; 7936 [35.0%] men), 1475 with bipolar disorder (age, 54.4 [41-68] years; 748 [50.7%] men), and 85 893 healthy controls (age, 53.7 [41-69] years; 43 000 [50.0%] men). In those with major depression, significant positive associations (P < .001) between maximal handgrip strength and improved performance on all 5 cognitive tasks were found, including visual memory (coefficient, -0.146; SE, 0.014), reaction time (coefficient, -0.036; SE, 0.002), reasoning (coefficient, 0.213; SE, 0.02), number memory (coefficient, 0.160; SE, 0.023), and prospective memory (coefficient, 0.341; SE, 0.024). Similar results were found in healthy controls. Among participants with bipolar disorder, handgrip strength was positively associated with improved visual memory (coefficient, -0.129; SE, 0.052; P = .01), reaction time (coefficient, -0.047; SE, 0.007; P < .001), prospective memory (coefficient, 0.262; SE, 0.088; P = .003), and reasoning (coefficient, 0.354; SE, 0.08; P < .001).

CONCLUSIONS AND RELEVANCE

Grip strength may provide a useful indicator of cognitive impairment in people with major depression and bipolar disorder. Future research should investigate causality, assess the functional implications of handgrip strength in psychiatric populations, and examine how interventions to improve muscular fitness affect neurocognitive status and socio-occupational functioning.

Handgrip strength and depression among 34,129 adults aged 50 years and older in six low- and middle-income countries

INTRODUCTION

Handgrip strength is a simple and inexpensive marker of health and mortality risk. It presents an ideal risk-stratifying method for use in low and middle-income countries (LMICs). There are, however, no population-based studies investigating the associations between handgrip strength and depression in LMICs. We aimed to assess these associations among community-dwelling middle-aged and older adults using nationally representative data from six LMICs.

METHOD

Cross-sectional data on individuals aged ≥ 50 years from the World Health Organization's Study on Global Ageing and Adult Health were analyzed. Depression was based on the Composite International Diagnostic Interview. Weak handgrip strength was defined as < 30 kg for men and < 20 kg for women using the average value of two handgrip measurements of the dominant hand. Multivariable logistic regression analysis was conducted.

RESULTS

The sample included 34,129 individuals (62.4 ± 16.0 years; 52.1% female). The prevalence of weak handgrip strength and depression were 47.4% and 6.2%, respectively. Individuals with weak handgrip strength had a higher prevalence of depression than those without this condition (8.8% vs. 3.8%; p < 0.001). Across all countries, after adjustment for potential confounders, weak handgrip strength was associated with a 1.45 (95%CI = 1.12-1.88) times higher odds for depression, although some between-country differences were noted.

DISCUSSION

Weaker handgrip strength is associated with higher odds for depression in LMICs. Future research should seek to establish the predictive value of this inexpensive measure for clinical use. Furthermore, interventional studies should examine if muscular strength can be a target of resistance-training interventions to address depressive symptoms in low-resourced settings.

Neurobiological effects of physical exercise in schizophrenia: a systematic review

PURPOSE

The aim of the present systematic review was to provide a summary of neurobiological effects of physical exercise for people with schizophrenia.

METHODS

A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Searches were conducted up to April 2013 across three databases: Medline, PsycINFO, and Embase. A methodological quality assessment using the Downs and Black Quality Index was carried out with all of the included studies.

RESULTS

Of the 654 initial data search results, two studies reported in 3 articles including 48 patients (six women) with schizophrenia, met the eligibility criteria. The methodological quality of each study was high. Data on hippocampal volume changes following physical exercise were conflicting while physical exercise-induced changes in other brain areas were absent. Increases in hippocampal volume following physical exercise were correlated with improvements in aerobic fitness and short-term memory.

CONCLUSIONS

Future research is needed to investigate whether brain health in people with schizophrenia is activity-dependent. Additionally, research that considers the neurobiological mechanisms and associated functional outcomes of physical exercise in individuals with schizophrenia is required.

IMPLICATIONS FOR REHABILITATION

Understanding the neurobiological effects of physical exercise in patients with schizophrenia may contribute to the development of new rehabilitation strategies. There is currently insufficient evidence to determine if physical exercise has a beneficial influence on the brain health of people with schizophrenia.

