Investigation of risk of dementia diagnosis and death in patients in older people's secondary care mental health services

OBJECTIVES

Previous studies have shown increased rates of death and dementia in older people in specific serious mental illnesses (SMI) such as bipolar disorder or depression. We examined the rates of death and dementia in older people referred into a secondary care psychiatric service across a range of SMIs.

METHODS

We used an anonymised dataset across 6 consecutive years with 28,340 patients aged 65 years and older from a single secondary care psychiatric trust in the United Kingdom. We identified deaths and incident dementia in patients with bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders. We compared mortality and dementia rates between these diagnostic groups and in different treatment settings. We also examined mortality rates and dementia rates compared with general population rates.

RESULTS

Patients with schizophrenia showed the highest hazard rate for death compared to other groups with SMIs (hazard ratio, 1.58; 95% confidence interval (CI), 1.18-2.1, with anxiety group the reference). Survival was reduced in patients referred to liaison psychiatry services. There were no significant differences between the SMI groups in terms of rates of dementia. However, risks of death and dementia were significantly increased compared to the general population (standardized mortality rates with 95% CI, 2.6(2.0-3.3), 3.5(2.6-4.5), 2.5(2.0-3.0) and 1.8 (1.4-2.2) and standardized dementia incidence rates with 95% CI, 2.7(1.5-4.1), 2.9(1.5-4.7), 3.8(2.6-5.2) and 4.3 (3.0-5.7) for bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders respectively.

CONCLUSIONS

Older adults referred into an old age psychiatry service show higher rates of dementia and death than those reported for the general population.

The Medium-Term Impact of COVID-19 Lockdown on Referrals to Secondary Care Mental Health Services: A Controlled Interrupted Time Series Study

To date, there is a paucity of information regarding the effect of COVID-19 or lockdown on mental disorders. We aimed to quantify the medium-term impact of lockdown on referrals to secondary care mental health clinical services. We conducted a controlled interrupted time series study using data from Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), UK (catchment population ~0.86 million). The UK lockdown resulted in an instantaneous drop in mental health referrals but then a longer-term acceleration in the referral rate (by 1.21 referrals per day per day, 95% confidence interval [CI] 0.41-2.02). This acceleration was primarily for urgent or emergency referrals (acceleration 0.96, CI 0.39-1.54), including referrals to liaison psychiatry (0.68, CI 0.35-1.02) and mental health crisis teams (0.61, CI 0.20-1.02). The acceleration was significant for females (0.56, CI 0.04-1.08), males (0.64, CI 0.05-1.22), working-age adults (0.93, CI 0.42-1.43), people of White ethnicity (0.98, CI 0.32-1.65), those living alone (1.26, CI 0.52-2.00), and those who had pre-existing depression (0.78, CI 0.19-1.38), severe mental illness (0.67, CI 0.19-1.15), hypertension/cardiovascular/cerebrovascular disease (0.56, CI 0.24-0.89), personality disorders (0.32, CI 0.12-0.51), asthma/chronic obstructive pulmonary disease (0.28, CI 0.08-0.49), dyslipidemia (0.26, CI 0.04-0.47), anxiety (0.21, CI 0.08-0.34), substance misuse (0.21, CI 0.08-0.34), or reactions to severe stress (0.17, CI 0.01-0.32). No significant post-lockdown acceleration was observed for children/adolescents, older adults, people of ethnic minorities, married/cohabiting people, and those who had previous/pre-existing dementia, diabetes, cancer, eating disorder, a history of self-harm, or intellectual disability. This evidence may help service planning and policy-making, including preparation for any future lockdown in response to outbreaks.

Three decades of inequality in neonatal and early childhood mortality in singleton births in Scotland

Background

Socioeconomic inequality in child mortality highlights opportunities for policies to reduce child deaths.

Methods

We used singleton birth, death and maternity records from Scotland, 1981-2011, to examine mortality rate differences by age across deprivation quintiles over time. We measured the difference between the most and least deprived quintiles (Q5-Q1) and the slope index of inequality (SII) across all quintiles-measures of the absolute deprivation gap, providing an indication of the public health impact.

