Trends in diagnosis and treatment for people with dementia in the UK from 2005 to 2015: a longitudinal retrospective cohort study

Substance use problems and disorders among adults 50 years and older receiving mental health treatment for a primary neurocognitive disorder

OBJECTIVES

This study sought to (1) identify the percentage of high-risk substance use or substance use disorder (SUD) and (2) examine the factors associated with high-risk substance use or SUD in adults aged 50 years and older receiving mental health treatment with a primary delirium or dementia diagnosis.

METHOD

This study used 7 years (2013-2019) of national administrative data on community mental health center patients aged 50 years and older with a primary delirium or dementia diagnosis receiving treatment in the United States (U.S.). To examine factors associated with the dependent variable (high-risk substance use or SUD), a multivariable binary logistic regression model was utilized.

RESULTS

The sample included 77,509 individuals who were mostly aged 65 years and older (69.7%), and did not have co-occurring high-risk substance use or SUD (90.1%). Receiving treatment in a U.S. region other than the Northeast, being younger, male, not non-Hispanic White, and having multiple mental health diagnoses had greater odds of co-occurring high-risk substance use or SUD.

CONCLUSION

One in ten persons in this sample having high-risk substance use or SUD highlights the clinical necessity for screening and subsequent treatment for co-occurring high-risk substance use among persons receiving treatment for a neurocognitive disorder.

The Impact of Training in Multimodal Communication Skills on Psychotropic Medication Use in Dementia Care

Aim This study aimed to assess the trends in psychotropic drug prescriptions among elderly residents with dementia following the continuous implementation of multimodal comprehensive care communication skills training for staff in a long-term care facility. Methods This retrospective single-center cross-sectional study utilized the database of an urban public hospital that included a long-term care facility. The data were collected from 2016 to 2020. All 130 staff members at the hospital (52 nurses, 48 professional caregivers, seven rehabilitation staff members, three physicians, and three pharmacists) initiated multimodal comprehensive care communication skills basic training from October 2014 to December 2015, which was followed by continuous monthly training until the end of 2020. Antipsychotic prescription rates for residents aged over 65 years with dementia were measured throughout the study period. Results A total of 506 eligible residents were identified, the median age was 86.0 years (IQR: 81.0-90.0), and 283 (55.9%) residents were females. The prescription rates for psychotropic drugs among residents with dementia decreased significantly (43.5% in 2016, 27.0% in 2020; p=0.01). Notably, the percentage of patients prescribed anxiolytics decreased significantly (from 4.7% to 0.0%), while the percentage of patients receiving antipsychotic drugs, hypnotics, antidepressants, or antiepileptic drugs remained unchanged over time. The prescription rates for antidementia drugs significantly decreased from 15.3% to 4.0%. Conclusion The prescription rates of psychotropic drugs were significantly reduced following multimodal comprehensive care communication skills training for staff at a long-term care facility. The improvement in communication skills among staff at long-term care facilities has a tangible impact on reducing drug use among elderly residents with dementia.

Trends of use and characterisation of anti-dementia drugs users: a large multinational-network population-based study

BACKGROUND

An updated time-trend analysis of anti-dementia drugs (ADDs) is lacking. The aim of this study is to assess the incident rate (IR) of ADD in individuals with dementia using real-world data.

SETTING

Primary care data (country/database) from the UK/CPRD-GOLD (2007-20), Spain/SIDIAP (2010-20) and the Netherlands/IPCI (2008-20), standardised to a common data model.

METHODS

Cohort study. Participants: dementia patients ≥40 years old with ≥1 year of previous data. Follow-up: until the end of the study period, transfer out of the catchment area, death or incident prescription of rivastigmine, galantamine, donepezil or memantine. Other variables: age/sex, type of dementia, comorbidities. Statistics: overall and yearly age/sex IR, with 95% confidence interval, per 100,000 person-years (IR per 105 PY (95%CI)).

RESULTS

We identified a total of (incident anti-dementia users/dementia patients) 41,024/110,642 in UK/CPRD-GOLD, 51,667/134,927 in Spain/SIDIAP and 2,088/17,559 in the Netherlands/IPCI.In the UK, IR (per 105 PY (95%CI)) of ADD decreased from 2007 (30,829 (28,891-32,862)) to 2010 (17,793 (17,083-18,524)), then increased up to 2019 (31,601 (30,483 to 32,749)) and decrease in 2020 (24,067 (23,021-25,148)). In Spain, IR (per 105 PY (95%CI)) of ADD decreased by 72% from 2010 (51,003 (49,199-52,855)) to 2020 (14,571 (14,109-15,043)). In the Netherlands, IR (per 105 PY (95%CI)) of ADD decreased by 77% from 2009 (21,151 (14,967-29,031)) to 2020 (4763 (4176-5409)). Subjects aged ≥65-79 years and men (in the UK and the Netherlands) initiated more frequently an ADD.

CONCLUSIONS

Treatment of dementia remains highly heterogeneous. Further consensus in the pharmacological management of patients living with dementia is urgently needed.

Incident dementia risk among patients with type 2 diabetes receiving metformin versus alternative oral glucose-lowering therapy: an observational cohort study using UK primary healthcare records

INTRODUCTION

4.2 million individuals in the UK have type 2 diabetes, a known risk factor for dementia and mild cognitive impairment (MCI). Diabetes treatment may modify this association, but existing evidence is conflicting. We therefore aimed to assess the association between metformin therapy and risk of incident all-cause dementia or MCI compared with other oral glucose-lowering therapies (GLTs).

RESEARCH DESIGN AND METHODS

We conducted an observational cohort study using the Clinical Practice Research Datalink among UK adults diagnosed with diabetes at ≥40 years between 1990 and 2019. We used an active comparator new user design to compare risks of dementia and MCI among individuals initially prescribed metformin versus an alternative oral GLT using Cox proportional hazards regression controlling for sociodemographic, lifestyle and clinical confounders. We assessed for interaction by age and sex. Sensitivity analyses included an as-treated analysis to mitigate potential exposure misclassification.

RESULTS

We included 211 396 individuals (median age 63 years; 42.8% female), of whom 179 333 (84.8%) initiated on metformin therapy. Over median follow-up of 5.4 years, metformin use was associated with a lower risk of dementia (adjusted HR (aHR) 0.86 (95% CI 0.79 to 0.94)) and MCI (aHR 0.92 (95% CI 0.86 to 0.99)). Metformin users aged under 80 years had a lower dementia risk (aHR 0.77 (95% CI 0.68 to 0.85)), which was not observed for those aged ≥80 years (aHR 0.95 (95% CI 0.87 to 1.05)). There was no interaction with sex. The as-treated analysis showed a reduced effect size compared with the main analysis (aHR 0.90 (95% CI 0.83 to 0.98)).

CONCLUSIONS

Metformin use was associated with lower risks of incident dementia and MCI compared with alternative GLT among UK adults with diabetes. While our findings are consistent with a neuroprotective effect of metformin against dementia, further research is needed to reduce risks of confounding by indication and assess causality.

Prevalence and Determinants of Diagnosed Dementia: A Registry Linkage Study Linking Diagnosis of Dementia in the Population-Based HUNT Study to Registry Diagnosis of Dementia in Primary Care and Hospitals in Norway

Background

A timely diagnosis of dementia can be beneficial for providing good support, treatment, and care, but the diagnostic rate remains unknown and is probably low.

Objective

To determine the dementia diagnostic rate and to describe factors associated with diagnosed dementia.

Methods

This registry linkage study linked information on research-based study diagnoses of all-cause dementia and subtypes of dementias, Alzheimer's disease, and related dementias, in 1,525 participants from a cross-sectional population-based study (HUNT4 70+) to dementia registry diagnoses in both primary-care and hospital registries. Factors associated with dementia were analyzed with multiple logistic regression.

Results

Among those with research-based dementia study diagnoses in HUNT4 70+, 35.6% had a dementia registry diagnosis in the health registries. The diagnostic rate in registry diagnoses was 19.8% among home-dwellers and 66.0% among nursing home residents. Of those with a study diagnosis of Alzheimer's disease, 35.8% (95% confidence interval (CI) 32.6-39.0) had a registry diagnosis; for those with a study diagnosis of vascular dementia, the rate was 25.8% (95% CI 19.2-33.3) and for Lewy body dementias and frontotemporal dementia, the diagnosis rate was 63.0% (95% CI 48.7-75.7) and 60.0% (95% CI 43.3-75.1), respectively. Factors associated with having a registry diagnosis included dementia in the family, not being in the youngest or oldest age group, higher education, more severe cognitive decline, and greater need for help with activities of daily living.

