Associations of Neuropsychiatric Symptoms and Antidepressant Prescription with Survival in Alzheimer’s Disease

Effect of a Financial Incentive Scheme for Medication Review on Polypharmacy in Elderly Inpatients With Dementia: A Retrospective Before-and-After Study

OBJECTIVES

Polypharmacy is an important healthcare issue, especially in elderly patients with dementia. As an incentive to reduce polypharmacy, a health insurance reimbursement scheme was introduced in 2016 for medication review and the reduction of medications for inpatients in Japan. However, the effects of these incentive schemes were not evaluated.

METHODS

We identified 1,465,881 inpatients aged ≥65 years with dementia. An interrupted time-series analysis was conducted by fitting a Prais-Winsten linear regression model. The outcome measure was the number of classes of medications prescribed during discharge.

RESULTS

No significant changes were observed in the average number of medication classes at discharge immediately after the introduction of the scheme (coefficient: -0.022, 95% confidence interval [CI]: -0.17 to 0.13). The slope change, representing the effect of the intervention over time, was also not significant (coefficient: -0.00053, 95% confidence interval: -0.0012 to 0.00018).

CONCLUSIONS

The incentive scheme was not associated with a reduction in the number of medication classes at discharge among older inpatients with dementia.

Neuropsychiatric Comorbidities and Psychotropic Medication Use in Medicare Beneficiaries With Dementia by Sex and Race

BACKGROUND

Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race.

METHODS

We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled.

RESULTS

Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic.

CONCLUSIONS

The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.

Predictors for survival in patients with Alzheimer's disease: a large comprehensive meta-analysis

The prevalence of Alzheimer's disease (AD) is increasing as the population ages, and patients with AD have a poor prognosis. However, knowledge on factors for predicting the survival of AD remains sparse. Here, we aimed to systematically explore predictors of AD survival. We searched the PubMed, Embase and Cochrane databases for relevant literature from inception to December 2022. Cohort and case-control studies were selected, and multivariable adjusted relative risks (RRs) were pooled by random-effects models. A total of 40,784 reports were identified, among which 64 studies involving 297,279 AD patients were included in the meta-analysis after filtering based on predetermined criteria. Four aspects, including demographic features (n = 7), clinical features or comorbidities (n = 13), rating scales (n = 3) and biomarkers (n = 3), were explored and 26 probable prognostic factors were finally investigated for AD survival. We observed that AD patients who had hyperlipidaemia (RR: 0.69) were at a lower risk of death. In contrast, male sex (RR: 1.53), movement disorders (including extrapyramidal signs) (RR: 1.60) and cancer (RR: 2.07) were detrimental to AD patient survival. However, our results did not support the involvement of education, hypertension, APOE genotype, Aβ42 and t-tau in AD survival. Our study comprehensively summarized risk factors affecting survival in patients with AD, provided a better understanding on the role of different factors in the survival of AD from four dimensions, and paved the way for further research.

Burden of Illness in People with Alzheimer's Disease: A Systematic Review of Epidemiology, Comorbidities and Mortality

BACKGROUND

Alzheimer's disease (AD) is the most common neurodegenerative disease worldwide, and an updated quantification of its impact on morbidity, disability, and mortality is warranted. We conducted a systematic literature review, focusing on the past decade, to characterize AD and assess its impact on affected individuals.

METHODS

Searches of Embase, MEDLINE, and the Cochrane Library were conducted on August 7, 2020 and updated on November 10, 2021. Observational studies from any country reporting incidence, prevalence, comorbidities, and/or outcomes related to disability and mortality/life expectancy, in people with mild cognitive impairment (MCI) due to AD, or mild, moderate, or severe AD dementia, were considered relevant.

RESULTS

Data were extracted from 88 studies (46 incidence/prevalence; 44 comorbidities; 25 mortality-/disability-related outcomes), mostly from Europe, the USA, and Asia. AD dementia diagnosis was confirmed using biomarkers in only 6 studies. Estimated 5-year mortality in AD was 35%, and comorbidity prevalence estimates varied widely (hypertension: 30.2-73.9%; diabetes: 6.0-24.3%; stroke: 2.7-13.7%). Overall, people with AD dementia were more likely to have cardiovascular disease or diabetes than controls, and 5-year mortality in people with AD dementia was double that in the age- and year-matched general population (115.0 vs 60.6 per 1,000 person-years).

CONCLUSIONS

AD is associated with excess morbidity and mortality. Future longitudinal studies of population aging, incorporating biomarker assessment to confirm AD diagnoses, are needed to better characterize the course of MCI due to AD and AD dementia.

