Non-tricyclic and Non-selective Serotonin Reuptake Inhibitor Antidepressants and Recurrent Falls in Frail Older Women

Recurrent Falls over Three Years among Older Adults Age 70+: Associations with Physical and Mental Health Status, Exercise, and Hospital Stay

We used the 2019-2021 U.S. National Health and Aging Trend Study (N = 3,063, age 70+) and multinomial logistic regression and generalized linear models with Poisson and log link to identify correlates of (1) recurrent falls (2 + falls) over 3 years (2019-2021); and (2) any subsequent fall among those who had a fall in 2019. We also examined the associations between falls and hospitalization in 2021. Results show that those with recurrent falls had greater physical/functional and psychological health problems in 2019, while single fallers over the 3 years were not significantly different from those without a fall. Exercise was associated with a lower likelihood of a subsequent fall among those who fell in 2019. Both a single fall and recurrent falls over the 3 years were associated with a higher risk of hospitalization in 2021. Multifactorial fall preventions including exercise and depression/anxiety treatment are needed to mitigate recurrent fall risks.

Risk of fracture in antidepressant users with concurrent use of benzodiazepines: A self-controlled case-series analysis

OBJECTIVE

Despite the fracture risk associated with both antidepressant (AD) medication and benzodiazepines (BDZs), they are commonly prescribed simultaneously. However, studies elucidating the effects of concurrent use of BDZs and ADs on the risk fracture are scant. The objective of this study was to evaluate the risk of fracture associated with concurrent use of BDZs in AD users, using a self-controlled case-series analysis.

METHODS

A self-controlled case-series analysis, in which the participants act as their own control, was conducted using the Korean National Health Insurance Service-National Sample Cohort database (2002-2015). We studied AD users who were prescribed BDZs and diagnosed with a fracture. The risk periods were subdivided into consecutive periods (1-30, 31-60, and > 60 days) after receiving a BDZ. A 2-week pre-exposure period and a 2-week post-exposure period were also included. The incidence rate ratio (IRR) was estimated after adjusting for age and use of co-medications.

RESULTS

A total of 3020 patients were identified during the study period. There was an increased fracture risk in the first 30 days following BDZ use (IRR: 1.88, 95% confidence interval [CI] 1.66-2.12), in the 31-60-day period (1.73, 95% CI 1.48-2.02), and beyond the 60-day period (IRR: 1.68, 95% CI 1.47-1.91). The risks of fracture were greater in men and older patients.

CONCLUSION

The concomitant use of BDZs and ADs was related to a significant increase in fracture risk. AD users should be aware of the fracture risk with concomitant BDZ use, especially for first-time BDZ users and for elderly patients.

Antidepressant Use Partially Mediates the Association Between Depression and Risk of Falls and Fall Injuries Among Older Adults

BACKGROUND

The association between depression and fall risk in older adults is recognized, yet the mechanisms underlying this association are unclear. This study estimated the mediating role of antidepressant use in the association between depression and falls and fall injuries.

METHODS

Longitudinal data from the Health and Retirement Study (2004-2006) were linked with medication data from the Prescription Drug Study (2005). The sample included community-dwelling adults aged ≥65 with data on depression and medication use (n = 3565). Depression was measured using 2 independent survey tools: Composite International Diagnostic Interview for depression short form and an 8-item version of the Center for Epidemiological Studies-Depression scale. We used causal mediation analysis to estimate and compare the direct and indirect (mediated by antidepressant use) effects of depression on falls and fall injuries.

RESULTS

Individuals with major depressive disorder were significantly more likely to experience a fall (OR: 1.92; 95% CI: 1.41, 2.62) and a fall injury (OR: 1.67; 95% CI: 1.09, 2.55) over 2 years. Indirect effect estimates showed that antidepressant medication use accounted for approximately 19% and 18% of the association between major depressive disorder and falls and fall injuries, respectively. Results were similar when using an alternative depression measure and when considering only selective serotonin reuptake inhibitor antidepressants.

CONCLUSIONS

Antidepressant use explains a significant proportion, but not a majority, of the association between depression and greater fall risk. Treatment benefits of antidepressants should be considered with, and may outweigh, concerns about increased risk of falls associated with antidepressant use.

The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center

The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM—73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Update on Unipolar Nonpsychotic Depression

BACKGROUND

The Psychopharmacology Algorithm Project at the Harvard South Shore Program presents evidence-based recommendations considering efficacy, tolerability, safety, and cost. Two previous algorithms for unipolar nonpsychotic depression were published in 1993 and 1998. New studies over the last 20 years suggest that another update is needed.

METHODS

The references reviewed for the previous algorithms were reevaluated, and a new literature search was conducted to identify studies that would either support or alter the previous recommendations. Other guidelines and algorithms were consulted. We considered exceptions to the main algorithm, as for pregnant women and patients with anxious distress, mixed features, or common medical and psychiatric comorbidities.

