Neurocognitive costs and benefits of psychotropic medications in older adults

The relationship between mood and anxiety and cognitive phenotypes in adults with pharmacoresistant temporal lobe epilepsy

OBJECTIVE

Patients with temporal lobe epilepsy (TLE) are often at a high risk for cognitive and psychiatric comorbidities. Several cognitive phenotypes have been identified in TLE, but it is unclear how phenotypes relate to psychiatric comorbidities, such as anxiety and depression. This observational study investigated the relationship between cognitive phenotypes and psychiatric symptomatology in TLE.

METHODS

A total of 826 adults (age = 40.3, 55% female) with pharmacoresistant TLE completed a neuropsychological evaluation that included at least two measures from five cognitive domains to derive International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) cognitive phenotypes (i.e., intact, single-domain impairment, bi-domain impairment, generalized impairment). Participants also completed screening measures for depression and anxiety. Psychiatric history and medication data were extracted from electronic health records. Multivariable proportional odds logistic regression models examined the relationship between IC-CoDE phenotypes and psychiatric variables after controlling for relevant covariates.

RESULTS

Patients with elevated depressive symptoms had a greater odds of demonstrating increasingly worse cognitive phenotypes than patients without significant depressive symptomatology (odds ratio [OR] = 1.123-1.993, all corrected p's < .05). Number of psychotropic (OR = 1.584, p < .05) and anti-seizure medications (OR = 1.507, p < .001), use of anti-seizure medications with mood-worsening effects (OR = 1.748, p = .005), and history of a psychiatric diagnosis (OR = 1.928, p < .05) also increased the odds of a more severe cognitive phenotype, while anxiety symptoms were unrelated.

SIGNIFICANCE

This study demonstrates that psychiatric factors are not only associated with function in specific cognitive domains but also with the pattern and extent of deficits across cognitive domains. Results suggest that depressive symptoms and medications are strongly related to cognitive phenotype in adults with TLE and support the inclusion of these factors as diagnostic modifiers for cognitive phenotypes in future work. Longitudinal studies that incorporate neuroimaging findings are warranted to further our understanding of the complex relationships between cognition, mood, and seizures and to determine whether non-pharmacologic treatment of mood symptoms alters cognitive phenotype.

Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA

PURPOSE

Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people.

METHODS

Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates.

RESULTS

Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures.

CONCLUSION

Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.

Cognition in older offenders in North Rhine-Westphalia: A comparison of prisoners and patients in forensic psychiatry hospitals

The number of elderly delinquent individuals living in prisons and forensic hospitals is increasing. For both settings, complex needs have been described for the elderly related to age-related changes and frequent somatic disorders as well as mental disorders, primarily depressive symptoms.. One of the biggest challenges are cognitive impairments which have been described for both groups, probably not least due to frequent risk factors (e.g., substance abuse, depressive symptoms). Given that the group of forensic patients has a manifest mental illness, which is usually treated with psychopharmaceuticals, the question arises as to what extent cognitive deficits are more frequent here. For both groups, the detection of cognitive deficits with regard to therapy and release planning is of relevance. In sum, studies on cognitive function in both populations are rare, and the results are hard to compare due to different instruments to assess cognition. Sociodemographic, health-, and incarceration-related data were collected as well as neuropsychological functions using established instruments to evaluate global cognitive functioning (Mini-Mental State Examination [MMSE], DemTect), executive function (Frontal Assessment Battery [FAB], and Trail Making Test [TMT]). In the final sample, 57 prisoners and 34 forensic inpatients from North Rhine Westphalia, Germany being 60 years and older were included. The groups were comparable in age (prisoners: M = 66.5 years, SD ± 5.3; forensic inpatients: M = 66.8 years, SD ± 7.5) and education (prisoners: M = 11.47, SD ± 2.91; forensic inpatients: M = 11.39, SD ± 3.64), but the offenders in forensic psychiatry had spent significantly more time in the correctional setting than prisoners (prisoners: M = 8.6, SD ± 10.8; forensic inpatients: M = 15.6 years, SD ± 11.9). In both groups cognitive deficits were frequent. Depending on the tests and population, between 42% and 64% showed impairments in global cognition, and between 22% and 70% were classified with impaired executive functioning. We found no significant differences in global cognition or executive functions assessed with the TMT between the two groups. However, forensic inpatients were significantly more impaired in the FAB compared to the prisoners. The results emphasize the high frequency of cognitive dysfunction in both settings and a possibly higher frequency of "frontal" dysfunction in forensic inpatients, and, thus, indicate the relevance of routine neuropsychological diagnostic and treatment procedures in these settings.

