Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults

Comparative analysis of psychiatric medications and their association with falls and fractures: A systematic review and network meta-analysis

An association between psychiatric medications and falls and fractures in people taking them has been demonstrated, but which class or medication leads to the greatest risk of falls or fractures should be further investigated. The aim of this study was to compare and rank the magnitude of risk of falls and fractures due to different psychiatric medications. Eight databases were searched for this meta-analysis and evaluated using a frequency-based network meta-analysis. The results included a total of 28 papers with 14 medications from 5 major classes, involving 3,467,314 patients. The results showed that atypical antipsychotics were the class of medications with the highest risk of falls, and typical antipsychotics were the class of medications with the highest risk of resulting in fractures. Quetiapine ranked first in the category of 13 medications associated with risk of falls, and class Z drugs ranked first in the category of 6 medications associated with risk of fractures. The available evidence suggests that atypical antipsychotics and typical antipsychotics may be the drugs with the highest risk of falls and fractures, respectively. Quetiapine may be the medication with the highest risk of falls, and class Z drugs may be the medication with the highest risk of fractures.

Association between antidepressants, benzodiazepine and all-cause mortality in elderly hip fracture: A Korean nationwide cohort study

BACKGROUND

The purpose of this study was to analyze the association between the preoperative and postoperative use of antidepressant and benzodiazepine and all-cause mortality in elderly hip fracture patients.

METHODS

Patients who underwent surgical treatment for hip fracture over 65 years old were classified into Past-user, Current-user, and Non-users for each period according to use history for antidepressants or benzodiazepines. And, for the subgroup analysis, patients were classified by presence of past history for psychiatric medication. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of antidepressants and benzodiazepines on all-cause mortality.

RESULTS

A total of 15,576 patients were included in this study. Past users of antidepressants and benzodiazepines were 5699 (36.59%) patients and 11,319 (72.67%) patients, respectively. Current users of antidepressants and benzodiazepines were 2888 (18.54%) patients and 6287 (40.36%) patients, respectively. There were no statistically significant differences in the adjusted hazard for death compared to the non-users for both the past and the current users (p > 0.05). In the subgroup analysis, there were 12,502 once-users and 3074 never-users according to psychiatric medication. Current uses of antidepressants and benzodiazepine in the once-user did not increase adjusted hazard for death compared to the non-users (p>0.05). However, current uses of antidepressants by never-users increased the adjusted hazard for death compared to the non-user (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.59; p = 0.007).

CONCLUSIONS

No association was observed between the uses of antidepressants and benzodiazepines after hip fracture and mortality risk in elderly patients who received psychiatric medication before hip fracture. However, the use of these medications was associated with increased all-cause mortality risk in patients who had no history of psychiatric medication before hip fracture.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Depressive Disorders Lead to Increased Complications After Geriatric Hip Fractures

Introduction:

Intertrochanteric hip fractures are a common injury treated by orthopedic surgeons and the incidence rate is rising. Preoperative depression is a known risk factor for postoperative complications in orthopaedic surgery, however its effects on outcomes after geriatric hip fractures is relatively unknown. The purpose of this study was to investigate the relationship between preoperative depression and potential complications following open reduction internal fixation (ORIF) and intramedullary nailing (IMN) of geriatric hip fractures.

Methods:

In this retrospective study, the Truven Marketscan claims database was used to identify patients over age 65 who underwent ORIF or IMN for a hip fracture from January 2009 to December 2019. Patient characteristics, such as medical comorbidities, were collected and from that 2 cohorts were established (one with and one without depression). Chi-squared and multivariate analysis was performed to investigate the association between preoperative depression and common postoperative complications following intertrochanteric hip fracture surgery.

Results:

In total, 78,435 patients were identified for analysis. In those patients with preoperative depression, the complications associated with the greatest increased odds after undergoing ORIF were surgical site infections (OR 1.32; CI 1.23-1.44), ED visit for pain (OR 1.27; CI 1.16-1.39), wound complications (OR 1.26; CI 1.14-1.35), and non-union (OR 1.25; CI 1.17-1.33). In the patients with preoperative depression undergoing IMN, the complications associated with the greatest increased odds after were surgical site infections (OR 1.37; CI 1.31- 1.45), ED visit for pain (OR 1.31; CI 1.19-1.44), wound complications (OR 1.23; CI 1.10-1.39), and pneumonia (OR 1.22; CI 1.10-1.31).

Conclusions:

Preoperative depression in patients undergoing hip fracture surgery is associated with increased complications. Recognizing a patients’ preoperative depression diagnosis can allow physicians to adapt perioperative and postoperative surveillance protocols for these higher risk patients. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor

A multi-site review of second hip fractures across 6 Dublin teaching hospitals

INTRODUCTION

Fragility hip fractures are common and costly. Secondary fracture prevention is a treatment goal following hip fracture; however, the number of those that proceed to fracture their contralateral hip in Ireland is unknown. There are plans to introduce a Fracture Liaison Service Database in Ireland which will aim to prevent secondary fractures. To establish a baseline figure for secondary hip fractures, the injury radiographs of 1284 patients from 6 teaching hospitals over a 1-year period were reviewed.