The Validity and Value of Self-reported Physical Activity and Accelerometry in People With Schizophrenia: A Population-Scale Study of the UK Biobank

BACKGROUND

Previous physical activity (PA) research in schizophrenia has relied largely upon self-report measures. However, the accuracy of this method is questionable. Obtaining accurate measurements, and determining what may influence PA levels in schizophrenia, is essential to understand physical inactivity in this population. This study examined differences in self-reported and objectively measured PA in people with schizophrenia and the general population using a large, population-based dataset from the UK Biobank.

METHODS

Baseline data from the UK Biobank (2007-2010) were analyzed; including 1078 people with schizophrenia (54.19 ± 8.39 years; 55% male) and 450549 without (56.44 ± 8.11; 46% male). We compared self-reported PA with objectively measured accelerometry data in schizophrenia and comparison samples. We also examined correlations between self-report and objective measures.

RESULTS

People with schizophrenia reported the same PA levels as those without, with no differences in low, moderate, or vigorous intensity activity. However, accelerometry data showed a large and statistically significant reduction of PA in schizophrenia; as people with schizophrenia, on average, engaged in less PA than 80% of the general population. Nonetheless, within the schizophrenia sample, total self-reported PA still held significant correlations with objective measures.

CONCLUSIONS

People with schizophrenia are significantly less active than the general population. However, self-report measures in epidemiological studies fail to capture the reduced activity levels in schizophrenia. This also has implications for self-report measures of other lifestyle factors which may contribute toward the poor health outcomes observed in schizophrenia. Nonetheless, self-report measures may still be useful for identifying how active individuals with schizophrenia relative to other patients.

The prevalence and moderators of clinical pain in people with schizophrenia: a systematic review and large scale meta-analysis

BACKGROUND

People with schizophrenia frequently have physical comorbidities that can cause pain. Experimental studies report reduced pain sensitivity among schizophrenia patients, but it remains unclear if clinically relevant pain is less prevalent in schizophrenia.

METHOD

We systematically searched major electronic databases from inception till 03/2014. Articles were included that reported the prevalence of clinical pain in people with schizophrenia. Two independent authors conducted searches, completed methodological quality assessment and extracted data. A random effects relative risks (RR) meta-analysis was conducted to determine the prevalence of all-cause and specific pain in schizophrenia, and the relative prevalence compared to the general population, and to assess moderators.

RESULTS

Altogether, 14 studies were included encompassing 242,703 individuals with schizophrenia (30.2-55.8 years) and 4,259,221 controls. Different types of pain were considered. The overall pooled prevalence of clinical pain in people with schizophrenia was 34.7% (95% CI=23.6-46.6). In the comparative analysis involving 7 studies with controls, the RR was 0.99 (95% CI=0.83-1.19). The pooled prevalence of headache among 94,043 individuals with schizophrenia was 29.9% (95% CI=3-69%) and the RR compared to 4,248,284 controls was 1.32 (95% CI=0.85-2.07). In moderator analyses, neither age, sex, study quality or pain assessment method influenced pain prevalence.

CONCLUSION

Clinical pain affects a third of people with schizophrenia and levels are similar with age- and sex-comparable controls. Future research is needed to determine if similar clinical pain prevalences in schizophrenia occur despite having more painful conditions, resulting from under-reporting, higher pain thresholds or lower help seeking behaviours.

Physical activity, exercise and mental disorders: It is time to move on

Introduction

Physical activity, conceptualized as any bodily movement that results in energy expenditure, and its structured form, exercise, play an important role in public health, preventing and treating a wide range of physical conditions, including metabolic and cardiovascular diseases and obesity.

Objective

This article aims to provide a brief overview and summary of the evidence on: 1) the preventive effects of physical activity on a wide range of mental disorders; 2) the role of physical activity in promoting the physical health of people with mental disorders; 3) the role of exercise as a strategy to manage mental health symptoms in a range of mental disorders; and 4) the challenges and barriers faced when implementing exercise in clinical practice.

Methods

This was a narrative review.