Effects of Vascular Comorbidity on Cognition in Multiple Sclerosis Are Partially Mediated by Changes in Brain Structure

Objective

Vascular comorbidities are associated with reduced cognitive performance and with changes in brain structure in people with multiple sclerosis (MS). Understanding causal pathways is necessary to support the design of interventions to mitigate the impacts of comorbidities, and to monitor their effectiveness. We assessed the inter-relationships among vascular comorbidity, cognition and brain structure in people with MS.

Methods

Adults with neurologist-confirmed MS reported comorbidities, and underwent assessment of their blood pressure, HbA1c, and cognitive functioning (i.e., Symbol Digit Modalities Test, California Verbal Learning Test, Brief Visuospatial Memory Test-Revised, and verbal fluency). Test scores were converted to age-, sex-, and education-adjusted z-scores. Whole brain magnetic resonance imaging (MRI) was completed, from which measures of thalamic and hippocampal volumes, and mean diffusivity of gray matter and normal-appearing white matter were converted to age and sex-adjusted z-scores. Canonical correlation analysis was used to identify linear combinations of cognitive measures (cognitive variate) and MRI measures (MRI variate) that accounted for the most correlation between the cognitive and MRI measures. Regression analyses were used to test whether MRI measures mediated the relationships between the number of vascular comorbidities and cognition measures.

Results

Of 105 participants, most were women (84.8%) with a mean (SD) age of 51.8 (12.8) years and age of symptom onset of 29.4 (10.5) years. Vascular comorbidity was common, with 35.2% of participants reporting one, 15.2% reporting two, and 8.6% reporting three or more. Canonical correlation analysis of the cognitive and MRI variables identified one pair of variates (Pillai's trace = 0.45, p = 0.0035). The biggest contributors to the cognitive variate were the SDMT and CVLT-II, and to the MRI variate were gray matter MD and thalamic volume. The correlation between cognitive and MRI variates was 0.50; these variates were used in regression analyses. On regression analysis, vascular comorbidity was associated with the MRI variate, and with the cognitive variate. After adjusting for the MRI variate, vascular comorbidity was not associated with the cognitive variate.

Conclusion

Vascular comorbidity is associated with lower cognitive function in people with MS and this association is partially mediated via changes in brain macrostructure and microstructure.

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients

Background

It has been hypothesized that polypharmacy may increase the frequency of multidrug interactions (MDIs) where one drug interacts with two or more other drugs, amplifying the risk of associated adverse drug events (ADEs). The main objective of this study was to determine the prevalence of MDIs in medication lists of elderly ambulatory patients and to identify the medications most commonly involved in MDIs that amplify the risk of ADEs.

Methods

Medication lists stored in the electronic health record (EHR) of 6,545 outpatients ≥60 years old were extracted from the enterprise data warehouse. Network analysis identified patients with three or more interacting medications from their medication lists. Potentially harmful interactions were identified from the enterprise drug-drug interaction alerting system. MDIs were considered to amplify the risk if interactions could increase the probability of ADEs.

Results

MDIs were identified in 1.3 % of the medication lists, the majority of which involved three interacting drugs (75.6 %) while the remainder involved four (15.6 %) or five or more (8.9 %) interacting drugs. The average number of medications on the lists was 3.1 ± 2.3 in patients with no drug interactions and 8.6 ± 3.4 in patients with MDIs. The prevalence of MDIs on medication lists was greater than 10 % in patients prescribed bupropion, tramadol, trazodone, cyclobenzaprine, fluoxetine, ondansetron, or quetiapine and greater than 20 % in patients prescribed amiodarone or methotrexate. All MDIs were potentially risk-amplifying due to pharmacodynamic interactions, where three or more medications were associated with the same ADE, or pharmacokinetic, where two or more drugs reduced the metabolism of a third drug. The most common drugs involved in MDIs were psychotropic, comprising 35.1 % of all drugs involved. The most common serious potential ADEs associated with the interactions were serotonin syndrome, seizures, prolonged QT interval and bleeding.

