Andrea Iaboni

The complex interplay of depression and falls in older adults: a clinical review.

Depression and falls have a significant bidirectional relationship. Excessive fear of falling, which is frequently associated with depression, also increases the risk of falls. Both depression and fear of falling are associated with impairment of gait and balance, an association that is mediated through cognitive, sensory, and motor pathways. The management of depression in fall-prone individuals is challenging, since antidepressant medications can increase the risk of falls, selective serotonin reuptake inhibitors may increase the risk of fragility fractures, and data are lacking about the effect of fall rehabilitation programs on clinically significant depression. Based on the current state of knowledge, exercise (particularly Tai Chi) and cognitive-behavioral therapy should be considered for the first-line treatment of mild depression in older fallers. Antidepressant medications are indicated to treat moderate to severe depression in fall-prone individuals, but with appropriate precautions including low starting dose and slow dose titration, use of psychotropic monotherapy whenever possible, and monitoring for orthostatic hypotension and hyponatremia. To date, there have been no recommendations for osteoporosis monitoring and treatment in individuals prescribed antidepressant medications, beyond the usual clinical guidelines. However, treatment of the older depressed person who is at risk of falls provides the opportunity to inquire about his or her adherence with osteoporosis and fracture prevention guidelines.

Immunocytochemical localisation and biological activity of diuretic peptides in the housefly, Musca domestica.

Abstract The distribution of a CRF-related diuretic peptide (Musca-DP) and the diuretic/myotropic insect myokinins in the central nervous system of larval and adult houseflies was investigated using antisera raised against Locusta-DH and leucokinin-I, respectively. Two separate, small populations of immunoreactive neurons are present in the brain and fused thoracic-abdominal ganglion mass. There is no evidence for these immunoreactivities being colocalised either within single neurons or at neurohaemal release sites. Crude extracts of tissues containing immunoreactive material increase fluid secretion by isolated Malpighian tubules from adult flies. Diuretic activity is highest in tissues containing myokinin-immunoreactive material. Consistent with this observation, myokinin analogues produce a four- to five-fold increase in fluid secretion, which is more than twice the response to Musca-DP. These effects are mimicked by treatments that increase intracellular calcium and cyclic AMP, respectively. When tested at threshold concentrations, the two classes of diuretic peptide act synergistically to accelerate tubule secretion, and their separate localisation may be important for the precise control of diuresis.

Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Association between Antidepressants and Fall-Related Injuries among Long-Term Care Residents

OBJECTIVES Antidepressants are associated with an increased risk of falls although little is known of the comparative risks of different types of antidepressants or individuals who are at greatest risk for falls. We examined the association between new use of antidepressants and fall-related injuries among older adults in long-term care (LTC). DESIGN, SETTING, PARTICIPANTS This was a matched, retrospective cohort study involving LTC residents in Ontario, Canada, from 2008 to 2014. New users of antidepressants were matched to non-users of antidepressants. MEASUREMENTS The primary outcome was any fall resulting in an emergency department (ED) visit or hospitalization within 90 days after exposure. Secondary outcomes included hip fractures, wrist fractures, and falls reported in LTC. Multivariate logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval associated with antidepressants and outcomes. RESULTS New users of any antidepressant had an increased risk of ED visits or hospitalization for falls within 90 days when compared with individuals not receiving antidepressants (5.2% versus 2.8%; adjusted OR: 1.9, 95% CI: 1.7-2.2). Antidepressants were also associated with an increased risk of all secondary outcomes. The increased risk of fall-related injuries was evident among selective-serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, trazodone, and across multiple patient subgroups. CONCLUSIONS New use of antidepressants is associated with significantly increased risk of falls and fall-related injuries among LTC residents across different patient subgroups and antidepressant classes. The potential risk of fall-related outcomes should be carefully considered when initiating antidepressants among older adults in LTC.