Results

Compelling evidence has demonstrated that physical activity and exercise can also prevent common mental disorders, such as depression and anxiety disorders, and have multiple beneficial effects on the physical and mental health of people with a wide range of mental disorders. This body of evidence has been incorporated in national and international guidelines over the last decades, which have recommended the inclusion of physical activity and exercise as therapeutic approaches for mental disorders, mainly for depression and schizophrenia. Nonetheless, implementation into clinical practice has been slow, probably due to barriers associated both with patients and mental health professionals.

Conclusion

Increases in physical activity levels in populations are likely to reduce the mental health burden. Exercise interventions should be incorporated to the routine care of people with mental disorders due its multiple benefits on physical and mental health outcomes. A multidisciplinary approach is needed to overcome patients barriers and enhance adherence and benefits.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

Physical activity and generalized anxiety disorder: results from The Irish Longitudinal Study on Ageing (TILDA)

Background

Generalized anxiety disorder (GAD) is prevalent and costly. Physical activity (PA) may protect against other mental health disorders, including depression, but its protective effect on GAD remains under-studied in the general population and unstudied among older adults. Therefore, the present study examines associations between meeting World Health Organization PA guidelines (i.e. ≥150 min of moderate PA, ≥75 min of vigorous PA or ≥600MET min of moderate and vigorous PA weekly) and the prevalence of probable GAD and incidence of GAD.

Methods

Participants (n  =  3950; 56.2% female) aged ≥50 years completed the short-form International Physical Activity Questionnaire and the abbreviated Penn State Worry Questionnaire at baseline and the Composite International Diagnostic Interview - Short Form to clinically assess GAD 2 years later. Prospective analyses included participants without probable GAD at baseline (n  =  3236).

Results

Prevalence and incidence of GAD were 18.1% (n  =  714) and 0.9% (n  =  29), respectively. More respondents with GAD were female (72.2% vs 52.7%), aged 50-59 years (51.7% vs 38.7%), had normal waist circumference (52.7% vs 47.8) and smoked (20.4% vs 13.3%; all P <0.05). Meeting PA guidelines was associated with 25% and 63% lower odds of prevalent [odds ratio (OR)  =  0.75, 95% confidence interval: 0.64 to 0.88] and incident (OR  =  0.37, 0.17 to 0.85) GAD, respectively, in crude models, and 17% and 57% lower odds of prevalent (OR  =  0.83, 0.70 to 0.98) and incident (OR  =  0.43, 0.19 to 0.99) GAD, respectively, following adjustment for age, sex, waist circumference, social class and smoking.

Conclusions

In addition to established physical health benefits of PA, the present findings support the importance of increasing PA at the population-level for mental health.

Predictors of Falls and Fractures Leading to Hospitalization in People With Dementia: A Representative Cohort Study

OBJECTIVES

Investigate predictors of falls and fractures leading to hospitalization in a large cohort of people with dementia.

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

People with diagnosed dementia between January 2007 and March 2013, aged >65 years, were assembled using data from the Maudsley Biomedical Research Centre Case Register, from 4 boroughs in London serving a population of 1.3 million people.

MEASURES

Falls and/or fractures leading to hospitalization were ascertained from linked national records. Demographic data, cognitive test scores, medications, and symptom and functioning scores from Health of the Nation Outcome Scales (HoNOS65+) were modeled in multivariate survival analyses to identify predictors of falls and fractures.

RESULTS

Of 8036 people with dementia (63.9% female), 2500 (31.1%, incidence rate 125.5 per 1000 person-years) had a fall during a mean follow-up of 2.5 years and 1437 (17.7%, incidence rate 65.5 per 1000 person-years) had a fracture. In multivariable models, significant predictors of falls were increased age, female gender, physical health problems, previous fall or fracture, vascular dementia vs Alzheimer's disease, higher neighborhood deprivation, noncohabiting status, and problems with living conditions. Ethnic minority status was protective of falls (eg, Caribbean/Asian ethnicity). Medications (including psychotropic and antipsychotics), neuropsychiatric symptoms, cognitive (Mini-Mental State Examination scores), or functional problems did not predict hospitalized falls. Predictors of fractures were similar to those predicting falls.

