Consumption of psychotropic medication in the elderly: a re-evaluation of its effect on cognitive performance

Impact of psychotropic medications on cognition among older adults: a systematic review

OBJECTIVES

The aim of this systematic review is to examine the cognitive impact of psychotropic medications including benzodiazepines, antidepressants, mood stabilizers, antipsychotics, or a combination of these drugs on older adults.

DESIGN

Systematic review.

SETTING

We searched Medline, PsycINFO, and Embase through the Ovid platform, CINAHL through EBSCO, and Web of Science.

PARTICIPANTS AND INTERVENTIONS

Randomized control trials (RCTs) and cohort studies that used a validated scale to measure cognition with a follow-up period of at least six months were included.

MEASUREMENT

The primary outcome of interest was cognitive change associated with psychotropic medication use.

RESULTS

A total of 7551 articles were identified from the primary electronic literature search across the five databases after eliminating duplicates. Based on full-text analysis, 27 articles (two RCTs, 25 cohorts) met the inclusion criteria. Of these, nine each examined the impact of benzodiazepines and antidepressants, five examined psychotropic combinations, three on antipsychotic drugs, and one on the effects of mood stabilizers.

CONCLUSIONS

This is the first systematic review to examine the cognitive impact of multiple psychotropic drug classes in older adults over an extended follow-up period (six months or more) using robust sample sizes, drug-free control groups, and validated cognitive instruments. We found evidence to indicate cognitive decline with the cumulative use of benzodiazepines and the use of antidepressants, especially those with anticholinergic properties among older adults without cognitive impairment at baseline. Further, the use of antipsychotics and psychotropic combinations is also associated with cognitive decline in older adults.

Benzodiazepines: Uses, Dangers, and Clinical Considerations

Benzodiazepines (BZDs) are among one of the most widely prescribed drug classes in the United States. BZDs are a class of psychoactive drugs known for their depressant effect on the central nervous system (CNS). They quickly diffuse through the blood-brain barrier to affect the inhibitory neurotransmitter GABA and exert sedative effects. Related to their rapid onset and immediate symptom relief, BZDs are used for those struggling with sleep, anxiety, spasticity due to CNS pathology, muscle relaxation, and epilepsy. One of the debilitating side effects of BZDs is their addictive potential. The dependence on BZDs generally leads to withdrawal symptoms, requiring careful tapering of the medication when prescribed. Regular use of BZDs has been shown to cause severe, harmful psychological and physical dependence, leading to withdrawal symptoms similar to that of alcohol withdrawal. Some of these withdrawal symptoms can be life threatening. The current treatment for withdrawal is through tapering with clonazepam. Many drugs have been tested as a treatment for withdrawal, with few proving efficacious in randomized control trials. Future research is warranted for further exploration into alternative methods of treating BZD withdrawal. This call to action proves especially relevant, as those seeking treatment for BZD dependence and withdrawal are on the rise in the United States.

Is Long-Term Benzodiazepine Use a Risk Factor for Cognitive Decline? Results of a Systematic Review

Background and Aims

Benzodiazepines have been widely used for long periods of time despite their adverse effects. The acute effects on cognition are well established. However, less is known about the long-term effects. This study critically reviewed existing evidence of the association between long-term exposure to benzodiazepines and risk of cognitive decline in adults.

Methods

A systematic review with narrative synthesis was conducted. PubMed and PsycINFO databases were searched using combinations of keywords related to “benzodiazepines” and “cognitive function” from database inception to 12 February 2018 to identify prospective longitudinal studies. The records were evaluated for relevance according to the inclusion and exclusion criteria.

Results

Fourteen studies involving 2145 long-term benzodiazepine users were included. Meta-analysis was not undertaken because the combined result would not be meaningful as the included studies differed in several key aspects such as frequency and duration of benzodiazepine use, follow-up periods, cognitive domains, cognitive tests, scoring systems, and statistical analysis. The definition of long-term benzodiazepine use was problematic in all the studies. The exposure was determined by measures which were assumed to represent the whole period in-between the follow-ups. Only 3 of the 14 studies provided support for an association between long-term benzodiazepine use and cognitive decline with a small to medium effect size. However, these three studies used different methods to assess the strength of this association. Global cognitive functioning, verbal memory, intelligence, psychomotor speed, and speed of processing were the cognitive domains affected which also varied across these three studies.

