Depressive symptomatology and fracture risk in community-dwelling older men and women

The prognostic role of depression as a predictor of chronic somatic diseases manifestation

The negative impact of depression on the course and outcome of somatic disorders is well-known and has a solid theoretical basis. The analyses of prospective studies confirm the role of depression as an independent and significant risk factor for widespread chronic somatic disorders including such severe and life-threatening conditions as cardiovascular diseases, diabetes and oncological pathology. The majority of somatic disorders and depression are the part of the big class of hereditary diseases with multifactorial character and polygenic nature. It is likely, that the genetic risk diversity of these diseases in population is close. There is also a high probability of genetic risks levels overlap (or of common «cluster») of two or more diseases in one individual, with one disorder being major depression. In that case such diseases could be considered «genetically comorbid» and manifestation of one disease could alter the risks of other. Precise and informative diagnostic tools could detect subsyndromal depression that could be the prognostic sign of the high risk and rapid manifestation of somatic diseases. Thus, patients with depressive disorder could be considered as a group with high risks of diverse range of somatic pathology. The coalescence of fundamental biomedical scientists and internists (psychiatrists and other physicians) could lead to the elaboration of specific complex preventative measures including social ones.

Association between depression and the risk for fracture: a meta-analysis and systematic review

BACKGROUND

Several studies have suggested that depression is associated with an increased risk for fracture; however, the results are conflicting. This study aimed to conduct a meta-analysis of cohort studies assessing the association between depression and the risk for fracture.

METHODS

Relevant studies were identified by a search of Web of Science, PubMed, Embase, China National Knowledge Infrastructure and WanFang database to Feb 2018. Cohort studies on the relationship between depression and the risk for fracture in the general population were included in the meta-analysis. Data collection was in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines, and the quality of the included studies was assessed using the Newcastle-Ottawa scale. Two independent investigators screened the abstracts and full texts of the studies, extracted data, and assessed the quality of the study. Either a fixed-effect or random-effects model was used to compute the pooled risk estimates when appropriate.

RESULTS

In total, 16 cohort studies with 25 independent reports that included 414,686 participants during a follow-up duration of 3-14 years were included in the analysis. The pooled hazard ratio (HR) for total fracture was 1.24 (95% confidence interval [CI]: 1.14-1.35; P < 0.001 for heterogeneity; random-effects model). In the subgroup analyses conducted in terms of study region, the pooled HR for the studies conducted in Europe was higher (HR: 1.76; 95% CI: 1.44-2.17; P = 0.792 for heterogeneity) than that in America and Asia, with a significant difference between the groups (P = 0.036).

CONCLUSION

The results of our meta-analysis suggest that depression is prospectively associated with a significantly increased risk for fracture, which may have substantial implications, both clinical and preventive.

Depression and risk of fracture and bone loss: an updated meta-analysis of prospective studies

This meta-analysis pooled results from 23 qualifying individual cohort studies and found that depression was significantly associated with an increased risk of fractures and bone loss.

INTRODUCTION

The association between depression and risk of fracture remains controversial. We conducted a comprehensive meta-analysis to examine the effect of depression on the risk of osteoporotic fractures and bone loss.

METHODS

We searched databases and reviewed citations in relevant articles for eligible cohort studies. Two investigators independently conducted study selection, appraisal, and data abstraction through the use of a standardized protocol. Random effect models were used for meta-analysis. Cochrane Q and I² statistics were used to assess heterogeneity. Funnel plots and rank correlation tests were used to evaluate publication bias.

RESULTS

Twenty-three studies were included for meta-analysis. In studies that reported hazard ratio (HR) as the outcome (nine studies [n = 309,862]), depression was associated with 26% increase in fracture risk (HR = 1.26, 95% CI, 1.10-1.43, p < 0.001). Studies that reported risk ratio (RR) as the outcome (seven studies [n = 64,975]) suggested that depression was associated with 39% increase in fracture risk (RR = 1.39, 95% CI, 1.19-1.62, p < 0.001). Among studies that reported hip bone mineral density (BMD) as an outcome (eight studies [n = 15,442]), depression was associated with a reduced mean annual bone loss rate of 0.35% (0.18-0.53%, p < 0.001). The increased risk of fracture and bone loss associated with depression was consistent in all meta-analysis having modified inclusion criteria and in different subgroup analyses as well. Significant heterogeneity was observed in the meta-analysis; however, no significant publication bias was detected.