Conclusions

Undiagnosed dementia is common, as only one-third of those with dementia are diagnosed. Diagnoses appear to be made at a late stage of dementia.

Dementia incidence trend in England and Wales, 2002-19, and projection for dementia burden to 2040: analysis of data from the English Longitudinal Study of Ageing

BACKGROUND

Dementia incidence declined in many high-income countries in the 2000s, but evidence on the post-2010 trend is scarce. We aimed to analyse the temporal trend in England and Wales between 2002 and 2019, considering bias and non-linearity.

METHODS

Population-based panel data representing adults aged 50 years and older from the English Longitudinal Study of Ageing were linked to the mortality register across wave 1 (2002-03) to wave 9 (2018-19) (90 073 person observations). Standard criteria based on cognitive and functional impairment were used to ascertain incident dementia. Crude incidence rates were determined in seven overlapping initially dementia-free subcohorts each followed up for 4 years (ie, 2002-06, 2004-08, 2006-10, 2008-12, 2010-14, 2012-16, and 2014-18). We examined the temporal trend of dementia incidence according to age, sex, and educational attainment. We estimated the trend of dementia incidence adjusted by age and sex with Cox proportional hazards and multistate models. Restricted cubic splines allowed for potential non-linearity in the time trend. A Markov model was used to project future dementia burden considering the estimated incidence trend.

FINDINGS

Incidence rate standardised by age and sex declined from 2002 to 2010 (from 10·7 to 8·6 per 1000 person-years), then increased from 2010 to 2019 (from 8·6 to 11·3 per 1000 person-years). Adjusting for age and sex, and accounting for missing dementia cases due to death, estimated dementia incidence declined by 28·8% from 2002 to 2008 (incidence rate ratio 0·71, 95% CI 0·58-0·88), and increased by 25·2% from 2008 to 2016 (1·25, 1·03-1·54). The group with lower educational attainment had a smaller decline in dementia incidence from 2002 to 2008 and a greater increase after 2008. If the upward incidence trend continued, there would be 1·7 million (1·62-1·75) dementia cases in England and Wales by 2040, 70% more than previously forecast.

INTERPRETATION

Dementia incidence might no longer be declining in England and Wales. If the upward trend since 2008 continues, along with population ageing, the burden on health and social care will be large.

FUNDING

UK Economic and Social Research Council.

A pragmatic, multicentre, double-blind, placebo-controlled randomised trial to assess the safety, clinical and cost-effectiveness of mirtazapine and carbamazepine in people with Alzheimer's disease and agitated behaviours: the HTA-SYMBAD trial

Background

Agitation is common and impacts negatively on people with dementia and carers. Non-drug patient-centred care is first-line treatment, but we need other treatment when this fails. Current evidence is sparse on safer and effective alternatives to antipsychotics.

Objectives

To assess clinical and cost-effectiveness and safety of mirtazapine and carbamazepine in treating agitation in dementia.

Design

Pragmatic, phase III, multicentre, double-blind, superiority, randomised, placebo-controlled trial of the clinical effectiveness of mirtazapine over 12 weeks (carbamazepine arm discontinued).

Setting

Twenty-six UK secondary care centres.

Participants

Eligibility: probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, Cohen-Mansfield Agitation Inventory score ≥ 45.

Interventions

Mirtazapine (target 45 mg), carbamazepine (target 300 mg) and placebo.

Outcome measures

Primary: Cohen-Mansfield Agitation Inventory score 12 weeks post randomisation. Main economic outcome evaluation: incremental cost per six-point difference in Cohen-Mansfield Agitation Inventory score at 12 weeks, from health and social care system perspective. Data from participants and informants at baseline, 6 and 12 weeks. Long-term follow-up Cohen-Mansfield Agitation Inventory data collected by telephone from informants at 6 and 12 months.

Randomisation and blinding

Participants allocated 1 : 1 : 1 ratio (to discontinuation of the carbamazepine arm, 1 : 1 thereafter) to receive placebo or carbamazepine or mirtazapine, with treatment as usual. Random allocation was block stratified by centre and residence type with random block lengths of three or six (after discontinuation of carbamazepine, two or four). Double-blind, with drug and placebo identically encapsulated. Referring clinicians, participants, trial management team and research workers who did assessments were masked to group allocation.

Results

Two hundred and forty-four participants recruited and randomised (102 mirtazapine, 102 placebo, 40 carbamazepine). The carbamazepine arm was discontinued due to slow overall recruitment; carbamazepine/placebo analyses are therefore statistically underpowered and not detailed in the abstract. Mean difference placebo-mirtazapine (-1.74, 95% confidence interval -7.17 to 3.69; p = 0.53). Harms: The number of controls with adverse events (65/102, 64%) was similar to the mirtazapine group (67/102, 66%). However, there were more deaths in the mirtazapine group (n = 7) by week 16 than in the control group (n = 1). Post hoc analysis suggests this was of marginal statistical significance (p = 0.065); this difference did not persist at 6- and 12-month assessments. At 12 weeks, the costs of unpaid care by the dyadic carer were significantly higher in the mirtazapine than placebo group [difference: £1120 (95% confidence interval £56 to £2184)]. In the cost-effectiveness analyses, mean raw and adjusted outcome scores and costs of the complete cases samples showed no differences between groups.

Limitations

Our study has four important potential limitations: (1) we dropped the proposed carbamazepine group; (2) the trial was not powered to investigate a mortality difference between the groups; (3) recruitment beyond February 2020, was constrained by the COVID-19 pandemic; and (4) generalisability is limited by recruitment of participants from old-age psychiatry services and care homes.

Conclusions

The data suggest mirtazapine is not clinically or cost-effective (compared to placebo) for agitation in dementia. There is little reason to recommend mirtazapine for people with dementia with agitation.

Future work

Effective and cost-effective management strategies for agitation in dementia are needed where non-pharmacological approaches are unsuccessful.

Study registration

This trial is registered as ISRCTN17411897/NCT03031184.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 23. See the NIHR Journals Library website for further project information.

Prevalence of treated patients with Alzheimer's disease: current trends and COVID-19 impact

BACKGROUND

There are few updated studies on the prevalence and management of Alzheimer's disease (AD), which could be underdiagnosed or undertreated. The COVID-19 pandemic may have worsened the deficiencies in the diagnosis and treatment of these patients. Electronic medical records (EMR) offer an opportunity to assess the impact and management of medical processes and contingencies in the population.

OBJECTIVE

To estimate AD prevalence in Spain over a 6-year period, based on treated patients, according to usual clinical practice. Additionally, to describe the management of AD-treated patients and the evolution of that treatment during the 2020 COVID-19 pandemic.

METHODS

Retrospective study using the Spanish IQVIA EMR database. Patients treated with donepezil, galantamine, rivastigmine, and/or memantine were included in the study. Annual AD prevalence (2015-2020) was estimated and extrapolated to the national population level. Most frequent treatments and involved specialties were described. To assess the effect of COVID-19, the incidence of new AD cases in 2020 was calculated and compared with newly diagnosed cases in 2019.

RESULTS

Crude AD prevalence (2015-2020) was estimated at 760.5 per 100,000 inhabitants, and age-standardized prevalence (2020) was 664.6 (male 595.7, female 711.0). Monotherapy was the most frequent way to treat AD (86.2%), in comparison with dual therapy (13.8%); rivastigmine was the most prescribed treatment (37.3%), followed by memantine (36.4%) and donepezil (33.0%). Rivastigmine was also the most utilized medication in newly treated patients (46.7%), followed by donepezil (29.8%), although donepezil persistence was longer (22.5 vs. 20.6 months). Overall, donepezil 10 mg, rivastigmine 9.5 mg, and memantine 20 mg were the most prescribed presentations. The incidence rate of AD decreased from 148.1/100,000 (95% confidence interval [CI] 147.0-149.2) in 2019 to 118.4/100,000 (95% CI 117.5-119.4) in 2020.