Conclusions

An identifiable number of medications, the majority of which are psychotropic, may be involved in MDIs in elderly ambulatory patients which may amplify the risk of serious ADEs. To mitigate the risk, providers will need to pay special attention to the overlapping drug-drug interactions which result in MDIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02594-z.

Associations Between Trauma, Sleep, and Cognitive Impairment Among Latino and Asian Older Adults

BACKGROUND/OBJECTIVES

Trauma survivors with chronic post-traumatic stress disorder (PTSD) have been found to have cognitive impairment. But little is known about these outcomes among Latino and Asians who comprise more than 80% of the U.S. immigrant population. They also experience disparities in PTSD and dementia care albeit increased exposure to trauma. This study aimed to (1) examine the association between trauma exposures and PTSD with cognitive impairment in a sample of Latino and Asian older adults; and (2) assess whether sleep quality attenuated the PTSD-cognitive impairment association.

DESIGN

Cross-sectional secondary analysis of baseline data from the Positive Minds-Strong Bodies randomized controlled trial on disability prevention.

SETTING

Community-based organizations serving minority or immigrant older adults in Massachusetts, New York, Florida, or Puerto Rico.

PARTICIPANTS

Hispanic/Latino and Asian/Pacific Islander adults aged 60 or older eligible per randomized controlled trial screening for elevated mood symptoms and minor-to-moderate physical dysfunction (n = 134 and n = 86, respectively).

MEASUREMENTS

Neuropsychiatric measures were cognitive impairment (Mini Montreal Cognitive Assessment (MoCA)), PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual-5), trauma exposure (Brief Trauma Questionnaire), depression (Patient Health Questionnaire-9), generalized anxiety (Generalized Anxiety Disorder Scale-7), and daytime sleepiness (Epworth Sleepiness Scale).

RESULTS

Mean age was 72.8 years and 77.5 years for the Latino and Asian groups, respectively. The Asian group was 100% immigrant, whereas 70.2% (n = 92) of the Latino group was foreign-born. In unadjusted models, higher Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual-5 scores were associated with decreased odds of normal cognitive functioning (MoCA ≥25) in the Asian group (odds ratio (95% confidence interval) = .93 (.87, .99)), but not the Latino group (odds ratio (95% confidence interval) = .99 (.95, 1.05)). This association remained significant after adjusting for covariates. Daytime sleepiness did not moderate the association between PTSD and cognitive functioning in the Asian group.

CONCLUSION

Higher PTSD symptoms were associated with cognitive impairment in Asian, but not Latino, older adults. Clinicians serving older Asians should integrate trauma and cognitive screening to ensure this growing, underserved population receives appropriate evidence-based treatments.

The Prevalence and Characteristics of Psychotropic-Related Hospitalizations in Older People: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the prevalence and characteristics of psychotropic medication-related hospitalizations in older people.

DESIGN

Systematic review with meta-analysis.

SETTING AND PARTICIPANTS

Older adults (≥65 years of age) with psychotropic-related hospitalizations.

METHODS

A search of published literature was performed in Medline, Embase, CINAHL, and Scopus from 2010 to March 2020. Three authors independently screened titles, abstracts, and full texts of relevant studies for relevance. Two authors independently extracted full text data, including characteristics, measures of causality, prevalence data, and performed quality assessment. A meta-analysis was conducted to estimate pooled prevalence and 95% confidence intervals (CIs) of psychotropic-related hospitalizations using random effects models. Heterogeneity was explored using subgroup analyses.

RESULTS

Of 815 potentially relevant studies, 11 were included in the final analysis. Five studies were cross-sectional studies, 5 were cohort studies, and 1 was a case control study. The majority of studies were rated as good quality. Psychotropic medications contributed to 2.1% (95% CI 1.2%-3.3%) of total hospitalizations and 11.3% (95% CI 8.2%-14.8%) of adverse drug event-related hospitalizations. The main psychotropic medications attributable to hospitalizations were antidepressants, hypnotics, sedatives, and antipsychotics.

CONCLUSIONS AND IMPLICATIONS

Psychotropic medications are a significant contributor to hospitalizations in older adults. The risk of hospitalization was greatest for those taking antidepressants, antipsychotics, hypnotics, and sedatives. Future studies should aim to address specific medication subgroups and implement uniform adverse drug event-related classification systems to improve comparability across studies.

