Andrea Gruneir

Antidepressants for agitation and psychosis in dementia

BACKGROUNDnAgitation and psychosis are common among older adults with dementia and are challenging to manage. At the present time, little is known about the efficacy and safety of antidepressant medications when used to treat these symptoms.nnnOBJECTIVESnTo assess the safety and efficacy of antidepressants in treating psychosis and agitation in older adults with Alzheimers disease, vascular, or mixed dementia.nnnSEARCH STRATEGYnWe searched the Cochrane Dementia and Cognitive Improvement Groups Specialized Register which included Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (January 1950 to October 2009), EMBASE (1980 - October 2009), CINAHL (all dates - October 2009) and PsycINFO (1806 to October 2009).nnnSELECTION CRITERIAnRandomized, controlled trials of antidepressants (selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, trazodone, and other antidepressants), compared to either placebo or comparator medications (typical or atypical antipsychotics, anticonvulsants, benzodiazepines, cholinesterase inhibitors, memantine or other medications) for treatment of agitation or psychosis in older adults with dementia.nnnDATA COLLECTION AND ANALYSISnTwo authors independently assessed trial quality and extracted trial data. We collected information on efficacy as measured by dementia neuropsychiatric symptom rating scales and adverse effects. Study authors were contacted for additional information.nnnMAIN RESULTSnNine trials including a total of 692 individuals were included in the review. Five studies compared SSRIs to placebo and two studies were combined in a meta-analysis for the outcome of change in Cohen-Mansfield Agitation Inventory (CMAI) scores. There was a significant difference between antidepressants and placebo on measures of agitation as reported on the change in CMAI total score (mean difference (MD), -0.89, 95% CI, -1.22 to -0.57) although the results were heavily weighted by one large study. There were no significant differences in change in behavioral symptoms of dementia for SSRIs compared to placebo in the one study that reported on changes in the Neuropsychiatric Inventory and Behavioral Pathology in Dementia scales. One study comparing citalopram to placebo found a significant difference in NPS as measured on the Neurobehavioral Rating Scale (NBRS) after controlling for baseline severity NBRS score although the unadjusted mean difference was not statistically significant (MD - 7.70, 95% CI: -16.57 to 1.17). There was no difference in the rates of trial withdrawals due to adverse events for SSRIs compared to placebo for four studies reporting this outcome (relative risk (RR), 1.07, 95% CI: 0.55 to 2.11) or in the number of trial withdrawals due to any cause in the three studies reporting this outcome (RR, 0.91, 95% CI, 0.65 to 1.26). One study compared the SSRI citalopram to the atypical antipsychotic risperidone and found no difference in NBRS scores, trial withdrawals due to any cause or trial withdrawals due to adverse events although the rates of adverse events as measured on the UKU side effect scale total score were lower for citalopram (MD -2.82, 95% CI: -4.94 to -0.70). Three studies compared SSRIs to typical antipsychotics. In meta-analysis of two studies there was no statistically significant differences in changes in CMAI total scores (MD, 4.66, 95% CI: -3.58 to 12.90). There was also no difference in trial withdrawals due to any cause or due to adverse events for SSRIs compared to typical antipsychotics. One study of trazodone compared to placebo did not find any significant difference in change in CMAI total scores (MD, 5.18, 95% CI, -2.86 to 13.22) or trial withdrawals due to any cause (RR, 1.06, 95% CI, 0.54 to 2.09). Two studies comparing trazodone to haloperidol also failed to detect any difference in change in CMAI total scores (MD, 3.28, 95% CI, -3.28 to 9.85) or trial withdrawals due to any cause (RR, 0.79, 95% CI, 0.43 to 1.46).nnnAUTHORS CONCLUSIONSnCurrently there are relatively few studies of antidepressants for the treatment of agitation and psychosis in dementia. The SSRIs sertraline and citalopram were associated with a reduction in symptoms of agitation when compared to placebo in two studies. Both SSRIs and trazodone appear to be tolerated reasonably well when compared to placebo, typical antipsychotics and atypical antipsychotics. Future studies involving more subjects are required to determine if SSRIs, trazodone, or other antidepressants are safe and effective treatments for agitation and psychosis in dementia.

Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs:

Older adults use emergency departments (EDs) more than any other age group and are more prone to subsequent adverse events. This article reviews the literature on ED use by older adults within the context of evaluating their need for emergency care and the extent to which access to primary and supportive care services affect use. While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention.