Conclusions

Little evidence of an association between long-term benzodiazepine use and a higher risk of cognitive decline among the general adult population was found. However, discrepancies among the results and inconsistencies regarding the cognitive domains affected and methodological limitations prevent definite conclusions. Therefore, future research with prospective studies specially designed would be of great value.

Is Benzodiazepine Use Associated With the Risk of Dementia and Cognitive Impairment–Not Dementia in Older Persons? The Canadian Study of Health and Aging

Background: The use of benzodiazepines in relation to cognitive decline remains an area of controversy in aging populations. Objective: This study aims to evaluate the risk of cognitive impairment–not dementia (CIND), Alzheimer disease (AD), and all-cause dementia with benzodiazepine use. The effect modification by sex was also investigated. Methods: Data come from the Canadian Study of Health and Aging, a 10-year multicentric study involving 10 263 participants randomly selected, 65 years and older, living in the community and in institutions. Current exposure to benzodiazepines was assessed in a face-to-face interview or self-reported in a questionnaire. Cox proportional hazard regression models, using age as time scale, were conducted to estimate hazard ratios, with adjustment for sex, education, smoking, alcohol intake, depression, physical activity, nonsteroidal anti-inflammatory drug use, and vascular comorbidities. Results: Data sets included 5281 participants for dementia as the outcome, 5015 for AD, and 4187 for CIND. Compared with nonusers, current use of benzodiazepines was associated with an increased risk of CIND (hazard ratio = 1.36; 95% CI = 1.08-1.72) in the simplest model. Results remained similar in the fully adjusted model (hazard ratio = 1.32; 95% CI = 1.04-1.68). There was no association between benzodiazepine use and the risk of dementia or AD. All these effects were similar between men and women. Conclusion and Relevance: Benzodiazepine use in older people from the general population is related to subsequent occurrence of cognitive dysfunction but not implicated in the pathogenesis of dementia or AD. Caution should be exercised when prescribing benzodiazepines to preserve global cognitive function.

Benzodiazepine Use and Cognitive Decline in Elderly With Normal Cognition

Benzodiazepine (BZD) use may be associated with dementia. However, differing opinions exist regarding the effect of BZDs on long-term changes in cognition. We evaluated the association between BZD use and cognitive decline in the elderly with normal cognition from the National Alzheimer's Disease Coordinating Center's Uniform Data Set. The study exposure, BZD use, was classified 2 ways: any-use [reported BZD use at a minimum of 1 Alzheimer's disease center (ADC) visit] and always-use (reported BZD use at all ADC visits). The reference group included participants without any declared BZD use at any Alzheimer's Disease Center (ADC) visit. The main outcome measures were Clinical Dementia Rating Sum of Boxes score and Mini-Mental State Examination score. We observed a decline in cognitive status over time in the 2 comparison groups. All participants who reported taking BZDs had poorer cognitive performance at all visits than nonusers. However, cognitive decline was statistically similar among all participants. We found no evidence of an association between BZD use and cognitive decline. The poor cognitive performance in BZD users may be due to prodromal symptoms caused by preclinical dementia processes.

Impact of alprazolam in allostatic load and neurocognition of patients with anxiety disorders and chronic stress (GEMA): observational study protocol

INTRODUCTION

The allostatic load model explains the additive effects of multiple biological processes that accelerate pathophysiology related to stress, particularly in the central nervous system. Stress-related mental conditions such as anxiety disorders and neuroticism (a well-known stress vulnerability factor), have been linked to disturbances of hypothalamo-pituitary-adrenal with cognitive implications. Nevertheless, there are controversial results in the literature and there is a need to determine the impact of the psychopharmacological treatment on allostatic load parameters and in cognitive functions. Gador study of Estres Modulation by Alprazolam, aims to determine the impact of medication on neurobiochemical variables related to chronic stress, metabolic syndrome, neurocognition and quality of life in patients with anxiety, allostatic load and neuroticism.