Disease severity and mortality in Alzheimer's disease: an analysis using the U.S. National Alzheimer's Coordinating Center Uniform Data Set

BACKGROUND

Evidence on the relative risk of death across all stages of Alzheimer's disease (AD) is lacking but greatly needed for the evaluation of new interventions. We used data from the Uniform Data Set (UDS) of the National Alzheimer's Coordinating Center (NACC) to assess the expected survival of a person progressing to a particular stage of AD and the relative risk of death for a person in a particular stage of AD compared with cognitively normal (CN) people.

METHODS

This was a retrospective observational cohort study of mortality and its determinants in participants with incident mild cognitive impairment (MCI) due to AD or AD dementia compared with CN participants. Overall survival and hazard ratios of all-cause mortality in participants ≥ 50 years of age with clinically assessed or diagnosed MCI due to AD, or mild, moderate, or severe AD dementia, confirmed by Clinical Dementia Rating scores, versus CN participants were estimated, using NACC UDS data. Participants were followed until death, censoring, or until information to determine disease stage was missing.

RESULTS

Aged between 50 and 104 years, 12,414 participants met the eligibility criteria for the study. Participants progressing to MCI due to AD or AD dementia survived a median of 3-12 years, with higher mortality observed in more severe stages. Risk of death increased with the severity of AD dementia, with the increase significantly higher at younger ages. Participants with MCI due to AD and CN participants had a similar risk of death after controlling for confounding factors.

CONCLUSIONS

Relative all-cause mortality risk increases with AD severity, more so at younger ages. Mortality does not seem to be higher for those remaining in MCI due to AD. Findings might imply potential benefit of lower mortality if preventing or delaying the progression of AD is successful, and importantly, this potential benefit might be greater in relatively younger people. Future research should replicate our study in other samples more representative of the general US population as well as other populations around the world.

Predictors of hospital readmission for patients diagnosed with delirium: An electronic health record data analysis

INTRODUCTION

Delirium is an acute and fluctuating change in attention and cognition that increases the risk of functional decline, institutionalisation and death in hospitalised patients. After delirium, patients have a significantly higher risk of readmission to hospital. Our aim was to investigate factors associated with hospital readmission in people with delirium.

METHODS

We carried out an observational retrospective cohort study using linked mental health care and hospitalisation records from South London. Logistic regression models were used to predict the odds of 30-day readmission and Cox proportional hazard models to calculate readmission risks when not restricting follow-up time.

RESULTS

Of 2814 patients (mean age 78.9 years SD ±11.8) discharged from hospital after an episode of delirium, 823 (29.3%) were readmitted within 30 days. Depressed mood (odds ratio (OR) 1.34 (95% confidence interval (CI) 1.08-1.66)), moderate-to-severe physical health problems (OR 1.67 (95% CI 1.18-2.2.36)) and a history of serious circulatory disease (OR 1.29 (95% CI 1.07-1.55)) were associated with higher odds of hospital readmission, whereas a diagnosis of delirium superimposed on dementia (OR 0.67 (95% CI 0.53-0.84)) and problematic alcohol/substance (OR 0.54 (95% CI 0.33-0.89)) use were associated with lower odds. Cox proportionate hazard models showed similar results.

CONCLUSION

Almost one-third of patients with delirium were readmitted within a short period of time, a more detailed understanding of the underlying risk factors could help prevent readmissions. Our findings indicate that the aetiology (as alcohol-related delirium), the recognition that delirium occurred in the context of dementia, as well as potentially modifiable factors, as depressed mood affect readmission risk, and should be assessed in clinical settings.

Ethnicity and survival after a dementia diagnosis: a retrospective cohort study using electronic health record data

BACKGROUND

Individuals from minority ethnic groups in the UK are thought to be at higher risk of developing dementia while facing additional barriers to receiving timely care. However, few studies in the UK have examined if there are ethnic disparities in survival once individuals receive a dementia diagnosis.

METHODS

We conducted a retrospective cohort study using electronic health record data of individuals diagnosed with dementia from a large secondary mental healthcare provider in London. Patients from Black African, Black Caribbean, South Asian, White British, and White Irish ethnic backgrounds were followed up for a 10-year period between 01 January 2008 and 31 December 2017. Data were linked to death certificate data from the Office of National Statistics to determine survival from dementia diagnosis. Standardised mortality ratios were calculated to estimate excess deaths in each ethnicity group as compared to the gender- and age-standardised population of England and Wales. We used Cox regression models to compare survival after dementia diagnosis across each ethnicity group.

RESULTS

Mortality was elevated at least twofold across all ethnicity groups with dementia compared to the general population in England and Wales. Risk of death was lower in Black Caribbean, Black African, White Irish, and South Asian groups as compared to the White British population, even after adjusting for age, gender, neighbourhood-level deprivation, indicators of mental and physical comorbidities. Risk of death remained lower after additionally accounting for those who emigrated out of the cohort.