Potentially Inappropriate Medications and Polypharmacy: A Study of Older People with Mild Cognitive Impairment and Mild Dementia

BACKGROUND

With multimorbidity increasing among older people, polypharmacy and the use of potentially inappropriate medications (PIMs) are assuming a prominent role in the life of the geriatric population.

OBJECTIVE

To investigate the association of polypharmacy and PIM use with a wide range of factors in older people with mild cognitive impairment (MCI) to mild dementia.

METHODS

The study population comprised 160 outpatients with a Clinical Dementia Rating of 0.5-1 and a Mini-Mental State Examination score of 20-30. Patients were classified as receiving polypharmacy when they took ≥5 different medications at the same time. PIMs were identified using the STOPP-J criteria. Cognitive, neuropsychological, nutritional, and physical function tests were performed and body measurements taken. Quality of life (QOL) was assessed using both components of the EQ-5D scale, the index score and the visual analogue scale (QOL VAS). A comorbidity index was calculated for all participants.

RESULTS

PIM use was significantly associated with lower scores on the verbal fluency (initial letters) test and QOL index. Participants receiving polypharmacy showed an increased likelihood of worse frailty status and lower QOL VAS score. The number of medications was significantly associated with a worse frailty status.

CONCLUSION

In a geriatric population with MCI to mild dementia, PIM use was associated with lower verbal fluency (initial letters) score and lower QOL, while the presence of polypharmacy was correlated with a worse frailty status and lower QOL. The number of medicines, instead, was correlated with a worse frailty status only.

Psychotropic Polypharmacy in Adults 55 Years or Older: A Risk for Impaired Global Cognition, Executive Function, and Mobility

Objectives

With their broad spectrum of action, psychotropic drugs are among the most common medications prescribed to the elderly. Consequently, the number of older adults taking multiple psychotropic drugs has more than doubled over the last decade. To improve knowledge about the deleterious effects of psychotropic polypharmacy, we investigated whether there is a threshold number of psychotropic molecules that could lead to impairment of global cognition, executive function, or mobility. Furthermore, relationships between the number of psychotropic molecules and cognitive and mobility impairment were examined.

Design

Cross-sectional study

Setting

University Hospital of Caen (France) and advertisements in medical offices

Participants

Community-dwelling older adults 55 years and older (n = 177; 69.8 ± 9.3 years; 81% women)

Measurements

Number of psychotropic molecules taken daily, global cognition assessed with the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), processing speed with the Trail Making Test (TMT) A, executive function with the TMT B and TMT B-A, and mobility with the Time Up and Go (TUG). The threshold numbers of psychotropic molecules were determined by ROC curves analysis. Based on these threshold values, multinomial logistic regression adjusting for covariates was then performed.

Results

Logistic regressions showed that the threshold of two daily psychotropic molecules, identified by the ROC curves analysis, increases the risk of impaired executive function (p = .05 and.005 for the TMT B and TMT B-A, respectively), global cognition (p = .006 and.001 for the MMSE and MoCA, respectively), and mobility (p = .005 for the TUG), independent of confounding factors, including comorbidities. Furthermore, psychotropic polypharmacy would affect mobility through executive functions.

Conclusion

Impairment of global cognition, executive function, and mobility when as few as two psychotropic molecules are consumed in relatively healthy young older adults should alert physicians when prescribing combinations of psychotropic medications.

U.S. Nursing Home Violations of International and Domestic Human Rights Standards

We present a review of the international covenants and conventions and U.S. domestic laws and regulations that are designed to protect nursing home residents in the United States. Based on a review of research studies, government reports, and news reports, we found extensive evidence of widespread and systematic abuse and neglect of nursing home residents in the United States that needs urgent government action to protect the basic human rights of residents.

Reversible Dementias

As the worldwide prevalence of dementia increases, there is a greater and more urgent need for all health care providers to understand how to evaluate and manage cognitive impairment. Many people presenting with a dementing illness have one or more reversible underlying conditions that worsen prognosis and, if treated, can improve cognitive function. This article reviews the major potentially reversible dementias, including the basic workup and management of each condition.

Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program

The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.