METHODS/ANALYSIS

In this observational prospective phase IV study, highly sympthomatic patients with anxiety disorders (six or more points in the Hamilton-A scale), neuroticism (more than 18 points in the Neo five personality factor inventory (NEO-FFI) scale), an allostatic load (three positive clinical or biochemical items at Crimmins and Seeman criteria) will be included. Clinical variables of anxiety, neuroticism, allostatic load, neurobiochemical studies, neurocognition and quality of life will be determined prior and periodically (1, 2, 4, 8, and 12 weeks) after treatment (on demand of alprazolam from 0.75 mg/day to 3.0 mg/day). A sample of n=55/182 patients will be considered enough to detect variables higher than 25% (pretreatment vs post-treatment or significant correlations) with a 1-ß power of 0-80. t Test and/or non-parametric test, and Pearson's test for correlation analysis will be determined.

ETHICS AND DISSEMINATION

This study protocol was approved by an Independent Ethics Committee of FEFyM (Foundation for Pharmacological Studies and Drugs, Buenos Aires) and by regulatory authorities of Argentina (ANMAT, Dossier # 61 409-8 of 20 April 2009), following the law of Habeas Data and psychotherapeutic drug control.

TRIAL REGISTRATION NUMBER

GEMA 20811.

A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs

BACKGROUND

Mild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized.

OBJECTIVE

The aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects.

METHODS

MEDLINE and EMBASE were searched for randomized, double-blind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient.

RESULTS

In studies of short-, intermediate- and long-acting benzodiazepine drugs (n = 68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship. H(1)-antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non-benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant antimuscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n = 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits.

CONCLUSION

Non-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects.

Benzodiazepine use and risk of dementia: prospective population based study

OBJECTIVE

To evaluate the association between use of benzodiazepines and incident dementia.

DESIGN

Prospective, population based study.

SETTING

PAQUID study, France.

PARTICIPANTS

1063 men and women (mean age 78.2 years) who were free of dementia and did not start taking benzodiazepines until at least the third year of follow-up.

MAIN OUTCOME MEASURES

Incident dementia, confirmed by a neurologist.

RESULTS

During a 15 year follow-up, 253 incident cases of dementia were confirmed. New use of benzodiazepines was associated with an increased risk of dementia (multivariable adjusted hazard ratio 1.60, 95% confidence interval 1.08 to 2.38). Sensitivity analysis considering the existence of depressive symptoms showed a similar association (hazard ratio 1.62, 1.08 to 2.43). A secondary analysis pooled cohorts of participants who started benzodiazepines during follow-up and evaluated the association with incident dementia. The pooled hazard ratio across the five cohorts of new benzodiazepine users was 1.46 (1.10 to 1.94). Results of a complementary nested case-control study showed that ever use of benzodiazepines was associated with an approximately 50% increase in the risk of dementia (adjusted odds ratio 1.55, 1.24 to 1.95) compared with never users. The results were similar in past users (odds ratio 1.56, 1.23 to 1.98) and recent users (1.48, 0.83 to 2.63) but reached significance only for past users.

CONCLUSIONS

In this prospective population based study, new use of benzodiazepines was associated with increased risk of dementia. The result was robust in pooled analyses across cohorts of new users of benzodiazepines throughout the study and in a complementary case-control study. Considering the extent to which benzodiazepines are prescribed and the number of potential adverse effects of this drug class in the general population, indiscriminate widespread use should be cautioned against.

Engagement in leisure activities and benzodiazepine use in a French community-dwelling elderly population

OBJECTIVE

The prevalence of benzodiazepine use among community-dwelling older persons varies between 10% and 30%. The aim of this study was to explore the association between leisure activities and the use of benzodiazepine among older persons living at home.

METHODS

The study population included 4848 persons aged 65 years and over living in either of two French cities. Information was collected from a questionnaire administered to the respondents by trained psychologists during face-to-face interviews at home and from a self-administered questionnaire. Baseline examination included socio-demographic characteristics, drug use and leisure activities. We classified as benzodiazepine users subjects who reported use of at least one benzodiazepine during the month preceding the interview. The association between the use of benzodiazepine and leisure activities was assessed by logistic regression adjusted on known potential confounders.