A Palliative Approach to Falls in Advanced Dementia

Falls are viewed as a preventable cause of injury, functional loss, and death in older adults with dementia, and have been used as a marker of quality of care in long-term care facilities. Despite intensive intervention around fall prevention in these settings, falls and injury remain frequent, particularly among residents in the advanced stages of dementia. In this clinical review, we consider the common challenges and pitfalls in both the management of falls and the provision of palliative care in advanced dementia. We then describe a palliative approach to falls in advanced dementia that involves identifying individuals who would benefit from this care approach, framing falls and loss of mobility as a quality of life issue, and devising an individualized symptom assessment and management plan. A palliative approach can lead to recognition and acceptance that recurrent falls are often symptomatic of advanced dementia, and that not all falls are preventable. We conclude that falls in the advanced stage of dementia can be sentinel events indicating the need for a palliative approach to care. Rather than replace falls prevention activities, a palliative approach to falls prompts us to select dementia stage-appropriate interventions with a focus on symptom management, comfort, and dignity.

Low-Dose Trazodone, Benzodiazepines, and Fall-Related Injuries in Nursing Homes: A Matched-Cohort Study: Low-dose trazodone, benzodiazepines, and falls

To evaluate whether risk of fall‐related injuries differs between nursing home (NH) residents newly dispensed low‐dose trazodone and those newly dispensed benzodiazepines.

CLINICAL ASSESSMENT OF MOBILITY IN DEMENTIA: A SCOPING REVIEW AND FEASIBILITY ANALYSIS

which individual and population health outcomes evolve. Population Health is a “conceptual framework for thinking about why some populations are healthier than others” which lends itself to the study of lifecourse transitions that lead to cognitive change such as Alzheimer’s and other dementias. Methods:This presentation will review emerging opportunities to incorporate cognitive change in later life within a Population Health framework. Working within the generalized framework as described in Figure 1, the presentation describes available databases within each information vector that can be used to measure cognitive change across time and be incorporated into Population Health models. The presentation will also discuss new tools emerging from the NACDA Program on Aging at the University of Michigan that will allow researchers to link confidential EHRs to contextual data, which provides insight on community and environmental impacts on the risk of cognitive health concerns. Results:The presentation shows that the Population Health framework is a very useful model to employ when describing cognitive change across individuals and population groups. While barriers do exist in terms of access to confidential and individual level health records, new approaches will allow researchers to incorporate contextual resources into health outcomes analysis of cognitive change in treatment. Conclusions:The use of Population Health models are becoming more common research framework across health research disciplines. The routine incorporation of this framework into the study of cognitive change will greatly enhance our understanding of this phenomenon at both the individual and population level.

NABILONE SIGNIFICANTLY IMPROVES AGITATION/AGGRESSION IN PATIENTS WITH MODERATE-TO-SEVERE AD: PRELIMINARY RESULTS OF A PLACEBO-CONTROLLED, DOUBLE-BLIND, CROSS-OVER TRIAL

is maintained. The primary hypothesis is that the agitation/aggression domain score on the Neuropsychiatric Inventory (NPI) will decrease more on lithium than placebo. The secondary hypothesis is that there will be a greater number of responders on lithium than placebo. Change in NPI psychosis scores on lithium compared to placebo will be explored. Treatment Emergent Symptom Scale (TESS) scores and emergent adverse events will be used to assess tolerability. Exploratory outcomes include change in serum brainderived neurotrophic factor (BDNF) levels and two genetic markers as potential predictors of response to lithium: a specific SNP on intron 1 of the ACCN1 gene, and variation at the 7q11.2 gene locus. Results:Trial Design; blinded study is in progress. Conclusions:This study will provide initial data on three potential roles for low-dose lithium in clinical practice: (1) first-line treatment; (2) adjunct treatment in partial responders; (3) second-line agent after non-response or intolerability to other medications. The results of this Phase II trial will determine the potential of a large-scale Phase III clinical trial of lithium in these patients.