Epigenetic Alterations Impact on Antipsychotic Treatment in Elderly Patients

PURPOSE OF THE REVIEW

Antipsychotics are commonly prescribed for the treatment of psychosis as well as behavioral and psychological symptoms of dementia (BPSD) in elderly patients. However, elderly patients often experience decreased antipsychotic efficacy and increased side effects, though the mechanisms underlying these changes with age are not clear.

RECENT FINDINGS

Although aging can affect drug metabolism and clearance through changes in renal and hepatic function, additional pharmacokinetic and pharmacodynamic changes due to aging-induced epigenetic alterations also impact processes important for antipsychotic function. Epigenetic mechanisms account for some of the altered efficacy and increased side effects seen in elderly patients.

SUMMARY

Both clinical and animal studies from our group and others have demonstrated a plausible epigenetic mechanism involving histone modifications that can adversely affect the efficacy of antipsychotics and increase their side effects in elderly patients. Hopefully, further investigation of this mechanism will benefit elderly patients who need treatment for psychosis and BPSD.

Patients reasons for obtaining psychotropic medications without a prescription at retail pharmacies in Central Saudi Arabia

OBJECTIVE

To explore the possible causes behind adults seeking psychotropic medications without a prescription; identify the most commonly used psychotropic medications without a prescription; and determine the prevalence of depression and anxiety disorders among adults who used psychotropic medications without a prescription in Riyadh, Kingdom of Saudi Arabia.

METHODS

A cross-sectional study was conducted from November 2014 to August 2015. A convenience sample was taken by distributing a self-administered questionnaire among participants who had obtained psychotropic medications without a prescription from retail pharmacies during the 4 weeks prior to study intake in Riyadh, Kingdom of Saudi Arabia. In addition to the study questionnaire, the 9-item Patient Health Questionnaire was used to screen for major depressive disorder, and the 7-item Generalized Anxiety Disorder Scale was used to screen for general anxiety disorders.

RESULTS

Of the 302 subjects, 42.4% attributed their use of psychotropic medications without a prescription to the non-seriousness of their symptoms and 28.5% to the high cost of psychiatric services. Escitalopram was the most commonly used medication (31.8%), and 3 atypical antipsychotics were used by more than one-fifth of the study participants. The prevalence for major depressive disorder was 46.0% and 41.7% for generalized anxiety disorder.

CONCLUSION

Most of the participants were able to easily obtain psychotropic medications without a prescription. We recommend implementing strong policies to prevent retail pharmacies from dispensing psychotropic medications without a prescription.

Long-Term Effects of Antipsychotic Medications in Older Adults

Many older adults across all settings are on antipsychotic medications; all too frequently for long periods of time. There are very few studies about the long-term effects of these medications, especially when used in those with declining physiological ability to metabolize medications. This paper looks at the three most commonly prescribed classes of antipsychotic medications used in older adults. A second purpose is to increase knowledge and potential strategies home health nurses can use to help their patients.

Exploration of 100 commonly used drugs and supplements on cognition in older adults

BACKGROUND

There are conflicting reports and a lack of evidence-based data regarding effects of medications on cognition in cognitively normal older adults. We explored whether use of 100 common medications taken by older adults is associated with longitudinal cognitive performance.

METHODS

A longitudinal observational cohort was used with analysis of data collected from September 2005 through May 2011 and maintained in the National Alzheimer's Coordinating Center (NACC) Uniform Data Set. Participants were aged 50 years or older and cognitively normal (N = 4414). Composite scores were constructed from 10 psychometric tests. Scores for each participant reflecting change in the psychometric composite score from the baseline clinical assessment to the next assessment were calculated. General linear models were used to test whether the mean composite change score differed for participants who reported starting, stopping, continuing, or not taking each of the 100 most frequently used medications in the NACC sample.

RESULTS

The average time between assessments was 1.2 years (SD = 0.42). Nine medications showed a difference (P < .05) across the four participant groups in mean psychometric change scores from the first to the second assessment. Medications associated with improved psychometric performance were naproxen, calcium-vitamin D, ferrous sulfate, potassium chloride, flax, and sertraline. Medications associated with declining psychometric performance were bupropion, oxybutynin, and furosemide.

CONCLUSIONS

Reported use of common medications is associated with cognitive performance in older adults, but studies are needed to investigate the mechanisms underlying these effects.