CONCLUSIONS

While mortality in dementia is elevated across all ethnic groups as compared to the general population, reasons for longer survival in minority ethnic groups in the UK as compared to the White British group are unclear and merit further exploration. Implications of longer survival, including carer burden and costs, should be considered in policy and planning to ensure adequate support for families and carers of individuals with dementia.

Centrally-acting anticholinergic drugs- associations with mortality, hospitalisation and cognitive decline following dementia diagnosis in people receiving antidepressant and antipsychotic drugs

OBJECTIVES

Long-term use of anticholinergic medication in older people is associated with increased risk of cognitive decline and mortality, but this relationship could be confounded by the underlying illness the drugs are treating. To investigate associations between central anticholinergic antidepressants or antipsychotics and mortality, hospitalisation and cognitive decline in people with dementia.

METHOD

In cohorts of patients with a dementia diagnosis receiving antidepressant and/or antipsychotic medication (N = 4,380 and N = 2,335 respectively), assembled from a large healthcare database, central anticholinergic burden scores were estimated using the Anticholinergic Effect on Cognition (AEC) scale. Data were linked to national mortality and hospitalisation data sources, and Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

There was a reduced mortality risk in people receiving agents with high central anticholinergic burden compared to those with no or low burden which was statistically significant in the antidepressant cohort (Hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.79-0.98; p = 0.023) but not the antipsychotic one (HR: 0.91; 95% CI: 0.82-1.02; p = 0.105). Patients on antidepressants with no central anticholinergic burden had accelerated cognitive decline compared with other groups, whereas no differences were found in the antipsychotic cohort. No significant associations were detected between antidepressant or antipsychotic-related central anticholinergic burden and hospitalisation.

CONCLUSION

These counter-intuitive findings may reflect factors underlying the choice of psychotropics rather than the agents themselves, although do not support a strong role for central anticholinergic drug actions on dementia outcomes. Further studies, including randomized switching of agents are needed to clarify this relationship.

Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

Stress-Induced Depression and Alzheimer's Disease: Focus on Astrocytes

Neurodegenerative diseases and depression are multifactorial disorders with a complex and poorly understood physiopathology. Astrocytes play a key role in the functioning of neurons in norm and pathology. Stress is an important factor for the development of brain disorders. Here, we review data on the effects of stress on astrocyte function and evidence of the involvement of astrocyte dysfunction in depression and Alzheimer's disease (AD). Stressful life events are an important risk factor for depression; meanwhile, depression is an important risk factor for AD. Clinical data indicate atrophic changes in the same areas of the brain, the hippocampus and prefrontal cortex (PFC), in both pathologies. These brain regions play a key role in regulating the stress response and are most vulnerable to the action of glucocorticoids. PFC astrocytes are critically involved in the development of depression. Stress alters astrocyte function and can result in pyroptotic death of not only neurons, but also astrocytes. BDNF-TrkB system not only plays a key role in depression and in normalizing the stress response, but also appears to be an important factor in the functioning of astrocytes. Astrocytes, being a target for stress and glucocorticoids, are a promising target for the treatment of stress-dependent depression and AD.

Differences in survival and mortality in minority ethnic groups with dementia: A systematic review and meta-analysis

OBJECTIVES

Although there are disparities in both risk of developing dementia and accessibility of dementia services for certain minority ethnic groups in the United States and United Kingdom, disparities in survival after a dementia diagnosis are less well-studied. Our objective was to systematically review the literature to investigate racial/ethnic differences in survival and mortality in dementia.

METHODS

We searched Embase, Ovid MEDLINE, Global Health and PsycINFO from inception to November 2018 for studies comparing survival or mortality over time in at least two race/ethnicity groups. Studies from any country were included but analysed separately. We used narrative synthesis and random-effects meta-analysis to synthesise findings. The Newcastle-Ottawa Scale was used to assess quality and risk of bias in individual studies.

RESULTS

We identified 22 articles, most from the United States (n = 17), as well as the United Kingdom (n = 3) and the Netherlands (n = 1). In a meta-analysis of US studies, hazard of mortality was lower in Black/African American groups (Pooled Hazard Ratio = 0.86, 95% CI = 0.82-0.91, I²  = 17%, from four studies) and Hispanic/Latino groups (Pooled HR = 0.65, 95% CI = 0.50-0.84, I²  = 86%, from four studies) versus comparison groups. However, study quality was mixed, and in particular, quality of reporting of race/ethnicity was inconsistent.

CONCLUSION

Literature indicates that Black/African American and Hispanic/Latino groups may experience lower mortality in dementia versus comparison groups in the United States, but further research, using clearer and more and consistent reporting of race/ethnicity, is necessary to understand what drives these patterns and their implications for policy and practice.

