Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale

Defining phenotypes of disease severity for long-term cardiovascular, renal, metabolic, and mental health conditions in primary care electronic health records: A mixed-methods study using the nominal group technique

OBJECTIVE

Inclusion of severity measures for long-term conditions (LTC) could improve prediction models for multiple long-term conditions (MLTC) but some severity measures have limited availability in electronic health records (EHR). We aimed to develop consensus on feasible severity phenotypes for nine cardio-renal-metabolic and mental health conditions.

METHODS

This was a mixed-methods study using novel methodology. From existing literature, we identified potential severity phenotypes and explored feasibility of their use in EHR through analysis of data from 31 randomly selected general practices in Clinical Practice Research Datalink (CPRD) Aurum, a large UK-based primary care EHR database. We recruited clinical academic experts to participate in a survey and nominal group technique workshop. Participants used a Likert scale to rate clinical importance and feasibility for each severity phenotype independently (informed by the exploratory analysis). For the optimal severity phenotype (highest combined score) for each condition, adjusted hazard ratios (aHR) of five-year mortality were calculated using Cox regression on the full CPRD database.

RESULTS

Fifteen existing severity indexes for nine conditions informed the survey. Eighteen clinical academics participated in the survey, twelve also participated in the workshops. Combined mean scores for clinical importance and feasibility were highest for estimated glomerular filtration rate (eGFR) for chronic kidney disease (CKD) (9.42/10) and for microvascular complications of diabetes (9.08/10). Mortality was higher for each reduction in eGFR stage; Stage 3b aHR 1.42, 95 %CI 1.41-1.44 versus Stage 3a CKD and for each additional microvascular complication of diabetes; one complication aHR 1.44, 95 %CI 1.32-1.57 versus none. Some phenotypes (e.g., aneurysm diameter) were not well recorded within the database and could not feasibly be applied.

CONCLUSION

We developed a methodology for identifying severity phenotypes in EHRs. Severity phenotypes were identified for diabetes (type 1 and 2), ischaemic heart disease, CKD and peripheral vascular disease. Data quality in EHR should be improved for under-recorded severity measures.

Physical multimorbidity is not independently associated with cognitive performance in patients with older-age bipolar disorder (OABD)

OBJECTIVES

Cognitive impairment is common in bipolar disorder (BD), especially in older age (≥50 years). Underlying causes of BD-related cognitive impairment are not fully elucidated. This study investigates the association between physical multimorbidity and subjective and objective cognitive performance in patients with older age bipolar disorder (OABD).

DESIGN

Cross-sectional design.

SETTING

Dutch Older Bipolars (DOBi) dynamic cohort.

PARTICIPANTS

170 outpatients with BD aged ≥ 50 years.

MEASUREMENTS

Chronic physical diseases were assessed in a structured interview. Objective cognitive performance was measured with neuropsychological tests, subjective cognitive performance with the Cognitive Failures Questionnaire (CFQ). Linear regression analyses were performed between multimorbidity, defined as two or more affected physical disease domains, and 1) objective cognitive performance, 2) subjective cognitive functioning, and 3) four cognitive domain scores (attention, learning and memory, verbal fluency, executive functioning). Analyses were hierarchically adjusted for demographic, lifestyle, and psychiatric characteristics.

RESULTS

Multimorbidity was significantly associated with a lower composite cognitive score (B=-0.205, p = 0.040), but after full adjustment statistical significance disappeared (B=-0.044, p = 0.633). Controlled for demographics only, multimorbidity was not significantly associated with higher CFQ (B=6.009, p = 0.053). Multimorbidity was associated with worse executive functioning (B=-0.279, p = 0.018), but statistical significance disappeared after full adjustment (B=-0.085, p = 0.469).

CONCLUSIONS

In OABD physical multimorbidity is not independently associated with poorer cognitive performance and subjective functioning. Rather, shared risk factors, such as demographics, psychiatric characteristics, and lifestyle factors might lead to both the presence of physical diseases and worse cognitive performance in OABD.

Racial Disparities in Parkinson Disease Clinical Phenotype, Management, and Genetics: Protocol for a Prospective Observational Study

BACKGROUND

Parkinson disease (PD) has been described and studied extensively in White populations, with little known about how the disease manifests and progresses in patients from the Black community. Studies investigating disease features in Black populations are uncommon, with some suggesting that the Black population with PD is more disabled and has greater disease severity and different clinical features compared with the White population with PD. These health disparities are likely to influence the quality of care for Black patients with PD.

OBJECTIVE

This study aimed to investigate the motor and nonmotor symptoms and quality of life in Black and White participants with PD in a case-case design.

METHODS

This is an observational, prospective, multicenter, case-case design study. Other aims will investigate the management of PD in Black individuals and the presence of shared or unique genetic risk factors among the Black PD population. A total of 400 Black and 200 White participants with PD will be recruited. Data will be collected at 7 US sites and entered into a Research Electronic Data Capture database. Linear multivariate regression analysis will be used, except for comparing PD management, which will be analyzed using the chi-square test or Fisher exact test. Bonferroni correction will be applied. This protocol also describes plans for educational programming for clinicians and patients at the end of the study in partnership with national PD organizations.

RESULTS

The Rush Institutional Review Board approved the project as the single-site institutional review board in February 2022, and it was funded by the National Institute of Neurological Disorders and Stroke in April 2022. Recruitment began in July 2022. At the time of submission of this manuscript, 131 participants had been recruited.

CONCLUSIONS

To our knowledge, this is the largest study of PD phenotype and management in Black patients in the United States. The planned collaboration with the Global Parkinson's Genetics Program and PD GENEration will enhance our understanding of genetic risk factors for PD in this understudied population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60587.

Prediction of remission of pharmacologically treated psychotic depression: A machine learning approach

BACKGROUND

The combination of antidepressant and antipsychotic medication is an effective treatment for major depressive disorder with psychotic features ('psychotic depression'). The present study aims to identify sociodemographic and clinical predictors of remission of psychotic depression treated with combination pharmacotherapy and determine the accuracy of prediction models.

METHODS

Two hundred and sixty-nine participants aged 18 to 85 years with psychotic depression were acutely treated with protocolized sertraline plus olanzapine for up to 12 weeks. Three cross-validated machine learning models were implemented to predict remission based on 74 sociodemographic and clinical variables measured at acute baseline. The optimal model for each method was selected by the average fold C-index. Based on the performance of each method, grouped elastic net (cox) regression was chosen to examine the association of each predictor with remission of psychotic depression.

RESULTS

Of the 269 participants, 145 (53.9 %) experienced full remission of the depressive episode and psychotic features. Multivariable models had 65.1 % to 67.4 % accuracy in predicting remission. In the grouped elastic net (cox) regression model, longer duration of index episode, somatic or tactile hallucinations, higher burden of comorbid physical problems, and single or divorced marital status were independent predictors of longer time to remission. A higher number of lifetime depressive episodes and peripheral vascular or cardiovascular disease were predictors of shorter time to remission.

CONCLUSIONS

Future research needs to determine whether the addition of biomarkers to clinical and sociodemographic variables can improve model accuracy in predicting remission of pharmacologically-treated psychotic depression.

Integrated management of atypical parkinsonism: a home-based patient-centered healthcare delivery based on telenursing-the IMPACT study protocol

Background

People with atypical parkinsonism, such as multiple system atrophy and progressive supranuclear palsy, experience a wide range of motor and non-motor symptoms associated with the increasing complexity of care delivery and the increased risk of complications and hospital admissions.

Objectives

To investigate the efficacy and cost-effectiveness of a 12-month remote home-based integrated program aiming to improve healthcare delivery coordinated by a nurse specialized in the management of individuals with atypical parkinsonism (parkinsonism nurse specialist, PKNS) compared to the standard-of-care model.

Design

Multicenter, randomized, single-blind, controlled clinical trial involving 164 individuals with atypical parkinsonism.

Methods and analysis

Participants will be randomized 1:1 in intervention (PKNS) and control (standard-of-care) arms. Assessments will be undertaken at baseline and after 6 and 12 months. Primary outcome measure is the Parkinson's Disease Questionnaire 39-items scale total score. Secondary measures include the clinical scales testing motor and non-motor symptoms, caregiver burden, adherence to therapy, cumulative disease burden and the number of unplanned hospital visits/admissions during the study period. The cost-effectiveness of this method will be evaluated by using the EuroQoL-5, which estimates the incremental cost per quality-adjusted life-years gain. Real-life motor autonomy will be objectively measured by collecting waist-worn wearable data on gait parameters (automatically detecting motor patterns indicative of freezing of gait and falls) in all subjects for five consecutive days each month during the 12-month duration of the study.

Ethic

Study protocol has been approved by the ethics committee of all participating centers. The study is conducted according to good clinical practice and the Declaration of Helsinki.

Discussion

An integrated remote care model at home coordinated by a specialized nurse in the management of parkinsonism (Telenursing) could offer significant benefits to patients and healthcare professionals through better health education, continuity of care, and careful monitoring of complications.

Trial registration

ClinicalTrials.gov identifier NCT05792332.

The Cognitive Profile of Older Adults With Treatment-Resistant Depression: An Analysis of the OPTIMUM Randomized Controlled Trial

OBJECTIVE

Major depressive disorder in older adults (late-life depression; LLD) is frequently associated with cognitive impairment, and some deficits (e.g., executive function) have been associated with a higher level of treatment resistance. However, the cognitive profile of treatment-resistant LLD (TR-LLD) has not been characterized. We hypothesized that patients with TR-LLD would show deficits in cognitive function, especially executive function, and that executive function deficits would predict poorer response to pharmacotherapy.

DESIGN

Secondary analysis of baseline cognitive data from OPTIMUM, a multicenter RCT evaluating pharmacotherapy strategies for TR-LLD.

SETTING

Five outpatient academic medical centers (4 US, 1 Canada).

PARTICIPANTS

About 369 participants aged 60 and older from the OPTIMUM study.

MEASUREMENTS

Baseline scores on individual tasks and composite scores from the NIH Toolbox-Cognition Battery were transformed into demographically-adjusted T-scores and compared to published norms. Impairments in the set shifting and inhibitory control tasks were investigated as predictors of depressive symptom change following treatment using ANCOVA models.

RESULTS

Participants had low performance on tasks evaluating inhibitory control, processing speed, verbal/nonverbal memory, and the fluid composite, but normative performance on working memory and set shifting. Participants had high estimated premorbid IQ (superior Performance on oral reading recognition). Age and physical comorbidity negatively associated with processing speed. Impairments in set shifting predicted less improvement in depressive symptoms; impairments in inhibitory control did not.

