Depression, antidepressants and fall risk: therapeutic dilemmas-a clinical review

Motoric Cognitive Risk Syndrome as a Predictor of Adverse Health Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION

Motoric cognitive risk syndrome (MCR) is a newly proposed pre-dementia syndrome characterized by subjective cognitive complaints (SCCs) and slow gait (SG). Increasing evidence links MCR to several adverse health outcomes, but the specific relationship between MCR and the risk of frailty, Alzheimer's disease (AD), and vascular dementia (VaD) remains unclear. Additionally, literature lacks analysis of MCR's components and associated health outcomes, complicating risk identification. This systematic review and meta-analysis aimed to provide a comprehensive overview of MCR's predictive value for adverse health outcomes.

METHODS

Relevant cross-sectional, cohort, and longitudinal studies examining the association between MCR and adverse health outcomes were extracted from ten electronic databases. The Newcastle-Ottawa Scale (NOS) and modified NOS were used to assess the risk of bias in studies included in the analysis. Relative ratios (RRs) and 95% confidence intervals (CIs) were pooled for outcomes associated with MCR.

RESULTS

Twenty-eight longitudinal or cohort studies and four cross-sectional studies with 1,224,569 participants were included in the final analysis. The risk of bias in all included studies was rated as low or moderate. Pooled analysis of RR indicated that MCR had a greater probability of increased the risk of dementia (adjusted RR = 2.02; 95% CI = 1.94-2.11), cognitive impairment (adjusted RR = 1.72; 95% CI = 1.49-1.99), falls (adjusted RR = 1.32; 95% CI = 1.17-1.50), mortality (adjusted RR = 1.66; 95% CI = 1.32-2.10), and hospitalization (adjusted RR = 1.46; 95% CI = 1.16-1.84); MCR had more prominent predictive efficacy for AD (adjusted RR = 2.23; 95% CI = 1.81-2.76) compared to VaD (adjusted RR = 3.78; 95% CI = 0.49-28.95), while excluding analyses from the study that utilized the timed-up-and-go test and one-leg-standing to evaluate gait speed. One study examined the association between MCR and disability (hazard ratios [HR] = 1.69; 95% CI = 1.08-2.02) and frailty (OR = 5.53; 95% CI = 1.46-20.89). SG was a stronger predictor of the risk for dementia and falls than SCC (adjusted RR = 1.22; 95% CI = 1.11-1.34 vs. adjusted RR = 1.19; 95% CI = 1.03-1.38).

CONCLUSION

MCR increases the risk of developing any discussed adverse health outcomes, and the predictive value for AD is superior to VaD. Additionally, SG is a stronger predictor of dementia and falls than SCC. Therefore, MCR should be routinely assessed among adults to prevent poor prognosis and provide evidence to support future targeted interventions.

Process management program to prevent falls in hospitalized patients with neuropsychiatric disorders: a quality improvement program

BACKGROUND

Falls were among the most common adverse nursing events. The incidence of falls in patients with neuropsychiatric disorders was high, and the occurrence of falls not only caused physical and psychological harm to patients but also led to medical disputes. Therefore, interventions for falls prevention were essential, but evaluations of the intervention process were lacking.

METHODS

In this study, a process management program to prevent falls based on the "structure-process-outcome" quality evaluation model was designed and applied to the clinical practice of falls prevention in hospitalized patients with neuropsychiatric disorders. The process quality evaluation checklist to prevent falls was used to supervise the implementation effect of intervention measures to prevent falls, identify the problems in the intervention measures, and make continuous improvements, to reduce the incidence of falls in such hospitalized patients as the final index.

RESULTS

The incidence of inpatient falls decreased from 0.199‰ (0.199 per 1000 patient-days) to 0.101‰ (0.101 per 1000 patient-days) before and after the implementation of the process management program for 12 months, 24 months, and 36 months, respectively, and the difference was statistically significant (P < .05). The probability of falls was reduced by 49% after 36 months of monitoring. Furthermore, the proportion of patients at high risk of falls exhibited a downward trend.

CONCLUSION

This quality improvement program was feasible and effective at reducing falls in hospitalized patients with neuropsychiatric disorders. Therefore, attention should be given to monitoring process quality in the management of falls.