Associations between cognitive performance and cortisol reaction to the DEX/CRH test in patients recovered from depression

BACKGROUND

Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis in major depression (MDD) is one of the most reliably reported neurobiological characteristics of affective disorders. Whether these alterations in HPA axis regulation are limited to the acute stage of MDD or whether they persist after recovery, remains ambiguous. A relationship between hypercortisolemia and cognitive dysfunction in acutely depressed patients has been repeatedly observed and it was also demonstrated in a number of studies that a discrete cognitive impairment often persists in the remitted state of depression. In the present study we were interested, whether these subtle impairments in cognitive functioning observed in patients recovered from depression compared to healthy control subjects are associated with HPA axis feedback sensitivity.

METHODS

In 20 recovered patients and 20 matched healthy controls we assessed HPA axis feedback sensitivity with the combined dexamethasone suppression/corticotropin-releasing-hormone (DEX/CRH) challenge test. Furthermore cognitive performance was investigated with respect to the following domains: verbal memory (Auditory Verbal Learning Test, VLMT), attention and executive control (Trail Making Test, TMT-A/B) as well as verbal fluency (Controlled Oral Word Association Test, COWAT).

RESULTS

Recovered patients showed a significantly poorer cognitive performance compared to healthy controls (all p<.05). With regard to HPA-axis activity, no overall difference was observed in the DEX/CRH test between recovered patients and controls. In recovered patients however, a significant association was observed between cortisol response and verbal memory (main effect VLMT trial 1-5: p=.046), attention (main effect TMT-A: p=.015) and executive functioning in terms of set shifting (interaction samples*TMT-B: p=.018). Poorer test performance was related to increased cortisol levels in response to challenge.

CONCLUSIONS

The present findings suggest that patients recovered from MDD are especially vulnerable toward detrimental effects of subtle HPA axis disturbances on cognitive performance.

Antidepressant suppression of non-REM sleep spindles and REM sleep impairs hippocampus-dependent learning while augmenting striatum-dependent learning

Rapid eye movement (REM) sleep enhances hippocampus-dependent associative memory, but REM deprivation has little impact on striatum-dependent procedural learning. Antidepressant medications are known to inhibit REM sleep, but it is not well understood if antidepressant treatments impact learning and memory. We explored antidepressant REM suppression effects on learning by training animals daily on a spatial task under familiar and novel conditions, followed by training on a procedural memory task. Daily treatment with the antidepressant and norepinephrine reuptake inhibitor desipramine (DMI) strongly suppressed REM sleep in rats for several hours, as has been described in humans. We also found that DMI treatment reduced the spindle-rich transition-to-REM sleep state (TR), which has not been previously reported. DMI REM suppression gradually weakened performance on a once familiar hippocampus-dependent maze (reconsolidation error). DMI also impaired learning of the novel maze (consolidation error). Unexpectedly, learning of novel reward positions and memory of familiar positions were equally and oppositely correlated with amounts of TR sleep. Conversely, DMI treatment enhanced performance on a separate striatum-dependent, procedural T-maze task that was positively correlated with the amounts of slow-wave sleep (SWS). Our results suggest that learning strategy switches in patients taking REM sleep-suppressing antidepressants might serve to offset sleep-dependent hippocampal impairments to partially preserve performance. State-performance correlations support a model wherein reconsolidation of hippocampus-dependent familiar memories occurs during REM sleep, novel information is incorporated and consolidated during TR, and dorsal striatum-dependent procedural learning is augmented during SWS.

Contributions of environment, comorbidity, and stage of dementia to the onset of walking and eating disability in long-term care residents

OBJECTIVES

To estimate the relative effects of environment, comorbidities, stage of dementia and other variables on disability onset.

DESIGN

A 1-year prospective cohort study was conducted in which the walking and eating abilities of long-term care residents were observed fortnightly. Structural equation modeling was used to assess the contributions of individual and environmental factors to the onset of disability.

SETTING

Fifteen nursing homes in western Canada.

PARTICIPANTS

One hundred twenty residents with middle-stage Alzheimer disease or related dementia.

MEASUREMENTS

Environmental quality was assessed using the Professional Environmental Assessment Protocol, comorbidity using the Charlson Comorbidity Index, and stage of dementia using the Global Deterioration Scale.