CONCLUSION

Depression is associated with a significant increased risk in fracture and bone loss. Effective prevention may decrease such risk.

Bipolar disorder and the risk of fracture: A nationwide population-based cohort study

BACKGROUND

The co-primary aims are: 1) to compare the risk of fracture between adults with bipolar disorder and those without bipolar disorder; and 2) to assess whether lithium, anticonvulsants and antipsychotics reduce risk of fracture among individuals with bipolar disorder.

METHODS

The analysis herein is a population-based retrospective cohort study, utilizing the National Health Insurance (NHI) medical claims data collected between 1997 and 2013 in Taiwan. We identified 3705 cases with incident diagnoses of bipolar disorder during study period and 37,050 matched controls without bipolar diagnoses. Incident diagnosis of fracture was operationalized as any bone fracture after the diagnosis of bipolar disorder or after the matched index date for controls.

RESULTS

Bipolar patients had significantly higher risk of facture when compared to matched controls (17.6% versus 11.7%, respectively p<0.001). The hazard ratio (HR) was 1.33 (95% confidence interval [CI]＝1.23-1.48, p<0.001) after adjusting for covariates. Persons with bipolar disorder and a prior history of psychiatric hospitalization were had higher risk for bone fracture than those without prior history of psychiatric hospitalization when compared to match controls. Higher cumulative dose of antipsychotics or mood stabilizers did not increase the risk of fracture.

LIMITATIONS

The diagnoses of bipolar disorder were not confirmed with structured clinical interview. Drug adherence, exact exposure dosage, smoking, lifestyle, nutrition and exercise habits were unable to be assessed in our dataset.

CONCLUSIONS

Bipolar disorder is associated with increased risk of fracture, and higher cumulative dose of mood stabilizers and antipsychotics did not further increase the risk of fracture.

Risk of Vertebral Fracture in Patients Diagnosed with a Depressive Disorder: A Nationwide Population-Based Cohort Study

OBJECTIVE:

Previous studies have reported that depression may play a crucial role in the occurrence of vertebral fractures. However, a clear correlation between depressive disorders and osteoporotic fractures has not been established. We explored the association between depressive disorders and subsequent new-onset vertebral fractures. Additionally, we aimed to identify the potential risk factors for vertebral fracture in patients with a depressive disorder.

METHODS:

We studied patients listed in the Taiwan National Health Insurance Research Database who were diagnosed with a depressive disorder by a psychiatrist. The comparison cohort consisted of age- and sex-matched patients without a depressive disorder. The incidence rate and hazard ratios of subsequent vertebral fracture were evaluated. We used Cox regression analysis to evaluate the risk of vertebral fracture among patients with a depressive disorder.

RESULTS:

The total number of patients with and without a depressive disorder was 44,812. The incidence risk ratio (IRR) between these 2 cohorts indicated that depressive disorder patients had a higher risk of developing a subsequent vertebral fracture (IRR=1.41, 95% confidence interval [CI]=1.26-1.57, p<0.001). In the multivariate analysis, the depressive disorder cohort showed a higher risk of vertebral fracture than the comparison cohort (adjusted hazard ratio=1.24, 95% CI=1.11-1.38, p<0.001). Being older than 50 years, having a lower monthly income, and having hypertension, diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease, autoimmune disease, or osteoporosis were considered predictive factors for vertebral fracture in patients with depressive disorders.

CONCLUSIONS:

Depressive disorders may increase the risk of a subsequent new-onset vertebral fracture.

Effects of depression and antidepressant medications on hip fracture: A population-based cohort study in Taiwan

This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19-2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91-1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30-1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with depression revealed that antidepressants had no negative impact on the incidence of hip fracture. In conclusion, major depression was found to be a risk factor for hip fracture and that use of antidepressants had no adverse effect on hip fracture in the Taiwanese population.

Depression and Reduced Bone Mineral Density at the Hip and Lumbar Spine: A Comparative Meta-Analysis of Studies in Adults 60 Years and Older

PURPOSE

Older adults with depression are more likely to experience fractures, but it is unclear if this group has reduced bone mineral density (BMD). We conducted a systematic review and meta-analysis to compare BMD in older adults (60 years or older) with or without depression.