CONCLUSIONS

Participants with TR-LLD presented with broad cognitive deficits relative to healthy norms. Given poorer outcomes following standard pharmacotherapy associated with impaired set shifting, future research needs to identify alternative treatment strategies.

Physical multimorbidity, concurrent psychiatric morbidity, and emergency department presentation among adults released from prison: a prospective cohort study from Queensland, Australia

BACKGROUND

People released from prison have elevated rates of physical and psychiatric morbidity, and emergency department (ED) presentation when compared with the general population. However, little is known about the specific health concerns that are associated with these high rates of ED presentation. The aims of this study were to (a) ascertain the prevalence of multimorbidity (physical multimorbidity and concurrent psychiatric morbidity) in a sample of adults prior to release from prison, and (b) examine the association between physical multimorbidity, psychiatric morbidity, and ED presentations in this sample following release from prison.

METHODS

We prospectively linked pre-release survey data collected between 1 August 2008 and 31 July 2010 from a representative cohort of 1325 sentenced adults in Queensland, Australia, to person-level ED, correctional, and death records. We assessed the multimorbidity of participants using the Cumulative Illness Rating Scale. The association between multimorbidity and rate of ED presentations was assessed by fitting a multivariable Andersen-Gill model to identify sociodemographic and criminal justice covariates. A sensitivity analysis was also conducted in which psychiatric morbidity was disaggregated into a 4-level dual diagnosis variable (none, mental illness only, substance use disorder only, dual diagnosis) and was fit separately from the physical multimorbidity measure to ascertain the degree to which these factors predicted ED presentation rates.

RESULTS

502 (48.0%) participants had multimorbidity, 265 (25.3%) had physical multimorbidity, and 608 (58.2%) had psychiatric morbidity. After adjustment for model covariates including dual diagnosis status, there was no statistically significant association between physical multimorbidity and ED presentation rate. However, after adjusting for model covariates including physical multimorbidity, participants with a diagnosis of either mental illness (aHR: 1.48; 95%CI: 1.08-2.03) or both mental illness and substance use disorder (aHR: 1.78; 95%CI: 1.33-2.37) had a higher rate of ED presentation than their counterparts without these diagnoses.

CONCLUSION

The presence of psychiatric morbidity is associated with an increased rate of ED presentation. Targeted interventions for adults released from prison with psychiatric morbidity are urgently needed.

Social functioning in bipolar disorder: investigating the role played by comorbid physical illnesses and cognition

Bipolar disorder (BD) is a psychiatric disorder associated with functioning and cognitive impairments, as well as a higher prevalence of physical disease comorbidities.

Objective

To determine the main predictors of functioning in patients with BD.

Methods

Thirty-five patients with BD type I in remission participated in this study. To better characterize the degree of impairment, 20 matched controls were also studied. Functioning was assessed through the Functioning Assessment Short Test (FAST) and the UCSD Performance-based Skills Assessment (UPSA), while cognition was assessed through the BAC-A. Current physical conditions were assessed and categorized according to the Cumulative Illness Rating Scale (CIRS). Regression analyses were performed to examine the relationship between functioning and clinical variables, global cognitive performance, and physical comorbidities in BD.

Results

UPSA correlated positively with the BAC-A total score (r=0.488; p=0.025), years of education (rho=0.41; p<0.01), and CIRS total score (rho=0.394; p<0.001). CIRS was the only predictor that remained negatively and significantly correlated with the UPSA total score (R2=0.446, F (1, 33)=8.198, p=0.007).

Conclusion

Patients with BD had poor functioning, with the primary determinant of poor functioning being the burden of physical illnesses. In addition, the low agreement between the FAST and UPSA scales suggests these tolls assess distinct constructs.

Impact of malnutrition on the clinical evolution in a cohort of older patients undergoing emergency surgery for abdominal pathology

PURPOSE

Analyse the influence of the nutritional status of older patients undergoing emergency abdominal surgery on postoperative complications, mortality and mean length of hospital stay.

METHODS

We performed a longitudinal observational study including patients older than 80 years who underwent emergency surgery by the general surgery service for abdominal pathology, who were followed by the geriatrics service between September 2018 and May 2021. Malnutrition was diagnosed using Global Leadership Initiative on Malnutrition (GLIM) criteria, classifying patients as malnourished and normonourished. A comprehensive geriatric assessment was performed on patients, and postoperative complications, mean length of hospital stay and mortality in-hospital were recorded.

RESULTS

131 patients were included, 84 of them were malnourished and 47 normonourished. Mean age was 86±4.7 years. Malnourished patients had higher incidence of new-onset atrial fibrillation (odds ratio [OR]: 6.1, 95% confidence interval [CI]: 1.33-27.6, p<0.05), urinary tract infection (OR 4.72, 95% CI: 1.02-21.95, p<0.05) and bacteraemia (OR 3.51, 95% CI: 1.14-11.1, p<0.05), compared with normonourished patients. Surgical complications were more frequent in malnourished patients (OR 3.34, 95% CI: 1.5-7.44, p<0.05). Mean length of hospital stay in malnourished patients was longer (22.6 (±14.1)) compared with normonourished patients (15.3 (±11.9)) (p<0.005).

CONCLUSION

Malnutrition in older patients (mean age 86 years old) undergoing emergency abdominal surgery is associated with a poorer clinical course; thus, it must be considered in the evaluation and follow-up of these patients.

Impact of Hospitalization on Sarcopenia, NADPH-Oxidase 2, Oxidative Stress, and Low-Grade Endotoxemia in Elderly Patients

BACKGROUND

Hospitalization in older adults often worsens sarcopenia due to prolonged bed rest, poor nutrition, and inactivity. This study examined how hospitalization impacts muscle mass, focusing on oxidative stress and gut-derived endotoxemia.

METHODS

Thirty-one hospitalized older adults were compared with 31 outpatients. Ultrasound was used to measure the thickness of the rectus femoris (RF), intercostal, and diaphragmatic muscles at admission and discharge. Serum levels of LPS, zonulin, sNOX2-dp, and H2O2 were also assessed.

RESULTS

Hospitalized patients had higher serum levels of sNOX2-dp, H2O2, LPS, and zonulin than outpatients. In hospitalized patients, significant increases were observed at discharge compared to admission levels in sNOX2-dp (20.9 ± 6.5 to 23.8 ± 7.5 pg/mL; p = 0.004), H2O2 (24.4 ± 9.8 to 32.8 ± 14.5 µM; p = 0.01), LPS (30.4 ± 12.6 to 43.3 ± 16.35 pg/mL; p < 0.001), and zonulin (2.06 ± 1.23 to 2.95 ± 1.33 ng/mL; p < 0.001). Ultrasound data revealed a reduction in RF muscle thickness (-35%) (0.58 ± 0.29 to 0.38 ± 0.31 cm, p < 0.001), intercostal muscle thickness (-28%) (0.22 ± 0.08 to 0.16 ± 0.06 cm, p < 0.001), and diaphragmatic muscle thickness (-26%) (0.19 ± 0.06 to 0.14 ± 0.04 cm, p < 0.001) at discharge compared to admission. Additionally, muscle strength, measured using the hand-grip test, showed a 25% reduction. Regression analysis revealed correlations between RF muscle loss and increases in sNOX2-dp and H2O2, as well as between NOX2, H2O2, and LPS with zonulin.

CONCLUSIONS

Hospitalization in older adult patients elevates NOX2 blood levels, correlating with reduced muscle mass. Increased low-grade endotoxemia may trigger NOX2 activation, generating oxidative stress that accelerates muscle degeneration and can lead to sarcopenia.

Applying Wearable Sensors and Machine Learning to the Diagnostic Challenge of Distinguishing Parkinson's Disease from Other Forms of Parkinsonism

Background/Objectives: Parkinson's Disease (PD) and other forms of parkinsonism share motor symptoms, including tremor, bradykinesia, and rigidity. The overlap in their clinical presentation creates a diagnostic challenge, as conventional methods rely heavily on clinical expertise, which can be subjective and inconsistent. This highlights the need for objective, data-driven approaches such as machine learning (ML) in this area. However, applying ML to clinical datasets faces challenges such as imbalanced class distributions, small sample sizes for non-PD parkinsonism, and heterogeneity within the non-PD group. Methods: This study analyzed wearable sensor data from 260 PD participants and 18 individuals with etiologically diverse forms of non-PD parkinsonism, which were collected during clinical mobility tasks using a single sensor placed on the lower back. We evaluated the performance of ML models in distinguishing these two groups and identified the most informative mobility tasks for classification. Additionally, we examined the clinical characteristics of misclassified participants and presented case studies of common challenges in clinical practice, including diagnostic uncertainty at the patient's initial visit and changes in diagnosis over time. We also suggested potential steps to address the dataset challenges which limited the models' performance. Results: Feature importance analysis revealed the Timed Up and Go (TUG) task as the most informative for classification. When using the TUG test alone, the models' performance exceeded that of combining all tasks, achieving a balanced accuracy of 78.2%, which is within 0.2% of the balanced diagnostic accuracy of movement disorder experts. We also identified differences in some clinical scores between the participants correctly and falsely classified by our models. Conclusions: These findings demonstrate the feasibility of using ML and wearable sensors for differentiating PD from other parkinsonian disorders, addressing key challenges in its diagnosis and streamlining diagnostic workflows.

Objective and subjective suicidal intent are differentially associated with attempt lethality based on age of onset of suicidal behavior

Predicting the medical seriousness, or lethality, of suicide attempts remains challenging for clinicians, as impulsive and planned attempts can both be fatal and risk may vary with age and suicidal intent. We investigated whether attempt lethality is driven by practical preparedness (objective suicidal intent) and/or psychological resolve (subjective suicidal intent) and whether these associations vary with age of onset of suicidal behavior. The study used a cross-sectional lifespan sample (N = 95; age range 16-76 years) with current depression and recent suicidal behavior (≤ 5 years). Linear regression models indicated that older age of onset of suicidal behavior (B = 0.86, SE = 0.20, p < 0.001), and both higher objective intent (B = 0.69, SE = 0.19, p < 0.001) and subjective intent (B = 0.50, SE = 0.20, p = 0.014) were associated with more severe lethality at the most recent attempt, although the association with subjective intent was driven by its shared portion with objective intent. The association between objective intent and lethality was stronger with older age of onset (interaction B = 0.75, SE = 0.20, p < 0.001), whereas the association between subjective intent and lethality was stronger with younger age of onset (interaction B = - 0.42, SE = 0.20, p = 0.036). Our findings suggest that contextualizing suicidal intentions with age of onset, rather than age at the current suicidal crisis, can help clinicians better appraise suicide risk.

Evaluation of the psychometric properties of PainChek in older general hospital patients with dementia

BACKGROUND

Pain is common in people with dementia in general hospitals. This can be difficult to identify.