Perceived Loneliness, Social Isolation, and Social Support Resources of Frail Older People Ageing in Place Alone in Italy

This paper presents some findings from the IN-AGE ("Inclusive ageing in place") study, which the authors carried out in 2019 in Italy. It explores the available social support resources for frail older people with functional limitations ageing in place alone, and possible links between their social isolation and perceived loneliness. The authors conducted qualitative/semi-structured interviews involving 120 participants aged 65 years and over, and used a mixed-methods analysis (quantitative/qualitative). The main results show the family as the main help resource for daily activities, but also for intimate confidences against social isolation, especially when said relatives live close. Family confidants are less present when seniors are supported by friends/neighbours or/and public services. Moreover, the family is valuable for decreasing loneliness, although not always. However, some older people feel particularly alone when they are supported by public services. Such a complex context draws attention on the need of support for frail seniors living alone and could provide insights for policymakers on adequate policies for preventing and managing loneliness and social isolation in later life. This is especially relevant when family (and other) resources are not available or scarce, also considering the opportunities offered by technology, which can help seniors remain socially connected to relatives, friends and their overall community.

Validation of the de Morton mobility index (DEMMI) among acute stroke patients aged ≥65 years: a register study

PURPOSE

To validate the de Morton Mobility Index (DEMMI) in older (≥65 years) patients with acute stroke in a hospital setting within the first week after stroke onset.

MATERIALS AND METHODS

In the Danish National Database of Geriatrics, we identified 4,176 patients with acute stroke (≥65 years). Floor and ceiling effects of DEMMI were investigated. Furthermore, convergent validity was investigated by correlations between DEMMI and the Barthel Index using Spearman's rho. Known-groups validity was tested by comparing DEMMI scores for different groups (with/without dementia, depression, comorbidity, and walking aids), and unidimensionality of DEMMI was evaluated by Mokken scale analysis.

RESULTS

A floor effect was identified with 22.1% of the patients scoring 0 on DEMMI on admission. Both convergent and known-groups validity were confirmed for DEMMI. Patients who were bedbound had a lower DEMMI score (median [IQR]: 0 [0;0]) than patients without any walking aid (median [IQR]: 62 [33;74]). Furthermore, Mokken scale analysis identified unidimensionality with overall fit to the model (Loevinger H 0.88 (p < 0.0001)).

CONCLUSION

DEMMI is a valid instrument for use in patients with acute stroke (≥65 years) in a hospital setting within the first week after stroke onset.

Association between falls and nonmotor symptoms in patients with Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is a chronic neurodegenerative disorder. Falls are common in patients with PD and can lead to disability, bedridden status, and death. The mechanisms of falls induced by symptoms of PD have not been fully clarified. We investigated the association between falls and nonmotor symptoms in PD patients.

METHODS

A total of 361 patients with Parkinson's disease were included. Whether the patients had fallen in the past half a year was recorded. Nonmotor symptoms were assessed by 30 items from the nonmotor symptom questionnaire (NMS Quest), Parkinson's Disease Sleep Scale (PDSS), Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and Montreal Cognitive Assessment Scale (MOCA).

RESULTS

A total of 63 patients experienced falls in the past six months, with an incidence of 17.5%. The patients with falls were elderly, had severe motor symptoms and disease severity, and the proportion of diabetic patients who experienced falls was higher. Adjusted for the above factors, the results showed that patients with falls had higher PD-NMS, HAMD and HAMA scores, but there was no significant difference in the total score and subscores of the MoCA scale between the two groups. The risk factors related to falling included age, history of diabetes, depression (HAMD), HAMD cognitive impairment, NMS urinary tract and NMS postural hypotension.

CONCLUSIONS

Falls were a common symptom in patients with PD and were not only related to motor symptoms but also closely related to nonmotor symptoms. urinary tract symptoms, postural hypotension, depression and HAMD cognitive impairment were risk factors related to falling in patients with PD.

Relationship Between Depression and Falls Among Nursing Home Residents: Protocol for an Integrative Review

BACKGROUND

Aging exposes individuals to new health disorders and debilitating chronic diseases, yet most older adults, even in functional decline, do not want to leave their homes. Nevertheless, for many, institutionalization in a nursing home (NH) may become essential to ensure their continued safety and health. Depression is one of the most common psychiatric disorders among older adults, especially among those who are institutionalized. Depressed NH residents face a high risk of future functional decline and falls, decreasing their quality of life. The relationship between depression and falls is complex and bidirectional. Previous reviews have focused on home-dwelling older adults or explored the relationship between antidepressant drugs and falls. To the best of our knowledge, no integrative literature reviews have explored the relationship between depression and falls among NH residents.