METHODS

Two independent authors conducted searches of major electronic databases from inception till April 2015. Articles that measured BMD (in g/cm) by dual-energy x-ray absorptiometry at the hip or lumbar spine in a sample with depression (including those with major depressive disorder and depressive symptoms, henceforth called "depression") and a control group were included. A random-effects meta-analysis and meta-regression were conducted.

RESULTS

Eleven publications across 10 unique studies representing 2511 participants with depression (mean [standard deviation] = 67.4 [6.5] years, 41.8% female) and 32,574 matched controls (mean [standard deviation] = 67.5 [5.9] years, 38.9% female) were included. Only one study confirmed a diagnosis of major depressive disorder, seven studies used a screening measure to define depressive symptoms, and two studies categorized depression by antidepressant medication use. Meta-analysis established that BMD is reduced at the hip in older adults with depression (g = -0.141, 95% confidence interval = -0.220 to -0.062, p < .0001, I = 61%). Meta-analysis from seven studies suggests that lumbar spine BMD may be reduced (g = -0.122, 95% confidence interval = -0.250 to 0.005, p = .06, I = 71%).

CONCLUSIONS

Hip BMD is reduced in older adults with depression, although the effect size is small. Nevertheless, considering the deleterious impact of hip fractures in this population, the results are important. Future research should seek to disentangle the independent effects of depression and antidepressant medication on bone loss in older age.

Depression as a risk factor for fracture in women: A 10 year longitudinal study

BACKGROUND

Previous research has demonstrated deficits in bone mineral density (BMD) among individuals with depression. While reduced BMD is a known risk for fracture, a direct link between depression and fracture risk is yet to be confirmed.

METHODS

A population-based sample of women participating in the Geelong Osteoporosis Study was studied using both nested case-control and retrospective cohort study designs. A lifetime history of depression was identified using a semi-structured clinical interview (SCID-I/NP). Incident fractures were identified from radiological reports and BMD was measured at the femoral neck using dual energy absorptiometry. Anthropometry was measured and information on medication use and lifestyle factors was obtained via questionnaire.

RESULTS

Among 179 cases with incident fracture and 914 controls, depression was associated with increased odds of fracture (adjusted odds ratio (OR) 1.57, 95%CI 1.04-2.38); further adjustment for psychotropic medication use appeared to attenuate this association (adjusted OR 1.52, 95%CI 0.98-2.36). Among 165 women with a history of depression at baseline and 693 who had no history of depression, depression was associated with a 68% increased risk of incident fracture (adjusted hazard ratio (HR) 1.68, 95%CI 1.02-2.76), with further adjustment for psychotropic medication use also appearing to attenuate this association (adjusted HR 1.58, 95%CI 0.95-2.61).

LIMITATIONS

Potential limitations include recall bias, unrecognised confounding and generalizability.

CONCLUSIONS

This study provides both cross-sectional and longitudinal evidence to suggest that clinical depression is a risk factor for radiologically-confirmed incident fracture, independent of a number of known risk factors. If there is indeed a clinically meaningful co-morbidity between mental and bone health, potentially worsened by psychotropic medications, the issue of screening at-risk populations needs to become a priority.

Multimorbidity in women with and without osteoporosis: results from a large US retrospective cohort study 2004-2009

To determine the incidence of comorbidities in women with and without osteoporosis, incidence rates per 1,000 person-years were calculated using electronic health records from an integrated healthcare system. The overall comorbidity burden and health service utilization were greater in women with osteoporosis than in the controls.

INTRODUCTION

This retrospective cohort study describes the incidence of an array of comorbidities in women with and without osteoporosis (OP).

METHODS

Using electronic health records from an integrated healthcare system, we identified 22,414 women aged 55-89 years with OP and 22,414 age-matched controls without OP. Incidence rates (IRs) per 1,000 person-years (P-Y) were calculated and 95% confidence intervals (CI) were estimated.

RESULTS

Women with OP had significantly more comorbidities, medications, hospitalizations, and outpatient visits than the controls. Most cardiac comorbidity rates were 20-25% lower in the OP cohort than in the control cohort. Hypertension had the largest rate difference; the IR was 42.0 per 1,000 P-Y (95% CI 40.2-44.0) in the OP cohort compared to 94.0 (95% CI 90.7-97.4) in the control cohort. Rates for cerebrovascular disease were similar for both cohorts at 26 per 1,000 P-Y. Bronchitis, sinusitis, and cystitis were each 55 per 1,000 P-Y in the OP cohort, whereas they ranged from 28 to 34 per 1,000 P-Y in the controls. The OP cohort had decreased incidence of ovarian, uterine, colorectal, and liver cancers and increased incidence of lung cancer, breast cancer, and multiple myeloma, compared to the non-OP cohort. Falls, depression, vision, and musculoskeletal issues were higher for the OP cohort than the controls.