OBJECTIVES

To evaluate the psychometric properties of PainChek electronic pain assessment tool.

DESIGN

Cross-sectional psychometric study.

SETTING

Six medical care of older people wards from two general hospitals in greater London, UK.

SUBJECTS

63 people with clinical diagnosis of dementia: mean 84 years (SD 6.7), 59% female, 69% living in their own homes, 64% white British, 77% moderate/severe dementia.

METHOD

Psychometric evaluation of PainChek, a point-of-care electronic pain assessment tool combining artificial intelligence, facial analysis and smartphone technology. From a total of 216 assessments, we tested PainChek's inter-rater reliability (IRR) (Cohen's kappa), internal consistency (Cronbach's alpha) and concurrent validity (Pearson's coefficient) between PainChek and Pain Assessment in Advanced Dementia (PAINAD) scores at rest and post-movement [95% confidence interval (95% CI) where appropriate]. We assessed convergent validity with Symptom Management-End of Life in Dementia scale (SM-EOLD) (Pearson's coefficient) and discriminant validity (rest vs post-movement).

RESULTS

IRR was 0.714 (95% CI 0.562 to 0.81) (rest) and 0.817 (95% CI 0.692 to 0.894) (post-movement). Internal consistency was 0.755 (rest) and 0.833 (post-movement). Concurrent validity with PAINAD was 0.528 (95% CI 0.317 to 0.690) (rest) and 0.787 (0.604 to 0.891) (post-movement). Convergent validity with SM-EOLD was -0.555 (95% CI -0.726 to -0.318) (rest) and -0.5644 (95% CI -0.733 to -0.331) (post-movement). Discriminant validity was significant.

CONCLUSIONS

PainChek is a valid and reliable pain assessment tool for people with dementia in general hospitals. Further consideration will be needed for implementation into this setting.

Associations of high-sensitivity C-reactive protein with neuropsychological outcomes and cerebral white matter hyperintensities in older adults at risk of dementia

Inflammation is becoming increasingly recognised as a core feature of dementia with evidence indicating that its role may vary and adapt across different stages of the neurodegenerative process. This study aimed to investigate whether the associations of high-sensitivity C-reactive protein (hs-CRP) with neuropsychological performance (verbal memory, executive function, processing speed) and cerebral white matter hyperintensities (WMHs) differed between older adults with subjective cognitive decline (SCD; n = 179) and mild cognitive impairment (MCI; n = 286). Fasting serum hs-CRP concentrations were grouped into low (<1.0 mg/L), moderate (1.0-3.0 mg/L), and high (>3.0-10.0 mg/L). Structural MRI scans were used to estimate WMH lesion volumes in the whole brain, as well as periventricular, deep white matter, and frontal regions. After adjusting for relevant demographic and clinical factors, multiple regression analyses revealed that in participants with SCD, high hs-CRP concentrations were significantly associated with poorer executive function (β[95% CI] = -.20[-.65, -.04], p = .025) and processing speed (β[95% CI] = -.19[-.53, .00], p = .048). Exploratory analyses suggested that this effect may be specific to APOE-ε4 non-carriers only. There were no significant associations between hs-CRP and neuropsychological outcomes in those with MCI. Hs-CRP was not associated with WMH volumes. Our findings suggest that hs-CRP may be involved in early disruptions to cerebral frontal-subcortical pathways, particularly in APOE-ε4 non-carriers, though this association may be independent of white matter lesions. In the earliest stages of cognitive decline where subjective complaints are paramount, addressing inflammation may offer potential benefits for supporting cognitive health.

Healthcare costs in relation to kidney function among older people: the SCOPE study

PURPOSE

In this study, a comprehensive analysis of costs of chronic kidney disease (CKD) was performed, to understand factors associated with the economic burden of the disease in a multicentre international framework.

METHODS

The impact on costs of demographics, socio-economics, clinical, and functional variables was tested in 2204 subjects aged 75 years or more attending outpatient clinics in Europe using a multicentre 2-year prospective cohort study. By means of collected resources consumption and unit cost data a comprehensive cost database was built and then investigated using multilevel regression modeling.

RESULTS

Overall, hospitalization, medications and specialist visits were the main cost items, with a notable variability among countries. Estimated yearly costs were 4478€ ± 9804€, rising up to 6683€ ± 10,953€ for subjects with estimated Glomerular Filtration Rate (eGFR) < 30. Costs increased significantly according to the severity of the disease, gender and age. Clinical and functional covariates were also significantly associated with CKD-related total costs, even after correcting for the inter-country variability.

CONCLUSION

Findings corroborate the importance of multidimensional assessment of participants with CKD, as multimorbidity and functional disability produce a detrimental impact on participant's prognosis and cost of care. Preservation of functional impairment and adequate management of comorbidities may thus help decreasing the overall consumption on health care resources in CKD patients, especially in older people.

Functional decline among bullous pemphigoid patients: A retrospective monocentric cohort study

BACKGROUND

Bullous pemphigoid (BP) affects older patients with numerous comorbidities. The impact of BP on patient autonomy remains poorly understood.

OBJECTIVES

To assess the frequency and factors associated with functional decline (FD) in BP.

METHODS

In this retrospective monocentric study, we selected patients aged ≥75 years with BP diagnosed between 1 January 2015 and 31 December 2021 and followed for more than 3 months. We assessed activity limitation at diagnosis and included patients with no or mild activity limitation. We described FD and its associated factors at 6 weeks and 3 months. FD was qualified as moderate or severe. Age, comorbidities (CIRS-G score), BP characteristics at diagnosis (including palms and soles involvement) and hospitalization were collected. Factors associated with FD were investigated through univariate and multivariate logistic regression models. Worsening of previous comorbidities or new comorbidities at Week 6 were collected.

RESULTS

One hundred and thirty-one patients were included (mean age 85 years), 75 (57.3%) had no activity limitation, and 56 (42.7%) a mild activity limitation at baseline. At Week 6, FD was observed in 44 (33.6%) patients, including 23 out of 75 (30.7%) with no activity limitation and 21 out of 56 (37.5%) with mild activity limitation at baseline. FD was moderate in 20 cases (45.5%) and severe in 24 (54.5%) and persisted at Month 3 in 37 (84%) patients. By multivariate analysis, factors associated with FD were a CIRS-G score >7, palms and soles involvement and anti-BP180 antibodies level. Fifty (38.2%) patients experienced a worsening of their pre-existing comorbidities or a new one.

CONCLUSIONS

FD is often observed in patients with BP, especially in those with severe symptoms, palms and soles involvement and comorbidities. A comprehensive, multidisciplinary approach involving geriatric assessments should be adopted to manage these patients.

Sleep efficiency in community-dwelling persons living with dementia: exploratory analysis using machine learning

STUDY OBJECTIVES

Sleep disturbances lead to negative health outcomes and caregiver burden, particularly in community settings. This study aimed to investigate a predictive model for sleep efficiency and its associated features in older adults living with dementia in their own homes.

METHODS

This was an exploratory, observational study. A total of 69 older adults diagnosed with dementia were included in this study. Data were collected via actigraphy for sleep and physical activity for 14 days, a sweat patch for cytokines for 2-3 days, and a survey of diseases, medications, psychological and behavioral symptoms, functional status, and demographics at baseline. Using 730 days of actigraphy, sweat patches, and baseline data, the best prediction model for sleep efficiency was selected and further investigated to explore its associated top 10 features using machine learning analysis.

RESULTS

The CatBoost model was selected as the best predictive model for sleep efficiency. In order of importance, the most important features were sleep regularity, number of medications, dementia medication, daytime activity count, instrumental activities of daily living, neuropsychiatric inventory, hypnotics, occupation, tumor necrosis factor-alpha, and waking hour lux.

CONCLUSIONS

This study established the best sleep efficiency predictive model among community-dwelling older adults with dementia and its associated features using machine learning and various sources, such as the Internet of Things. This study highlights the importance of individualized sleep interventions for community-dwelling older adults with dementia based on associated features.

CITATION

Lee JY, Yang E, Cho AY, Choi Y, Lee S, Lee KH. Sleep efficiency in community-dwelling persons living with dementia: exploratory analysis using machine learning. J Clin Sleep Med. 2025;21(2):393-400.

Cognitive considerations for adults with sickle cell disease completing the brief pain inventory

Introduction

Accurate assessment of pain severity is important for caring for patients with sickle cell disease (SCD). The Brief Pain Inventory was developed to address limitations of previous pain-rating metrics and is available in a short form (BPI-SF). However, the BPI-SF is a self-report scale dependent on patient comprehension and interpretation of items.

Objective

To examine patterns in how patients completed the BPI-SF and determine whether incorrectly completing the BPI-SF was related to cognitive functioning or education.

Methods

A secondary analysis was completed using data from a study examining brain aging and cognitive impairment in SCD. T-tests were performed to examine whether neurocognitive function (immediate and delayed memory, visuospatial skills, attention, and language), word reading, and years of education differed based on correct BPI-SF completion.

Results

The sample (n = 71) was 43.7% male, 98.6% African American or mixed race. Of that, 53.5% had sickle cell anemia, and the mean years of education was 13.6. Overall, 21.1% of participants (n = 15) incorrectly completed the BPI-SF pain severity items, and 57.7% completed the body map item incorrectly. Those who completed the severity items incorrectly had statistically significant differences in education. Group differences in neurocognitive function were no longer significant after familywise error rates were controlled for. Literacy was not associated with error rates.

Conclusion

Education level may influence patients' ability to correctly complete the BPI-SF. Findings suggest that careful consideration is warranted for use of the BPI in patients with SCD. Recommended revisions to the BPI include simplifying the language, shortening sentence length, and clearly specifying the timeframes.

Risk factors of dementia in a cohort of individuals with mild cognitive impairment in the Italian Interceptor project

BACKGROUND

The Italian Interceptor project is aimed at identifying a prodromal dementia phase and developing a nationwide organizational model. This study compares the sociodemographic and neuropsychological characteristics of mild cognitive impairment non-converters (MCI-NC) and MCI-converters (MCI-C) to dementia, including Alzheimer's disease (AD), enrolled during the Interceptor project.

METHODS

Sociodemographic, clinical, and neuropsychological data of MCI individuals were collected at baseline (December 2018 to October 2020) and every six-month follow-up visit for 3 years. Logistic regression and Random Forest classifier were used to describe the study population.

RESULTS

From 356 participants, 104 were MCI-C, whereas 252 were MCI-NC. Compared to MCI-NC, MCI-C were predominantly female (p = 0.020), older (p < 0.001), and more cognitively impaired (p < 0.001). Higher physical activity was protective for progression (p < 0.001), but no difference was observed for smoking exposure (p = 0.312) between the two groups. Similar results were found for AD individuals compared to MCI-C/non-AD. The ROC curve based on a Random Forest classifier distinguishing MCI-C from MCI-NC showed an area under the curve (AUC) of 0.7347.