OBJECTIVE

Analyze studies on the relationship between depression and falls among NH residents.

METHODS

We will conduct an integrative literature review of published articles in relevant scientific journals on the relationship between depression and depressive symptomatology and falls among NH residents. As usually defined, we will consider NH residents to be people aged 65 years and older who can no longer live safely and independently in their homes. We will also consider older adults on short-term stays in an NH for rehabilitation after hospital discharge. Retrieved articles will be screened for eligibility and analyzed following previously reported steps. The most pertinent bibliographical databases will be examined for qualitative, quantitative, and mixed methods studies, from inception until August 31, 2023, thus ensuring that all relevant literature is included. We will also hand-search the bibliographies of all the relevant articles found and search for unpublished studies in any language. If appropriate, we will consider conducting a meta-analysis of the studies retrieved.

RESULTS

A first round of data collection was completed in March 2023. We retrieved a total of 2276 references. A supplementary literature search to ensure the most up-to-date evidence is ongoing. We anticipate that the review will be completed in late September 2023, and we expect to publish results at the end of December 2023.

CONCLUSIONS

This integrative review will increase knowledge and understanding of the complex relationship between depression and falls in NH environments. Its findings will be important for developing integrated, multidisciplinary models and care recommendations, adaptable to each NH resident's situation and health status, and for creating preventive interventions to help them maintain or recover optimal health stability.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46995.

European position paper on polypharmacy and fall-risk-increasing drugs recommendations in the World Guidelines for Falls Prevention and Management: implications and implementation

Falls prevention and management in older adults is a critical global challenge. One of the key risk factors for falls is the use of certain medications. Therefore, to prevent medication-related falls, the following is recommended in the recent World Guidelines for Falls Prevention and Management: (1) assess for fall history and the risk of falls before prescribing potential fall-risk-increasing drugs (FRIDs), (2) use a validated, structured screening and assessment tool to identify FRIDs when performing a medication review, (3) include medication review and appropriate deprescribing of FRIDs as a part of the multifactorial falls prevention intervention, and (4) in long-term care residents, if multifactorial intervention cannot be conducted due to limited resources, the falls prevention strategy should still always include deprescribing of FRIDs.In the present statement paper, the working group on medication-related falls of the World Guidelines for Falls Prevention and Management, in collaboration with the European Geriatric Medicine Society (EuGMS) Task and Finish group on FRIDs, outlines its position on how to implement and execute these recommendations in clinical practice.Preferably, the medication review should be conducted as part of a comprehensive geriatric assessment to produce a personalized and patient-centered assessment. Furthermore, the major pitfall of the published intervention studies so far is the suboptimal implementation of medication review and deprescribing. For the future, it is important to focus on gaining which elements determine successful implementation and apply the concepts of implementation science to decrease the gap between research and practice.

Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review

PURPOSE

Both heart failure and its treatment with diuretics or SGLT2 inhibitors increase fall risk in older adults. Therefore, decisions to continue or deprescribe diuretics or SGLT2 inhibitors in older heart failure patients who have fallen are generally highly complex and challenging for clinicians. However, a comprehensive overview of information required for rationale and safe decision-making is lacking. The aim of this clinical review was to assist clinicians in safe (de)prescribing of these drug classes in older heart failure patients.

METHODS

We comprehensively searched and summarized published literature and international guidelines on the efficacy, fall-related safety issues, and deprescribing of the commonly prescribed diuretics and SGLT2 inhibitors in older adults.

RESULTS

Both diuretics and SGLT2 inhibitors potentially cause various fall-related adverse effects. Their fall-related side effect profiles partly overlap (e.g., tendency to cause hypotension), but there are also important differences; based on the currently available evidence of this relatively new drug class, SGLT2 inhibitors seem to have a favorable fall-related adverse effect profile compared to diuretics (e.g., low/absent tendency to cause hyperglycemia or electrolyte abnormalities, low risk of worsening chronic kidney disease). In addition, SGLT2 inhibitors have potential beneficial effects (e.g., disease-modifying effects in heart failure, renoprotective effects), whereas diuretic effects are merely symptomatic.