Results

Q5-Q1 remained relatively constant from 1990 onwards for early neonates, widened in the mid-2000s for late neonates, increased in the 1990 s then decreased in the 2000 s in the post-neonates and declined over time in early childhood. The trend over time in SII showed no significant change for early neonates (P = 0.440), significant decrease for post-neonates (P = 0.010) and early childhood (P = 0.043), and significant increase for late neonates (P = 0.011).

Conclusions

Over three decades, the absolute deprivation gap in mortality widened in late neonates but stabilized or declined at other ages. This may reflect improved survival beyond the early neonatal period of babies with conditions related to socioeconomic inequality such as prematurity. Monitoring birth cohort data could enhance understanding of this vulnerable group.

Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a randomised controlled trial

BACKGROUND

For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.

METHODS/DESIGN

This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.

DISCUSSION

We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN12595588 .

Abstract P3-06-03: Oral bisphosphonates and survival of breast and colon malignancies

Bisphosphonates are traditionally used for treatment of osteoporosis and more recently for treatment and prevention of bone metastases in various malignancies. The use of 2nd-generation oral bisphosphonates has been reported to reduce the risk of developing breast and colon cancer but their influence on cancer survival has not been studied.

Methods Two large cohorts of consecutively diagnosed cases with breast or colorectal cancer were studied for the association between use of 2nd-generation oral bisphosphonates and cancer survival. Using computerized prescription records, sustained use of alendronate/risedronate was assessed in postmenopausal women with newly diagnosed breast (n = 2,843) or colorectal cancer (n = 1,706). Overall survival and cancer-specific survival were evaluated using time dependent analysis.

Results Postmenopausal women with breast cancer previously unexposed to bisphosphonates who used 2nd-generation bisphosphonates after diagnosis for at least one year had a significantly better survival than non-users, adjusted for age, tumor stage and grade (Overall survival: HR = 0.53, 0.33-0.86, breast cancer-specific survival: HR = 0.26, 0.10-0.71, p = 0.009). A similar advantageous hazard ratio was found in users with ER positive, ER negative and HER2neu positive tumors. A similar significantly better survival was noted for colorectal cancer after adjustment for age, tumor stage and grade (Overall survival: HR = 0.53, 0.33-0.85, colorectal cancer-specific survival: HR = 0.44, 0.21-0.88, p = 0.02). Women who used bisphosphonates before diagnosis did not exhibit a significant survival benefit. Pharmacogenetic studies of F(D)PPS (Farnesyl Pyrophosphate Synthase), a gene coding a key step in the mevalonate pathway revealed direct correlation between a minor homozygous status and survival in bisphosphonate users.

Conclusions The use of 2nd-generation bisphosphonates initiated after diagnosis was associated with a significant improvement in overall and in cancer-specific survival of postmenopausal women with breast or colon cancers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-06-03.

The longitudinal variability of serum 25(OH)D levels

BACKGROUND

The extent to which a single serum 25(OH)D measurement represents long-term vitamin D status remains unclear. This study aims to assess the variability of serum 25(OH)D between tests taken at different time intervals.

METHODS

Using the computerized database of the largest healthcare provider in Israel, we identified subjects in whom a serum 25(OH)D test was performed on at least two different occasions between January 2008 and September 2011 (n = 188,771). For these subjects we selected the first and the last dated tests, then we identified those who were not treated with supplements during the last 6 months before the first and before the last test (n = 94,418). Of these we analyzed subjects in whom the first and the last tests were performed in the same month of the year (n = 8881).

RESULTS

The mean serum 25(OH)D level at the first test was 51.7 ± 24.0 nmol/L and was 56.7 ± 24.7 at the last test (P<0.001); the overall correlation was 0.63 (P < 0.001). For vitamin D status in two categories (<50 versus ≥ 50 nmol/L), the percentage of agreement between the first and last tests was 74.4%, and was 50.8% for vitamin D status in four categories (<30, 30-49.9, 50-74.9, and ≥ 75 nmol/L). The correlation decreased with increasing time between the tests ranging from 0.83 for tests done at the same year to 0.55 after 3 years. The more the first levels were higher or lower, the more likely subjects remain in their first category (≥ 50 versus <50 nmol/L).