IMPLICATIONS

Over an average of 2.5 years, a third of people with dementia had a fall leading to hospitalization, necessitating action in clinical practice. Clinicians should consider that besides established demographic and physical health-related factors, the risk of hospitalization due to a fall or fractures in dementia is largely determined by environmental and socioeconomic factors. Interestingly, our data suggest that neuropsychiatric symptoms, cognitive status, functioning, or pharmacotherapy were not associated with falls/fractures.

Association between depression and smoking: A global perspective from 48 low- and middle-income countries

BACKGROUND

Smoking is a leading modifiable cause of global morbidity and mortality. Research from high-income countries has found a high prevalence of smoking among people with depression and suggested that this may partially contribute to the increased premature mortality in this population. Limited research has investigated smoking behaviors across the depression spectrum and in low- and middle-income countries (LMICs). This study explored the relationship between depression and smoking across 48 LMICs.

METHODS

We conducted a cross-sectional, community-based study comprising 242,952 people [mean age 38.4 (SD = 16.1) years, 50.8% females] from the World Health Survey. Multivariable binary logistic regression analyses were performed to investigate the relationship between depression (including subsyndromal, brief depressive episode and depressive episodes) and smoking behaviours.

RESULTS

Overall, the prevalence of current smoking was lowest in Africa (13.5%) and highest in Asia (32.2%). A depressive episode was present in 6.7% of the sample. Compared to people without depression, subsyndromal depression, brief depressive episode, and depressive episodes were all significantly associated with smoking with similar effect sizes (ORs: 1.36-1.49). Countrywide meta-analysis found that the pooled overall OR for smoking in depression was 1.42 (95%CI = 1.32-1.52, I² = 39.7%). Furthermore, alcohol consumption and male gender were consistently associated with smoking across all regions and smoking was consistently less common in those who were wealthier and had a higher education.

CONCLUSION

These data suggest that the depression spectrum is consistently associated with high levels of smoking behaivours in LMICs. Given that most of the world's smokers reside in LMICs, future smoking cessation interventions are required to target people with depression.

Reliability, minimal detectable changes, practice effects and correlates of the 6-min walk test in patients with schizophrenia

We examined the reproducibility of the 6-min walk test (6 MWT) in patients with schizophrenia. Secondary aims were to assess minimal detectable changes and practice effects of the 6 MWT and the presence of clinical conditions that might interfere. From 71 patients with schizophrenia two trials of the 6 MWT, administered within 3 days, were analysed. The intraclass correlation coefficient between the two tests was 0.96. The minimal detectable change was 56.2m for men and 50.2m for women. Body mass index, daily antipsychotic dose, negative and depressive symptoms, resting heart rate, age, smoking behavior and different musculoskeletal complaints were all significantly associated with the distance walked. The 6 MWT can be recommended for evaluating the functional exercise capacity in patients with schizophrenia. Some practice effect could however not be excluded.

The Association Between Sedentary Behavior and Sarcopenia Among Adults Aged ≥65 Years in Low- and Middle-Income Countries

The present study aimed to assess the association between sedentary behavior and sarcopenia among adults aged ≥65 years. Cross-sectional data from the Study on Global Ageing and Adult Health were analyzed. Sarcopenia was defined as having low skeletal muscle mass and either a slow gait speed or a weak handgrip strength. Self-reported sedentary behavior was assessed as a continuous variable (hours per day) and also as a categorical variable (0-<4, 4-<8, 8-<11, ≥11 hours/day). Multivariable logistic regression was conducted to assess the association between sedentary behavior and sarcopenia. Analyses using the overall sample and country-wise samples were conducted. A total of 14,585 participants aged ≥65 years were included in the analysis. Their mean age was 72.6 (standard deviation, 11.5) years and 55% were females. Compared to sedentary behavior of 0-<4 hours/day, ≥11hours/day was significantly associated with 2.14 (95% CI = 1.06-4.33) times higher odds for sarcopenia. The country-wise analysis showed that overall, a one-hour increase in sedentary behavior per day was associated with 1.06 (95% CI = 1.04-1.10) times higher odds for sarcopenia, while the level of between-country heterogeneity was low (I2 = 12.9%). Public health and healthcare practitioners may wish to target reductions in sedentary behavior to aid in the prevention of sarcopenia in older adults.