CONCLUSIONS

This study demonstrates the high disease burden in women with OP. This knowledge may help guide the clinical management of this population and may aid in the interpretation of adverse events in randomized clinical trials of OP therapies.

Depression, antidepressants, and bone health in older adults: a systematic review

OBJECTIVES

To examine the association between depression, antidepressant use, and bone health in older adults and the implications for treatment.

DESIGN

Systematic review.

SETTING

All studies that measured depression or antidepressant exposure and bone mineral density (BMD).

PARTICIPANTS

Adults aged 60 and older.

MEASUREMENTS

Age, site of BMD measurement using dual-energy X-ray absorptiometry (DXA), measure of depression or depressive symptoms, association between BMD changes, and depression or antidepressant use.

RESULTS

Nineteen observational studies met the final inclusion criteria; no experimental studies were found. Several cross-sectional and longitudinal studies found that depression or depressive symptoms were associated with a decrease in BMD. Few studies and only two longitudinal studies addressed the association between serotonin reuptake inhibitor (SRI) antidepressant use and a decrease in BMD and they had conflicting results.

CONCLUSION

Depression and depressive symptoms are associated with low bone mass and accelerated bone loss in older adults; putative mechanisms underlying this relationship are discussed. There is insufficient evidence that SRI antidepressants adversely affect bone health. Thus, a change in current recommendations for the use of antidepressants in older adults is not justified at the present time. Given the high public health significance of this question, more studies are required to determine whether (and in whom) antidepressants may be deleterious for bone health.

Antidepressant use and 10-year incident fracture risk: the population-based Canadian Multicentre Osteoporosis Study (CaMoS)

We used data from a large, prospective Canadian cohort to assess the association between selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) and fracture. We found an increased risk of fractures in individuals who used SSRI or SNRI, even after controlling for multiple risk factors.

INTRODUCTION

Previous studies have suggested an association between SSRIs and increasing risk of fragility fractures. However, the majority of these studies were not long-term analyses or were performed using administrative data and, thus, could not fully control for potential confounders. We sought to determine whether the use of SSRIs and SNRIs is associated with increased risk of fragility fracture, in adults aged 50 + .

METHODS

We used data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective randomly selected population-based community cohort; our analyses focused on subjects aged 50+. Time to event methodology was used to assess the association between SSRI/SNRI use, modeled time-dependently, and fragility fracture.

RESULTS

Among 6,645 subjects, 192 (2.9%) were using SSRIs or/and SNRIs at baseline. During the 10-year study period, 978 (14.7%) participants experienced at least one fragility fracture. In our main analysis, SSRI/SNRI use was associated with increased risk of fragility fracture (hazard ratio (HR), 1.88; 95% confidence intervals (CI), 1.48-2.39). After controlling for multiple risk factors, including Charlson score, previous falls, and bone mineral density hip and lumbar bone density, the adjusted HR for current SSRI/SNRI use remained elevated (HR, 1.68; 95% CI, 1.32-2.14).

CONCLUSIONS

Our results lend additional support to an association between SSRI/SNRI use and fragility fractures. Given the high prevalence of antidepressants use, and the impact of fractures on health, our findings may have a significant clinical impact.

The "depressive" face of osteoporosis and the "osteoporotic" face of depression

Osteoporosis and depression are two chronic diseases that affect large population groups with great impact on morbidity, mortality and quality of life. An association between osteoporosis and depression has been described in the literature. Definitely, limited data suggest that osteoporosis may enhance depressive symptoms, while far more studies have shown that depression adversely affects bone density and increases fracture risk. However, neither causation nor a firm pathophysiological connection has been established. Thus the correlation of these diseases is still under research. This review comments on a plausible causative relationship and underlying mechanisms that might elucidate the link between two very common diseases. We describe the possible impact of osteoporosis on moods and the (better established) effect of depression on bone health. We also describe the effect of medication and review hormonal and cellular signals that may explain this effect.