CONCLUSION

(De)prescribing diuretics and SGLT2 inhibitors in older heart failure patients who have fallen is often highly challenging, but this clinical review paper assists clinicians in individualized and patient-centered rational clinical decision-making: we provide a summary of available literature on efficacy and (subclass-specific) safety profiles of diuretics and SGLT2 inhibitors, and practical guidance on safe (de)prescribing of these drugs (e.g. a clinical decision tree for deprescribing diuretics in older adults who have fallen).

Old-age mental telehealth services at primary healthcare centers in low- resource areas in Greece: design, iterative development and single-site pilot study findings

BACKGROUND

Even though communities in low-resource areas across the globe are aging, older adult mental and cognitive health services remain mainly embedded in tertiary- or secondary hospital settings, and thus not easily accessible by older adults living in such communities. Here, the iterative development of INTegRated InterveNtion of pSychogerIatric Care (INTRINSIC) services addressing the mental and cognitive healthcare needs of older adults residing in low-resource areas of Greece is depicted.

METHODS

INTRINSIC was developed and piloted in three iterative phases: (i) INTRINSIC initial version conceptualization; (ii) A 5-year field testing in Andros island; and (iii) Extending the services. The INTRINSIC initial version relied on a digital platform enabling videoconferencing, a flexible battery of diagnostic tools, pharmacological treatment and psychosocial support and the active involvement of local communities in service shaping.

RESULTS

Ιn 61% of the 119 participants of the pilot study, new diagnoses of mental and/or neurocognitive disorders were established. INTRINSIC resulted in a significant reduction in the distance travelled and time spent to visit mental and cognitive healthcare services. Participation was prematurely terminated due to dissatisfaction, lack of interest or insight in 13 cases (11%). Based on feedback and gained experiences, a new digital platform, facilitating e-training of healthcare professionals and public awareness raising, and a risk factor surveillance system were created, while INTRINSIC services were extended to incorporate a standardized sensory assessment and the modified problem adaptation therapy.

CONCLUSION

The INTRINSIC model may be a pragmatic strategy to improve access of older adults with mental and cognitive disorders living in low-resource areas to healthcare services.

Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA

PURPOSE

Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people.

METHODS

Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates.

RESULTS

Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures.

CONCLUSION

Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.

Factors associated with unrecovered falls among older adults

This cross-sectional exploratory study investigated factors associated with unrecovered falls among older patients with a history of falls in the previous year participating in a clinical trial on fall prevention by asking them about their inability to get up independently after the fall. Participants' sociodemographic, clinical, functional (ADL/IADL, TUG, chair-stand test, hand grip, risk of falling) and fall location were investigated. We conducted a multivariate regression analysis adjusted for covariates to identify the main factors associated with unrecovered falls. Out of 715 participants (mean age: 73.4 years; 86% women), 51.6% (95% IC; 47.9 - 55.3%) experienced unrecovered falls. Depressive symptoms, ADL/IADL limitation, mobility limitation, undernutrition, and outdoor falls were associated with unrecovered falls. While assessing the risk of falling, professionals should consider preventive strategies and preparedness procedures for those who are more likely to experience unrecovered falls, such as training to get up from the floor, alarms, and support services.

[Antidepressant drugs-State of the art]

BACKGROUND

Due to their frequency, complications, and sequelae, depressive disorders are of great significance to patients, their environment, and society. They are considered the most frequent form of mental disturbances in old age. The use of antidepressant drugs (AD) represents a cornerstone of the treatment, which is always multidimensional.

OBJECTIVE

The classification, mechanism of action, efficacy and tolerability of AD are described. Furthermore, the practical treatment procedure as well as special aspects, such as treatment resistance and special features in old age are presented.

MATERIAL AND METHODS

Narrative review incorporating the most recent literature and the new edition of the national healthcare guidelines on unipolar depression.

RESULTS

In the past 20 years, a large number of so-called 2nd generation ADs have been approved worldwide with comparable efficacy but more favorable side effect profiles than conventional (tricyclic) substances. Almost all ADs act by enhancing monoaminergic, mostly serotonergic, neurotransmission. Other common features include a latency in the onset of action, moderate response rates, and potential efficacy on all core symptoms of depression. Side effects can include cardiovascular, metabolic, or sexual dysfunction, but these may significantly differ between drug classes. This enables individualized treatment taking age, individual risk factors, comorbidities and comedications into account.

CONCLUSION

With the correct interpretation of indications, knowledge of the risks, and consideration of the defined precautionary measures outlined here, treatment with AD is a safe and effective tool in the treatment of moderate and severe depression.