CONCLUSIONS

Our findings confirm previous evidence in literature and may increase the insight on dementia pathology and help in defining intervention strategies to prevent or slow down disease progression.

Charlson comorbidity index has no incremental value for mortality risk prediction in nursing home residents with COVID-19 disease

BACKGROUND

During the COVID-19 pandemic, nursing home (NH) residents faced the highest risk of severe COVID-19 disease and mortality. Due to their frailty status, comorbidity burden can serve as a useful predictive indicator of vulnerability in this frail population. However, the prognostic value of these cumulative comorbidity scores like the Charlson comorbidity index (CCI) remained unclear in this population. We evaluated the incremental predictive value of the CCI for predicting 28-day mortality in NH residents with COVID-19, compared to prediction using age and sex only.

METHODS

We included older individuals of ≥ 70 years of age in a large retrospective observational cohort across NHs in the Netherlands. Individuals with PCR-confirmed COVID-19 diagnosis from 1 March 2020 to 31 December 2021 were included. The CCI score was computed by searching for the comorbidities recorded in the electronic patient records. All-cause mortality within 28 days was predicted using logistic regression based on age and sex only (base model) and by adding the CCI to the base model (CCI model). The predictive performance of the base model and the CCI model were compared visually by the distribution of predicted risks and area under the receiver operator characteristic curve (AUROC), scaled Brier score, and calibration slope.

RESULTS

A total of 4318 older NH residents were included in this study with a median age of 88 years [IQR: 83-93] and a median CCI score of 6 [IQR: 5-7]. 1357 (31%) residents died within 28 days after COVID-19 diagnosis. The base model, with age and sex as predictors, had an AUROC of 0.61 (CI: 0.60 to 0.63), a scaled brier score of 0.03 (CI: 0.02 to 0.04), and a calibration slope of 0.97 (CI: 0.83 to 1.13). The addition of CCI did not improve these predictive performance measures.

CONCLUSION

The addition of the CCI as a vulnerability indicator did not improve short-term mortality prediction in NH residents. Similar (high) age and number of comorbidities in the NH population could reduce the effectiveness of these predictors, emphasizing the need for other population-specific predictors that can be utilized in the frail NH residents.

Cognitive Outcomes After Transcranial Magnetic Stimulation for the Treatment of Late-Life Depression: Résultats cognitifs après la stimulation magnétique transcrânienne pour le traitement de la dépression chez les personnes âgées

BACKGROUND

Late-life depression (LLD) is often accompanied by cognitive impairment, which may persist despite antidepressant treatment. Repetitive transcranial magnetic stimulation (rTMS) is an efficacious treatment for depression, with potential benefits on cognitive functioning. However, research on cognitive effects is inconclusive, relatively sparse in LLD, and predominantly focused on group-level cognitive changes. This study aimed to explore individual-level cognitive changes following rTMS treatment in patients with LLD.

METHOD

Data were analyzed from 153 patients with LLD from the FOUR-D study (ClinicalTrials.gov identifier: NCT02998580) who received bilateral standard rTMS or theta burst stimulation (TBS) targeting the dorsolateral prefrontal cortex (DLPFC). Cognitive function was assessed pre- and post-treatment using measures of executive function, information processing speed, and learning and memory. Reliable change indices, adjusted for practice effects and test-retest reliability, were employed to evaluate individual-level cognitive changes. Chi-square tests examined if proportions of cognitive improvers differed from expected proportions.

RESULTS

Cognitive performance from baseline to end of treatment remained stable for most patients. Reliably improved performance was observed in 0.0% to 20.0% of participants across cognitive measures, while worsened performance was observed in 0.0% to 2.7%. A small but significant proportion (20.0%) of participants showed improvement in verbal learning.

CONCLUSIONS

Bilateral standard rTMS or TBS of the DLPFC in LLD yielded no substantial cognitive enhancing effects, although a small proportion showed improved verbal learning after treatment. Importantly, both interventions were cognitively safe with relatively stable performance across time. Future research is needed to explore approaches to enhance the cognitive benefits of standard rTMS and TBS in patients with LLD.

The impact of brain-systemic oxygenation coupling in sleep-disordered breathing on cognitive function in elderly

BACKGROUND

Intermittent hypoxia, a consequence of sleep-disordered breathing (SDB), may contribute to an increased risk of cognitive decline. However, the association between SDB and cognition remains highly variable.

METHODS

Fifty-two community-dwelling healthy older adults (28 women) were recruited. All participants underwent neuropsychiatric evaluations, simultaneous ambulatory polysomnography (PSG), and near-infrared spectroscopy (NIRS) recordings. We quantified the average coherence between oxy-Hb and SpO2 signals during SDB events to determine whether it could predict cognitive outcomes in healthy older adults, where higher coherence indicates reduced protection against systemic hypoxia.

RESULTS

The mean (SD) coherence of oxy-Hb and SpO2 was 0.16 (0.07). Linear regression analysis showed a significant association between mean coherence and worse Stroop Color Word Test scores (t=-0.304, p = .004). In contrast, oxy-Hb reduction alone and conventional SDB parameters did not show a significant association with cognition.

CONCLUSION

This is the first report to demonstrate an association between a novel parameter of brain-systemic oxygenation coherence in SDB and cognition in older adults. A higher coherence rate of cortical oxy-Hb and systemic SpO2 during SDB may reflect a loss of compensatory mechanisms against systemic hypoxia and could help stratify older adults with a higher risk for cognitive decline.

Reconsidering remission in recurrent late-life depression: clinical presentation and phenotypic predictors of relapse following successful antidepressant treatment

BACKGROUND

Late-life depression (LLD) is characterized by repeated recurrent depressive episodes even with maintenance treatment. It is unclear what clinical and cognitive phenotypic characteristics present during remission predict future recurrence.

METHODS

Participants (135 with remitted LLD and 69 comparison subjects across three institutions) completed baseline phenotyping, including psychiatric, medical, and social history, psychiatric symptom and personality trait assessment, and neuropsychological testing. Participants were clinically assessed every two months for two years while receiving standard antidepressant treatment. Analyses examined group differences in phenotypic measure using general linear models. Concurrent associations between phenotypic measures and diagnostic groups were examined using LASSO logistic regression.

RESULTS

Sixty (44%) LLD participants experienced a relapse over the two-year period. Numerous phenotypic measures across all domains differed between remitted LLD and comparison participants. Only residual depressive symptom severity, rumination, medical comorbidity, and executive dysfunction significantly predicted LLD classification. Fewer measures differed between relapsing and sustained remission LLD subgroups, with the relapsing group exhibiting greater antidepressant treatment intensity, greater fatigue, rumination, and disability, higher systolic blood pressure, greater life stress and lower instrumental social support. Relapsing group classification was informed by antidepressant treatment intensity, lower instrumental social support, and greater life stress.

CONCLUSIONS

A wide range of phenotypic factors differed between remitted LLD and comparison groups. Fewer measures differed between relapsing and sustained remission LLD subgroups, with less social support and greater stress informing vulnerability to subsequent relapse. This research suggests potential targets for relapse prevention and emphasizes the need for clinically translatable relapse biomarkers to inform care.

The relationship between sleep quality and quality of life in middle-aged and older inpatients with chronic diseases: Mediating role of frailty and moderating role of self-esteem

OBJECTIVE

This study aimed to investigate the influence of sleep quality on the quality of life in middle-aged and older inpatients with chronic diseases (MAOICDs) while examining the mediating role of frailty and the moderating role of self-esteem.

METHODS

This study utilized a cross-sectional design. Between October 2021 and February 2022, we administered questionnaires to 319 subjects at the Second Hospital of Zhejiang University School of Medicine, Zhejiang Province, China. The questionnaire consisted of the General Information Scale, the Cumulative Disease Rating Scale, the Sleep Quality Questionnaire, the Frailty Scale, the Self-Esteem Scale, and the Quality of Life Questionnaire. Data were analyzed using SPSS 25.0 software and PROCESS3.5 macros for descriptive statistics, correlation analysis, and tests for mediating and moderating effects.

RESULTS

The results of this study suggest that sleep quality is negatively related to quality of life and mediated by frailty. Self-esteem plays a moderating role in the relationship between frailty and quality of life.

CONCLUSION

Frailty mediates the relationship between sleep quality and quality of life. Meanwhile, self-esteem plays a moderating role in the relationship between frailty and life quality. Specifically, the correlation between frailty and life quality becomes stronger at higher levels of self-esteem. Therefore, to improve the life quality of MAOICDs, interventions should focus not only on enhancing sleep quality and reducing frailty but also on helping patients maintain an appropriate level of self-esteem.

The trajectory of functional status of patients with kidney failure choosing conservative kidney management

PURPOSE

In older patients with kidney failure (KF) starting dialysis, there is a high rate of functional decline. Not much is known about the functional trajectory of patients receiving conservative kidney management (CKM). Therefore, the aim of this study is to assess this functional trajectory and explore clinical parameters associated with functional decline.

METHODS

The functional trajectory of patients choosing CKM was evaluated using data from the Geriatric Assessment in Older Patients Starting Dialysis (GOLD) study, which included patients aged ≥ 65 years with KF at the moment of decision-making. Functional status was assessed using a combined score for activities of daily living (ADL) and instrumental activities of daily living (iADL) dependency at baseline and after six months of follow-up. Change in functional status was divided into improvement (gain of one or more domains in functional status), stable (no change), decline (loss of one or more domains in functional status), and death at follow-up. The association between functional status at baseline and functional decline after six months was assessed with chi-squared test or Fisher's exact test. Furthermore, caregiver experiences were explored using self perceived pressure of informal care (SPPIC) at baseline and 6-month follow-up.

RESULTS

Follow-up data were available for 86 patients. Mean age was 82 ± 6 years and 43% were women. At baseline, 12% of the patients were independent, 55% were mild/moderately dependent, and 34% severely dependent. After 6 months of follow-up, 9% of all patients had improved, 35% remained stable, 41% had declined, and 15% had died. No significant associations were found between baseline characteristics and the composite outcomes.

CONCLUSION

In patients aged ≥ 65 years receiving CKM, functional decline and death are highly prevalent. No association was found between poor outcome ("decline/death") and different potential risk factors.

Brain Age Is Not a Significant Predictor of Relapse Risk in Late-Life Depression

BACKGROUND

Late-life depression (LLD) has been associated cross-sectionally with lower brain structural volumes and accelerated brain aging compared with healthy control participants (HCs). There are few longitudinal studies on the neurobiological predictors of recurrence in LLD. We tested a machine learning brain age model and its prospective association with LLD recurrence risk.