Depressive symptoms and rates of bone loss at the hip in older men

In this prospective cohort study, depressive symptoms were associated with higher rates of bone loss in older men. Poorer performance on physical function tests partly explained the association between depressive symptoms and bone loss, suggesting that efforts to increase exercise and improve physical performance in depressed men may be beneficial.

INTRODUCTION

The aim of this study was to ascertain whether depressive symptoms are associated with increased rates of bone loss at the hip in older men.

METHODS

A population-based prospective cohort study of 2,464 community-dwelling men, aged 68 and older, enrolled in the Osteoporosis in Men Sleep Ancillary Study had depressive symptoms assessed by the Geriatric Depression Scale (GDS). Subjects were categorized as depressed if GDS ≥6 at the initial examination. Bone mineral density (BMD) at the hip was measured using dual-energy X-ray absorptiometry at the initial and follow-up examination (average 3.4 years between exams). Use of antidepressant medications was assessed by interview and verified from medication containers at the two examinations. A computerized dictionary was used to categorize type of medication.

RESULTS

In a base model adjusted for age, race/ethnicity, and clinic site, the mean total hip BMD decreased 0.70 %/year in 136 men with a GDS score of ≥6 compared to 0.39 %/year in 2,328 men with a GDS score of <6 (p = 0.001). Walking speed and timed chair stand partly explained the association between depressive symptoms and rates of bone loss.

CONCLUSION

Depression, as defined by a score of 6 or greater on the Geriatric Depression Scale, is associated with an increased rate of bone loss at the hip in this cohort of older men. Adjustment for walking speed and timed chair stand attenuated the strength of the association, suggesting that differences in physical functioning do partially explain the observed association.

Risk of nonvertebral fractures among elderly postmenopausal women using antidepressants

OBJECTIVE

To examine the association between antidepressants, including TCAs, SSRIs, and miscellaneous antidepressants and the risk of nonvertebral fractures among women with osteoporosis.

MATERIALS AND METHODS

This study was a post-hoc analysis of pooled data from two international, phase III, randomized, placebo-controlled, double-blind studies (the Spinal Osteoporosis Therapeutic Intervention [SOTI] and TReatment Of Peripheral OSteoporosis [TROPOS]). A nested case-control study was performed in the placebo treated population. Adjusted logistic regression models were used to estimate the risk of nonvertebral fracture associated with the use of antidepressants.

RESULTS

After 3 years of follow-up, 391 nonvertebral fractures cases were identified and matched to 1955 controls. Compared with non-users of antidepressants, antidepressants use was associated with an increased risk of nonvertebral fractures (adjusted OR=1.64; 95%CI, 1.03-2.62]). Particularly, there was a 2-fold risk increase (95%CI, 1.07-3.79) of nonvertebral fracture for current users of SSRIs and a 2.1-fold risk increase for subjects who were current users of TCAs (95%CI, 1.02-4.30). Among patients categorized as recent or past users, none of the classes of antidepressants were statistically associated with increased risk of nonvertebral fracture.

CONCLUSIONS

Our findings confirm that both SSRIs and TCAs increase the risk of nonvertebral fracture in current users.

Depressed mood and cause-specific mortality: a 40-year general community assessment

PURPOSE

The current study describes how the excess mortality risk associated with depression translates into specific causes of death occurring during a 40-year follow-up period, with focus on deaths related to injuries, cardiovascular diseases, and cancer.

METHODS

Data come from a cross-sectional survey (Community Mental Health Epidemiology Study) conducted in the early 1970s in Washington County, Maryland. Random sampling for the survey resulted in 2762 interviews. For the current analyses, baseline depressed mood was linked to current participant vital status through the use of death certificates.

RESULTS

The relative subdistribution hazards for cardiovascular deaths (3.08 [1.74-5.45]) and fatal injuries (4.63 [1.76-12.18]) were significant during the entire 40-year period for young adults (18-39 years old at baseline). The relative subdistribution hazard for cardiovascular deaths during the first 15 years of follow-up was pronounced in elderly (≥ 65 years) males (2.99 [1.67-5.37]) subjects. There were no significant associations between depressed mood and cancer deaths.

CONCLUSIONS

Individuals in the general community with depressed mood may be at increased risk of deaths as the result of cardiovascular disease and injury, even several decades after exposure assessment. Young adults with depressed mood appear to be particularly vulnerable to these associations.

Symptoms of anxiety or depression and risk of fracture in older people: the Hertfordshire Cohort Study

The aim of this study was to examine the prospective association between symptoms of anxiety and depression and risk of fracture in older people. Results showed that men, but not women, with probable anxiety at baseline had an increased risk of fracture.