CONCLUSIONS

Long-term month specific serum 25(OH)D levels are relatively stable.

Serum 25(OH)D concentrations in sunny Israel

SUMMARY

This study assesses vitamin D status in Israel. Serum 25(OH)D levels <25 and <50 nmol/L are common in Israel with noted differences between Arabs and Jews, Arab females were particularly at high risk. These findings may require public health intervention at the population level.

INTRODUCTION

Small studies from Israel have suggested a high prevalence of hypovitaminosis D. The objective of this study was to evaluate the extent of hypovitaminosis D among demographic subgroups in Israel.

METHODS

The data of this study are from the Clalit Health Services (CHS) which is a non-for-profit health maintenance organization (HMO) covering more than half of the Israeli population. We included all CHS members for whom a 25(OH)D test result in 2009 was available and who were not taking vitamin D supplements in 2008-2009 before that 25(OH)D result. Complete data were available for 198,834 members.

RESULTS

The mean level of 25(OH)D was 51.9 ± 24.5 nmol/L and was higher in summer compared to winter (P < 0.0001). Level <25, <37.5, and <50 nmol/L were detected in 14.4%, 30.7%, and 49.9% of tests; 16.4% had levels >75 nmol/L. Females had higher prevalence of 25(OH)D levels < 50 nmol/L which were found in 51.8% of females versus 45.0% in males (P < 0.0001); 76.7% of the Arabs had levels <50 nmol/L versus 46.5% in Jews (P < 0.0001). Arabs females were particularly at high risk for 25(OH)D <50 nmol/L; 84.8% of them had levels <50 nmol/L versus 48.1% of Jewish females (P < 0.0001). The relation of 25(OH)D levels with age had a sinusoidal shape among Jews, a U-shape in Arab females, and inverse linear pattern in Arab males.

CONCLUSIONS

25(OH)D levels <25 and <50 nmol/L are common in Israel. Public health measures are needed for values lesser than about 30 nmol/L and further monitoring of concentrations between about 30 and 50 nmol/L to determine if there are adverse health effects.

Rock hyrax (Procavia capensis) den site selection: preference for artificial sites

Context Objective assessments of habitat requirements for endangered species are often lacking when planning management strategies, and inappropriate landscape manipulation can sometimes turn an endangered species into a pest. Recent expansive population growth of the rock hyrax Procavia capensis in northern Israel has been attributed largely to the proliferation of man-made boulder piles on the fringes of new residential developments. Aims The hyrax is a protected species, but when in proximity to residential areas it can be a garden pest and is medically important as a reservoir of cutaneous leishmaniasis. Management should thus consider preservation of hyrax populations in combination with minimising pest potential. We examined the hypothesis that hyraxes prefer artificial boulder piles to natural outcrop crevices as den sites. Methods We surveyed all 57 potential den sites in a 1 × 1 km area around a village in northern Israel, and conducted logistic regression to examine the correlation of hyrax presence with site type (pile or crevice), size, distance from the village, distance from other den sites and network centrality within the den site network. We used the Aikaike information criterion (AIC) to compare logistic models. Key results Occupancy was well predicted by site type, site size, and distance from other sites, explaining 59% of the variation in the logistic regression. These three predictors were selected both by considering the combination of predictors that gave the lowest AIC value, and also by the stepwise logistic algorithm. Conclusions and implications Hyrax den site preference, and in particular preference for boulder piles over natural crevices, should be integrated into managing this species simultaneously for conservation and pest control in the face of continuing residential encroachment on natural areas.

A new approach to blood pressure measurement in the primary care setting

In this study, a method of taking one blood pressure reading using a sphygmomanometer was compared with a method of taking multiple successive readings using an automatic device. With multiple readings the blood pressure tended to be lower and fewer patients were classified as hypertensive. Using an automatic blood pressure recording device seems to be a practical way of achieving multiple readings in a busy clinic setting.

Bilateral foot-drop in a patient with anorexia nervosa

We report the occurrence of bilateral foot-drop in a patient with anorexia nervosa. To the best of our knowledge this has not been reported previously. The underlying pathology was found to be peroneal nerve palsy probably related to mechanical pressure at the head of the fibula. Nutritional deficiency may also be implicated.