RESULTS

More than 18% of participants reported use of at least one benzodiazepine. The adjusted odds ratio (OR) of benzodiazepine use associated with no or lower participation versus participation in the following activities were as follows: OR = 1.31 (95% confidence interval (CI): 1.09 to 1.58) for mental activity; OR = 1.50 (CI: 1.12 to 2.03) for physical activity; OR = 1.28 (CI: 1.05 to 1.55) for productive activity and OR = 0.82 (CI: 0.69 to 0.97) for recreational activity.

CONCLUSION

Low engagement in stimulating activities and high engagement in sedentary activities were associated with recent benzodiazepine use.

Prevalence of psychiatric disorders in community-dwelling older men and women with cognitive impairment no dementia: results from the ESA study

OBJECTIVES

To assess the prevalence rate of mood disorders, anxiety disorders, benzodiazepine dependence, and insomnia in older men and women with probable cognitive impairment no dementia (CIND) and to examine the independent associations between each disorder and CIND.

METHOD

Participants were a random sample of community-dwelling individuals aged 65-96 (N = 2414). Semi-structured in-home interviews based on DSM-IV-TR (DSM, Diagnostic and Statistical Manual of Mental Disorders) criteria evaluated the prevalence rates of mood disorders, anxiety disorders, benzodiazepine dependence, and insomnia. Participants were classified as probable CIND based on their Mini-Mental State Examination score using sex, age, and education-stratified cut-offs (lower than the 15th percentile).

RESULTS

In men, 22.7% of individuals with probable CIND and 12.1% of those with normal cognition had at least one psychiatric disorder (crude odds ratio (OR): 2.13, 95% confidence interval (CI): 1.23-3.69). More specifically, mood disorders (3.43, 1.74-6.75), benzodiazepine dependence (5.10, 1.23-21.11), and comorbid anxiety and mood disorders (8.67, 2.00-37.68) were significantly associated with probable CIND, but not anxiety disorders alone and insomnia. The prevalence rate of psychiatric disorders was similar in women with probable CIND (23.1%) and in women without CIND (23.9%; 0.95, 0.64-1.42). No specific psychiatric disorder was significantly associated with probable CIND in women. All associations remained unchanged after adjustments for potential confounders.

CONCLUSIONS

The association between psychiatric disorders and probable CIND appears to be sex-specific. In clinical practice, mood disorders, and benzodiazepine dependence should receive particular attention since these disorders are associated with a condition increasing the risk of dementia.

Sedative use and incident cognitive decline among persons aged 75 years and older: a population-based longitudinal study

BACKGROUND

Acute exposure to sedative drugs may induce memory impairment, but there is mixed evidence that long-term sedative use may result in incident cognitive decline. The objective of this study was to investigate the use of sedative drugs and incident cognitive decline in a population-based sample of persons aged 75 years and older.

METHODS

The study sample comprised 781 participants in the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study in Kuopio, Finland. Data on health status, drug use, and sociodemographic factors were elicited during annual nurse interviews from 2004 to 2007. A linear mixed model was used to compare change in Mini-Mental State Examination (MMSE) scores (2005-2007) among users of sedative drugs in 2004 and 2005 (n = 139) to non-users of sedative drugs from 2004 to 2007 (n = 310). The model was adjusted for covariates including age, gender, education, depressive symptoms and antipsychotic use.

RESULTS

Unadjusted mean MMSE scores were 27.50 in 2005, 26.58 in 2006, and 25.95 in 2007 among users of sedative drugs. Unadjusted mean MMSE scores were 28.05 in 2005, 27.61 in 2006, and 27.09 in 2007 among non-users of sedative drugs. Adjusted mean MMSE scores were 0.31 points lower in 2005, 0.62 points lower in 2006, and 0.93 lower in 2007 among users compared to non-users of sedative drugs (P = 0.051).

CONCLUSIONS

Sedatives were not associated with statistically significant cognitive decline. However, clinicians should maintain a judicious approach to prescribing sedative drugs given the risk of adverse drug events.

Pharmacoepidemiology of psychotropic drugs: examples of current research challenges on major public health issues

Background– As a large number of persons are exposed to prescribed psychotropic drugs, their utilisation and impact should be further explored at the population level.Aims– To illustrate the interest of pharmacoepidemiological studies of psychotropic drugs by selected examples of major public health issues.Method– Selective review of the literature. Results – Many questions remain unsolved regarding the behavioural teratogenicity of prenatal exposure to psychotropic drugs, the impact of their increasing use in children, the long-term cognitive consequences of exposure to benzodiazepines, and the risks associated with extension of indications of antipsychotic drugs.Conclusion– Pharmacoepidemiological studies need to be further developed owing to the large number of public health questions raised by the extensive and expanding use of psychotropic drugs.