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals

BACKGROUND

It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support.

METHODS

This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale.

RESULTS

The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses.

CONCLUSIONS

It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

Association of recent hospitalisation with antidepressant initiation among community dwellers with Alzheimer's disease

OBJECTIVES

Antidepressant are commonly prescribed to persons with cognitive disorders to treat depressive and other neuropsychiatric symptoms despite the inconclusive evidence on their effectiveness on this indication. We studied whether recent hospitalisation was associated with antidepressant initiation in people with Alzheimer's disease (AD).

METHODS

The register-based Finnish nationwide Medication use and Alzheimer's disease cohort includes community-dwelling persons diagnosed with AD during 2005-2011 in Finland (n = 70,718). This study was restricted to people who initiated antidepressant use after AD diagnosis and had no active cancer treatment and schizophrenia or bipolar disorder diagnoses. We performed a nested case-control study with antidepressant initiators as cases. A matched noninitiator (sex, age and AD duration), was identified for each initiator (15,360 matched pairs). Recent hospitalisation was defined as hospital discharge within the past 14 days of initiation.

RESULTS

Antidepressant initiators were four times more likely (adjusted odds ratio: 4.41, 95% confidence interval: 4.06-4.80) to have been hospitalised within the past 2 weeks before initiation (21.2%, n = 3250) than matched noninitiators (5.4%, n = 831) and the duration of hospital stay was significantly longer among initiators. Dementia was the most common main discharge diagnosis among both initiators (43.8%, n = 1423) and noninitiators (24.8%, n = 206).

CONCLUSION

Recent hospitalisation was strongly associated with antidepressant initiation in persons with AD. Further studies are needed to investigate whether this is due to neuropsychiatric symptoms leading to hospital admission, inpatient care triggering or worsening neuropsychiatric symptoms or other indications. Nonpharmacological treatments for neuropsychiatric symptoms should be prioritised and the threshold for prescribing antidepressants should be high.

The Potential of Research Drawing on Clinical Free Text to Bring Benefits to Patients in the United Kingdom: A Systematic Review of the Literature

Background: The analysis of clinical free text from patient records for research has potential to contribute to the medical evidence base but access to clinical free text is frequently denied by data custodians who perceive that the privacy risks of data-sharing are too high. Engagement activities with patients and regulators, where views on the sharing of clinical free text data for research have been discussed, have identified that stakeholders would like to understand the potential clinical benefits that could be achieved if access to free text for clinical research were improved. We aimed to systematically review all UK research studies which used clinical free text and report direct or potential benefits to patients, synthesizing possible benefits into an easy to communicate taxonomy for public engagement and policy discussions. Methods: We conducted a systematic search for articles which reported primary research using clinical free text, drawn from UK health record databases, which reported a benefit or potential benefit for patients, actionable in a clinical environment or health service, and not solely methods development or data quality improvement. We screened eligible papers and thematically analyzed information about clinical benefits reported in the paper to create a taxonomy of benefits. Results: We identified 43 papers and derived five themes of benefits: health-care quality or services improvement, observational risk factor-outcome research, drug prescribing safety, case-finding for clinical trials, and development of clinical decision support. Five papers compared study quality with and without free text and found an improvement of accuracy when free text was included in analytical models. Conclusions: Findings will help stakeholders weigh the potential benefits of free text research against perceived risks to patient privacy. The taxonomy can be used to aid public and policy discussions, and identified studies could form a public-facing repository which will help the health-care text analysis research community better communicate the impact of their work.

Antipsychotic use in dementia: the relationship between neuropsychiatric symptom profiles and adverse outcomes

Antipsychotic treatments are associated with safety concerns in people with dementia. The authors aimed to investigate whether risk of adverse outcomes related to antipsychotic prescribing differed according to major neuropsychiatric syndromes-specifically psychosis, agitation, or a combination. A cohort of 10,106 patients with a diagnosis of dementia was assembled from a large dementia care database in South East London. Neuropsychiatric symptoms closest to first dementia diagnosis were determined according to the Health of the Nation Outcome Scales' mental and behavioural problem scores and the sample was divided into four groups: 'agitation and psychosis', 'agitation, but no psychosis', 'psychosis, but no agitation', and 'neither psychosis nor agitation'. Antipsychotic prescription in a one-year window around first dementia diagnosis was ascertained as exposure variable through natural language processing from free text. Cox regression models were used to analyse associations of antipsychotic prescription with all-cause and stroke-specific mortality, emergency hospitalisation and hospitalised stroke adjusting for sixteen potential confounders including demographics, cognition, functioning, as well as physical and mental health. Only in the group 'psychosis, but no agitation' (n = 579), 30% of whom were prescribed an antipsychotic, a significant antipsychotic-associated increased risk of hospitalised stroke was present after adjustment (adjusted hazard ratio (HR) 2.16; 95% confidence interval (CI) 1.09-4.25). An increased antipsychotic-related all-cause (adjusted HR 1.14; 95% CI 1.04-1.24) and stroke-specific mortality risk (adjusted HR 1.28; 95% CI 1.01-1.63) was detected in the whole sample, but no interaction between the strata and antipsychotic-related mortality. In conclusion, the adverse effects of antipsychotics in dementia are complex. Stroke risk may be highest when used in patients presenting with psychosis without agitation, indicating the need for novel interventions for this group.

