Purushottam B. Thapa

Antidepressants and the Risk of Falls among Nursing Home Residents

BACKGROUND In nursing home residents, the use of tricyclic and other heterocyclic antidepressants is associated with an increased risk of falls. The newer selective serotonin-reuptake-inhibitor antidepressants are largely free of the side effects of the tricyclic agents thought to cause falls and so have been hypothesized to be safer for those at high risk for falls. METHODS We retrospectively identified an inception cohort of 2428 nursing home residents in Tennessee who were new users of tricyclic antidepressants (665 subjects), selective serotonin-reuptake inhibitors (612 subjects), or trazodone (304 subjects) or nonusers of antidepressants (847 subjects). We ascertained the number of falls during therapy and during a similar follow-up period for nonusers, then calculated the rate ratios for falls with adjustments for an extensive set of potential confounding factors. RESULTS The new users of each type of antidepressant had higher rates of falls than the nonusers, with adjusted rate ratios of 2.0 (95 percent confidence interval, 1.8 to 2.2) for tricyclic antidepressants, 1.8 (1.6 to 2.0) for selective serotonin-reuptake inhibitors, and 1.2 (1.0 to 1.4) for trazodone. The rate ratios increased with the daily dose for tricyclic antidepressants, reaching 2.4 (95 percent confidence interval, 2.1 to 2.8) for doses of 50 mg or more of amitriptyline or its equivalent, and for the serotonin-reuptake inhibitors, reaching 1.9 (1.7 to 2.2) for 20 mg or more of fluoxetine or its equivalent. The elevated rates of falls persisted through the first 180 days of therapy and beyond. CONCLUSIONS In this large study of nursing home residents, there was little difference in rates of falls between those treated with tricyclic antidepressants and those treated with selective serotonin-reuptake inhibitors. Hence, the preferential use of the newer antidepressants is unlikely to reduce the higher rate of falls among nursing home residents taking antidepressants.

Cyclic antidepressants and the risk of sudden cardiac death

Tricyclic and other related cyclic antidepressants (TCAs), used frequently for the treatment of depression and several other indications, have cardiovascular effects that may increase the risk of sudden cardiac death. We thus sought to quantify the risk of sudden cardiac death among TCA users, according to dose, as well as among users of selective serotonin reuptake inhibitors (SSRIs).

Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors.

OBJECTIVE: To determine the circumstances of, incidence of, and risk factors for falls resulting in serious injuries in nonambulatory nursing home residents compared with those for ambulatory residents.

Benzodiazepines and the risk of falls in nursing home residents.

CONTEXT: For nursing home residents who require a benzodiazepine, short‐acting agents are recommended, primarily to avoid increased risk of falls and other injuries associated with the long‐acting agents. However, much of the data for the clinical outcomes of falls and injuries comes from community‐dwelling older people.

Comparison of clinical and biomechanical measures of balance and mobility in elderly nursing home residents

Objective: To compare biomechanics force platform measurements of postural sway with clinical measures of balance and mobility, in frail elderly residents of community nursing homes, in terms of feasibility, correlation with other known risk factors for falls, and intercorrelation with each other.

Effects of antipsychotic withdrawal in elderly nursing home residents.

To study the effects of antipsychotic withdrawal in elderly nursing home residents.

Predictors of Antipsychotic Withdrawal or Dose Reduction in a Randomized Controlled Trial of Provider Education

OBJECTIVES: To evaluate the effects of an educational program to reduce antipsychotic use in nursing homes that had high use rates post‐OBRA‐87 and to identify factors that predicted antipsychotic withdrawal or 50% or greater dose reduction.

Prenatal exposure to metronidazole and risk of childhood cancer

To evaluate the role of in utero exposure to metronidazole (a carcinogen in some animal models) and the risk of subsequent cancer, the authors conducted a retrospective cohort study of childhood cancer.

Adverse Childhood Experiences and Geriatric Depression: Results from the 2010 BRFSS

OBJECTIVE Adverse childhood experiences (ACEs), including physical, sexual, and emotional abuse, have been shown to result in a variety of poor outcomes including depression. The majority of research has examined the impact of such events on adolescents and young adults leaving a dearth of information regarding how these events may affect depressive symptom point prevalence later in life. METHODS Data from the U.S. CDCs 2010 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to estimate the point prevalence of depression in individuals 60 years of age and greater based on presence or absence of certain ACEs. Depressive symptoms were assessed using eight items from the Patient Health Questionnaire (PHQ). Subjects with a PHQ score of 10 or greater were categorized as depressed. Six different types of ACE were included in the study: parents being physically abusive to each other, being physically harmed by a parent, being sworn at by the parent, being touched sexually by an adult, being forced to sexually touch an adult, and being forced into a sexual encounter. ACEs were categorized as never, single if subject reported it occurring once, or repeated if subject reported multiple episodes. RESULTS The study sample consisted of 8,051 adults aged 60 years and greater who responded to questions about adverse childhood experiences. The study sample comprised 53% women, 83% Caucasian patients, and had a mean age of 70.4 years. After controlling for age, sex, and race, depression was significantly correlated with repeated ACEs of all types (adjusted odds ratio [AOR] ranging from 2.41 to 9.78, all statistically significant). The only ACE where a single occurrence was significantly associated with late-life depression was forced sexual intercourse (AOR: 2.92, 95% CI: 1.06-8.02). After controlling for all types of abuse in a single model, repeated physical abuse and repeated forced sexual intercourse remained significant (AOR: 2.94, 95% CI: 1.68-5.13; AOR: 3.66, 95% CI: 1.01-13.2, respectively). DISCUSSION These results indicate a significant association between repeated ACEs and depression in older adults. When controlling for all forms of abuse, repeated physical abuse and forced sexual intercourse are significantly correlated with late-life depression. They emphasize the need to continue developing techniques to help individuals with a history of ACEs in order to decrease their negative effects, not only immediately, but also later in life.

The Effectiveness of Guideline Implementation Strategies on Improving Antipsychotic Medication Management for Schizophrenia

Objectives:To compare the effectiveness of a conceptually-based, multicomponent “enhanced” strategy with a “basic” strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines. Methods:Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose. Results:Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0–30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention. Conclusions:The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.