METHODS

We recruited individuals with LLD (n = 102) and HCs (n = 43) into a multisite, 2-year longitudinal study. Individuals with LLD were enrolled within 4 months of remission. Remitted participants with LLD underwent baseline neuroimaging and longitudinal clinical follow-up. Over 2 years, 43 participants with LLD relapsed and 59 stayed in remission. We used a previously developed machine learning brain age algorithm to compute brain age at baseline, and we evaluated brain age group differences (HC vs. LLD and HC vs. remitted LLD vs. relapsed LLD). We conducted a Cox proportional hazards model to evaluate whether baseline brain age predicted time to relapse.

RESULTS

We found that brain age did not significantly differ between the HC and LLD groups or between the HC, remitted LLD, and relapsed LLD groups. Brain age did not significantly predict time to relapse.

CONCLUSIONS

In contrast to our hypothesis, we found that brain age did not differ between control participants without depression and individuals with remitted LLD, and brain age was not associated with subsequent recurrence. This is in contrast to existing literature which has identified baseline brain age differences in late life but consistent with work that has shown no differences between people who do and do not relapse on gross structural measures.

Screening for obstructive sleep apnea in the memory clinic: A comparison of questionnaires, pulse oximetry, and polysomnography

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent among older adults and has been associated with cognitive decline and dementia risk. The suitability of screening tools for detecting OSA in memory clinic settings is unclear.

OBJECTIVE

To evaluate the utility and validity of the STOP-Bang questionnaire (SBQ) and pulse oximeter as a screening tool, compared to gold-standard polysomnography (PSG) in older adults attending a memory clinic.

METHODS

Participants aged over 50 with new onset cognitive/mood concerns attended a memory clinic, then completed the SBQ, oximetry, and PSG. The SBQ and oximetry's accuracy in detecting moderate-severe and severe OSA was evaluated using receiver operating curves. Intraclass correlation and Bland-Altman plots compared the oximeter's adjusted oxygen desaturation index (ODI-Ox) and PSG's apnea-hypopnea index (AHI-PSG).

RESULTS

Of 194 participants (mean age = 65.6, 64 males) who completed PSG, 184 completed the SBQ, and 138 completed oximetry. SBQ demonstrated limited performance for moderate-severe OSA (sensitivity = 52%, specificity = 62%, AUC = 0.600) and severe OSA (sensitivity = 18%, specificity = 87%, AUC = 0.577). Oximetry was satisfactory for moderate-severe OSA (sensitivity = 67%, specificity = 73%, AUC = 0.769) and severe OSA (sensitivity = 50%, specificity = 88%, AUC = 0.730). The diagnostic performance was improved with new cut-offs at ODI-Ox ≥ 11 for AHI-PSG ≥ 15 and ODI-Ox ≥ 20 for AHI-PSG ≥ 30. Bland-Altman plots and intraclass correlation indicated acceptable agreement for oximetry.

CONCLUSIONS

The findings suggest that while the SBQ may be unsuitable to detect moderate or severe OSA for older adults with cognitive impairment, oximetry may be a viable screening tool. Given OSA treatment can optimize sleep and may slow cognitive decline, routine screening for OSA should be part of memory clinic assessments.

Persistent pro-inflammatory trait in elderly patients following treatment-resistant major depressive disorder: a longitudinal exploratory study

OBJECTIVES

Considering that the remission rate for major depressive disorder (MDD) in elderly patients is below 50%, there is a compelling requirement for an enhanced comprehension of the underlying mechanisms. Chronic low-grade inflammation has been posited as one potential contributor to treatment-resistant MDD in the elderly. Accordingly, the objective of our study was to explore the longitudinal trends of systemic immune markers in elderly inpatients referred to electroconvulsive therapy due to an episode of treatment resistant unipolar MDD.

METHODS

The study encompassed 64 elderly inpatients with unipolar MDD that had failed to respond to therapy in primary health care, and 18 non-depressed controls. Blood samples were collected at pre-treatment, mid-treatment, post-treatment and 12 weeks follow-up. We assessed 27 immune markers via multiplex assays. Depressive symptoms were evaluated using the Hamilton Rating Scale of Depression at these timepoints. For controls, the immune markers and depressive symptoms, were measured at baseline and eight weeks follow-up using identical methods.

RESULTS

At follow-up, patients showed higher concentrations of 23 immune markers compared to controls, although the concentration of 19 immune markers decreased significantly from pre-treatment to follow-up. No differences in immune marker concentrations between treatment responders and non-responders were observed pre- and post-treatment in the patient group.

CONCLUSION

Our findings suggest that a pro-inflammatory trait persists in elderly after an episode of treatment resistant unipolar MDD. Thus, our study supports that chronic low-grade inflammation may characterise elderly with treatment-resistant unipolar MDD.

Poor Sleep is Common in Treatment-Resistant Late-life Depression and Associated With Poorer Antidepressant Response: Findings From the OPTIMUM Clinical Trial

BACKGROUND

Adults with treatment-resistant late-life depression (TRLLD) have high rates of sleep problems; however, little is known about the occurrence and change in sleep during pharmacotherapy of TRLLD. This analysis examined: (1) the occurrence of insufficient sleep among adults with TRLLD; (2) how sleep changed during pharmacotherapy; and (3) whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep.

METHODS

Secondary analysis of data from 634 participants age 60+ years in the OPTIMUM clinical trial for TRLLD. Sleep was assessed using the sleep item from the Montgomery-Asberg Depression Rating Scale at the beginning (week-0) and end (week-10) of treatment. The analyses examined whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep during depression treatment.

RESULTS

About half (51%, n = 323) of participants reported insufficient sleep at baseline. Both persistent insufficient sleep (25%, n = 158) and worsened sleep (10%, n = 62) during treatment were associated with antidepressant nonresponse. Participants who maintained sufficient sleep (26%, n = 164) or who improved their sleep (n = 25%, n = 158) were three times more likely to experience a depression response than those with persistent insufficient sleep or worsened sleep.

CONCLUSION

Insufficient sleep is common in TRLLD and it is associated with poorer treatment response to antidepressants.

Amygdala-Centered Emotional Processing in Prolonged Grief Disorder: Relationship With Clinical Symptomatology

BACKGROUND

Prolonged grief disorder (PGD) is a multidimensional condition with adverse health consequences. We hypothesized that enhanced negative emotional bias characterizes this disorder and underlies its key clinical symptoms.

METHODS

In a cross-sectional design, chronically grieving older adults (age 61.5 ± 8.9 years) experiencing probable PGD (n = 33) were compared with demographic- and time since loss-equated integrated (adaptive) grief participants (n = 38). To probe generalized negative affective reactivity, participants performed an emotional face-matching task during functional magnetic resonance imaging scanning and completed demographic and clinical assessments. Contrast maps (fearful + angry faces [-] shapes) were generated to determine group differences in brain activity within hypothesized affective and regulatory processing regions (amygdala, anterior insula, dorsal anterior cingulate, dorsolateral prefrontal cortex) and in exploratory whole-brain regression analyses.

RESULTS

The PGD group showed higher right amygdala activation to negative emotional stimuli than the integrated grief group (pcorrected < .05), which positively correlated with intrusive thoughts. Generalized psychophysiological interaction analysis revealed lower task-dependent functional connectivity (FC) between the right amygdala and posterior cingulate cortex/precuneus in PGD (pcorrected < .05), which negatively correlated with avoidance of loss reminders. Resting-state FC between the identified right amygdala and thalamus was higher in PGD (pcorrected < .05), which negatively correlated with loneliness.

CONCLUSIONS

Dysregulated amygdala-centric neural activity and FC during processing of negative affective stimuli and at rest appear to differentiate prolonged from integrated grief in older adults. Future investigations that use interventions to target amygdala-centric neural circuit abnormalities may provide new insights into the role of enhanced negative bias and related mechanisms that underlie PGD and support treatment efficacy.

Exploring Perceived Limitations to Daily Activities Due to Chronic Conditions: A Person-Centered Approach to Measuring Multimorbidity Severity

BACKGROUND

Person-centered approaches to measuring severity of multimorbidity (≥ 2 chronic conditions) can help clinicians assess the individual experience of multimorbidity and inform effective caregiving and intervention strategies. We examine how limitations in everyday activities attributable to specific chronic conditions act independently and in tandem to influence individual perceptions of multimorbidity severity.

METHODS

Data from the Panel Study of Income Dynamics (2005-2021) were used to investigate self-reported limitations in normal daily activities resulting from nine chronic conditions (hypertension, arthritis, diabetes, heart condition [heart disease/heart attack], cancer, lung disease, stroke, depression, and memory loss) in 4 318 adults aged 55-95 (18 878 person-wave observations). We used descriptive and inferential analyses to estimate limitations resulting from specific conditions, limitations attributable to condition combinations, and the contribution of comorbid conditions to condition-specific and overall severity. Follow-up analyses addressed mortality selection using inverse probability weighting and examined cancer type and cancer status/treatment modality among respondents reporting cancer diagnosis.

RESULTS

Of the more prevalent conditions, arthritis was associated with the most severe limitations to normal activities. Memory loss was the least frequent condition reported but resulted in the most severe limitations, and as a comorbid condition, increased limitations reported for most conditions. Inverse probability weighting adjusted models revealed heterogeneity in estimates for some conditions including cancer and cancer survivors tended to report less lethal cancers that were cured or in remission.

CONCLUSIONS

Our results suggest that efforts to prevent and treat arthritis and support cognitive function may reduce the severity of multimorbidity experienced by the individual.

Radiotherapy with cetuximab or durvalumab for locoregionally advanced head and neck cancer in patients with a contraindication to cisplatin (NRG-HN004): an open-label, multicentre, parallel-group, randomised, phase 2/3 trial

BACKGROUND

Management of patients with locoregionally advanced head and neck squamous cell carcinoma (HNSCC) when cisplatin is contraindicated is controversial. We aimed to assess whether radiotherapy with concurrent and adjuvant durvalumab would improve outcomes compared with radiotherapy with cetuximab.