The Association Between a Previous Diagnosis of Mild Cognitive Impairment as a Proxy for an Early Diagnosis of Dementia and Mortality: A Study of Secondary Care Electronic Health Records

BACKGROUND

Dementia policy states that the early diagnosis of dementia can keep people living well for longer; however, there is little robust evidence to support this. Mild cognitive impairment (MCI) is considered a prodrome to dementia and can aid with the earlier diagnosis of dementia.

OBJECTIVE

The objective of this study was to use a previous diagnosis of MCI, before dementia, as a proxy for early diagnosis to investigate the relationship between an early diagnosis and mortality.

METHODS

A retrospective cohort study of electronic health care records from South London and Maudsley NHS. Patients aged 50+, diagnosed with dementia between January 2008 and November 2018, were divided into two groups: those with a previous diagnosis of MCI (early diagnosis) and those without. Cox regression models used to compare the risk of mortality between groups.

RESULTS

Of 18,557 participants, 5.6%(n = 1,030) had an early diagnosis; they had fewer cognitive, psychiatric, and functional problems at dementia diagnosis. The early diagnosis group had a reduced hazard of mortality (HR = 0.86, CI = 0.77-0.97). However, the magnitude of this effect depended on the scale used to adjust for cognitive difficulties.

CONCLUSION

A previous diagnosis of MCI is a helpful proxy for early diagnosis. There is some evidence that an early diagnosis is associated with a reduced risk of mortality; however, it is not clear how Mini-Mental State Exam scores affect this relationship. While these findings are promising, we cannot be conclusive on the relationship between an early diagnosis and mortality.

Risk of Hospitalized Falls and Hip Fractures in 22,103 Older Adults Receiving Mental Health Care vs 161,603 Controls: A Large Cohort Study

OBJECTIVES

To investigate the risk of hospitalized fall or hip fracture among older adults using mental health services.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents of a South London catchment aged >60 years receiving specialist mental health care between 2008 and 2016.

MEASURES

Falls and/or a hip fracture leading to hospitalization were ascertained from linked national records. Incidence rates and incidence rate ratios (IRRs) were age- and gender-standardized to the catchment population. Multivariable survival analyses were applied investigating falls and/or hip fractures as outcomes.

RESULTS

In 22,103 older adults, incidence rates were 60.1 per 1000 person-years for hospitalized falls and 13.7 per 1000 person-years for hip fractures, representing standardized IRRs of 2.17 [95% confidence interval (CI) 2.07-2.28] and 4.18 (3.79-4.60), respectively. The IRR for falls was high in those with substance-use disorder [IRR = 6.72 (5.35-8.33)], bipolar disorder [IRR = 3.62 (2.50-5.05)], depression [IRR = 2.28 (2.00-2.59)], and stress-related disorders [IRR = 2.57 (2.10-3.11)]. Hip fractures were increased in all populations (IRR > 2.5), with greatest risk in substance use disorders [IRR = 12.64 (7.22-20.52)], dementia [IRR = 4.38 (3.82-5.00)], and delirium [IRR = 4.03 (3.00-5.29)]. Comparing mental disorder subgroups with each other, after the adjustment for 25 potential confounders, patients with dementia and substance use had a significantly increased risk of falls, and patients with dementia also had an increased risk of hip fractures.

CONCLUSION AND IMPLICATIONS

Older people using mental health services have more than double the incidence of falls and 4 times the incidence of hip fractures compared to the general population. Although incidences differ between diagnostic subgroups, all groups have a higher incidence than the general population. Targeted interventions to prevent falls and hip fractures among older adult mental health service users are urgently needed.

Dementia in People from Ethnic Minority Backgrounds: Disability, Functioning, and Pharmacotherapy at the Time of Diagnosis

OBJECTIVES

Increasingly, older populations in the United Kingdom and other well-resourced settings are ethnically diverse. Despite a concern that the prevalence of dementia is expected to rise, very little is known about the association of ethnicity and dementia among aging older adults. The current study aimed to compare ethnic group differences in symptom profile, functioning and pharmacotherapy at dementia diagnosis.