Effect of benzodiazepine discontinuation on dementia risk

OBJECTIVES

This study aimed to examine whether benzodiazepine (BZD) discontinuation would decrease the risk of dementia.

DESIGN

A population-based nested case-control study of dementia was used.

SETTING

All subjects aged 45 years or older and enrolled in the National Health Insurance Research Database in Taiwan between 1997 and 2007 were randomly selected.

PARTICIPANTS

A total of 8,434 cases had been identified with dementia at least three times in ambulatory claims or with one record in inpatient claims. They were individually matched with two comparison subjects (N = 16,706) by age, gender, and index date.

MEASUREMENTS

The lengths of discontinuation, cumulative BZD dose, and potential confounding factors, including medical and psychiatric disorders, were measured and used for further analysis.

RESULTS

Compared with nonusers, current users had an increased risk of dementia (adjusted odds ratio [aOR] = 2.71; 95% confidence interval [CI], 2.46-2.99). The dementia risk for former users was reduced as the duration of discontinuation lengthened (<1 month aOR = 2.40, 95% CI, 1.98-2.92; 1-3 months aOR = 1.93, 95% CI, 1.67-2.23; 3-6 months aOR = 1.49, 95% CI, 1.28-1.74; 6-12 months aOR = 1.43, 95% CI, 1.25-1.64; 1-2 years aOR = 1.23, 95% CI, 1.09-1.40; 2-3 years aOR = 1.22, 95% CI, 1.06-1.40; and >3 years aOR = 1.08, 95% CI, 0.98-1.20). The decreasing trend was significant (p < 0.001).

CONCLUSION

The risk of dementia was high for current users and decreased as the duration of BZD discontinuation lengthened. Further investigations are needed to replicate this association and explore the underlying mechanism that links long-term BZD use, BZD discontinuation, and the pathogenesis of neurocognitive dysfunction.

Psychotropic drug use among older people in general practice: discrepancies between opinion and practice

BACKGROUND

The use of psychotropic drugs has increased over recent years in France. GPs are the first prescribers, especially for older patients.

AIM

To analyse discrepancies between GPs' opinions and practice when prescribing psychotropic drugs to older patients.

SETTING

Postal surveys sent to GPs all over mainland France.

DESIGN OF STUDY

Cross-sectional postal study.

METHOD

A questionnaire collected data on characteristics of GPs' practices, their opinions about psychotropic drug consumption in older people, and a full description of their last older patient receiving a psychotropic drug and seen last by the GP on that particular day.

RESULTS

A total of 350 participating GPs saw 2498 patients aged > or =65 years. Among these patients, the prevalence of psychotropic use was 32.1% (803/2498) for anxiolytics/hypnotics, and 17.5% for antidepressants (438/2498). A total of 91% of GPs agreed that it was possible to reduce or stop psychotropic drugs for these patients. Characteristics of 339 patients taking psychotropic drug were reported: 85.8% (291/339) received at least one anxiolytic/hypnotic and 56.9% (193/339) received at least one antidepressant; there were prescribed for more than 1 year in 68.4% (199/291) and 43.5% (84/193) of the cases respectively. GPs stated that it was possible to reduce or stop anxiolytic/hypnotic drugs for only 27% (79/291) of these patients. Barriers to doing this were patients' refusal (79%), and the absence of any local offer of psychotherapy (73%) or alternative therapy (70%).

CONCLUSION

A mismatch exists between GPs' intent (91%) and practice (27%) regarding reduction of psychotropic prescription in individuals aged > or =65 years. The barriers encountered should be examined further to help physicians improve management of psychotropic prescription.

The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data

OBJECTIVES

The aim of this study was to examine the association between long-term benzodiazepines (BZDs) use and the risk of dementia.

DESIGN

Population-based nested case-control study of dementia.

SETTING

All subjects were aged 45 and older and enrolled in the National Health Insurance Research Database in Taiwan, 1997-2004.