INTRODUCTION

The use of psychotropic drugs has been linked with an increased risk of fracture in older people, but there are indications that the conditions for which these drugs were prescribed may themselves influence fracture risk. The aim of this study was to investigate the relation between symptoms of anxiety and depression and risk of fracture in older people. The study design is a prospective cohort study.

METHODS

One thousand eighty-seven men and 1,050 women aged 59-73 years completed the Hospital Anxiety and Depression Scale (HADS). Data on incident fracture during an average follow-up period of 5.6 years were collected through interview and a postal questionnaire.

RESULTS

Compared to men with no or few symptoms of anxiety (score ≤7 on the HADS anxiety subscale), men with probable anxiety (score ≥11) had an increased risk of fracture: After adjustment for age and potential confounding factors, the odds ratio (OR) (95 % confidence interval) was 4.03 (1.55, 10.5). There were no associations between levels of anxiety and fracture risk in women. Few men or women had probable depression at baseline (score ≥11 on the HADS depression subscale). Amongst men with possible depression (score 8-10), there was an increased risk of fracture that was of borderline significance: multivariate-adjusted OR 3.57 (0.99, 12.9). There was no association between possible depression and fracture risk in women.

CONCLUSIONS

High levels of anxiety in older men may increase their risk of fracture. Future research needs to replicate this finding in other populations and investigate the underlying mechanisms.

Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study

OBJECTIVES

To examine whether overall depressive symptoms and symptom clusters are associated with fall risk and to determine whether chronic pain mediates the relationship between depression and fall risk in aging.

DESIGN

Prospective cohort study.

SETTING

Boston, Massachusetts, and surrounding communities.

PARTICIPANTS

Older community-dwelling adults (N = 722, mean age 78.3).

MEASUREMENTS

Depressive symptomatology was assessed at baseline using the 20-item Hopkins Revision of the Center for Epidemiologic Studies Depression Scale (CESDR) as overall depression and two separate domains: cognitive and somatic symptoms. Chronic pain was examined at baseline as number of pain sites (none, single site, or multisite), pain severity, and pain interference with activities of daily living. Participants recorded falls on monthly postcards during a subsequent 18-month period.

RESULTS

According to negative binomial regression, the rate of incident falls was highest in those with the highest burden of depressive symptoms (according to total CESDR and the cognitive and somatic CESDR domains). After adjustment for multiple confounders and fall risk factors, fall rate ratios comparing the highest three CESDR quartiles with the lowest quartile were 1.91, 1.26, and 1.11, respectively. Similarly graded associations were observed according to the CESDR domains. Although pain location and interference were mediators of the relationship between depression and falls, adjustment for pain reduced fall risk estimates only modestly. There was no interaction between depression and pain in relation to fall risk.

CONCLUSION

Depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain. Research is needed to determine effective strategies for reducing fall risk and related injuries in older people with pain and depressive symptoms.

Connections between the outcomes of osteoporotic hip fractures and depression, delirium or dementia in elderly patients: rationale and preliminary data from the CODE study

BACKGROUND

osteoporosis, depression and other neuro-psychiatric disorders are very common after 50 years of age. Although these conditions recognize several and specific etiologic factors, they however appear to share physiologic, environmental processes and risk factors which may explain their possible association.

METHODS

we have built up a specific research project (the CODE study, Connections between the outcomes of osteoporotic hip fractures and depression, delirium or dementia in elderly patients), and carried out a preliminary survey on 55 hip fractured elderly patients (42 women, mean age 85 years old and 13 men, mean age 82 years old), hospitalized at SS. Annunziata hospital in Florence from July to September 2010.

RESULTS

there was a significant difference (p=0.010) in the functional recovery after surgery (as measured by Cumulated Ambulation Score, CAS) between depressed and non-depressed subjects (n=38), with a worse recovery and a lower CAS score in depressed patients (n=17). We also observed a higher prevalence of depression in the osteoporotic-fragile elderly people (69,1% of total sample).

CONCLUSION

our preliminary survey has validated the suitability of the CODE study protocol in assessing connections between outcomes of osteoporotic hip fractures and depression in elderly patients, fostering the extension of the study (and suggesting also the inclusion of delirium and dementia) within a multicentric prospective study aimed to provide specific information and guidelines for osteoporotic fractured patients with concomitant depression or other neuro-psychiatric disorders.