DESIGN

Cross-sectional study of patient characteristics at the point of dementia diagnosis.

SETTING AND PARTICIPANTS

In total, 12,154 patients aged 65 years or older diagnosed with dementia in Southeast London between 2007 and 2015.

METHODS

Data were extracted from the Clinical Record Interactive Search system, which provides anonymized access to the electronic health records of a large mental healthcare provider in Southeast London. Patients from ethnic minority backgrounds were compared with white British individuals on mental and physical well-being, functional scales and medications prescribed at dementia diagnosis, as well as subtype of dementia documented anywhere in the record.

RESULTS

Compared with white British patients, Black African and Black Caribbean patients were more likely to present with psychotic symptoms and were less likely to have an antidepressant prescribed; white Irish patients had higher rates of substance/alcohol use and depressive symptoms were more prevalent in South Asian patients; all ethnic minority groups had higher odds of polypharmacy; and vascular dementia diagnoses were more common in Black and Irish ethnic minority groups.

CONCLUSIONS AND IMPLICATIONS

At dementia diagnosis, there are substantial differences in noncognitive mental health symptoms and pharmacotherapy across ethnic minority groups and compared with the white British majority population. Some of these differences might reflect access/treatment inequalities or implicit unconscious bias related to ethnicity, influencing both. They need to be taken into consideration to optimize pathways into care and personalize assessment and management.

Antidepressant Use and Progression of Mild to Moderate Alzheimer's Disease: Results from the European ICTUS Cohort

OBJECTIVES

Neuropsychiatric symptoms (NPS) are a core and troubling feature among patients with Alzheimer disease (AD). Because of growing safety warnings against antipsychotics, the use of antidepressants (ATD) in AD has increased extensively. We investigated the potential long-term associations between ATD exposure and functional and cognitive progression in patients with mild to moderate AD.

DESIGN

Two-year prospective multicenter cohort ICTUS (Impact of Cholinergic Treatment USe) study with biannual assessments.

SETTING

Twenty-nine memory clinics from 12 European countries.

PARTICIPANTS

Community-dwelling patients with mild to moderate AD.

METHODS

Global cognitive function was measured using the Mini Mental State Examination (MMSE) and the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog). Functional impairment was measured using the Activities of Daily Living (ADL). Assessments were performed biannually for 2 years. Antidepressant exposure was defined by an ATD prescription for a minimum period of 6 months. Linear mixed models were used to study the associations between ATD exposure and cognitive and functional progression.

RESULTS

Antidepressant exposure was not associated with cognitive decline [MMSE: β-coefficients of the linear mixed models (Coef) = 0.06, 95% confidence interval (CI) -0.65 to 0.76, P = .87; ADAS-Cog: Coef = -13.9, 95% CI -34.80 to 7.03, P = .19] or with functional decline (ADL: Coef = -0.05, 95% CI -0.21 to 0.09, P = .48) at 2-year follow-up. Antipsychotic exposure at baseline was associated with a greater functional decline in the ADL score (Coef = -0.39, 95% CI - 0.68 to 0.10, P < .01).

CONCLUSIONS AND IMPLICATIONS

Antidepressant exposure was not associated with a faster rate of cognitive or functional decline in patients with mild to moderate AD. Antidepressants might be appropriate alternatives to antipsychotics in the management of NPS in mild to moderate AD.

New use of psychotropic medication after hospitalization among people with dementia

OBJECTIVES

Psychotropic medication is commonly used among people with dementia (PWD), but it shows modest efficacy and it has been associated with severe adverse events. Hospitalizations are an opportunity for medication management as well as treatment recommendations for outpatient physicians. The aim of this study was to asses factors associated with new use of psychotropic medication after hospitalization among PWD.

METHODS

We conducted a retrospective dynamic cohort study from 2004 to 2015 using claims data from a German health insurance company. PWD were identified by an algorithm that included ICD-10 diagnosis and diagnostic measures. The medication classes included were antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication. The assessment period was up to 30 days after discharge from the hospital across four hospitalizations.

RESULTS

The main predictors for new use of psychotropic medication were similar across medication classes. Neuropsychiatric symptoms (NPS) and the need of care were associated with higher odds of new use of antidepressants, antipsychotics, and anxiolytics or hypnotics/sedatives. A hospital stay due to dementia was an independent predictor for new use across medication classes as well. Delirium increased the odds for new use of antipsychotics and anxiolytics or hypnotics/sedatives.