PARTICIPANTS

Cases (N = 779) were patients who were identified with dementia at least two times in their outpatient claims. They were individually matched to six comparison subjects (N = 4,626) based on age and gender.

MEASUREMENTS

BZD usage (average dosage per year, average days per year, and cumulative dose and periods) and potential confounding comobidities, including cardiovascular and psychiatric diseases.

RESULTS

Subjects with dementia had higher cumulative dose, longer duration of BZDs exposure, and more likelihood to be long-term BZDs users.

CONCLUSION

Our findings suggest that long-term use of BZDs is associated with an increased risk for dementia, but the underlying mechanisms remain unclear, and further investigations are needed. Long-term use of BZDs should be avoided among the elderly, who may be at a higher risk for developing dementia, in addition to other health problems.

Psychotropic medication use and cognition in institutionalized older adults with mild to moderate dementia

BACKGROUND

Most studies examining psychotropic medication use on cognition in older persons with dementia include measures of global cognitive function. The present study examined the relationship between different types of psychotropic medication and specific cognitive functions in older people with dementia.

METHODS

Two hundred and six institutionalized older adults with dementia (180 women, mean age 85 years) were administered neuropsychological tests. Psychotropic medication use was extracted from their medical status and categorized as: sedatives, antidepressants and antipsychotics.

RESULTS

Analysis of covariance revealed that psychotropic consumers, and particularly those who used antipsychotics, performed worse on neuropsychological tests of executive/attentional functioning than non-consumers. There were no differences between consumers of other classes of psychotropic drugs and non-consumers. The number of psychotropic drugs used was inversely related to executive/attentional functioning.

CONCLUSIONS

These findings show that in institutionalized older adults with dementia, specific impairment of cognitive function, i.e. executive/attentional impairments, are associated with antipsychotic medication use. Future longitudinal studies are recommended.

Factors associated with antidepressant use in depressed and non-depressed community-dwelling elderly: the three-city study

OBJECTIVES

The aim of this study was to identify factors associated with antidepressant use in non-depressed and depressed elderly persons, assuming that they varied according to clinical status.

METHODS

We studied 7,868 French community-dwelling subjects aged 65 years and over. The Center for Epidemiological Studies-Depression scale and the Mini International Neuropsychiatric Interview were used to define three groups: non-depressed, high depressive symptoms and current major depressive disorder. Separate analyses were performed to identify the factors which were associated with antidepressant use in each group.

RESULTS

Antidepressant use (55% selective serotonin re-uptake inhibitors, 25% tricyclic antidepressants, 20% other types) increased from 4.9% in non-depressed subjects to 17.3% in subjects with high depressive symptoms (HDS) and 33.6% of in those with current major depressive disorder (MDD). The factors associated with antidepressant use varied according to depression status. In particular, men with current MDD were more often treated with antidepressants than women whereas, in both the HDS and the non-depressed groups, antidepressant use was, as has been observed elsewhere, more frequent in women. Gender also had a strong modifying effect on the relationship between antidepressant use and history of major depression. Finally, the direction of the association between antidepressant use and cognitive performance varied according to depression status.

CONCLUSIONS

This study showed that the direction and strength of the association between antidepressant use and demographic and health-related factors varied according to the severity of depression symptoms. Further studies are needed to clarify the relationship between gender and cognition and antidepressant use.

The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent?

OBJECTIVE

This study investigates the effects of benzodiazepine (BZ) use on cognitive performance in elderly persons in a longitudinal design.

STUDY DESIGN AND SETTING

Data were obtained from the Longitudinal Aging Study Amsterdam (LASA), in the Netherlands. 2,105 respondents (>/=62 years of age) were included and had repeated measurements over a period of 9 years. For all BZs the type, dosage, frequency and duration of use was measured. The equivalent of a dose of diazepam was determined with regard to type and dosage and a cumulative dosage was calculated. General cognitive functioning was measured with the Mini-Mental State Examination, information processing speed was measured with the coding task, fluid intelligence with Raven's Coloured Progressive Matrices and episodic memory with the Auditory Verbal Learning Test. Multilevel analyses were used to investigate the relationship between BZ use and cognitive decline.

RESULTS

A negative effect of BZ use on cognitive performance was found. However, the effect sizes were very small.