CONCLUSIONS

The obtained prevalence of AD-treated patients was consistent with previous face-to-face studies. In contrast with previous studies, rivastigmine, rather than donepezil, was the most frequent treatment. A decrease in the incidence of AD-treated patients was observed during 2020 in comparison with 2019, presumably due to the significant impact of the COVID-19 pandemic on both diagnosis and treatment. EMR databases emerge as valuable tools to monitor in real time the incidence and management of medical conditions in the population, as well as to assess the health impact of global contingencies and interventions.

Models of care and the role of clinical pharmacists in UK primary care for older adults: A scoping review protocol

INTRODUCTION

There has been global investment of new ways of working to support workforce pressures, including investment in clinical pharmacists working in primary care by the NHS in the England. Clinical pharmacists are well suited to support older adults who have multiple long-term conditions and are on multiple medications. It is important to establish an evidence base for the role of clinical pharmacists in supporting older adults in primary care, to inform strategic and research priorities. The aim of this scoping review is to identify, map and describe existing research and policy/guidance on the role of clinical pharmacists in primary care supporting older adults, and the models of care they provide.

METHODS AND ANALYSIS

A scoping review guided by the Joanne Briggs Institute methodology for scoping reviews, using a three-step strategy. We will search Medline, CINAHL, Scopus, EMBASE, Web of Science, PSYCHInfo, and Cochrane for English language articles, from 2015 -present day. Grey literature will be searched using Grey Matters guidelines, the Index of Grey Literature and Alternative Sources and Resources, and Google keyword searching. References of all included sources will be hand searched to identify further resources. Using the Population, Concept and Context framework for inclusion and exclusion criteria, articles will be independently screened by two reviewers. The inclusion and exclusion criteria will be refined after we become familiar with the search results, following the iterative nature of a scoping review. Data will be extracted using a data extraction tool using Microsoft Excel and presented using a narrative synthesis approach.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Review findings will be disseminated in academic conferences and used to inform subsequent qualitative research. Findings will be published and shared with relevant local and national organisations.

Trends in the incidence of dementia in people with hypertension in the UK 2000 to 2021

INTRODUCTION

We investigated trends in the incidence of dementia in UK adults with hypertension.

METHODS

Primary care electronic health records from IQVIA Medical Research Data UK, previously known as THIN, were used to identify 2,133,118 adults aged ≥40 years with hypertension over 2000 to 2021. The annual incidence rate and average annual percentage change in recorded dementia diagnoses were estimated and stratified by sex, 10-year age bands, Townsend deprivation quintiles and dementia subtype.

RESULTS

The crude incidence rate of dementia in people with hypertension increased from 1.98 (95% confidence internal [CI] 1.89-2.07) per 1000 person-years at risk (PYAR) in 2000 to 5.29 per 1000 PYAR (95% CI 5.07-5.53) in 2021, corresponding to an average annual increase of 4.1% (95% CI 3.3-5.0). Those aged ≥80 years, the most economically deprived (Townsend = 5), and Alzheimer's disease subtype reported the highest incidence rate within their respective categories.

DISCUSSION

The annual incidence rate of dementia in the hypertensive population has increased over the last 22 years.

Highlights

New dementia diagnosis in the hypertensive population has increased over 22 years.The Alzheimer's disease subtype reported the highest incidence rate in people with hypertension.Difference in dementia incidence between hypertensive females and males has reduced.Difference in dementia incidence among deprivation categories has reduced in recent years.

Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland

BACKGROUND

Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round.

METHODS

The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities.

RESULTS

In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community.

CONCLUSION

This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.

Extemporaneous combination of donepezil and memantine to treat dementia in Alzheimer disease: evidence from Italian real-world data

OBJECTIVE

Providing evidence on donepezil and memantine administration as extemporaneous combination (DM-EXT) to treat Alzheimer Disease (AD) in Italy, and describing demographic and clinical features of AD patients prescribed DM-EXT.

METHODS

Retrospective observational study using IQVIA Italian LifeLink Treatment Dynamics (LRx) and Longitudinal Patient Database (LPD). Prevalent users of DM-EXT were identified on the databases (cohorts DMp_LRx and DMp_LPD) including patients with donepezil and memantine overlapping prescriptions during the selection period (DMp_LRx: "July 2018-June 2021"; DMp_LPD: "July 2012-June 2021"). Demographic and clinical profiles of patients were provided. Starting from cohort DMp_LPD, new users of DM-EXT were selected to calculate treatment adherence. Three additional cohorts of prevalent users of DM-EXT were identified on IQVIA LRx over subsequent 12-month periods, from July 2018 to June 2021, to get national-level yearly estimates accounting for database representativeness.

RESULTS

Cohorts DMp_LRx and DMp_LPD included 9862 and 708 patients, respectively. For both cohorts, two-third of patients were female, and more than half were aged 80+. Concomitant conditions and co-treatments prevalence was very high; most frequent comorbidities included psychiatric and cardiovascular diseases. An intermediate-to-high adherence was observed in 57% of DM-EXT new users. National-level yearly estimates showed an increasing trend (+4%) in DM-EXT prescription, which led to estimate about 10,000 patients being treated during the period "July 2020-June 2021".

CONCLUSIONS

Prescription of DM-EXT is a common practice in Italy. Because the administration of fixed-dose (FDCs) instead of extemporaneous combinations improves treatment adherence, the introduction of an FDC containing donepezil and memantine might enhance AD patients' management and reduce caregiver burden.

Comparative Risk of Harm Associated with Zopiclone or Trazodone Use in Nursing Home Residents: a Retrospective Cohort Study in Alberta, Canada

Background

There is growing evidence of harm associated with trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone); however, their comparative risk of harm is unknown.

Methods

We conducted a retrospective cohort study with linked health administrative data, which enrolled older (≥66 years old) nursing home residents living in Alberta, Canada, between December 1, 2009, and December 31, 2018; the last follow-up date was June 30, 2019. We compared the rate of injurious falls and major osteoporotic fractures (primary outcome) and all-cause mortality (secondary outcome) within 180 days of first prescription of zopiclone or trazodone with cause-specific hazard models and inverse probability of treatment weights to control for confounding; primary analysis was intention-to-treat and secondary analysis was per-protocol (i.e., residents censored if dispensed the other exposure drug).

Results

Our cohort included 1,403 residents newly dispensed trazodone and 1,599 residents newly dispensed zopiclone. At cohort entry, the mean resident age was 85.7 (standard deviation [SD] 7.4), 61.6% were female, and 81.2% had dementia. New zopiclone use was associated with similar rates of injurious falls and major osteoporotic fractures (intention-to-treat-weighted hazard ratio 1.15, 95% confidence interval [CI] 0.90-1.48; per-protocol-weighted hazard ratio 0.85, 95% CI 0.60-1.21) and all-cause mortality (intention-to-treat-weighted hazard ratio 0.96, 95% CI 0.79-1.16; per-protocol-weighted hazard ratio 0.90, 95% CI 0.66-1.23) compared to trazodone.

Conclusions

Zopiclone was associated with a similar rate of injurious falls, major osteoporotic fractures, and all-cause mortality compared to trazodone-suggesting one medication should not be used in lieu of the other. Appropriate prescribing initiatives should also target zopiclone and trazodone.

Inflammatory Diseases, Inflammatory Biomarkers, and Alzheimer Disease: An Observational Analysis and Mendelian Randomization

BACKGROUND AND OBJECTIVES

Whether chronic autoimmune inflammatory diseases causally affect the risk of Alzheimer disease (AD) is controversial. We characterized the relationship between inflammatory diseases and risk of AD and explored the role of circulating inflammatory biomarkers in the relationships between inflammatory diseases and AD.

METHODS

We performed observational analyses for chronic autoimmune inflammatory diseases and risk of AD using data from 2,047,513 participants identified in the UK Clinical Practice Research Datalink (CPRD). Using data of a total of more than 1,100,000 individuals from 15 large-scale genome-wide association study data sets, we performed 2-sample Mendelian randomizations (MRs) to investigate the relationships between chronic autoimmune inflammatory diseases, circulating inflammatory biomarker levels, and risk of AD.