METHODS

Irish Hip Fracture Datasheets and corresponding injury radiographs were reviewed locally for all hip fractures within each respective teaching hospital for a 1-year period (2019).

RESULTS

A total of 8.7% of all fragility hip fractures across the 6 hospitals were secondary hip fractures (range 4.9-11.5%). 46% occurred within years 1 to 3 following index hip fracture. Forty-eight per cent of patients were started on bone protection medications following their second hip fracture.

DISCUSSION/CONCLUSION

Approximately 1 in 11 hip fractures treated across the 6 teaching hospitals assessed in 2019 was a patient's second hip fracture. We advocate for the widespread availability of Fracture Liaison Services to patients throughout Ireland to assist secondary fracture prevention.

Epidemiology of Fragility Fractures and Social Impact

Hip fracture is an important and debilitating condition in older people, especially in women. The epidemiological data vary between countries, but it is globally estimated that hip fractures currently affect around 18% of women and 6% of men. Although the age-standardised incidence is gradually decreasing in many countries, this is far outweighed by the ageing of the population. Thus, the global number of hip fractures is expected to increase. The direct costs associated with this condition are enormous since it requires a long period of hospitalisation and subsequent rehabilitation. Furthermore, hip fracture is associated with the development of other negative consequences, such as disability, depression, and cardiovascular diseases, with additional costs for society. At the same time, increasing attention is given to other osteoporotic fractures, such as vertebral ones, that are associated with negative health outcomes and enormous costs. In this chapter, we describe the most recent epidemiological data regarding hip and other osteoporotic fractures, with special attention to the well-known risk factors and conditions that seem relevant for determining fractures in older people. A specific part is dedicated to the social costs due to fractures. Although the costs of hip fracture are probably comparable to other common diseases with a high hospitalisation rate (e.g. cardiovascular disease), the other social costs (due to onset of new comorbidities, sarcopenia, poor quality of life, disability and mortality) are probably greater.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

All-cause mortality with current and past use of antidepressants or benzodiazepines after major osteoporotic and hip fracture

In the first year, after an osteoporotic fracture of a hip, forearm, upper arm, or spine, the dispensing rates of antidepressants and benzodiazepines increased significantly. After those fractures, recent and past use of antidepressants and benzodiazepines was associated with increased all-cause mortality; current use was not associated with mortality risk.

INTRODUCTION

It remains unclear to what extent use of antidepressants and benzodiazepines is associated with mortality risk after a major osteoporotic fracture (MOF). We aimed to study the cumulative use of antidepressants and benzodiazepines during the year after MOF or hip fracture (HF) and whether the use was associated with mortality.

METHODS

A cohort study was performed within the Dutch PHARMO Database Network including all patients aged 65+ with a first record of MOF (hip, humerus, forearm, and clinical vertebral fracture) between 2002 and 2011. Data were analyzed using Cox regression models, adjusted for comorbidities, and concomitant medication use and broken down to index fracture type.

RESULTS

A total of 4854 patients sustained a first MOF, of whom 1766 patients sustained a HF. Mean follow-up was 4.6 years, divided in 30-day periods. The cumulative antidepressant and benzodiazepine use during the first year after MOF increased from 10.6 to 14.7% and from 24.0 to 31.4%, respectively. Recent (31-92 days before each follow-up period) and past use (> 92 days before) of antidepressants and benzodiazepines after MOF or HF was associated with an increased all-cause mortality risk but current use (< 30 days before) was not.

CONCLUSION

There is a considerable increase in dispensing rate of antidepressants and benzodiazepines in the first year after a MOF. Recent and past use of these medications was associated with all-cause mortality. The finding that current use was not associated with mortality should be further explored and may probably be explained by the healthy survivor's bias.

Epidemiology and social costs of hip fracture

Hip fracture is an important and debilitating condition in older people, particularly in women. The epidemiological data varies between countries, but it is globally estimated that hip fractures will affect around 18% of women and 6% of men. Although the age-standardised incidence is gradually falling in many countries, this is far outweighed by the ageing of the population. Thus, the global number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. The direct costs associated with this condition are enormous since it requires a long period of hospitalisation and subsequent rehabilitation. Furthermore, hip fracture is associated with the development of other negative consequences, such as disability, depression, and cardiovascular diseases, with additional costs for society. In this review, we show the most recent epidemiological data regarding hip fracture, indicating the well-known risk factors and conditions that seem relevant for determining this condition. A specific part is dedicated to the social costs due to hip fracture. Although the costs of hip fracture are probably comparable to other common diseases with a high hospitalisation rate (e.g. cardiovascular disease), the other social costs (due to onset of new co-morbidities, sarcopenia, poor quality of life, disability and mortality) are probably greater.