METHODS

NRG-HN004 was designed as an open-label, multicentre, parallel-group, randomised, phase 2/3 trial with safety lead-in conducted at 89 academic and community medical centres in North America. Eligible patients were aged 18 years or older with American Joint Committee on Cancer 8th edition stage III-IVB p16-negative HNSCC or unfavourable stage I-III p16-positive oropharyngeal or unknown primary carcinoma, who had a contraindication to cisplatin (Eastern Cooperative Oncology Group [ECOG] performance status 2, renal or hearing impairment, peripheral neuropathy, aged at least 70 years with moderate or severe comorbidity, or aged younger than 70 years with severe comorbidity). Patients were randomly assigned (2:1) by permuted block randomisation (multiples of 6) to intravenous durvalumab 1500 mg starting 2 weeks before radiotherapy then every 4 weeks starting week 2 of radiotherapy (seven cycles) or intravenous cetuximab 400 mg/m2 1 week before radiotherapy then 250 mg/m2 weekly beginning week 1 of radiotherapy (eight cycles), with intensity-modulated radiotherapy (70 Gy in 35 fractions over 7 weeks). Stratification factors were tumour and nodal stage, ECOG performance status and comorbidity, and primary site and p16 status. The phase 2 primary endpoint was progression-free survival in the intention-to-treat population. There was one prespecified interim futility analysis at 50% of progression-free survival information. If the observed hazard ratio was 1·0 or more, favouring cetuximab, early stopping would be considered. Extended follow-up analysis was post hoc. This trial is registered with ClinicalTrials.gov, NCT03258554, and is closed to enrolment.

FINDINGS

Following a ten-patient safety lead-in, the phase 2 trial enrolled 190 patients from March 12, 2019, to July 30, 2021, 186 of whom were randomly assigned (123 to durvalumab and 63 to cetuximab). Median age was 72 years (IQR 64-77), 30 (16%) patients were women and 156 (84%) were men. Phase 2 accrual was suspended in July 30, 2021, following an interim futility analysis, and permanently closed in Sept 1, 2022. The phase 3 part of the trial was not conducted. At a median follow-up of 2·3 years (IQR 1·9-3·1) for the extended follow-up (data cutoff July 31, 2023; post-hoc analysis), 2-year progression-free survival was 50·6% (95% CI 41·5-59·8) in the durvalumab group versus 63·7% (51·3-76·1) in the cetuximab group (hazard ratio 1·33 [95% CI 0·84-2·12]; p=0·89). Adverse events were similar in both groups. The most common grade 3-4 adverse events were dysphagia (26 [22%] of 119 patients in the durvalumab group vs 18 [30%] of 61 patients in the cetuximab group), lymphopenia (33 [28%] vs 20 [33%]), and oral mucositis (13 [11%] vs 11 [18%]). Four (3%) patients in the durvalumab group and one (2%) in the cetuximab group died from treatment-related adverse events (death not otherwise specified, laryngeal oedema, lung infection, and respiratory failure in the durvalumab group and sudden death not otherwise specified in the cetuximab group).

INTERPRETATION

Our findings suggest that durvalumab did not improve outcomes compared with cetuximab in patients with HNSCC with contraindications to cisplatin. Further trials are needed to define the standard of care for this population.

FUNDING

US National Cancer Institute and AstraZeneca.

Outpatient rehabilitation in post-acute COVID-19 patients: a combined progressive treatment protocol

PURPOSE

to investigate the effectiveness of a 4-week combined progressive program on functional abilities, disability status and quality of life (QoL) in COVID-19 recovered patients.

MATERIALS & METHODS

18 COVID-19 recovered patients performed a combined rehabilitation treatment accounting for 12 sessions, including both respiratory and motor training sessions. A careful monitoring of exercise intensity, duration and progression to tailor complexity evolution on patients' competencies was carried out. Patients were monitored with different functional scales and self-reported questionnaires before (T0) and after (T1) rehabilitation.

RESULTS

6-Minutes Walk Test, Timed Up and Go Test and Short Physical Performance Battery significantly improved, while Physiological Cost Index presented a significant reduction after rehabilitation. Moreover, Barthel Index significantly improved and patients presented significantly increased upper and lower limbs strength at T1. Furthermore, mMRC Dyspnoea Scale presented a significant reduction after training. Finally, physical and psychological well-being scales improved according to Short-Form 36; while, self-reported questionnaires related to mood and depression showed no significant modification after rehabilitation.

CONCLUSIONS

results evidenced the efficacy of the combined progressive intervention in COVID-19 recovered patients. The specific customization on patients' needs and the careful exercise monitoring promoted improvements on functional abilities and disability status, with positive impact on QoL.

Italian standardization of the BPSD-SINDEM scale for the assessment of neuropsychiatric symptoms in persons with dementia

Introduction

Behavioral and Psychological Symptoms of Dementia (BPSD) are a heterogeneous set of psychological reactions and abnormal behaviors in people with dementia (PwD). Current assessment tools, like the Neuropsychiatric Inventory (NPI), only rely on caregiver assessment of BPSD and are therefore prone to bias.

Materials and methods

A multidisciplinary team developed the BPSD-SINDEM scale as a three-part instrument, with two questionnaires administered to the caregiver (evaluating BPSD extent and caregiver distress) and a clinician-rated observational scale. This first instrument was tested on a sample of 33 dyads of PwD and their caregivers, and the results were qualitatively appraised in order to revise the tool through a modified Delphi method. During this phase, the wording of the questions was slightly changed, and the distress scale was changed into a coping scale based on the high correlation between extent and distress (r = 0.94). The final version consisted of three 17-item subscales, evaluating BPSD extent and caregiver coping, and the unchanged clinician-rated observational scale.

Results

This tool was quantitatively validated in a sample of 208 dyads. It demonstrated good concurrent validity, with the extent subscale correlating positively with NPI scores (r = 0.64, p &lt; 0.001) and the coping subscale inversely correlating with NPI distress (r = −0.20, p = 0.004). Diagnosis (Lewy body dementia and frontotemporal dementia), medication (antidepressants and antipsychotics), caregiver, and PwD age predicted BPSD burden on the BPSD-SINDEM scale. Caregiver coping was influenced by diagnosis (Alzheimer’s and Lewy body dementia) and benzodiazepine.

Discussion

The BPSD-SINDEM scale offers a more comprehensive approach compared to NPI, by combining caregiver ratings with clinician observations. The design of the scale allows for rapid administration in diverse clinical contexts, with the potential to enhance the understanding and management of BPSD.

Early Telephone-Based Frailty Screening With the Vulnerable Elders Survey in Adults Aged 75 Years and Older With Lung and Gynecological Cancer

BACKGROUND

The International Society of Geriatric Oncology recommends that all older people with cancer have a geriatric evaluation before beginning treatment.

OBJECTIVE

To determine the prevalence of frailty in people 75 years and older diagnosed with lung or gynecological cancer and evaluate the adaptation of standard therapeutic strategies based on frailty, following the implementation of telephone-based frailty screening with the Vulnerable Elders Survey (VES-13).

INTERVENTIONS/METHODS

We performed a retrospective observational study in 362 people screened by an advanced practice nurse before their first oncology appointment. We collected secondary data from electronic medical records. The main variables were degree of frailty (according to VES-13 and comprehensive geriatric assessment), type of cancer treatment (standard and prescribed), treatment completion, sociodemographic characteristics, and comorbidities.

RESULTS

The VES-13 detected 186 people (51.4%) at risk of health deterioration, and the comprehensive geriatric assessment confirmed some degree of frailty in 157 people (43.4%), with a κ coefficient of 0.84. People with more comorbidities, greater frailty, and more geriatric syndromes were more likely to need treatment readjustment ( P < .001).

CONCLUSIONS

Telephone-based frailty screening by an advanced practice nurse showed high applicability, with very good agreement between the proportion of people classified as frail before the initial visit and in the subsequent geriatric assessment.

IMPLICATIONS FOR PRACTICE

A protocol for establishing frailty risk through telephone screening by an advanced practice nurse facilitates the care process and helps clinicians adapt therapeutic decision-making to the needs of each patient and their family.

Prediction of moderate and severe toxicities of chemotherapy in older patients with cancer: a propensity weighted analysis of ELCAPA cohort

BACKGROUND

Currently available predictive models for chemotherapy-related toxicity are not sufficiently discriminative in older patients with cancer and do not consider moderate toxicities. The purpose of this study was to identify factors associated with moderate and severe chemotherapy toxicities in older patients with cancer.

MATERIALS AND METHODS

Patients aged 70+ recruited in the prospective ELCAPA cohort were analyzed. A total of 837 patients with data on toxicities had received chemotherapy without other systemic treatment and were included between 2015 and 2022. To adjust for any imbalances in the distribution of covariates between patients receiving single-agent chemotherapy vs combination chemotherapy, we applied overlap weighting (a propensity-score-based technique). We used multinomial logistic regression.

RESULTS

Median (interquartile range) age was 81 (77-84). Forty-one percent experienced moderate toxicity, and 33% experienced severe toxicity. Hematologic toxicities accounted for 53% of severe toxicities and 66% of moderate toxicities. Age <80 years, cancer type, metastatic status, Eastern Cooperative Oncology Group performance status (ECOG-PS) >1, no cognitive impairment were associated with combination chemotherapy decision. In a univariate analysis with overlap weighting, no factors were associated with moderate toxicity. Hemoglobin < 10 g/dL and a CIRS-G score >12 were associated with severe toxicity. In a multivariate analysis, only hemoglobin < 10 g/dL was independently associated with severe toxicity, adjusted OR 2.96 (95% CI, 1.20-7.29).

CONCLUSION

By addressing indication bias for combination chemotherapy decision, only anemia and not cancer type, combination chemotherapy was predicting for severe chemotherapy-related toxicity in older patients with cancer. We did not find any predictors of moderate chemotherapy-related toxicity.

Diligent for better or worse: Conscientiousness is associated with higher likelihood of suicidal behavior and more severe suicidal intent in later life

BACKGROUND

Contradictory findings link trait conscientiousness in mid- and late life to increased healthspan and lifespan, as well as to death by suicide. It remains unclear whether conscientiousness is associated with higher odds of attempting suicide or with more severe suicidal behavior among attempters, and whether its relationship to suicide risk varies with aging-related stressors, such as declining health.

METHODS

In this cross-sectional study comprising 313 depressed adults aged ≥40 years and participating in the Longitudinal Research Program in Late-Life Suicide (Pittsburgh, USA), we employed logistic and linear regression to test whether conscientiousness was associated with the presence of recent suicidal behavior (≤2 years) and with intent severity in recent attempters (n = 84). We further tested whether the above relationships varied based on mental, cognitive, and physical health status, measured as depression severity, cognitive functioning, and the presence/absence of severe physical illness.

RESULTS

Participants were 62.1 years old on average (SD = 7.6), 85% White, and 53% female. Recent attempters had a mean age of 61.8 years at their most recent attempt (SD = 8.5), had lower cognitive functioning and were more likely severely physically ill than comparisons. Conscientiousness was positively associated with a higher likelihood of recent suicidal behavior overall (adjusted OR = 1.44, 95% CI = 1.09, 1.90, p = .010), but not in case of co-occurring severe physical illness (interaction OR = 0.54, 95% CI = 0.30, 0.97, p = .039). Conscientiousness was also positively associated with suicidal intent at the most recent attempt (adjusted β = 1.60, SE = 0.62, p = .012), explaining 7% of its variance, although this association lost significance after adjusting for other personality dimensions.