RESULTS

Cox regression models using CPRD data showed that the overall incidence of AD was higher among patients with inflammatory bowel disease (hazard ratio [HR] 1.17; 95% CI 1.15-1.19; p = 2.1 × 10-4), other inflammatory polyarthropathies and systematic connective tissue disorders (HR 1.13; 95% CI 1.12-1.14; p = 8.6 × 10-5), psoriasis (HR 1.13; 95% CI 1.10-1.16; p = 2.6 × 10-4), rheumatoid arthritis (HR 1.08; 95% CI 1.06-1.11; p = 4.0 × 10-4), and multiple sclerosis (HR 1.06; 95% CI 1.04-1.07; p = 2.8 × 10-4) compared with the age (±5 years) and sex-matched comparison groups free from all inflammatory diseases under investigation. Bidirectional MR analysis identified relationships between chronic autoimmune inflammatory diseases and circulating inflammatory biomarkers. Particularly, circulating monokine induced by gamma interferon (MIG) level was suggestively associated with a higher risk of AD (odds ratio from inverse variance weighted [ORIVW] 1.23; 95% CI 1.06-1.42; p IVW = 0.007) and lower risk of Crohn disease (ORIVW 0.73; 95% CI -0.62 to 0.86; p IVW = 1.3 × 10-4). Colocalization supported a common causal single nucleotide polymorphism for MIG and Crohn disease (posterior probability = 0.74), but not AD (posterior probability = 0.03). Using a 2-sample MR approach, genetically predicted risks of inflammatory diseases were not associated with higher AD risk.

DISCUSSION

Our data suggest that the association between inflammatory diseases and risk of AD is unlikely to be causal and may be a result of confounding. In support, although inflammatory biomarkers showed evidence for causal associations with inflammatory diseases, evidence was weak that they affected both inflammatory disease and AD.

Diagnostic and Management Strategies for Common Neurobehavioral and Psychiatric Disturbances Among Patients with Cognitive Impairment and the Dementias

Neurobehavioral and neuropsychiatric symptoms are highly prevalent among individuals diagnosed with cognitive impairment or dementia and impact the quality of life for patients and caregivers alike. Diagnosis and management of these conditions (including primarily depression, anxiety, apathy, psychosis, agitation, and aggression) is crucial to optimal patient care outcomes in clinical practice. The present article provides a practical review of diagnostic approaches and management strategies for behavioral and neuropsychiatric disorders arising in patients with cognitive impairment, up to and including dementia.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia

BACKGROUND

There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle.

AIM

This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India.

METHOD

A retrospective case file study was conducted across several centers in India.

RESULTS

Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions.

CONCLUSIONS

Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Characteristics and general practice resource use of people with comorbid cancer and dementia in England: a retrospective cross-sectional study

Background

Cancer and dementia are common in older people and management of the conditions as comorbidities can be challenging, yet little is known about the size or characteristics of this group. We aimed to estimate the prevalence, characteristics and general practice resource usage of people living with both conditions in England.

Methods

Anonymised electronic healthcare records from 391 National Health Service general practices across England using the TPP SystmOne general practice system were obtained from ResearchOne. Data included demographic and clinical characteristics, and general practice healthcare useage (appointments, prescriptions, referrals and secondary care contacts) for people aged 50 and over with a cancer and/or dementia diagnosis consistent with the Quality and Outcomes Framework between 2005 and 2016. Multi-level negative binomial regression was used to analyse the association between having cancer and/or dementia and the number of general practice appointments.

Results

Data from 162,371 people with cancer and/or dementia were analysed; 3616 (2.2%) people were identified as having comorbid cancer and dementia. Of people with cancer, 3.1% also had dementia, rising to 7.5% (1 in 13 people) in those aged 75 and over. Fewer people with both conditions were female (50.7%) compared to those with dementia alone (65.6%) and those with comorbid cancer and dementia were older than those with cancer alone [mean ages 83 (sd = 7), 69 (sd = 12) respectively]. Those with both conditions were less likely to have lung cancer than those with cancer alone (7.5% vs. 10.3%) but more likely to have prostate cancer (20.9% vs. 15.8%). Additional comorbidities were more prevalent for those with both conditions than those with cancer or dementia alone (68.4% vs. 50.2% vs. 54.0%). In the year following the first record of either condition, people with cancer and dementia had 9% more general practice appointments (IRR:1.09, 95% CI:1.01–1.17) than those with cancer alone and 37% more appointments than those with dementia alone (IRR: 1.37, 95% CI: 1.28–1.47).

Conclusions

A significant number of people are living with comorbid cancer and dementia in England. This group have additional comorbidity and higher general practice usage than those with cancer/dementia alone. The needs of this group should be considered in future general practice care planning and research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01882-w.

Trends in prevalence and incidence of registered dementia and trends in multimorbidity among patients with dementia in general practice in Flanders, Belgium, 2000-2021: a registry-based, retrospective, longitudinal cohort study

OBJECTIVES

With the ageing of our population, it seems plausible that the prevalence of both dementia and multimorbidity will increase in the following decades. The aim of this study is to examine the trends in prevalence and incidence of registered dementia and trends in multimorbidity in patients with dementia in general practice in Flanders.

DESIGN

Retrospective, longitudinal cohort study.

SETTING

Primary care practices across Flanders, Belgium.

PARTICIPANTS

Patients included in the Intego database.

METHODS

Data were collected from the Intego database, a Belgian general practice registration network, from 1 January 2000 to 31 December 2021. Joinpoint regression, the Cochran-Armitage test and Jonckheere-Terpstra test were used for the trend analysis.

RESULTS

Data from 149 492 unique patients aged 65 years and older were available. From 2000 to 2021, 3835 incident cases of dementia were found. The age-adjusted prevalence of registered dementia significantly increased during this study period, from 1.19% to 2.43% (average annual percentage change (AAPC) 3.3; 95% CI 2.7 to 4.0). Incidence increased from 3.68 to 5.86 per 1000 patient years overall (AAPC 1.8, 95% CI -2.0 to 5.7), but declined in recent years (annual percentage change -8.1, 95% CI -14.8 to -0.8). Almost three-quarters of the patients with dementia (74.8%) suffered from multimorbidity (three or more comorbidities) and this increased significantly during the study period (p=0.0031). By 2021, 86.7% and 74.8% of the patients with dementia suffered from two or more or three or more chronic conditions, respectively. Hypertension (47.9%), osteoarthritis (29.7%) and lipid metabolism disorders (25.7%) were the most prevalent conditions.

CONCLUSIONS

The prevalence of registered dementia doubled over a 22-year time period, mirroring the increasing health burden by this disease globally. Furthermore, three-quarters of the patients with dementia suffered from multimorbidity, underlining the urgent need to implement comorbidity management and patient-centred care in dementia.

Older adults and the unique role of the radiation therapist: Future directions for improving geriatric oncology training and education

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This article reviews the status quo of the available evidence and guidance for geriatric oncology clinical practice, training and education for radiation therapists worldwide.

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We explore the unique clinical role that radiation therapists play in the management of older adults undergoing radiation therapy.

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We define multiple clinical care points in which the radiation therapists role could potentially expand or specialise into geriatric screening, assessment and intervention to optimise the care of older adults.

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Current GO educational offerings and future directions to improve RTT knowledge and skills around caring for older adults are outlined.

There is widespread recognition that the provision of high quality, appropriate and equitable care to older adults with cancer is a growing challenge in oncology practice. Radiation therapy (RT) is an effective and localised treatment that represents an attractive curative or palliative option for many older adults, and radiation therapists (RTT) play an important role in the delivery, support and quality of care for people during RT. The need to develop an evidence-based, global approach to improving all radiation oncology (RO) professionals’ knowledge and clinical practice in geriatric oncology (GO) has been previously identified. This article specifically focusses on the status quo of GO clinical practice and education for RTT worldwide. We explore the unique clinical role that RTT play in the management of older adults with cancer and define multiple clinical care points in which RTT could potentially participate in geriatric screening, geriatric assessment and intervention to optimise the care of older adults, with a focus on dementia. Directions for future efforts to improve the knowledge and clinical skills of RTT in caring for older adults are discussed.

Causes of and Alternatives to Medication for Behaviours That Challenge in People with Intellectual Disabilities: Direct Care Providers' Perspectives

Behaviours that challenge (BtC), such as aggression and self-injury, are manifested by many people with intellectual disabilities (ID). National and international guidelines recommend non-pharmacological psychosocial intervention before considering medication to address BtC. Support staff play a pivotal role in the prescription process. Using coproduction, we developed a training programme for support staff, called SPECTROM, to give them knowledge and empower them to question inappropriate prescriptions and ask for the discontinuation of medication if appropriate and instead look for ways to help people with ID when they are distressed without relying on medication. We have presented data from two focus groups that we conducted during the development of SPECTROM: one that included support staff, and another that had service managers and trainers. In these focus groups, we explored participants' views on the use of medication to address BtC with a particular emphasis on the causes of and alternatives to medication for BtC. Along with the participants' views, we have also presented how we have addressed these issues in the SPECTROM resources.