Detecting and Managing Neuropsychiatric Symptoms in Dementia: What Psychiatrists Need to Know and Why

This issue of the Canadian Journal of Psychiatry contains two review articles on the issue of neuropsychiatric symptoms of dementia. We welcome attention to this topic for two reasons. First, it is a reflection of the growing importance of seniors’ mental health and geriatric psychiatry as our population ages. Second, it provides general psychiatrists with concise and helpful information about recent developments and controversies in recognizing and treating neuropsychiatric symptoms in dementia. The disciplines of geriatric psychiatry and dementia care have been advancing quickly in the past five years. Subspecialty training in geriatric psychiatry was recognized in Canada in 2012, and since that time, 11 universities have opened formal geriatric psychiatry training programs in Canada. More than 180 psychiatrists—many of whom have been in practice for decades—have qualified with the new geriatric psychiatry subspecialty designation. Even so, we are currently at less than half of the benchmarks set by the guidelines for comprehensive services for elderly persons in Canada. In most of the country, geriatric psychiatrists remain a scarce resource. Therefore, there is still tremendous need for general psychiatrists across the country to provide expert assessment and management of patients with dementia, particularly as the population ages and the prevalence of dementia climbs. The first article in this issue reflects on the early presence of neuropsychiatric symptoms prior to the diagnosis of dementia and provides suggestions for using the symptoms as an opportunity for early diagnosis and intervention. The second article focuses on the problem of widespread antipsychotic use in patients with dementia, a topic of significant interest to any psychiatrist working with older people. Both of these topics are of importance to all psychiatrists. Gallagher, Fischer, and Iaboni argue that neuropsychiatric or behavioural symptoms, even in individuals with no or little change in cognitive functioning, can herald a neurocognitive disorder. This ‘‘precognitive’’ stage, with mood and sleep changes, anxiety, agitation, and apathy symptoms, is understood to have biological as well as psychological underpinnings. Pathological changes in the brain precede the onset of clinical dementia by decade or two. Neurodegenerative or vascular damage disrupts frontal-subcortical circuits in the brain, affecting drive, affect regulation, salience, perception, and impulse control. The regulation of emotion and behaviour is thus subtly altered as cognitive performance begins to slip. There is clearly value in considering whether late-onset psychiatric symptoms indicate the presence of a neurocognitive disorder. The prevalence of mild cognitive impairment (MCI) is about 18% to 35% in those older than 65 years. While the overall rate of conversion of MCI to dementia is around 5% per year, in those who are exhibiting neuropsychiatric symptoms, 25% will convert to dementia per year. Almost a third of people with dementia come to psychiatric attention prior to receiving a dementia diagnosis. However, vigilance for dementia must be balanced by the risk of mislabeling a primary psychiatric disorder as dementia, leading to the serious consequences of a neurodegenerative diagnosis when none exists in reality. For example, while individuals with late-life depression are at severalfold increased risk of dementia, most do not develop dementia. Likewise, as many as one-quarter of people with MCI will convert to ‘‘cognitively normal’’ within 1 year. As such, more study of the use of the new term mild behavioural impairment and its ramifications is warranted. In the

A MOBILE DEMENTIA OBSERVATION SYSTEM (DOBS): DEVELOPMENT AND PILOT USABILITY TESTING

currently operationalized across research studies, and to identify barriers and enablers to its implementation. Methods: This was a narrative review of the literature. Articles were identified through a search of electronic academic data bases (Medline, Web of Science, Scopus, EBSCO, ProQuest) and grey literature (OpenGrey, Google). Articles were included for review if they met one the following criteria: 1) described the characteristics or elements of transdisciplinary research approach; 2) reported on factors that influence transdisciplinary research process and outcomes. Results: Transdisciplinarity is not well established in dementia; the majority of literature on this approach has come from the field of sustainability science and translational medicine. Transdisciplinarity is typically used to characterize large-scale inter-disciplinary and intersectoral collaborations between scientists, academics and experiential stakeholders (e.g. industry, policy-makers, end-users) for the purpose of solving complex and “socially-relevant” problems. Key principles of this approach include: embracing complexity and multiplicity of perspectives on the scope of the problem; seeking to integrate knowledge across diverse stakeholders; and the adoption of integrated, recursive and participatory research methods. Engaging in this type of research presents a challenge as it requires culture change regarding the current way we think about and conduct research. Barriers identified include: communication, established research hierarchies and practices, dealing with uncertainty, and lengthy research process. Facilitators identified include: institutional support, heterogeneous team make-up, multi-directional communication, and collaborative leadership. Conclusions:Transdisciplinary research has received limited attention in dementia and technology research to date, highlighting the urgent need for more research in this area. Our findings can importantly support the development of ethical and participatory principles to guide future research efforts.