CONCLUSION

This study suggests that both duration and cumulative exposure to BZ has a small negative effect on the long-term cognitive functioning of elderly people in the community.

Effect of antidepressant therapy on executive function after stroke

BACKGROUND

Executive dysfunction is common after stroke and may impair long-term outcome. Remedies for this condition are limited.

AIMS

To examine the effect of antidepressants on executive function after stroke.

METHOD

Forty-seven patients who had had a stroke during the prior 6 months received 12 weeks of antidepressant treatment in double-blind placebo-controlled fashion, followed by assessment of executive function at the end of treatment and after 2 years.

RESULTS

No significant group effect was found at the end of treatment. However, 21 months after the end of treatment the placebo group showed deterioration of executive function, whereas the active treatment group showed clear and significant improvement independent of depressive symptoms (F=12.1, d.f.=1,45, P= 0.001).

CONCLUSIONS

Antidepressant treatment fosters long-term improvement of executive function following stroke. This phenomenon is consistent with a reorganisation of neuronal networks associated with prefrontal functions based on modulation of monoaminergic neurotransmission and the activity of neurotrophins.

Psychotropics use in the Spanish elderly: predictors and evolution between years 1993 and 2003

PURPOSE

This study mainly aimed at describing the prevalence of psychotropic medication consumption in the Spanish elderly population between the years 1993 and 2003.

METHODS

Descriptive, cross-sectional study covering the Spanish population aged 65 years and over, using data drawn from the 1993 and 2003 Spanish National Health Surveys (ENSS). A total of 9570 interviews were analysed (3436 from 1993 and 6134 from 2003). The independent variables were sociodemographic and health-related, and the dependent variable was total consumption of psychotropic medication. Using logistic multivariate regression models, we have analysed the temporal evolution of psychotropic medication consumption between 1993 and 2003.

RESULTS

The prevalence of consumption was significantly higher in women (6.7% from 1993 and 26.4 % from 2003) versus men (2.4% from 1993 and 10.6% from 2003) (p < 0.001). Multivariate analysis, highlighted the association between increased psychoactive drug intake and sex, nervous, depressive, sleep disorders and negative perception of health, displayed a strong association with consumption of psychoactive drugs across the 2 years.

CONCLUSIONS

In Spain, the prevalence of psychoactive drug consumption is higher among elderly women than men, and increases with negative perception of health. The prevalence of consumption was significantly higher in the year 2003.

Co-morbid and socio-demographic factors associated with cognitive performance in an elderly community dwelling Irish population

BACKGROUND

Epidemiological studies suggest an association between health factors and dementia. The impact of these factors on the cognitive performance of the elderly population is unclear. Possible correlates of poor cognitive performance in a community dwelling elderly Irish population were examined.

METHODS

Subjects were from a sample of individuals over 65 years agreeable to interview using the Geriatric Mental State (GMS)-Automated Geriatric Examination for Computed Assisted Taxonomy (AGECAT) package conducted at the subject's home. Associations between patient profiles and Mini Mental State Examination (MMSE) score were investigated in a multivariate model.

RESULTS

There were 793 subjects, 528 (66.6%) female with mean (s.d.) age 74.8 (6.7) yrs. Mean MMSE score was 26.5 (3.3). 169 (21.3%) were current smokers, 198 (25%) ex-smokers. Two hundred and twenty-four (28.3%) had a history of hypertension, 85 (10.7%) case level anxiety or depression, 51 (6.4%) stroke, ten0 (1.3%) epilepsy, nine (1.1%) Parkinson's disease and 29 (3.7%) dementia. Two hundred and fifty-five (32.2%) subjects were on psychotropic medications. Factors associated with MMSE score included age (p < or = 0.0001), diagnosis of dementia (p < or = 0.0001), socioeconomic group (p < or = 0.0001), education (p < or = 0.0001), previous stroke (p = 0.0013) and use of psychotropic medication (p = 0.03). Case level anxiety or depression (p = 0.99), Parkinson's disease (p = 0.52), epilepsy (p = 0.26), smoking status (p = 0.99) and hypertension (p = 0.34) were not found to be associated with cognitive performance.