Osteoporosis piece of multi-morbidity puzzle in geriatric care

Osteoporosis frequently coexists with other chronic diseases and syndromes of aging, and therefore multimorbidity interactions can potentially complicate its evaluation and treatment. This article reviews osteoporosis comorbidity interactions with select common diseases of aging including cardiovascular, neurologic, and geriatric syndromes, and select commonly used medications by older adults. Using depression as a case example, we describe the complex relationship between osteoporosis, mood, and antidepressant medications, and the implications of these interactions for patients and clinicians.

Depression, fracture risk, and bone loss: a meta-analysis of cohort studies

Whether depression can increase the risk of bone fractures is uncertain. This meta-analysis, which pooled results from 14 qualifying individual cohort studies, found that depression was associated with a significantly increased risk of fractures and bone loss.

INTRODUCTION

The effect of depression on the risk of bone fractures is controversial. We conducted a meta-analysis of prospective studies that examined the risk of osteoporotic fractures and bone loss associated with depression.

METHODS

We searched databases and reviewed citations in relevant articles to identify cohort studies that met prestated inclusion criteria; 14 studies were identified. Information on study design, participant characteristics, exposure and outcome measures, control for potential confounders, and risk estimates was abstracted independently by two investigators using a standardized protocol. Data were pooled by use of a random-effects model.

RESULTS

In studies that reported fracture outcomes as hazard ratios (HRs) (six studies [n = 108,157]), depression was associated with a 17% increase in fracture risk (HR = 1.17; 95% confidence interval [CI], 1.00-1.36; P = 0.05); in studies that reported risk ratios as fracture outcomes (four studies [n = 33,428]), depression was associated with a 52% increase in risk (risk ratio, 1.52; 95% CI, 1.26-1.85; P < 0.001). In studies that reported bone mineral density as an outcome (five studies [n = 8,931]), depression was associated with a reduced annualized bone loss rate of 0.25% (0.05-0.45%; P = 0.02) at the hip and 0.29% (-0.07-0.64%; P = 0.11) at the spine. The HR for the three studies (n = 14,777) that did not adjust for antidepressant treatment was 1.30 (95% CI, 1.11-1.52; P = 0.01), and the HR for the three studies (n = 93,380) that did adjust for antidepressant treatment was 1.05 (95% CI, 0.86-1.29; P = 0.6).

CONCLUSION

Evidence supports an association between depression and increased risk of fracture and bone loss that may be mediated by antidepressants.

Update in serotonin and bone

CONTEXT

Serotonin (5-HT) may be an important regulatory agent in bone, and agents that modify 5-HT signaling, such as selective serotonin reuptake inhibitors (SSRIs), are in widespread clinical use.

EVIDENCE ACQUISITION

Evidence was obtained by PubMed search and the author's knowledge of the field.

EVIDENCE SYNTHESIS

Recent data suggest that gut-derived 5-HT may mediate the skeletal effects of LDL receptor-related protein 5, stimulating intense interest in a novel mechanism for regulating bone mass. However, the specific biochemical nature of serotonergic pathways influencing bone and their direct and/or indirect effects on bone metabolism are still unclear. The weight of epidemiological evidence suggests that SSRIs are associated with reduced bone mass, increased bone loss, and increased risk of fractures. Interpretation of these studies is complicated by the confounding effects of depression, the usual indication for treatment with SSRIs. The mechanisms for putative SSRI-induced deleterious effects on the skeleton are unknown, and are likely multifactorial.

CONCLUSIONS

5-HT may have regulatory effects on bone. Initial preclinical data suggest that its effects may be deleterious and may be regulated by low-density lipoprotein receptor-related protein 5. These studies need confirmation, as well as elucidation, of the biochemical pathways utilized and the feedback loops involved among bone, gut, and perhaps brain. Paradoxically, targeting of 5-HT synthesis and/or signaling in selective tissues may hold promise as an anabolic intervention for bone. Epidemiological data suggest that clinicians should be vigilant about detection of bone disease in patients who are using SSRIs.

Sleep quality in residents of assisted living facilities: effect on quality of life, functional status, and depression

OBJECTIVES

To describe sleep patterns in older adults living in assisted living facilities (ALFs) and to explore the relationship between sleep disturbance and quality of life, functional status, and depression over 6 months of follow-up.