[Polypharmacy and Neuroleptics in Swiss Nursing Homes in the Years 2019 and 2020]

Polypharmacy and Neuroleptics in Swiss Nursing Homes in the Years 2019 and 2020 Abstract. We present data from 92404 clinical assessments from 619 Swiss nursing homes . The data were collected in 2019 and 2020 from over 65-year-old residents. Two-thirds of those studied had severe cognitive limitations, one quarter had significant behavioral disorders and just over half of the assessed patients showed signs of emotional instability or depression. 46% were treated with nine or more different drugs, 37% received a neuroleptic in 85% for more than 90 days. There is a positive correlation between the number of drugs taken, age, cognitive impairment and susceptibility to falls. Since neuroleptics are administered in 30% under uncertain indication and the susceptibility to falls is increased by 40% under neuroleptics, their use should be reduced in the course of structured interprofessional processes.

The impact of healthcare executive seniority on implementation of innovative methods of diagnosis and prevention

Innovative methods of diagnosis and prevention play a key role in the survival of healthcare systems as well as the wellbeing of patients. Effective healthcare management is a critical factor in implementing hospital innovation. Healthcare executive (HE) personal and job characteristics such as age and seniority have been found to affect innovative decision-making. However, no study has yet investigated age and seniority effects on the propensity to implement innovation in health prevention strategies. This study fills the literature gap by providing evidence for the effect of HE age and seniority on the implementation of innovative methods for diagnosis and prevention. Predicated on 57 in-depth interviews with HEs, we employ mixed methods research, combining qualitative and quantitative analysis. Structural Equation Modeling was used to test the model's goodness-of-fit. Results show that while HE age and number of years in the organization positively affect job tenure, job tenure, in turn, negatively affects willingness to implement innovative methods of diagnosis and prevention in hospitals. This study extends the Upper-Echelon Theory to health workforce management. Practical implications are discussed.

Alzheimer Disease: Standard of Diagnosis, Treatment, Care, and Prevention

Alzheimer disease (AD) is the most frequent cause of dementia in people 60 y old or older. This white paper summarizes the current standards of AD diagnosis, treatment, care, and prevention. Cerebrospinal fluid and PET measures of cerebral amyloidosis and tauopathy allow the diagnosis of AD even before dementia (prodromal stage) and provide endpoints for treatments aimed at slowing the AD course. Licensed pharmacologic symptomatic drugs enhance cholinergic pathways and moderate excess of glutamatergic transmission to stabilize cognition. Disease-modifying experimental drugs moderate or remove brain amyloidosis, but so far with modest clinical effects. Nonpharmacologic interventions and a healthy lifestyle (diet, socioaffective inclusion, cognitive stimulation, physical exercise, and others) provide some beneficial effects. Prevention targets mainly modifiable dementia risk factors such as unhealthy lifestyle, cardiovascular-metabolic and sleep-wake cycle abnormalities, and mental disorders. A major challenge for the future is telemonitoring in the real world of these modifiable risk factors.

Changes in Polypharmacy and Psychotropic Medication Use After Diagnosis of Major Neurocognitive Disorders: A Population-based Study in Québec, Canada

BACKGROUND

Older adults with major neurocognitive disorder (MNCD) are often exposed to polypharmacy. We aimed to assess the prescribing and discontinuation patterns of medications following diagnosis of MNCD among community-dwelling older adults.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study comparing 1-year prediagnosis and postdiagnosis use of medications between a group of individuals older than 65 years newly diagnosed with MNCD in 2016-2017 and a control group without MNCD. The difference-in-difference method was used to estimate the prediagnosis and postdiagnosis variation in the number of medications prescribed and in the proportion of psychotropic and anticholinergic medication users.

RESULTS

In the MNCD group, the mean number of medications used (excluding Alzheimer disease treatments) increased by 1.25 in the year after the diagnosis. The respective increase was 0.45 in the control group, yielding an adjusted difference-in-differences of 0.81 (95% confidence interval: 0.74; 0.87) between groups. The adjusted difference-in-differences in the proportions of antipsychotic, antidepressant, and anticholinergic medication users was 13.2% (12.5; 13.9), 7.1% (6.5; 7.7), and 3.8% (3.1; 4.6), respectively.

CONCLUSIONS

The medication burden among older adults tends to increase in the year following a diagnosis of MNCD. The use of antipsychotics and antidepressants may explain a part of the observed increase.

A National Assessment of Alzheimer Disease and Antipsychotic Medication Prescribing Among Older Adults in Ambulatory Care Settings

OBJECTIVE

The objective of this study was to assess antipsychotic prescribing within ambulatory settings in the United States among older adults with Alzheimer disease after adjusting for demographic, provider, and clinical factors.

METHODS

This cross-sectional cohort study utilized Centers for Disease Control's (CDC) National Ambulatory Medical Care Survey (NAMCS) ambulatory care data from 2014 to 2016 among visits 65 years old or older with any listed diagnosis of Alzheimer. Multivariable logistic regression analyses assessed the association between the outcome of antipsychotic prescribing after controlling for numerous demographic, provider, and clinical covariates. An extension of the Oacaxa-Blinder decomposition was used to assess observed differentials.

RESULTS

An estimated 15,471,125 ambulatory visits involving Alzheimer disease among those 65 years old or older occurred from 2014 to 2016. Antipsychotics were prescribed in 9.3% of these visits, equating to 6.81 times higher multivariable-adjusted odds relative to non-Alzheimer visits (95% confidence interval: 2.86-16.20, P <0.001). The decomposition analysis indicated that the study's predictor variables explained 15.6% of the outcome gap between Alzheimer versus non-Alzheimer visits.

CONCLUSIONS

Despite potential mortality risks with antipsychotics in adults 65 years old or older with Alzheimer disease and recommendations discouraging their use, this nationally representative study observed significantly higher odds of prescribing independent of demographic, provider, and clinical characteristics. Polypharmacy may be a risk factor that warrants continued assessment regarding the appropriateness of antipsychotic prescribing in this vulnerable population.

Evaluation of routinely collected records for dementia outcomes in UK: a prospective cohort study

OBJECTIVES

To evaluate the characteristics of individuals recorded as having a dementia diagnosis in different routinely collected records and to examine the extent of overlap of dementia coding across data sources. Also, to present comparisons of secondary and primary care records providing value for researchers using routinely collected records for dementia outcome capture.

STUDY DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

A cohort of 25 639 men and women in Norfolk, aged 40-79 years at recruitment (1993-1997) followed until 2018 linked to routinely collected to identify dementia cases. Data sources include mortality from death certification and National Health Service (NHS) hospital or secondary care records. Primary care records for a subset of the cohort were also reviewed.

PRIMARY OUTCOME MEASURE

Diagnosis of dementia (any-cause).

RESULTS

Over 2000 participants (n=2635 individuals) were found to have a dementia diagnosis recorded in one or more of the data sources examined. Limited concordance was observed across the secondary care data sources. We also observed discrepancies with primary care records for the subset and report on potential linkage-related selection bias.

CONCLUSIONS

Use of different types of record linkage from varying parts of the UK's health system reveals differences in recorded dementia diagnosis, indicating that dementia can be identified to varying extents in different parts of the NHS system. However, there is considerable variation, and limited overlap in those identified. We present potential selection biases that might occur depending on whether cause of death, or primary and secondary care data sources are used. With the expansion of using routinely collected health data, researchers must be aware of these potential biases and inaccuracies, reporting carefully on the likely extent of limitations and challenges of the data sources they use.

Hospital admission profile related to poisoning by, adverse effect of and underdosing of psychotropic drugs in England and Wales: An ecological study

Background

Drug poisoning is considered as one of the main principal reasons for acute care hospitals admissions, and it places a significant burden on emergency medical services resources. The aim of this study is to examine the trend of hospital admission due to poisoning by psychotropic drugs and prescriptions of psychotropic medications in England and Wales in the past 21 years.