CONCLUSIONS

Factors associated with new use of psychotropic medication included delirium, NPS, and the need of care in PWD. The findings highlight the need for preventive interventions and non-medical treatment options in regards to delirium and NPS as well as for a more intensive use of screening tools for inappropriate medication use among PWD. Key points The percentage of new users was 1.8%, 7.1%, 2.1%, and 2.5% across hospitalizations for antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication, respectively. 83.0%, 61.9%, 56.9%, and 88.1% of new users received antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication for more than 6 weeks. Delirium and neuropsychiatric symptoms were associated with significantly increased odds of new psychotropic medication use. Hospital stays due to dementia and the need of care were predictors for new use of psychotropic medication.

Predictors of mortality in people with late-life depression: A retrospective cohort study

OBJECTIVES

Late-life depression (LLD) is associated with an increased mortality risk in the general older population. It remains however unclear which signs or symptoms are predictive of mortality in those suffering from LLD.

SETTING AND PARTICIPANTS

Patients aged 65 years or older with depressive disorder diagnosed in Southeast London between January 2008 and December 2017.

METHODS

We assembled patients diagnosed with late-life depression from the Maudsley Biomedical Research Centre Case Register, which is linked to national mortality data. Using depression diagnosis as index date, we followed patients until death or censoring point. Sociodemographic data, scores of Health of the Nation Outcome Scales (HoNOS65+), which include a physical illness scale, profiles of depressive symptoms, and psychotropic medications were extracted and modeled in multivariable survival analyses to determine predictors of mortality.

RESULTS

Of 4,243 patients with LLD (mean age 77.0 years; 61.2% female), 2,327 (54.8%) died over a median follow-up time of 3.5 years. In multivariable Cox regression models, an increased risk of all-cause mortality was associated with older age, cognitive problems, physical illness/disability, impaired activities of daily living, apathy, lack of appetite and mirtazapine prescription; conversely, female gender, non-white ethnicity, guilt feelings, tearfulness, impaired concentration, disturbed sleep and delusions were associated with lower mortality risk.

CONCLUSIONS

Besides demographic factors, physical health, functioning and cognition, different depressive symptoms were significantly associated with the prognosis of LLD. Elderly patients presenting with depressive symptoms predicting higher mortality risk should be examined and followed more closely.

Predictors of cerebrovascular event reoccurrence in patients with depression: a retrospective cohort study

OBJECTIVES

To identify predictors of recurrent cerebrovascular morbidity in a cohort of patients with depression and a cerebrovascular disease (CBVD) history.

METHODS

We used the Maudsley Biomedical Research Centre Case Register to identify patients aged 50 years or older with a diagnosis of depressive disorder between 2008 and 2017 and a previous history of hospitalised CBVD. Using depression diagnosis as the index date we followed patients until first hospitalised CBVD recurrence or death due to CBVD. Sociodemographic data, symptom and functioning scores of Health of the Nation Outcome Scales, medications and comorbidities were extracted and modelled in multivariate survival analyses to identify predictors of CBVD reoccurrence.

RESULTS

Of 1292 patients with depression and CBVD (mean age 75.6 years; 56.6% female), 264 (20.4%) experienced fatal/non-fatal CBVD recurrence during a median follow-up duration of 1.66 years. In multivariate Cox regression models, a higher risk of CBVD recurrence was predicted by older age (HR, 1.02; 95% CI, 1.01 to 1.04) (p=0.002), physical health problems (moderate to severe HR, 2.47; 95% CI, 1.45 to 4.19) (p=0.001), anticoagulant (HR, 1.40; 95% CI, 1.01 to 1.93) (p=0.041) and antipsychotic medication (HR, 0.66; 95% CI 0.44 to 0.99) (p=0.047). Neither depression severity, mental health symptoms, functional status, nor antidepressant prescribing were significantly associated with CBVD recurrence.

CONCLUSIONS

Approximately one in five patients with depression and CBVD experienced a CBVD recurrence over a median follow-up time of 20 months. Risk of CBVD recurrence was largely dependent on age and physical health rather than on severity of depressive symptoms, co-morbid mental health or functional problems, or psychotropic prescribing.

Drug Use before and after Initiating Treatment with Acetylcholinesterase Inhibitors

Background/Aims

The aim was to study the prevalence of use of different drugs prescribed for behavioral and psychological symptoms of dementia in persistent users of acetylcholinesterase inhibitors (AChEIs) before and after AChEI initiation, and to compare with the use in the general population.

Methods

Use of antidepressants, antipsychotics, and analgesics in the 4 years before and 2 years after AChEI initiation was studied based on data from the Norwegian Prescription Database 2004–2016.

Results

The prevalence of use of antidepressants and antipsychotics the year before AChEI initiation was twice the prevalence in the age-adjusted general population and continued to rise in the first 2 years after initiation of AChEIs. The prevalence of weak analgesics and antipsychotics increased strongly in the last year before AChEI initiation. The increase in the use of antidepressants started at least 4 years before initiation of AChEIs. Opioid use was generally lower than in the general population and was not influenced by AChEI initiation.