Geriatric Depression

Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.

Depressive symptoms and falls among Chinese older adults: A bidirectional relationship

BACKGROUND

Falls and depressive symptoms are prevalent and costly. Although they are frequently interrelated, the nature of interrelationships between them was not well understood. Therefore, using longitudinal data, we aimed to explore whether there is a longitudinal bidirectional relationship between falls and depressive symptoms among older Chinese and whether this is different for men and women.

METHODS

Older adults aged 60 years+ who completed all 2011, 2013, 2015 waves of data from the China Health and Retirement Longitudinal Study on falls and depressive symptoms were included (N=2,203). Random intercept multilevel models were used to analyze data.

RESULTS

Significant bidirectional associations at between-person (b=0.09, SE=0.01, p<0.001) and within-person levels (b=0.05, SE=0.02, p=0.005) were observed between depressive symptoms and falls. When participants reported falls, they reported higher levels of depressive symptoms. However, no gender differs in these relationships.

CONCLUSIONS

Regardless of gender, there are significant bidirectional associations between falls and depressive symptoms.

Are higher antidepressant plasma concentrations associated with fall risk in older antidepressant users?

PURPOSE

Antidepressants are well-established fall-risk increasing drugs (FRIDs) and therefore falls should be considered an important adverse drug event (ADE) of antidepressants. However, not all antidepressant users experience fall incidents and factors associated with increased fall risk among antidepressant users are incompletely understood. Our objective was to explore whether antidepressant plasma concentrations are associated with falls in older antidepressant users.

METHODS

For this study, we included antidepressant users of the multicenter B-PROOF study. Fall incidents were recorded prospectively using fall calendars. Antidepressant plasma concentrations were analyzed by Liquid chromatography-mass spectrometry (LC-MS) at baseline and at 2 years follow-up. The associations between the observed antidepressant concentration and fall risk were assessed using Cox proportional hazard and logistic regression models and adjusted for potential confounders.

RESULTS

In total 93 selective serotonin reuptake inhibitor (SSRI) and 41 antidepressant (TCA) users were identified. There was a significant association between baseline TCA plasma concentration and fall risk within users (HR 2.50, 95% CI 1.07-5.87, crude model). In the adjusted model, there were no significant associations between concentrations of SSRIs and fall risk.

CONCLUSION

There might be an association between plasma concentrations of TCAs and the risk of falling in older users. However, these results needs to be interpreted with caution considering the small sample size and accompanying limitation of confinement to crude analyses. Therefore, these novel findings need to replicated in a larger cohort, preferably including adjustment for potential confounders and more frequent measures of plasma concentrations is needed.

Falls and associated risk factors in a sample of old age population in Egyptian community

Introduction

Falling is a major health problem among old age persons and are the sixth cause of mortality and morbidity among them. Assessing the prevalence of falls among elderly in an Egyptian community and investigating its associated risk factors using the Arabic translation of the SHARE-Questionnaire.

Subjects and methods

This cross-sectional analytic study was a part of the pilot for AL-SEHA project. It included 289 old age people (50+ years age) residing in the study areas. The main project data were collected using the Arabic translation of the SHARE (Survey of Health, Aging, and Retirement in Europe) questionnaire. The original project data were collected by investigators from five universities, then uploaded to the internet server domain of the American University in Cairo (AUC) Social Research Center.

Results

The prevalence of falls was 11.07% (95% CI: 7.95-15.21). Falls were significantly more among 70 years or older (p < 0.001), unemployed or housewives (p = 0.026), have a family caregiver (p = 0.022), and home facilities for disability (p = 0.015). They had significantly higher rates of ischemic heart disease, hypertension, dyslipidemia, stroke, and diabetes mellitus. The most frequently reported problems were the fear of fall and dizziness (62.5%). The multivariate analysis identified the history of stroke and diabetes mellitus, the fear of fall and dizziness, and the total number of health problems and the score of difficulty in performing physical activities as significant independent predictors of fall occurrence. The history of stroke was the strongest risk factor (OR 33.49, CI: 3.45-325.40).

Discussion and recommendations

The prevalence of falls among old age persons in the studied community is not alarmingly high. It is highest among stroke patients. Community interventions and rehabilitation programs are recommended to train and educate old age people, especially those at risk such as stroke and diabetic patients, and those with dizziness to improve their physical fitness and reduce the fear of fall among them.