SUMMARY

For inpatients with severe melancholic depression and acute safety concerns, electroconvulsive therapy (or ketamine if ECT refused or ineffective) may be the first-line treatment. In the absence of an urgent indication, we recommend trialing venlafaxine, mirtazapine, or a tricyclic antidepressant. These may be augmented if necessary with lithium or T3 (triiodothyronine). For inpatients with non-melancholic depression and most depressed outpatients, sertraline, escitalopram, and bupropion are reasonable first choices. If no response, the prescriber (in collaboration with the patient) has many choices for the second trial in this algorithm because there is no clear preference based on evidence, and there are many individual patient considerations to take into account. If no response to the second medication trial, the patient is considered to have a medication treatment-resistant depression. If the patient meets criteria for the atypical features specifier, a monoamine oxidase inhibitor could be considered. If not, reconsider (for the third trial) some of the same options suggested for the second trial. Some other choices can also considered at this stage. If the patient has comorbidities such as chronic pain, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, or posttraumatic stress disorder, the depression could be secondary; evidence-based treatments for those disorders would then be recommended.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder

A previous algorithm for the pharmacological treatment of obsessive-compulsive disorder was published in 2012. Developments over the past 7 years suggest an update is needed. The authors conducted searches in PubMed, focusing on new studies and reviews since 2012 that would support or change previous recommendations. We identified exceptions to the main algorithm, including pregnant women and women of child-bearing potential, the elderly, and patients with common medical and psychiatric co-morbidities. Selective serotonin reuptake inhibitors (SSRIs) are still first-line. An adequate trial requires a period at typical antidepressant doses and dose adjustments guided by a plasma level to evaluate for poor adherence or ultra-rapid metabolism. If the response is inadequate, consider a trial of another SSRI this time possibly taken to a very high dose. Clomipramine could be an alternative. If the response to the second trial remains inadequate, the next recommendation is to augment with aripiprazole or risperidone. Alternatively, augmentation with novel agents could be selected, including glutamatergic (memantine, riluzole, topiramate, n-acetylcysteine, lamotrigine), serotonergic (ondansetron), and anti-inflammatory (minocycline, celecoxib) agents. A third option could be transcranial magnetic stimulation. Lastly, after several of these trials, deep brain stimulation and cingulotomy have evidence for a role in the most treatment-refractory patients.

Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study

BACKGROUND

Trazodone is increasingly prescribed for behavioural and psychological symptoms of dementia, but little is known about its risk of harm. Our objective was to describe the comparative risk of falls and fractures among older adults with dementia dispensed trazodone or atypical antipsychotics.

METHODS

The study cohort included adults with dementia (excluding patients with chronic psychotic illnesses) living in long-term care and aged 66 years and older. Data were obtained from routinely collected, linked health administrative databases in Ontario, Canada. We compared new users of trazodone with new users of atypical antipsychotics (quetiapine, olanzapine or risperidone) between Dec. 1, 2009, and Dec. 31, 2015. The primary outcome was a composite of fall or major osteoporotic fracture within 90 days of first prescription. Secondary outcomes were falls, major osteoporotic fractures, hip fractures and all-cause mortality.

RESULTS

We included 6588 older adults dispensed trazodone and 2875 dispensed an atypical antipsychotic, of whom 95.2% received a low dose of these medications. Compared with use of atypical antipsychotics, use of trazodone was associated with similar rates of falls or major osteoporotic fractures (weighted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.73 to 1.07), major osteoporotic fracture (weighted HR 1.03, 95% CI 0.73 to 1.47), falls (weighted HR 0.91, 95% CI 0.75 to 1.11) and hip fractures (weighted HR 0.92, 95% CI 0.59 to 1.43). Use of trazodone was associated with a lower rate of mortality (weighted HR 0.75, 95% CI 0.66 to 0.85).

INTERPRETATION

Trazodone is not a uniformly safer alternative to atypical antipsychotics, given the similar risk of falls and fractures among older adults with dementia.

Antidepressants and the risk of traumatic brain injury in the elderly: differences between individual agents

Objective

To determine the association of individual antidepressants (ADs) with the risk of traumatic brain injury (TBI) in the elderly.

Patients and methods

We conducted a case-control study nested in a cohort of new users of ADs aged ≥65 years, identified in the German Pharmacoepidemiological Research Database during 2005-2014. Cases were patients first hospitalized for TBI. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at the index date based on the supply of last dispensing (adding 150% of the defined daily doses [DDDs]; in sensitivity analysis, no additional DDDs were considered). We estimated adjusted ORs (aORs) and 95% CIs using conditional logistic regression.