CONCLUSIONS

Highly conscientious middle-aged and older adults may be at increased risk of resolute suicidal behavior, although conscientiousness may not confer additional suicide risk among those severely physically ill.

Cognitive Profiles in Treatment-Resistant Late-Life Depression and Their Impact on Treatment Outcomes

BACKGROUND

Late-life depression (LLD) is associated with cognitive impairment, but substantial heterogeneity exists among patients. Data on the extent of cognitive impairments are inconclusive, particularly in patients with treatment-resistant depression (TRD). We investigated the cognitive profiles of patients with treatment-resistant versus nonresistant LLD and aimed to identify distinct cognitive subgroups. We also examined whether cognitive subgroups responded differentially to treatment with bilateral repetitive transcranial magnetic stimulation (rTMS).

METHODS

A total of 165 patients with LLD were divided into treatment-resistant and nonresistant groups and compared with healthy control participants on measures of executive function, information processing speed, verbal learning, and memory. Cluster analysis identified subgroups based on cognitive scores. Demographic and clinical variables, as well as outcomes with bilateral rTMS, were compared between cognitive subgroups.

RESULTS

Patients with LLD, particularly TRD, exhibited significantly worse cognitive performance than healthy controls. A 3-cluster solution was found, including cognitively intact (n = 89), cognitively diminished (n = 29), and impaired memory (n = 47) subgroups. Both the cognitively diminished and impaired memory subgroups had more anxiety symptoms and a higher proportion of patients with TRD than the cognitively intact group, although the latter difference did not survive multiple comparison correction. No significant differences were observed in outcomes to rTMS treatment.

CONCLUSIONS

Patients with LLD exhibited impairments across cognitive domains, which were more pronounced in TRD. Three cognitive subgroups responded similarly to rTMS treatment, indicating its effectiveness across cognitive profiles, especially when medications are not tolerated. Future research should examine the relationships among cognitive subgroups, cognitive decline, and neurodegeneration.

Intrinsic capacity loss rates and protective factors among individuals aged 80 years and older in Chinese nursing homes: A latent class analysis

Prior to this cross-sectional study, the intrinsic capacity (IC) loss rates and protective factors in nursing homes for individuals aged 80 and older remained unexplored. Analysing 434 participants, this study found 86.9 % of individuals experienced the loss of at least one IC domain, with detailed losses in locomotion, vision, vitality, hearing, psychological, and cognitive capacities at rates of 83.2 %, 52.8 %, 50.9 %, 46.5 %, 44.9 %, and 44.0 %, respectively. Following latent class analysis (LCA), five distinct IC impairment patterns were noted, with locomotor impairment emerging as a central component across most classes. IC protective factors for persons aged 80 years and older included financial stability, being male or younger within the cohort, junior high school or higher education, being married, no smoking history, manageable comorbidity levels, minimal medication use, good sleep, and not using assistive devices. Based on these five classes, this study provides a potential practical framework alongside recommendations for IC care strategies in the oldest-old, emphasising the importance of locomotor function in maintaining the overall IC.

Exploring mitochondrial blood-based and genetic markers in older adults with mild cognitive impairment and remitted major depressive disorder

Mild cognitive impairment (MCI) is a prodromal stage in aging to possible progression to Alzheimer's disease and related dementia (ADRD), where co-occurrence of major depressive disorder (MDD) accelerates the progression. Metabolic and mitochondrial abnormalities in ADRD and other neurodegenerative disorders have been widely suggested, while possible mitochondrial dysfunction has been associated with etiopathology of both MCI and MDD. Hence, investigation of mitochondrial markers in MCI, MDD, and presence of both conditions is warranted. In total, 332 older adult participants were included: 168 with MCI, 108 with MCI plus remitted MDD (rMDD), and 56 with rMDD but without MCI. We measured plasma circulating mitochondrial DNA (ccf-mtDNA), lactate, and extracted nuclear mitochondrial encoded (NMt) single-nucleotide variants (SNVs) (n = 312). Non-parametric statistical tests on ccf-mtDNA and lactate levels were performed on the diagnosis, clinical and cardiometabolic variables. Binary sequence kernel association test (SKAT-O) and burden test were performed on NMt-SNV, adjusted for age, race, gender, type II diabetes, and APOE genotype. Lower level of lactate was observed in MCI (KW χ2 = 14.8, P = 0.0024), more specifically, significant differences of lower plasma lactate between MCI only and rMDD, but not between MCI+rMDD and MCI were found, suggesting potential roles in MCI driving lactate lower levels. While higher levels of ccf-mtDNA were observed in APOE-ε4 carrier (χ2 = 5.04, P = 0.05). This relationship was present only in MCI (P = 0.043) and MCI+rMDD groups (P = 0.023). No significant nuclear-encoded mitochondrial gene associations were observed with MCI or MDD. The results suggest decreased level of plasma lactate in individuals with MCI and MCI+rMDD, with inverse correlation with ccf-mtDNA, in addition to effect of APOE-ε4 in further increasing ccf-mtDNA specifically in participants with cognitive impairment. These findings contribute to a deeper understanding of the mitochondrial markers in MCI and MDD, warranting further research to explore the precise roles of mitochondrial abnormalities in the development and progression of MCI.

Prehabilitation in Frail Octogenarian and Nonagenarian Patients in Colorectal Cancer Surgery: Short- and Medium-Term Outcomes

Background: There is still limited evidence on the results of prehabilitation in very old frail patients. The aim of this study is to analyze the outcomes and course of octogenarian and nonagenarian patients undergoing prehabilitation before surgery for colorectal cancer (CRC). Methods: a prospective study was conducted in a tertiary hospital from 2018 to 2022. All patients diagnosed with CRC over 80 years old and proposed for surgery were included. A comprehensive geriatric assessment (CGA) for frailty detection was performed, and the therapeutic decision was taken by the multidisciplinary tumor committee. Prehabilitation led by the geriatric team was performed. The rate of medical and surgical complications, hospital stay, in-hospital mortality, and first-year mortality were recorded. Results: CRC surgery was proposed in 184 patients >80 years. After a multidisciplinary decision, surgery was performed on 126 (68.5%) patients, of whom 12 (0.5%) were nonagenarians. Fifty percent of octogenarians and 86% of nonagenarians were frail. Prehabilitation consisted of the following: adapted physical exercise (100%); oral nutritional supplementation (73.8%); anemia treatment (59.5%); delirium prevention (5.6%); antidepressant treatment (15.9%); vitamin D supplementation (21.4%); and pharmacological deprescription (38.1%). The post-surgical complication rate was low (4.3% surgical and 29.4% medical complications), and in-hospital mortality was very low (3.2%). Nonagenarian patients had a higher rate of complications compared to octogenarians (OR 4.0 (95% CI 1.13-14.12))-mainly heart failure (OR 4.68 (95% CI 1.21-18.09))-but there were no differences in hospital stay or first-year mortality. Conclusions: prehabilitation in very old patients with CRC surgery is possible and provides good results.

Exosome-associated mitochondrial DNA in late-life depression: Implications for cognitive decline in older adults

BACKGROUND

Disrupted cellular communication, inflammatory responses and mitochondrial dysfunction are consistently observed in late-life depression (LLD). Exosomes (EXs) mediate cellular communication by transporting molecules, including mitochondrial DNA (EX-mtDNA), playing critical role in immunoregulation alongside tumor necrosis factor (TNF). Changes in EX-mtDNA are indicators of impaired mitochondrial function and might increase vulnerability to adverse health outcomes. Our study examined EX-mtDNA levels and integrity, exploring their associations with levels of TNF receptors I and II (TNFRI and TNFRII), and clinical outcomes in LLD.

METHODS

Ninety older adults (50 LLD and 40 controls (HC)) participated in the study. Blood was collected and exosomes were isolated using size-exclusion chromatography. DNA was extracted and EX-mtDNA levels and deletion were assessed using qPCR. Plasma TNFRI and TNFRII levels were quantified by multiplex immunoassay. Correlation analysis explored relationships between EX-mtDNA, clinical outcomes, and inflammatory markers.

RESULTS

Although no differences were observed in EX-mtDNA levels between groups, elevated levels correlated with poorer cognitive performance (r = -0.328, p = 0.002) and increased TNFRII levels (r = 0.367, p = 0.004). LLD exhibited higher deletion rates (F(83,1) = 4.402, p = 0.039), with a trend remaining after adjusting for covariates (p = 0.084). Deletion correlated with poorer cognitive performance (r = -0.335, p = 0.002). No other associations were found.

LIMITATION

Cross-sectional study with a small number of participants from a specialized geriatric psychiatry treatment center.

CONCLUSION

Our findings suggest that EX-mtDNA holds promise as an indicator of cognitive outcomes in LLD. Additional research is needed to further comprehend the role of EX-mtDNA levels/integrity in LLD, paving the way for its clinical application in the future.

The impact of mobility limitations on geriatric rehabilitation outcomes: Positive effects of resistance exercise training (RESORT)

BACKGROUND

Regaining walking ability is a key target in geriatric rehabilitation. This study evaluated the prevalence of walking ability at (pre-)admission and related clinical characteristics in a cohort of geriatric rehabilitation inpatients; in inpatients without walking ability, feasibility and effectiveness of progressive resistance exercise training (PRT) were assessed.

METHODS

Inpatients within RESORT, an observational, longitudinal cohort of geriatric rehabilitation inpatients, were stratified in those with and without ability to walk independently (defined by Functional Ambulation Classification (FAC) score ≤ 2) at admission; further subdivision was performed by pre-admission walking ability. Clinical characteristics at admission, length of stay, and changes in physical and functional performance throughout admission were compared depending on (pre-)admission walking ability. Feasibility (relative number of PRT sessions given and dropout rate) and effectiveness [change in Short Physical Performance Battery, FAC, independence in (instrumental) activities of daily living (ADL/IADL)] of PRT (n = 11) in a subset of inpatients without ability to walk independently at admission (able to walk pre-admission) were investigated compared with usual care (n = 11) (LIFT-UP study).

RESULTS

Out of 710 inpatients (median age 83.5 years; 58.0% female), 52.2% were not able to walk independently at admission, and 7.6% were not able to walk pre-admission. Inpatients who were not able to walk independently at admission, had a longer length of stay, higher prevalence of cognitive impairment and frailty and malnutrition risk scores, and a lower improvement in independence in (I)ADL compared with inpatients who were able to walk at both admission and pre-admission. In LIFT-UP, the relative median number of PRT sessions given compared with the protocol (twice per weekday) was 11 out of 44. There were no dropouts. PRT improved FAC (P = 0.028) and ADL (P = 0.034) compared with usual care.