Variability and symmetry of gait kinematics under dual-task performance of older patients with depression

BACKGROUND

Depression in old age is associated with an increased fall risk. Especially in cognitively challenging situations, fall-promoting gait deviations could appear due to depression- and age-related cognitive deficits.

AIM

This study investigates (i) whether there are differences in gait performance between depressed older patients and healthy controls and (ii) if gait patterns aggravate when performing a cognitive task whilst walking.

METHODS

16 depressed older patients (mean age: 73.1 ± 5.8 years) and 19 healthy controls (mean age: 73.3 ± 6.1 years) were included in the study. Spatiotemporal gait parameters (speed, stride length, swing time) and minimum toe clearance were recorded using a three-dimensional motion-capture system under a single- and a dual-task condition (counting backwards).

RESULTS

After Bonferroni correction, depressed older patients showed significantly slower walking speed, shorter strides and smaller minimum toe clearance, as well as greater variability in stride length than healthy controls. Under the dual-task, gait performance deteriorated compared with single-task, with slower gait speed, shorter strides, and longer swing time.

DISCUSSION

Slower walking speed and shorter steps of depressed patients may be a strategy to counteract their fall risk. Increased variability suggests a less stable gait pattern in patients, which could be a reason for their increased fall risk.

CONCLUSIONS

Depression in old age has a strong effect on gait performance. Possible interventions that might prevent falls in this vulnerable group are discussed. The study was registered at Open Science Framework on May 18, 2021 (publicly accessible May 30, 2023).

The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits

Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

A retrospective cohort study of factors associated with severity of falls in hospital patients

Severity of falls in hospital patients are threat to patient safety which can result in a financial burden on the patient’s family and health care services. Both patient specific and environmental and organisational factors are associated with severity of falls in hospital. It is important to continuously analyse the factors associated with severity of fall which can inform the implementation of any fall preventive strategies. This study aims to identify factors associated with the severity of falls in hospitalised adult patients in Western Australia. This study involved a retrospective cohort analysis of inpatient falls records extracted from the hospital’s Clinical Incident Database from May 2014 to April 2019. Severity of falls were classified as three Severity Assessment Code (SAC): SAC 1 was “high” causing serious harm or death; SAC 2 was “medium” causing moderate or minor harm; and SAC 3 was “low” indicating no harm. Univariable and multivariable generalised ordinal logistic regression models were used to quantify the magnitude of effects of the potential risk factors on severity of falls at 5% level of significance and reported the crude odds and adjusted odds ratio of falling at a higher severity level. There were 3705 complete reported cases of falls with the average age of the patients was 68.5 ± 17.0 years, with 40.2% identified as female. The risk of falling at a higher level of severity increased by patient age over 50 years. Females were 15.1% more likely to fall at higher severity level compared to females. Fall incidents occurred during toileting and showering activities and incidents in a communal area were 14.5% and 26% more likely to occur at a higher severity respectively. Similarly, depression (167%), influence of alcohol or illicit drugs (more than 300%), use of medications (86%) and fragile skin (75%) significantly increased the odds of falling at higher level of severity. Identification of underlying risk factors associated with fall severity provides information which can guide nurses and clinicians to design and implement effective interventional strategies that mitigate the risk of serious fall injuries. The results suggest that fall prevention strategies should target patients with these risk factors to avoid severity of falls.

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery

BACKGROUND

No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population.

METHODS

A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls.

RESULTS

The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls.

CONCLUSION

This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Falls in older adults: a practical approach

BACKGROUND

Falls are a major problem in public health since they are an important cause of morbidity and mortality. To evaluate the risk of fall and prescribe preventive interventions may be a challenging task.

OBJECTIVES

The objectives of this study are to summarize the most relevant information on the topic "falls in the elderly" and to give a critical view and practical clinical approach on this topic.

METHODS

In March 2022, a search of Pubmed database was performed, using the terms "fall elderly", fall prevention", "fall risk", with the following parameters: five years, review, systematic review, meta-analysis, practice guidelines.

RESULTS

There are several risk factors for falls that can be grouped in different areas (psychosocial, demographic, medical, medication, behavioral, environmental). The clinical evaluation of an older adult prone to falls must include identification of risk factors through history and examination and identification of risk of falls through an assessment tool such as gait velocity, functional reach test, timed up and go, Berg balance test, and miniBEST test. Fall prevention strategies can be single or multiple, and physical activity is the most cited. Technology can be used to detect and prevent falls.