DESIGN

Prospective, observational cohort study.

SETTING

Eighteen ALFs in the Los Angeles area.

PARTICIPANTS

One hundred twenty-one ALF residents aged 65 and older (mean age 85.3, 86% female, 88% non-Hispanic white).

MEASUREMENTS

Data were collected at baseline and 3 and 6 months after enrollment. Data collected were demographics, physical and cognitive functioning, depression, quality of life, comorbidities, medications, and subjective (i.e., questionnaires) and objective (i.e., 3 days and nights of wrist actigraphy) measures of sleep.

RESULTS

Sixty-five percent of participants reported clinically significant sleep disturbance on the Pittsburgh Sleep Quality Index, and objective wrist actigraphy confirmed poor sleep quality. In regression analyses including sleep variables and other predictors, more self-reported sleep disturbance at baseline was associated with worse health-related quality of life (Medical Outcomes Study 12-item Short Form Survey Mental Component Summary score) and worse depressive symptoms five-item Geriatric Depression Scale at follow-up. Worse nighttime sleep (according to actigraphy) at baseline was associated with worse activities of daily living functioning and more depressive symptoms at follow-up.

CONCLUSIONS

Sleep disturbance is common in older ALF residents, and poor sleep is associated with declining functional status and quality of life and greater depression over 6 months of follow-up. Studies are needed to determine whether improving sleep in ALF residents will result in improvements in these outcomes. Well-established treatments should be adapted for use in ALFs and systematically evaluated in future research.

Effects of selective serotonin reuptake inhibitors on bone health in adults: time for recommendations about screening, prevention and management?

Evidence regarding a functional serotonin (5-hydroxytryptamine) signaling system in bone has generated considerable recent interest. The specific biochemical nature of serotoninergic pathways and their direct and/or indirect effects on bone metabolism are still unclear. Clinical evidence supports an effect of serotonin and altered serotonin signaling on bone metabolism. Serotonin is involved in the pathophysiology of depression, and therefore studies of depression and antidepressant treatments (as modulators of the serotonin system) are relevant with regard to bone outcomes. Studies on the effect of depression on bone mineral density (BMD) and fractures have been mixed. Studies on the associations between antidepressant use and BMD and/or fractures are more consistent. SSRIs have been associated with lower BMD and increased rates of bone loss, as well as increased rates of fracture after accounting for falls. These studies are limited by confounding because depression is potentially associated with both the outcome of interest (BMD and fracture) and the exposure (SSRIs). With mounting evidence for an effect on bone, this review considers the question of causality and whether selective serotonin reuptake inhibitors should be considered among those medications that contribute to bone loss, and therefore prompt clinicians to evaluate BMD proactively. Future research will be required to confirm the serotoninergic effects on bone and the biochemical pathways involved, and to identify clinical implications for treatment based on this novel pathway.

Bone T-scores and functional status: a cross-sectional study on German elderly

Background

We explore the association between bone T-scores, used in osteoporosis diagnosis, and functional status since we hypothesized that bone health can impact elderly functional status and indirectly independence.

Methods

In a cross-sectional study (2005–2006) on community dwelling elderly (> = 75 years) from Herne, Germany we measured bone T-scores with Dual-energy X-ray Absorptiometry, and functional status indexed by five geriatric tests: activities of daily living, instrumental activities of daily living, test of dementia, geriatric depression score and the timed-up-and-go test, and two pooled indexes: raw and standardized. Generalized linear regression was used to determine the relationship between T-scores and functional status.

Results

From 3243 addresses, only 632 (19%) completed a clinical visit, of which only 440 (male∶female, 243∶197) could be included in analysis. T-scores (−0.99, 95% confidence interval [CI], −1.1–0.9) predicted activities of daily living (95.3 CI, 94.5–96.2), instrumental activities of daily living (7.3 CI, 94.5–96.2), and timed-up-and-go test (10.7 CI, 10.0–11.3) (P< = 0.05). Pooled data showed that a unit improvement in T-score improved standardized pooled functional status (15 CI, 14.7–15.3) by 0.41 and the raw (99.4 CI, 97.8–101.0) by 2.27 units. These results were limited due to pooling of different scoring directions, selection bias, and a need to follow-up with evidence testing.

Conclusions

T-scores associated with lower functional status in community-dwelling elderly. Regular screening of osteoporosis as a preventive strategy might help maintain life quality with aging.