Method

Hospital admission data from the Hospital Episode Statistics database in England and the Patient Episode Database in Wales were used in this ecological study. For the period from April 1999 to March 2020, hospital admissions data relating to poisoning by, classified by adverse effects of, and underdosing of psychiatric medications were extracted. Data on CNS drug prescriptions was collected for the time period 2004–2020.

Results

During the study period, hospital admission rate increased by19.9% [from 39.94 (95% CI 39.40–40.48) in 1999 to 47.90 (95% CI 47.34–48.45) in 2020 per 100,000 persons, trend test, p < 0.05]. The most common reason of poisoning by psychotropic drugs that lead to hospital admissions was unspecified poisoning by antidepressants (accidental (unintentional), intentional self-harm, assault, as adverse effect, and under-dosing), which accounted for 48.9% of the total number of admissions. CNS medications prescription rates increased by 56.4% [from 247629.78 (95% CI 247593.18–247666.39) in 2004 to 387372.48 (95% CI 387333.41–387411.55) in 2020 prescriptions per 100,000 persons, trend test, p < 0.001]. The most commonly prescribed CNS medications prescriptions were analgesics, antidepressant, antiepileptic, and hypnotics and anxiolytics, which accounted for: 35.0%, 28.7%, 10.0%, and 9.5%, respectively. During the study.

period between 2004 and 2020, the overall medications prescribing rate showed to be very strongly and positively correlating the hospital admissions rate with the overall poisoning by psychotropic drugs (r = 0.799; p ≤ 0.001).

Conclusion

Over the last two decades, there has been a parallel increase in the hospitalization rate for psychotropic drug poisoning and the prescription rate for CNS medications. Future research should focus on identifying high-risk populations who are more prone to psychotropic drug poisoning.

Time trends in psychotropic drug prescriptions in Dutch nursing home residents with dementia between 2003 and 2018

OBJECTIVE

Several European studies investigated the trends in psychotropic drug prescriptions (PDPs) among nursing home (NH) residents and reported a decline in antipsychotics prescriptions. Since the Dutch long-term care system differs from other European systems (e.g. higher threshold for NH admission and trained elderly care physicians), this study explores the trends in PDPs in Dutch NH residents with dementia.

METHODS

The study used data from nine studies, comprising two cross-sectional studies, one cohort study, and six cluster-randomized controlled trials, collected in Dutch NHs between 2003 and 2018. With multilevel logistic regression analysis, NHs as a random effect, we estimated the trends in PDPs overall and for five specific psychotropic drug groups (antipsychotics, antidepressants, anxiolytics, hypnotics, and anti-dementia drugs), adjusting for confounders: age, gender, severity of dementia, severity of neuropsychiatric symptoms, and length of stay in NHs.

RESULTS

The absolute prescription rate of antipsychotics was 37.5% in 2003 and decreased (OR = 0.947, 95% CI [0.926, 0.970]) every year. The absolute prescription rate of anti-dementia drugs was 0.8% in 2003 and increased (OR = 1.162, 95% CI [1.105, 1.223]) per year. The absolute rate of overall PDPs declined from 62.7% in 2003 to 40.4% in 2018.

CONCLUSIONS

Among Dutch NH residents with dementia, the odds of antipsychotics prescriptions decreased by 5.3% per year while the odds of anti-dementia drug prescriptions increased by 16.2%. There were no distinct trends in antidepressants, anxiolytics, and hypnotics prescriptions. However, overall PDPs were still high. The PDPs in NH residents remain an issue of concern.

Support and Empowerment for Older Adult Spousal Caregiving of People with Mild and Moderate Dementia: A Participatory Action Research

Background: Little attention has been given to the older adult caregivers of spouses with mild and moderate dementia in the caring dynamics process. The aim of this action research was to develop a program for providing support and empowerment to older adult caregivers of spouses with mild and moderate dementia in the community. Methods: The researchers acted as facilitators, with a view to empowering participants. We recruited participants from a day-care center and two community service stations. Data were collected with semi-structured, in-depth interviews with 19 dementia care dyads and from the notes, reflections, and feedback of collaborative researchers. Relevant themes for content analysis were extracted. Results: Three action cycles were completed over 18 months. The results revealed goals of three cycles: to connect the home situation and effective dialogue as a bridge to the researcher, to confirm the daily needs or expectations of the caregiver and the patient, and to enhance the interactions and quality of life of family members with resources and network. This process was cyclical and repetitive, and it also generated partnerships that built relationships among the interdisciplinary team, families, and researchers. At the same time, team workers formed a cooperative and coordinated family service mechanism to reflect the professional values and practice capabilities. Conclusions: The intervention program was based on the promotion of factors for the caregiver, linking to environmental protective factors, and the stabilization of mental and neurological symptoms of dementia patients, thereby enhancing the response capabilities of home caregivers while meeting the patient’s care needs in life. It is a tool that can effectively be used for support and empowerment in this population.

Antipsychotic treatment patterns in Alzheimer's disease patients with agitation: a cohort study using the UK clinical practice research datalink

OBJECTIVES

There is a lack of robust epidemiological evidence on antipsychotic (AP) use in patients with agitation in Alzheimer's disease (AD). Authors studied AP use in patients with AD and agitation and compared their use with patients with other or no neuropsychiatric symptoms (NPS).

METHODS

A retrospective cohort study in the UK Clinical Practice Research Datalink, included patients with AD between January 1^st, 2015, and December 31^st, 2017. AP use was compared between patients with agitation, other types of NPS and no NPS.

RESULTS

There were 24,464 patients with AD, median follow-up of 1.1 years (interquartile range [IQR] 0.5-2.1), and median age 83 years (78-88). A larger percentage of patients with agitation (n = 2432) were prescribed APs (38.2%) than other NPS (n = 13,076, 20.4%) and no NPS (n = 11,816, 12.2%). Compared to patients with no NPS, adjusted hazard ratios for AP use were 3.45 (95% CI 2.86-4.17) for patients with agitation and 1.31 (95% CI 1.19-1.44) for patients with other NPS. Among users of APs, the treatment discontinuation rate at six months was 44.8% in patients with agitation (other NPS 57.1%; no NPS 63.5%).

CONCLUSIONS

Patients with AD and agitation were frequently prescribed APs and for long periods in routine clinical practice in the UK. The high real-life usage of APs suggests that physicians prefer using APs for the treatment of agitation despite recommendations against their long-term use. These data support a need for AP therapies that better address known safety concerns with currently used APs to treat agitation in elderly patients with AD.

Epidemiology of dementia onset captured in Canadian primary care electronic medical records

BACKGROUND

Dementia is an increasing concern in many countries, especially in those experiencing rapid growth in the proportion of older adults in their population.

OBJECTIVE

This study aims to describe trends and demographic characteristics of incident dementia cases in community-dwelling older adults managed by primary care physicians.

METHODS

We used electronic medical records from the Canadian Primary Care Sentinel Surveillance Network database to conduct a retrospective analysis to determine the number of, and trends for, incident diagnoses of dementia. Age-standardized annual incidence rates were calculated. Participants in our cohort are Canadian community dwelling seniors aged 65+ years who were not diagnosed with dementia before baseline with at least six years of record at their primary care clinics.

RESULTS

The cohort consisted of 39 067 patients of whom 57% were females; the mean (SD) follow-up was 8.4 (1.5) years. During follow-up, 4935 patients were diagnosed with dementia. The risk for dementia diagnosis increased with increasing age but decreased in the last four years among people aged 80 and older at baseline (P < 0.001). People with dementia were more likely to be females (P = 0.001) and urban residents (P < 0.001), they are less likely to be classified into the least deprived group (P = 0.012).

CONCLUSIONS

The incidence of dementia diagnosis increased with age except in the oldest old in both sexes. This may be attributed to the effect of mortality competing risk. Future research on the association between risk factors and dementia should consider studying dementia among the oldest old separately to minimize bias.

What gets recorded, counts: dementia recording in primary care compared with a specialist database

BACKGROUND

databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care.

METHODS

a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared.

RESULTS

3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06).

DISCUSSION

there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Agitation is common in people with dementia and negatively affects the quality of life of both people with dementia and carers. Non-drug patient-centred care is the first-line treatment, but there is a need for other treatment when this care is not effective. Current evidence is sparse on safer and effective alternatives to antipsychotics. We assessed the efficacy and safety of mirtazapine, an antidepressant prescribed for agitation in dementia.