CONCLUSION

Factors associated with cognitive performance included age, socioeconomic group, education, previous stroke and use of psychotropic medication. These factors should be adjusted for in studies assessing cognition in this population. Stroke prevention strategies and avoidance of psychotropic medication may benefit cognitive performance.

Structured reminiscence: an intervention to decrease depression and increase self-transcendence in older women

AIMS/OBJECTIVES

The purpose of this study was to assess the effect of group reminiscing on depression and self-transcendence of older women residing in an assisted living facility in southeast Texas. There were two major objectives for this study. One objective was to determine if depression decreased in older women after structured reminiscence group sessions held twice weekly for a six-week period. A second objective was to determine if self-transcendence increased after structured reminiscence group sessions held twice weekly for a six-week period.

BACKGROUND

Reminiscence has been studied to determine its impact on a variety of conditions including but not limited to depression, self-esteem, fatigue, isolation, socialization, well-being, language acquisition and cognitive functioning. This review of research specifically focused on reminiscence, depression, self-transcendence and older people.

DESIGN/METHODS

Two groups were assessed at baseline, three and six weeks to answer the research questions. A sample of 24 women between the ages of 72 and 96 years were randomly assigned to either a reminiscence (experimental) group or the activity (control) group of the facility. Pearson's r was used to determine the magnitude of the relationship between subjects' responses on the Geriatric Depression Scale and the Self-Transcendence Scale. A mixed design analysis of variance (anova) was used to determine if there was a difference between the experimental and control groups on scores of the Geriatric Depression Scale and the Self-Transcendence Scale at baseline, three and six weeks.

CONCLUSIONS

Data revealed a non-significant decrease in depression and increase in self-transcendence in the reminiscence group at the completion of six weeks, indicating a trend toward a positive result with reminiscence group sessions. The study also revealed an inverse relationship between depression and self-transcendence. These findings underscore the importance of screening older people for depression.

RELEVANCE TO CLINICAL PRACTICE

One of the primary modalities used for the treatment of depression in elderly women is medication. Antidepressant medications lead to harmful side effects without alleviating the underlying depression. For these reasons, there is a need to research alternative therapies for treatment of depression in the older female. Reminiscence offers a possible intervention for treatment of depression in older women.

The Association Between Psychotropic Medication Use and Functional Outcome of Elderly Hip-Fracture Patients Undergoing Rehabilitation

OBJECTIVE

To study the interrelations between use of psychotropic medications and functional outcomes of elderly hip fracture patients undergoing rehabilitation.

DESIGN

A retrospective parallel group study.

SETTING

A geriatric rehabilitation department in a large urban academic hospital.

PARTICIPANTS

Records of 432 elderly people with extracapsular or intracapsular hip fractures were initially screened between 1999 and 2003. Of these, 263 subjects were eligible for the study. Their average age was 82.2+/-6.9 years. The average length of stay was 29.0+/-10.2 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Absolute (uncorrected) functional gains measured by the FIM instrument and relative (corrected) FIM gains calculated according to the Montebello equation.

RESULTS

Of the 263 patients included in the final analysis, 153 (62.4%) were treated with psychotropics. The 2 groups were similar, yet psychotropic drug users were more likely to be women (P = .028) and to suffer intracapsular fractures (P = .027). Similar improvements in absolute FIM scores were observed during rehabilitation in both groups. However, both total and motor relative functional gains were lower in psychotropic drug users (.33+/-0.1 vs .39+/-0.1, P = .021) than in nonusers (.31+/-0.1 vs .42+/-0.2, P = .039). Regression analysis showed that female sex ( P = .029), higher Folstein Mini-Mental State Examination score (P < .001), and independent prefracture function (P < .01) were associated with higher motor FIM gains. Use of minor tranquillizers was only slightly-and adversely-associated with lower FIM gains (r = -2.68, P = .047), whereas the use of antidepressants and antipsychotics had no effect on these parameters.

CONCLUSIONS

Use of psychotropic medications does not appear to be associated with functional outcome of elderly hip fracture patients undergoing rehabilitation.

Prevalence of DSM-IV psychiatric disorder in the French elderly population

BACKGROUND

France has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates.

AIMS

To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder.

METHOD

A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM-IV criteria were re-examined by a clinical panel.

RESULTS

Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis.

CONCLUSIONS

Results show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.