Dihydropyridine calcium channel blockers and the progression of parkinsonism

A study was undertaken to test the association between dihydropyridine calcium channel blocker use and the time to important milestones of disease progression among patients with parkinsonism.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study

BackgroundHome care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario.MethodsA retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences.ResultsThe study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death.ConclusionsOur study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Investigator experiences with financial conflicts of interest in clinical trials

BackgroundFinancial conflicts of interest (fCOI) can introduce actions that bias clinical trial results and reduce their objectivity. We obtained information from investigators about adherence to practices that minimize the introduction of such bias in their clinical trials experience.MethodsEmail survey of clinical trial investigators from Canadian sites to learn about adherence to practices that help maintain research independence across all stages of trial preparation, conduct, and dissemination. The main outcome was the proportion of investigators that reported full adherence to preferred trial practices for all of their trials conducted from 2001-2006, stratified by funding source.Results844 investigators responded (76%) and 732 (66%) provided useful information. Full adherence to preferred clinical trial practices was highest for institutional review of signed contracts and budgets (82% and 75% of investigators respectively). Lower rates of full adherence were reported for the other two practices in the trial preparation stage (avoidance of confidentiality clauses, 12%; trial registration after 2005, 39%). Lower rates of full adherence were reported for 7 practices in the trial conduct (35% to 43%) and dissemination (53% to 64%) stages, particularly in industry funded trials. 269 investigators personally experienced (n = 85) or witnessed (n = 236) a fCOI; over 70% of these situations related to industry trials.ConclusionFull adherence to practices designed to promote the objectivity of research varied across trial stages and was low overall, particularly for industry funded trials.

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review

There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re‐visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge.

ACUTE CARE TRANSITIONS AND OUTCOMES AMONG ASSISTED LIVING RESIDENTS WITH AND WITHOUT DEMENTIA

andmutual cooperation during the exercises (with and without cooperation). Each group received a distinct exercise protocol. At three months they were reversed about variables and protocols. The hypothesis is the beneficial effect in the analyzed aspects. To evaluate the results, it was used the SPSS17.0 software (Statistical Package for Social Sciences), the Friedman test for descriptive analysis and for analysis of the tests performance it was applied the SPAD (Syst eme Portables d’Analyse dês Don ees). Significant difference (p<0,05) in behavior (GDS) with improvement of depression as well as trends towards improvements in the tests analysed, in distinct phases. Analysis of performance in tests classified them into three groups: mixed results, good results and bad results. Although the short period and frequency of intervention,this physiotherapeutical protocolproved positive for the elderly with Alzheimer ’s Disease, a neurodegenerative pathology.

ACCESS TO REHABILITATION AND OUTCOMES FOLLOWING HIP FRACTURE FOR OLDER ADULTS WITH DEMENTIA

P3-286 ACCESS TO REHABILITATION AND OUTCOMES FOLLOWING HIP FRACTURE FOR OLDER ADULTS WITH DEMENTIA Dallas Seitz, Sudeep Gill, Peter Austin, Chaim Bell, Andrea Gruneir, Geoffrey Anderson, Paula Rochon, Queen’s University, Kingston, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Mt. Sinai Hospital, Toronto, Ontario, Canada; Women’s College Hospital, Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada; Women’s College Research Institute, Toronto, Ontario, Canada. Contact e-mail: seitzd@providencecare.ca

Resident and facility predictors of hospitalization among older adults with dementia residing in assisted living facilities

expenditures as a result of their comorbidities. This study assessed the risk of potentially avoidable hospitalizations (PAHs) that might be prevented with good outpatient management among ADRD patients. Methods: We examined the proportions of subjects with PAHs among Medicare beneficiaries with and without ADRD using data from 2007-2008 Medicare claims files. We used logistic regression to calculate propensity scores of having ADRD, matching cases (n1⁄4195,024) and an equal number of controls based on age, sex, race, Medicare-Medicaid dual eligibility, residence in a metropolitan statistical area, and number of comorbidities. We defined PAHs as admissions for: serious short-term complications of diabetes, serious long-term complications of diabetes, COPD or asthma, hypertension, and heart failure, based on the Medicare Ambulatory Care Indicators for the Elderly. We used logistic regression to investigate patient characteristics associated with PAHs. Results: Approximately one in five (20.2%) beneficiaries with ADRD and concurrent COPD/asthma had a PAH directly related to COPD/asthma. Corresponding proportions of patients with PAHs were 11.7% for heart failure, 2.8% for diabetes long-term complications, 1.3% for diabetes short-term complications, and 0.5% for hypertension. Compared to propensity-matched non-ADRD subjects, ADRD beneficiaries were more likely to have PAHs for diabetes shortterm complications (OR1⁄41.43; 95% CI1⁄41.31-1.57), diabetes long-term complications (OR1⁄41.08; 95% CI1⁄41.02-1.14), and hypertension (OR1⁄41.22; 95% CI1⁄41.08-1.38), but less likely to have PAHs for COPD/ asthma (OR1⁄40.85; 95% CI1⁄40.82-0.87) and heart failure (OR1⁄40.89; 95% CI1⁄40.86-0.92). Among ADRD patients, the risk of PAHs increased with comorbidity burden and the presence of medical complications associated with late-stage ADRD (ulcers, feeding disorders and malnutrition, aspiration pneumonia, and incontinence). Conclusions: A substantial proportion of Medicare beneficiaries with ADRD had preventable hospital admissions related to uncontrolled comorbidities. For some conditions, such as diabetes and hypertension, ADRD patients had a higher risk of condition-related PAHs compared to matched controls without dementia. Future ADRD management programs should improve care coordination between ambulatory, inpatient, and post-acute care, and these efforts should target high-risk patients, especially patients with multiple chronic conditions.