METHODS

This parallel-group, double-blind, placebo-controlled trial-the Study of Mirtazapine for Agitated Behaviours in Dementia trial (SYMBAD)-was done in 26 UK centres. Participants had probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, and a Cohen-Mansfield Agitation Inventory (CMAI) score of 45 or more. They were randomly assigned (1:1) to receive either mirtazapine (titrated to 45 mg) or placebo. The primary outcome was reduction in CMAI score at 12 weeks. This trial is registered with ClinicalTrials.gov, NCT03031184, and ISRCTN17411897.

FINDINGS

Between Jan 26, 2017, and March 6, 2020, 204 participants were recruited and randomised. Mean CMAI scores at 12 weeks were not significantly different between participants receiving mirtazapine and participants receiving placebo (adjusted mean difference -1·74, 95% CI -7·17 to 3·69; p=0·53). The number of controls with adverse events (65 [64%] of 102 controls) was similar to that in the mirtazapine group (67 [66%] of 102 participants receiving mirtazapine). However, there were more deaths in the mirtazapine group (n=7) by week 16 than in the control group (n=1), with post-hoc analysis suggesting this difference was of marginal statistical significance (p=0·065).

INTERPRETATION

This trial found no benefit of mirtazapine compared with placebo, and we observed a potentially higher mortality with use of mirtazapine. The data from this study do not support using mirtazapine as a treatment for agitation in dementia.

FUNDING

UK National Institute for Health Research Health Technology Assessment Programme.

Cholinesterase inhibitors for the treatment of dementia: real-life data in Hungary

Dementia is one of the leading causes of death and disability in older population. Previous reports have shown that antidementia medications are associated with longer survival; nonetheless, the prevalence of their use and the compliance with them are quite different worldwide. There is hardly any available information about the pharmacoepidemiology of these drugs in the Eastern-European region; we aimed to analyze the use of cholinesterase inhibitors (ChEis) for the treatment of dementia to provide real-life information from the Eastern European region. All medical and medication prescription reports of the in- and outpatient specialist services collected in the NEUROHUN database in Hungary were analyzed between 2013 and 2016. Survival, adherence, and persistence values were calculated. 8803 patients were treated with ChEis during the study period, which was only 14.5% of the diagnosed demented patients. The survival of treated patients (more than 4 years) was significantly longer than patients without ChEi treatment (2.50 years). The best compliance was observed with rivastigmine patch. Choosing the appropriate medication as soon as possible after the dementia diagnosis may lead to increased life expectancy.

Impact of the COVID-19 pandemic on use of anti-dementia medications in 34 European and North American countries

INTRODUCTION

The impact of the COVID-19 pandemic on the global use of anti-dementia medication is unknown. We aimed to determine the changes of anti-dementia medication use in Europe (EU) and North America (NA) during the pandemic.

METHODS

This is a cross-sectional study using sales data of anti-dementia medications in 2019 and 2020 from 34 EU and NA countries. The monthly uses of anti-dementia medications from January through June in 2020 were compared to the corresponding months in 2019 for each country.

RESULTS

In the pre-pandemic period of January to March 2020, 70 out of 102 (3 months x 34 countries) measurements (68.6%) of monthly sales volume showed an increase. In contrast, 76.5% and 85.3% countries showed reduced sales in April and May 2020, respectively.

DISCUSSION

These findings indicate changes in use of anti-dementia medications during the pandemic. The delivery of pharmaceutical care for dementia patients may be heavily disrupted in certain countries.

Effect of trazodone on cognitive decline in people with dementia: Cohort study using UK routinely collected data

OBJECTIVES

Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants.

METHODS

Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis.

RESULTS

We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses.

CONCLUSIONS

There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.

Psychotropic prescribing for English care home residents with dementia compared with national guidance: findings from the MARQUE national longitudinal study

Background

Despite policy pressure and concerns regarding the use of antipsychotics and benzodiazepines, many care home residents with dementia are prescribed psychotropic medication, often off licence. This is the first large study to report psychotropic prescribing and ‘as required’ administration patterns in English care homes.

Aims

To explore the prevalence and associates of psychotropic prescription in care home residents with dementia and compare the results with national guidance.

Method

We collected data in a longitudinal cohort study of residents with diagnosed or probable dementia in 86 care homes in England in 2014–2016. We reported the prevalence of psychotropic (antipsychotics, anxiolytics/hypnotics, antidepressants) prescriptions and drug receipt. We explored the associations between resident factors (sociodemographic, agitation [Cohen–Mansfield Agitation Inventory], dementia severity [Clinical Dementia Rating]) and care home factors (type, ownership, size, dementia registration/specialism, quality rating) in prescription and ‘as required’ administration, using multilevel regression models.

Results

We analysed data from 1425 residents. At baseline, 822 residents (57.7%, 95% CI: 55.1–60.2) were prescribed a psychotropic drug, 310 residents (21.8% 95% CI: 19.7–24.0) were prescribed an anxiolytic/hypnotic, 232 (94.3%, 95% CI: 90.6–96.6) were prescribed one antipsychotic and 14 (5.7%, 95% CI: 3.4–9.4) were prescribed two antipsychotics. The median prescription duration during the study was 1 year. Residents with clinically significant agitation were prescribed more antipsychotics (odds ratio [OR] = 2.00, 95% CI: 1.64–2.45) and anxiolytics/hypnotics (OR = 2.81, 95% CI: 2.31–3.40).

Conclusions

Antipsychotics and anxiolytics/hypnotics are more commonly prescribed for people with dementia in care homes than in the community, and prescribing may not reflect guidelines. Policies which advocate reduced use of psychotropics should better support psychosocial interventions.

Changes in the use of psychotropic drugs during the course of Alzheimer's disease: A large-scale longitudinal study of French medical records

INTRODUCTION

We aim to understand how patients with Alzheimer's disease (AD) are treated by identifying in a longitudinal fashion the late-life changes in patients' medical history that precede and follow AD diagnosis.

METHODS

We use prescription history of 34,782 patients followed between 1996 and 2019 by French general practitioners. We compare patients with an AD diagnosis, patients with mild cognitive impairment (MCI), and patients free of mental disorders. We use a generalized mixed-effects model to study the longitudinal changes in the prescription of eight drug types for a period 15 years before diagnosis and 10 years after.

RESULTS

In the decades preceding diagnosis, we find that future AD patients are treated significantly more than MCI patients with most psychotropic drugs and that most studied drugs are increasingly prescribed with age. At the time of diagnosis, all psychotropic drugs except benzodiazepines show a significant increase in prescription, while other drugs are significantly less prescribed. In the 10 years after diagnosis, nearly all categories of drugs are less and less prescribed including antidementia drugs.

DISCUSSION

Pre-diagnosis differences between future AD patients and MCI patients may indicate that subtle cognitive changes are recognized and treated as psychiatric symptoms. The disclosure of AD diagnosis drastically changes patients' care, priority being given to the management of psychiatric symptoms. The decrease of all prescriptions in the late stages may reflect treatment discontinuation and simplification of therapeutic procedures. This study therefore provides new insights into the medical practices for management of AD.

Global trends in symptomatic medication use against dementia in 66 countries/regions from 2008 to 2018

BACKGROUND AND PURPOSE

The aim was to determine trends and patterns of symptomatic medication used against dementia in 66 countries and regions.

METHODS

This was a cross-sectional study that used the wholesale data from the IQVIA Multinational Integrated Data Analysis System database. Sale data for symptomatic medication against dementia from 66 countries and regions from 2008 to 2018 were analysed and stratified by income level (low/middle-income countries [LMICs], n = 27; high-income countries [HICs], n = 37; regions, n = 2). The medication use volume was estimated by defined daily dose (DDD) per 1000 inhabitants per day (World Health Organization DDD harmonized the size, strength and form of each pack and reflects average dosing). Changes in medication use over time were quantified as percentage changes in compound annual growth rates (CAGRs).

RESULTS

Total symptomatic medication against dementia sales increased from 0.85 to 1.33 DDD per 1000 inhabitants per day between 2008 and 2018 (LMICs 0.094-0.396; HICs 3.88-5.04), which is an increase of CAGR of 4.53% per year. The increase was mainly driven by the LMICs (CAGR = 15.42%) in comparison to the HICs (CAGR = 2.65%). The overall medication use from 2008 to 2018 increased for all four agents: memantine (CAGR = 8.51%), rivastigmine (CAGR = 6.91%), donepezil (CAGR = 2.72%) and galantamine (CAGR = 0.695%). In 2018, the most commonly used medication globally was donepezil, contributing to 49.8% of total use volume, followed by memantine (32.7%), rivastigmine (11.24%) and galantamine (6.36%).