CONCLUSIONS

High prevalence of inpatients who are not able to walk independently and its negative impact on independence in (I)ADL during geriatric rehabilitation highlights the importance of tailored interventions such as PRT, which resulted in improvement in FAC and ADL.

Effects of open-label transdermal nicotine antidepressant augmentation on affective symptoms and executive function in late-life depression

BACKGROUND

Late-life depression (LLD) is characterized by a poor response to antidepressant medications and diminished cognitive performance, particularly in executive functioning. There is currently no accepted pharmacotherapy for LLD that effectively treats both mood and cognitive symptoms. This study investigated whether transdermal nicotine augmentation of standard antidepressant medications benefitted mood and cognitive symptoms in LLD.

METHODS

Nonsmoking participants aged 60 years or older with unremitted LLD on stable SSRI or SNRI medications (N = 29) received transdermal nicotine patches up to a 21 mg daily dose over 12 weeks. Clinical measures assessed depression severity, secondary affective symptoms, and cognitive performance. Nicotine metabolite concentrations were obtained from blood samples.

RESULTS

Depression severity significantly decreased over the trial, with a 76 % response rate and 59 % remission rate. Change in depression severity was positively associated with nicotine exposure. Participants also exhibited improvement in self-reported affective symptoms (apathy, insomnia, rumination, and generalized anxiety symptoms), negativity bias, and disability. Executive function test performance significantly improved, specifically in measures of cognitive control, as did subjective cognitive performance. Adverse events were generally mild, with 75 % of the sample tolerating the maximum dose.

CONCLUSION

The current study extends our previous pilot open-label trial in LLD, supporting feasibility and tolerability of transdermal nicotine patches as antidepressant augmentation. Although preliminary, this open-label study supports the potential benefit of transdermal nicotine patches for both mood and cognitive symptoms of LLD. Further research, including definitive randomized, blinded trials, is warranted to confirm these findings and explore long-term risk and benefit.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (NCT04433767).

Geriatric Syndromes Frequently (Co)-Occur in Geriatric Rehabilitation Inpatients: Restoring Health of Acutely Unwell Adults (RESORT) and Enhancing Muscle Power in Geriatric Rehabilitation (EMPOWER-GR)

OBJECTIVE

To determine the prevalence and co-occurrence of common geriatric syndromes in geriatric rehabilitation inpatients.

DESIGN

Restoring Health of Acutely Unwell Adults (RESORT) and Enhancing Muscle Power in Geriatric Rehabilitation (EMPOWER-GR) are observational, longitudinal cohorts.

SETTING

Geriatric rehabilitation.

PARTICIPANTS

Geriatric rehabilitation inpatients (N=1890 and N=200).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Geriatric syndromes included polypharmacy, multimorbidity (Cumulative Illness Rating Scale), cognitive impairment, depression (Hospital Anxiety and Depression Scale/Geriatric Depression Scale), malnutrition (Global Leadership Initiative on Malnutrition), functional limitation (Katz index), falls, physical frailty (Fried), and sarcopenia (European Working Group on Sarcopenia in Older People 2).

RESULTS

Inpatients in RESORT (R) (N=1890, 56% females) had a median age of 83.4 years (interquartile range [IQR], 77.6-88.4) and in EMPOWER-GR (E) (N=200, 57% females) of 79.8 years (IQR, 75.0-85.9). Polypharmacy (R, 82.2%; E, 84.0%), multimorbidity (R, 90.4%; E, 85.5%), functional limitation (R, 96.0%; E, 76.5%), and frailty (R, 91.8%; E, 92.2%) were most prevalent. Most inpatients had ≥5 geriatric syndromes at admission in both cohorts (R, 70.0%; E, 72.4%); few inpatients had only 1 (R, 0.4%; E, 1.5%) or no geriatric syndrome (R, 0.2%; E, 0.0%). Geriatric syndromes did not occur in isolation (without other syndromes), except for multimorbidity (R, 1%; E, 5%), functional limitation (R, 3%; E, 2%), falls (R, 0%; E, 4%), and frailty (R, 2%; E, 5%), which occurred in isolation in some inpatients; sarcopenia did not.

CONCLUSIONS

Geriatric syndromes are highly prevalent at admission to geriatric rehabilitation, with a median of 5 co-occurring syndromes. Implications for diagnosis and intervention potential should be further addressed.

Validating the CogSleep Screener in older adults at a memory and cognition clinic

While sleep disturbances are prevalent in older people and are linked with poor health and cognitive outcomes, screening for the range of sleep disturbances is inefficient and therefore not ideal nor routine in memory and cognition clinic settings. We aimed to develop and validate a new brief self-report questionnaire for easy use within memory and cognition clinics. The design for this study was cross-sectional. Older adults (aged ≥50 in Sydney, Australia) were recruited from a memory and cognition research clinic. Participants (N = 402, mean age 67.3 years, range 50-86, 63.6% female) completed a comprehensive medical, neuropsychological, and mental health assessment, alongside self-report instruments, including existing sleep questionnaires and a new 10-item sleep questionnaire, the CogSleep Screener. We examined the factor structure, convergent validity, internal consistency, and discriminant validity of this novel questionnaire. Using exploratory principal component analysis, a 3-factor solution was generated highlighting the factors of Insomnia, Rapid Eye Movement (REM) Symptoms and Daytime Sleepiness. Each factor was significantly correlated with currently used sleep questionnaires for each subdomain (all Spearman rho >0.3, all p < 0.001), suggesting good convergent validity. Internal consistency was also good (Cronbach's α = 0.73). Receiver operating characteristic curves showed good discriminative ability between participants with and without sleep disturbances (all area under curve >0.7, all p < 0.01). The CogSleep Screener has good psychometric properties in older to elderly adults attending a memory and cognition clinic. The instrument has the potential to be used in memory clinics and other clinical settings to provide quick and accurate screening of sleep disturbances.

Adverse Events During a 12-month Multi-Site and Dose-Response Aerobic Exercise Intervention

Purpose

This study aimed to assess the incidence of adverse events (AE) in older adults participating in a year-long exercise intervention, investigating potential dose-response relationships between exercise intensity and AE frequency, and identifying demographic factors associated with AE risk.

Methods

A total of 648 older adults were randomized into one of three exercise groups: low-intensity stretching and toning (S&T), 150 minutes of aerobic exercise per week (150Ex), or 225 minutes of aerobic exercise per week (225Ex). Adverse events were tracked during the intervention, with event rates calculated based on participant adherence and time in the study. Generalized linear models were employed to compare AE incidence across groups. Post hoc comparisons were used to calculate incidence rate ratios (IRRs) for AE between groups, adjusting for multiple comparisons.

Results

Overall, 306 AE were reported, with 44% related to the intervention. No significant dose-response relationship was observed for all-cause AE between groups. However, intervention-related AE were more frequent in the aerobic exercise groups. Participants in the 150Ex group had a 77% higher rate of intervention-related AE compared to the S&T group, and the 225Ex group had an 88% higher rate. Higher adherence was associated with fewer all-cause AE, and greater comorbid burden was associated with more AE.

Conclusions

While aerobic exercise increased the risk of intervention-related AE, the overall risk remained low. Higher adherence to the exercise regimen was associated with fewer AE. These findings suggest aerobic exercise is generally safe in older adults, with the benefits outweighing the risks.

Predictors of attrition during acute pharmacotherapy of psychotic depression in a clinical trial

Little is known about factors that contribute to attrition in clinical trials of the pharmacotherapy of psychotic depression. The purpose of this study was to identify factors associated with attrition during acute pharmacotherapy in the Study of the Pharmacotherapy of Psychotic Depression II (STOP-PD II) clinical trial. Sociodemographic and clinical variables were assessed at baseline in 269 men and women, aged 18-85 years, who were treated with up to 12 weeks of open-label sertraline plus olanzapine. Univariate analyses examined the association of baseline variables with overall non-completion, as well as reasons for non-completion. Logistic regression was used to model the relationship of the significant univariate predictors with non-completion and its reasons. Seventy-four (27.5 %) participants did not complete the acute treatment phase of STOP-PD II. Male gender, younger age, inpatient status, higher Clinical Global Impression (CGI) severity of illness, and higher severity of psychomotor disturbance were associated with non-completion in univariate analyses. In regression models, higher CGI severity of illness score was the only significant independent predictor of non-completion, explained by withdrawal of consent. Our findings have implications for the retention of persons with psychotic depression in clinical trials.

Elevated senescence-associated secretory phenotype index in late-life bipolar disorder

BACKGROUND

The senescence-associated secretory phenotype (SASP) is a biomarker index based on the profile of 22 blood proteins associated with cellular senescence. The SASP index has not been assessed in older patients with bipolar disorder (BD). We hypothesized that older adults with BD will have elevated cellular senescence burden as measured by the SASP index.

METHODS

We measured the 22 SASP proteins to calculate the SASP index in 38 older patients with BD and 34 non-psychiatric comparison individuals (HC).

RESULTS

The SASP index scores were significantly higher in BD than HC after controlling for age, sex, psychopathology, and physical health (F(1,8) = 5.37, p = 0.024, η2 = 0.08). SASP index scores were also associated with higher age, more severe depressive symptoms, and physical illness burden (p < 0.05) in the whole sample.

LIMITATION

Cross-sectional study and small sample size.

CONCLUSION

This is the first report of increased SASP index scores in older adults with BD. Our results suggest that dysregulation of age-related biological processes may contribute to more severe depressive symptoms and worse physical health in older adults with BD.

Hippocampal subfield volume in older adults with and without mild cognitive impairment: Effects of worry and cognitive reappraisal

Studies have confirmed that anxiety, especially worry and rumination, are associated with increased risk for cognitive decline, including Alzheimer's disease and related dementias (ADRD). Hippocampal atrophy is a hallmark of ADRD. We investigated the association between hippocampus and its subfield volumes and late-life global anxiety, worry, and rumination, and emotion regulation strategies. We recruited 110 participants with varying worry severity who underwent magnetic resonance imaging and clinical interviews. We conducted cross-sectional regression analysis between each subfield and anxiety, worry, rumination, reappraisal, and suppression while adjusting for age, sex, race, education, cumulative illness burden, stress, neuroticism, and intracranial volume. We imputed missing data and corrected for multiple comparisons across regions. Greater worry was associated with smaller subiculum volume, whereas greater use of reappraisal was associated with larger subiculum and CA1 volume. Greater worry may be detrimental to the hippocampus and to subfields involved in early ADRD pathology. Use of reappraisal appears protective of hippocampal structure. Worry and reappraisal may be modifiable targets for ADRD prevention.