CONCLUSION

A systematic approach to the older patient in risk of falls is feasible and may impact fall prevention.

The understanding and experience of falls among community-dwelling adults aged 50 and over living with mental illness: A qualitative study

OBJECTIVES

Compared to the general older population, older adults living with mental illness are at greater risk of falling and these risks can be present from middle age. This study aimed to explore the understanding of falls and the experiences community-dwelling adults aged 50 years and over living with mental illness who have had a fall, and to identify any falls prevention strategies valued by them.

METHODS

A qualitative descriptive approach was adopted. Ten adults with past experience of falls were recruited at a community mental health service in Sydney, Australia. Semi-structured interviews were conducted between July and September 2018. Interviews were transcribed verbatim and data were thematically analysed.

RESULTS

Three major themes emerged: (1) making sense of falls, (2) being self-reliant and enduring the consequences of falls, and (3) preventing future falls - perceptions and strategies. Most participants in this study were uncertain about the cause of their falls and seemed to have limited understanding of falls risk factors. They were also less likely to seek help after a fall, despite an injury. Consequences of falls included physical injuries and negative emotional impacts experienced following a fall. Most participants expressed a certain degree of concern regarding future falls, however, their strategy to prevent falls was to simply "be careful."

CONCLUSION

Adults aged over 50 years and living with mental illness in the community need support to identify and manage their falls risk. Fall prevention interventions tailored to the needs of this population are needed.

Humanoid robot intervention vs. treatment as usual for loneliness in long-term care homes: Study protocol for a pilot randomized controlled trial

BACKGROUND

Loneliness affects up to 42% of long-term care residents and is associated with poor health outcomes. Humanoid robot interventions hold promise for reducing loneliness and decreasing barriers to social interaction in long-term care settings, such as the current COVID-19 safety measures in many countries, limited mobility, and poor health. We present a protocol describing an assessor-blinded randomized controlled trial comparing the effects of a humanoid robot intervention to treatment as usual, on loneliness and mental health outcomes in long-term care residents.

METHODS

Seventy-four (n = 74) older adults experiencing loneliness in 3 long-term care homes will be randomized 1:1 to an 8-week, twice a week social intervention with the Grace humanoid robot vs. a treatment as usual active control. We will assess change (baseline to week 8) in (1) loneliness (primary outcome), (2) depression severity, and (3) stress (secondary outcomes), as well as (4) other exploratory outcomes: anxiety, quality of life and reduction in acute healthcare utilization. We will also assess the feasibility and acceptability of the intervention using qualitative methods.

DISCUSSION

The proposed study will assess the effects of a social robot on loneliness and other mental health outcomes, as well as the feasibility of the intervention in older adults living in long-term care settings.

TRIAL REGISTRATION

NCT05423899.

The complex associations between late life depression, fear of falling and risk of falls. A systematic review and meta-analysis

INTRODUCTION

Depression rates in older people worldwide vary from 10% to 15% of community-dwelling older persons. There are two others problems related to depression in old age, namely the high incidence of falls and the so-called fear of falling (FOF), with a prevalence ranging from 20% to 85%; it was initially considered a post-fall syndrome, which later as a fall-independent event.

AIMS

Study aims to conduct a systematic review and meta-analysis to bridge the existing gap in literature about the association between depressive symptomatology, FOF, use of antidepressant therapy and falls, also identifying a possible effect of the study quality on the outcome.

METHODS

The selection of studies was carried out between May 20, 2020, and July 27, 2020 and only observational clinical trials, written in English, with participants aged more or equal to 60 years affected by diagnosis of depression or treatment for depression mentioned both as a clinical diagnosis in older patient, and as a predictor/consequence of falls were included. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis, and the protocol was recorded in the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS AND DISCUSSION

The screening process ultimately led to the inclusion of 18 articles. Many of the included studies showed that depressive symptoms caused the subsequent increase in the number of falls. Results from the meta-analysis had no highlighted association between depression and falls, in contrast to other review and meta-analysis works: our work includes a substantial number of studies, with a relatively recent publication date, including patients diagnosed with depression, clearly evaluating the association between depression and falls. Results all seem to confirm the hypothesis of an interdependent association between the presence of FOF and the risk of fall, despite the high percentage of cross-sectional studies prevents inferring on the direction of the association. Therapeutic interventions aimed at decrease rate of falls reducing depressive symptoms and FOF.