Conclusion

Increased use of antidepressants and antipsychotics was observed both before and after initiation of AChEIs and may indicate that behavioral symptoms occur in a preclinical or early phase of Alzheimer's disease. The prescription pattern of analgesics with a low use of opioids may indicate an undertreatment of pain in people with dementia.

Survival time and differences between dementia with Lewy bodies and Alzheimer's disease following diagnosis: A meta-analysis of longitudinal studies

OBJECTIVE

To synthesize the evidence across longitudinal studies comparing survival in dementia with Lewy bodies (DLB) and Alzheimer's disease (AD).

METHODS

We conducted a systematic review and meta-analysis of studies comparing survival in clinically diagnosed DLB to AD. Longitudinal cohort studies were identified through a systematic search of major electronic databases from inception to May 2018. A random effects meta-analysis was performed to calculate survival time and relative risk of death.

RESULTS

Overall, 11 studies were identified including 22,952 patients with dementia: 2029 with DLB (mean diagnosis age 76.3; 47% female) compared with 20,923 with AD (mean diagnosis age 77.2; 65.1% female). Average survival time in DLB from diagnosis was 4.11 years (SD ± 4.10) and in AD 5.66 (SD ± 5.32) years, equating to a 1.60 (95% CI: -2.44 to -0.77) years shorter survival in DLB (p < 0.01). Relative risk of death was increased by 1.35 (95%CI: 1.17-1.55) in DLB compared to AD (p < 0.01). Differences in survival were not explained by follow-up time, age at diagnosis, gender, or cognitive score.

CONCLUSIONS

There is consistent evidence for higher and earlier mortality in DLB compared to AD. This is important for all stakeholders and underlines the importance of expanding research into DLB.

[Effects of drug treatment on the surviral-time in patients with dementia]

AIM

The effect of polypharmacy on the surviral-time in patients with dementia has never been fully elucidated.

METHODS

A retrospective study was conducted in a hospital in Aichi, Japan, by reviewing the medical charts and autopsy reports. Patients were hospitalized and neuropathologically diagnosed with dementia. The data on medication was collected from the prescribed drugs taking right before the admission. Patients were divided into two groups according to the number of prescribed drugs: ≥ 5 drugs (polypharmacy) vs. ≤ 4 drugs (non-polypharmacy). "Drugs to be prescribed with special caution" were defined in accordance with the guidelines for medical treatment and its safety in the elderly (2015).

RESULTS

Seventy-six patients were eligible, and 39.5% of patients had polypharmacy. The Kaplan-Meier method showed that the polypharmacy group tended to have a shorter survival-time than the non-polypharmacy group (p=0.067). A Cox proportional hazard model showed that the polypharmacy group tended to have a higher risk for a reduced survival-time than the non-polypharmacy group, and this tendency was more prominent after adjusting for sex and age at admission (adjusted hazard ratio, 1.631; 95% confidence interval, 0.991-2.683; p=0.054). "Drugs to be prescribed with special caution", including hypnotic-sedative drugs, antianxiety drugs, antipsychotics, and benzodiazepines, were not found to be risk factors for a reduced survival-time.

CONCLUSIONS

The present study showed that polypharmacy in terminal patients with dementia tended to carry a risk for reducing their remaining lifespan. The results warrant further additional study.

Diagnosed depression and sociodemographic factors as predictors of mortality in patients with dementia

BACKGROUND

Potentially modifiable risk factors for developing dementia have been identified. However, risk factors for increased mortality in patients with diagnosed dementia are not well understood. Identifying factors that influence prognosis would help clinicians plan care and address unmet needs.AimsTo investigate diagnosed depression and sociodemographic factors as predictors of mortality in patients with dementia in UK secondary clinical care services.

METHOD

We conducted a cohort study of patients with a dementia diagnosis in an electronic health records database in a UK National Health Service mental health trust.

RESULTS

In 3374 patients with 10 856 person-years of follow-up, comorbid depression was not associated with mortality (adjusted hazard ratio 0.94; 95% CI 0.71-1.24). Single patients had higher mortality than those who were married (adjusted hazard ratio 1.25; 95% CI 1.03-1.50). Patients of Asian ethnicity had lower mortality rates than White British patients (adjusted hazard ratio 0.50; 95% CI 0.34-0.73).

CONCLUSIONS

Clinically diagnosed depression does not increase mortality in patients with dementia. Patients who are single are a potential high-mortality risk group. Lower mortality rates in Asian patients with dementia that have been reported in the USA also apply in the UK.Declaration of interestNone.

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

OBJECTIVES

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

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

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

MEASURES

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

RESULTS

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

IMPLICATIONS

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