Results

Among 701,309 cohort members, 16,750 cases were identified and matched to 1,673,320 controls (in both groups: 70.4% women; median age 80 years). Compared with remote users of the same AD, current users had an aOR (95% CI) of 1.87 (1.56-2.24) for duloxetine, 1.74 (1.41-2.15) for escitalopram, 1.70 (1.58-1.83) for citalopram, 1.66 (1.40-1.97) for sertraline, 1.64 (1.24-2.15) for fluoxetine and 1.57 (1.20-2.06) for paroxetine. The aOR was lower for amitriptyline (1.45; 1.32-1.58), trimipramine (1.17; 0.99-1.38) and opipramol (1.11; 0.99-1.25). Mirtazapine had an aOR of 1.03 (0.94-1.12). Sensitivity analysis confirmed the findings.

Conclusion

The large variability between individual ADs shows the importance of considering the safety of individual agents rather than focusing on class alone.

Variation in Placebo Effect Sizes in Clinical Trials of Oral Interventions for Management of the Behavioral and Psychological Symptoms of Dementia (BPSD): A Systematic Review and Meta-Analysis

Increasing placebo effect sizes over time have been reported in randomized controlled trials (RCTs) for outcomes related to psychiatric symptoms. The Neuropsychiatric Inventory (NPI) is a key outcome measure in clinical trials of the behavioral and psychological symptoms of dementia (BPSD). Accurate placebo effect size estimates for NPI are needed for sample size calculations in order to adequately power future studies. This study investigated variation in placebo effect sizes for NPI in RCTs testing oral interventions for BPSD. A search of PubMed was conducted in April 2016 for two-armed, double-blinded, placebo-controlled RCTs testing any oral intervention for management of BPSD using the NPI. Meta-analysis was conducted of baseline versus end of treatment placebo group data of included studies. Twenty-five RCTs published from 2000 to 2015 were included. Substantial variation in placebo effect sizes was detected. Participants in placebo groups showed greater improvements in recent studies compared with earlier studies. Subgroup analyses indicated robustness of this finding. From 2000 to 2008 there was no significant change in total NPI scores within placebo groups (12 studies; 1,056 participants), whereas from 2009 to 2015 there was significant improvement (mean difference: -2.68; 95% confidence interval: -4.38, -0.99; z = 3.10; p = 0.002, random effects; I² = 76%; 13 studies; 1,170 participants). This increase in NPI effect sizes in placebo groups has important implications for power calculations for future clinical trials of BPSD. Effect size estimates for NPI need to be based on more recent studies.

Association of psychotropic drug use with falls among older adults in Germany. Results of the German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1)

Purpose

To investigate the association of psychotropic drug use with falls among older adults in Germany based on data from the National Health Interview and Examination Survey for Adults 2008–2011 (DEGS1).

Methods

DEGS1 collected data on drug use in the past 7 days and on falls occurred in the last 12 months. Study participants were older adults aged 65–79 years with complete data on drug use and falls (N = 1,833). Odds ratio (OR) and 95% confidence intervals (95% CI) were derived from logistic regression models adjusting for potential confounders including socio-demographic characteristics, health-related behaviors (alcohol drinking), body mass index and health conditions (frailty, vision impairment, disability, polypharmacy, blood pressure) as well as use of potential falls-risk-increasing drugs. SPSS complex sample methods were used for statistical analysis.

Results

Compared to people without falls, people with falls (n = 370) had a higher psychotropic drug use (33.1% vs. 20.7%, p < .001). After adjusting for potential confounders, use of psychotropic drugs overall was associated with a higher risk of falls (OR 1.64, 95% CI 1.14–2.37). This was particularly true for the use of synthetic psychotropic drugs (1.57, 1.08–2.28), antidepressants overall (2.88, 1.63–5.09) or synthetic antidepressants (2.66, 1.50–4.73), specifically, selective serotonin reuptake inhibitors (SSRIs) (6.22, 2.28–17.0). Similar results were found for recurrent falls.

Conclusions

Use of psychotropic drugs overall, especially synthetic antidepressants like SSRIs, is associated with higher risks of falls and recurrent falls among community dwelling older adults aged 65–79 years in Germany.

Falls: the adverse drug reaction of the elderly and the impact of pharmacogenetics

Falls is a frequent type of adverse drug reactions causing significant morbidity and mortality in the elderly. We reviewed, with which drugs the risk of falls is relevant and might depend on genomic variation. Pharmacogenetic variability may contribute to drug-induced falls for instance mediated by impaired drug elimination due to inherited deficiency in enzymes like CYP2C9, CYP2C19 and CYP2D6. The relative role of specific genes and polymorphisms in old age may differ from younger people. Biomarkers for frailty, but also genomic biomarkers might help identifying patients at high risk for drug-induced falls. Many other factors including disease and drug-drug interactions also contribute to risk of falls. Further studies analyzing the impact of genomic variation on the medication-related fall risk in the older adult are urgently needed.