Potentially Inappropriate Medications and the Time to Full Functional Recovery After Hip Fracture

BACKGROUND

Older adults after hip fracture are at increased risk of being prescribed potentially inappropriate medications, and may be particularly vulnerable to their adverse effects.

OBJECTIVE

The objective of this study was to examine the association of potentially inappropriate medication use with the time to full functional recovery within 1 year of hip fracture repair.

METHODS

We conducted a secondary analysis of a prospective longitudinal study of eight hospitals in St. Louis, MO, USA. The participants were older adults (n = 477) aged 60 years or older who had undergone surgical repair of a hip fracture free of delirium, dementia or depression at baseline. Drugs at baseline were categorised using the American Geriatrics Society 2012 Beers criteria. The outcome was the Functional Recovery Scale total score measured at four time points during a 12-month period of observation. Cox proportional hazards models examined the time to 95% recovery of function ('full recovery'), adjusting for demographics, cognition, depression, medical co-morbidity, pre-fracture functioning and pain as covariates.

RESULTS

Potentially inappropriate medication use was common following hip fracture, with 51% of participants prescribed at least one potentially inappropriate medication and 17.4% prescribed two or more potentially inappropriate medications. Potentially inappropriate medication use was significantly associated with a longer time to achieve full recovery with a hazard ratio of 0.69 (95% confidence interval 0.52-0.92; p = 0.012) and this association was stronger for two or more potentially inappropriate medications compared with one potentially inappropriate medication (hazard ratio = 0.60; 95% confidence interval 0.40-0.90; p = 0.014).

CONCLUSION

Potentially inappropriate medication use was associated with a longer time to full functional recovery in older adults who underwent surgery for a hip fracture, particularly in those using two or more potentially inappropriate medications at baseline.

Effects of Prefracture Depressive Illness and Postfracture Depressive Symptoms on Physical Performance After Hip Fracture

OBJECTIVES

To compare the effect of prefracture depressive illness and postfracture depressive symptoms on changes in physical performance after hip fracture.

DESIGN

Longitudinal observational cohort.

SETTING

Baltimore metropolitan area.

PARTICIPANTS

Older adults with hip fracture (N = 255).

MEASUREMENTS

Prefracture depressive illness (from medical records) at baseline and postfracture depressive symptoms at 2 months (using the Center for Epidemiologic Studies Depression Scale) were measured. Physical performance was measured 2, 6, and 12 months after fracture using the Short Physical Performance Battery (SPPB), a composite metric of functional status with a score ranging from 0 to 12. Weighted estimating equations were used to assess mean SPPB over time, comparing participants with and without prefracture depressive illness and subjects with and without postfracture depressive symptoms.

RESULTS

Participants with prefracture depressive illness had an SPPB increase of 0.4 units (95% confidence interval (CI) = -0.5-1.3) from 2 to 6 months, smaller than the increase of 1.0 SPPB unit (95% CI = 0.4-1.6) in those without prefracture depressive illness. Participants with postfracture depressive symptoms had an SPPB increase of 0.2 units (95% CI = -1.0-1.5) from 2 to 12 months, and those without postfracture depressive symptoms had a larger increase of 1.2 units (95% CI = 0.6-1.8) over the same period. Nevertheless, prefracture depressive illness and postfracture depressive symptoms were not significantly associated with SPPB.

CONCLUSIONS

Neither prefracture depressive illness nor postfracture depressive symptoms were significantly associated with changes in physical performance after hip fracture, but the magnitude of estimates suggested possible clinically meaningful effects on functional recovery.

Trajectories of depressive symptoms after hip fracture

BACKGROUND

Hip fracture is often complicated by depressive symptoms in older adults. We sought to characterize trajectories of depressive symptoms arising after hip fracture and examine their relationship with functional outcomes and walking ability. We also investigated clinical and psychosocial predictors of these trajectories.

METHOD

We enrolled 482 inpatients, aged ⩾60 years, who were admitted for hip fracture repair at eight St Louis, MO area hospitals between 2008 and 2012. Participants with current depression diagnosis and/or notable cognitive impairment were excluded. Depressive symptoms and functional recovery were assessed with the Montgomery-Asberg Depression Rating Scale and Functional Recovery Score, respectively, for 52 weeks after fracture. Health, cognitive, and psychosocial variables were gathered at baseline. We modeled depressive symptoms using group-based trajectory analysis and subsequently identified correlates of trajectory group membership.

RESULTS

Three trajectories emerged according to the course of depressive symptoms, which we termed 'resilient', 'distressed', and 'depressed'. The depressed trajectory (10% of participants) experienced a persistently high level of depressive symptoms and a slower time to recover mobility than the other trajectory groups. Stressful life events prior to the fracture, current smoking, higher anxiety, less social support, antidepressant use, past depression, and type of implant predicted membership of the depressed trajectory.

CONCLUSIONS

Depressive symptoms arising after hip fracture are associated with poorer functional status. Clinical and psychosocial variables predicted membership of the depression trajectory. Early identification and intervention of patients in a depressive trajectory may improve functional outcomes after hip fracture.