CONCLUSION

There was an increasing trend in the use of symptomatic medications against dementia globally, but the use remained low in LMICs. Interventions may be needed to support the medication use in some countries.

Practical Strategies for Extreme Missing Data Imputation in Dementia Diagnosis

Accurate computational models for clinical decision support systems require clean and reliable data but, in clinical practice, data are often incomplete. Hence, missing data could arise not only from training datasets but also test datasets which could consist of a single undiagnosed case, an individual. This work addresses the problem of extreme missingness in both training and test data by evaluating multiple imputation and classification workflows based on both diagnostic classification accuracy and computational cost. Extreme missingness is defined as having ~50% of the total data missing in more than half the data features. In particular, we focus on dementia diagnosis due to long time delays, high variability, high attrition rates and lack of practical data imputation strategies in its diagnostic pathway. We identified and replicated the extreme missingness structure of data from a real-world memory clinic on a larger open dataset, with the original complete data acting as ground truth. Overall, we found that computational cost, but not accuracy, varies widely for various imputation and classification approaches. Particularly, we found that iterative imputation on the training dataset combined with a reduced-feature classification model provides the best approach, in terms of speed and accuracy. Taken together, this work has elucidated important factors to be considered when developing a predictive model for a dementia diagnostic support system.

Systemic medicines taken by adult special care dental patients and implications for the management of their care

Introduction Significant changes have taken place in the profile of prescription medicines being taken by the adult UK population over the last decade. The aims of this article are to review the literature to understand the overall trends and underlying factors, and then to compare this with the medication profile of a cohort of adult special care dental (SCD) patients. Materials and method Five hundred patient records were examined and retrospective data on systemic medicines being taken were obtained and classified according to the index used in the British National Formulary (BNF).Results The results revealed a high level of polypharmacy with 57% of SCD patients taking three or more medicines compared to 24% of the population in England. Antiepileptic drugs were the most frequently taken group of medicines (42%), followed by antidepressants (39.7%) and antipsychotics (37.6%). Conclusions Our results demonstrate the medical complexity of patients in this cohort and enable clinicians to increase their familiarity with the most commonly taken medicines and the tools available to manage the implications for dental care.

Glycemic Control, Diabetic Complications, and Risk of Dementia in Patients With Diabetes: Results From a Large U.K. Cohort Study

OBJECTIVE

Type 2 diabetes is an established risk factor for dementia. However, the roles of glycemic control and diabetic complications in the development of dementia have been less well substantiated. This large-scale cohort study aims to examine associations of longitudinal HbA_1c levels and diabetic complications with the risk of dementia incidence among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data of eligible patients with diabetes, aged ≥50 years in the U.K. Clinical Practice Research Datalink from 1987 to 2018, were analyzed. Time-varying Cox regressions were used to estimate adjusted hazard ratios (HRs) and 95% CIs for dementia risk.

RESULTS

Among 457,902 patients with diabetes, 28,627 (6.3%) incident dementia cases were observed during a median of 6 years' follow-up. Patients with recorded hypoglycemic events or microvascular complications were at higher risk of dementia incidence compared with those without such complications (HR 1.30 [95% CI 1.22-1.39] and 1.10 [1.06-1.14], respectively). The HbA_1c level, modeled as a time-varying exposure, was associated with increased dementia risk (HR 1.08 [95% CI 1.07-1.09] per 1% HbA_1c increment) among 372,287 patients with diabetes with postdiagnosis HbA_1c records. Similarly, a higher coefficient of variation of HbA_1c during the initial 3 years of follow-up was associated with higher subsequent dementia risk (HR 1.03 [95% CI 1.01-1.04] per 1-SD increment).

CONCLUSIONS

Higher or unstable HbA_1c levels and the presence of diabetic complications in patients with type 2 diabetes are associated with increased dementia risk. Effective management of glycemia might have a significant role in maintaining cognitive health among older adults with diabetes.

Ageing and dementia: age-period-cohort effects of policy intervention in England, 2006-2016

Background

Dementia is one of the most critical challenges of our time. According to the Dementia Statistics Hub, only about 66 % of all UK residents with dementia were diagnosed in 2017–2018. Yet, there are reservations about the early diagnosis of dementia-related diseases. As a result, the UK National Screening Committee does not recommend systematic population screening of dementia, although case-finding strategies are still applied for high-risk groups.

Methods

This study added additional evidence of the effectiveness of the National Dementia Strategy and increased numbers of diagnosis of dementia on the younger cohorts of the older people, using the intrinsic estimator age-period-cohort (APC) models and the English Longitudinal Study of Ageing data.

Results

Age effects show that diagnosis increases in volume only among those aged 75 and above, suggesting that many of those aged below 75 might not be diagnosed in time. Period effects show that although there was an initial increase due to the new policy implementation, the trend stalled in later years, indicating that the increase might not have been even across the period when controlled for age and cohort. The study also shows that cohort effects indicate lower prevalence in younger cohorts controlled for age and period effects.

Conclusions

Although more research in diverse contexts is warranted, this study cautions against the abandonment of timely diagnosis, increased screening and case-finding, and shows some effectiveness of prevention strategies on the national level.

Association of renal impairment with cognitive dysfunction in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA)

Introduction

Chronic kidney disease (CKD) is a recognized risk factor for cognitive impairment. Identification of those at greatest risk of cognitive impairment may facilitate earlier therapeutic intervention. This study evaluated associations between estimated glomerular filtration rate (eGFR) and cognitive function in the Northern Ireland Cohort for the Longitudinal Study of Ageing.

Methods

Data were available for 3412 participants ≥50 years of age living in non-institutionalized settings who attended a health assessment between February 2014 and March 2016. Measures of serum creatinine (SCr) and cystatin C (cys-C) were used for eGFR. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE).

Results

Following adjustment for potential confounders, a single unit decrease in eGFR was significantly associated with reduced cognitive function defined by an MMSE ≤24/30 {eGFR calculated using serum cys-C [eGFRcys]: β = −0.01 [95% confidence interval (CI) −0.001 to −0.01], P = 0.01} and MoCA <26/30 [β = −0.01 (95% CI −0.002 to −0.02), P = 0.02]. Similarly, CKD Stages 3–5 were also associated with a moderate increase in the odds of cognitive impairment (MMSE ≤24) following adjustment for confounders [eGFRcys: odds ratio 2.73 (95% CI 1.38–5.42), P = 0.004].

Conclusions

Decreased eGFRcys was associated with a significantly increased risk of cognitive impairment in a population-based cohort of older adults. However, there was no evidence of an association between cognitive impairment and the more commonly used eGFR calculated using SCr. eGFRcys may offer improved sensitivity over eGFRcr in the determination of renal function and associated risk of cognitive impairment.

Decreasing trend in the incidence and prevalence of dementia: a systematic review

INTRODUCTION

The progressive ageing of the population is one of the main socio-demographic phenomena, taking place at a global level. Several recent population-based studies conducted worldwide suggest that the age-specific risk of dementia may be changing in some countries and areas.

EVIDENCE ACQUISITION

This systematic review was performed using the methodology proposed by the Cochrane handbook for systematic reviews and reported following the PRISMA statement. A structured bibliographic search was performed on the databases PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews. All included studies were qualitatively assessed using the Methodological Evaluation of Observational REsearch (MORE).

EVIDENCE SYNTHESIS

The bibliographic search yielded 2394 records. Three more articles were retrieved from other sources. A total of ten studies were included, five reported data on a possible reduction in the prevalence of dementia, and five reported data on a possible reduction in its incidence.

CONCLUSIONS

The present systematic review focused on the recent observations of a possible decrease in the frequency of dementia and cognitive impairment in some Western countries (USA, UK, Sweden, the Netherlands, France, Iceland) between 1977 and 2014. The included studies have a high heterogeneity in terms of the clinical criteria used to diagnose dementia, and of the criteria used to define the clinical condition preceding dementia, such as isolated cognitive impairment. Moreover, the methodological quality with which they were conducted was also heterogeneous, with scores ranging from 1 to 7 using the MORE tool.