RESULTS

More-advanced baseline dementia had a direct effect on onset of walking and eating disability (standardized maximum likelihood estimate (SMLE) = 0.24, P = .006). Resident environment (SMLE = -0.25, P = .007) and comorbidities (SMLE = 0.32, P < .001) influenced disability onset approximately as strongly as stage of dementia. Smaller and publicly owned facilities provided superior environmental quality, which indirectly contributed to a delay in onset of walking and eating disability.

CONCLUSION

Environmental quality and extent of comorbidity are at least as important as progression of dementia in initiating or delaying the onset of disability.

Benzodiazepines and adequacy of initial antidepressant treatment for depression

In short-term efficacy studies, coprescription of a benzodiazepine improves first-month adherence and response to antidepressant treatment. We used Veterans Health Administration data to examine the impact of coprescribed benzodiazepines on initial antidepressant adherence in routine clinical practice and the risks of long-term benzodiazepine use, abuse, and dependence. Our study population was 43,915 Veterans Health Administration patients diagnosed with depression and started on an antidepressant between October 2006 and September 2007. Using logistic regression, adjusting for demographic and clinical covariates, we predicted the likelihood that patients received antidepressant treatment for an adequate duration (90 days), with our primary independent variable of interest being receipt of a benzodiazepine on the same day as the start of the antidepressant. We also assessed the frequency and characteristics of patients whose benzodiazepine use persisted for 1 year or who were diagnosed with anxiolytic abuse or dependence after receiving combined treatment. The adjusted probability of receiving antidepressant treatment of adequate duration was 42.4% for patients who received a benzodiazepine with their initial antidepressant compared with 39.3% for patients initially treated with an antidepressant alone (P < 0.001). Among patients who received combined treatment, 14.1% subsequently used benzodiazepines for at least 1 year, and 0.7% were diagnosed with anxiolytic abuse or dependence. Anxiolytic abuse or dependence, but not long-term benzodiazepine use, was associated with other substance use disorders. These findings should be considered by clinicians when assessing the individual risks and benefits of combining a benzodiazepine with antidepressant treatment.

Pre- and post- GPi DBS neuropsychological profiles in a case of X-linked dystonia-Parkinsonism

We present the pre to post bilateral globus pallidus interna (GPi) deep brain stimulation neuropsychological profiles of a 69-year-old patient with a 12-year history of X-linked dystonia-Parkinsonism (XDP). Pre-operative cognitive function was impaired in almost all domains and this impaired performance was not dependent on his medications. Following DBS, changes in neuropsychological functioning were examined using Reliable Change Indices and standardized z-score comparisons. Results showed reductions in processing speed in the context of stable performance in language and visuospatial domains. Post-operative improvements occurred on a cognitive screening measure, verbal memory, and a test of problem-solving skills. This is the first report on an individual with XDP who was cognitively impaired, but had good outcome following GPi bilateral stimulation to treat debilitating motor symptoms. The possible mechanisms for his stable cognitive performance include the target of his DBS, reduced medication dosage, and improvement in dystonia that may in turn have reduced patient's pain.

Prevalence and predictors of cognitive dysfunction in opioid-treated patients with cancer: a multinational study

PURPOSE

To identify prevalence and associated factors of cognitive dysfunction in opioid-treated patients with cancer.

PATIENTS AND METHODS

EPOS (European Pharmacogenetic Opioid Study) is a prospective cross-sectional multicenter study in which adult patients with cancer who received treatment with opioids for moderate or severe pain for at least 3 days were included. Cognitive function was assessed using the Mini-Mental State Examination (MMSE). MMSE scores were categorized into definite cognitive dysfunction (scores < 24), possible cognitive dysfunction (scores 24-26), and no cognitive dysfunction (scores > 26). Factors potentially associated with cognitive dysfunction were assessed. Associations between MMSE and explanatory variables were analyzed by ordinal logistic regression models.

RESULTS

We included 1,915 patients with cancer from 17 centers. MMSE scores less than 27 were observed in 32.9% of patients. Patients with lung cancer had higher odds (adjusted odds ratio, 1.46; 95% CI, 1.09 to 1.95) for having lower MMSE scores compared with patients with other cancer diagnoses. Patients receiving daily opioid doses of 400 mg or more (oral morphine equivalents) had 1.75 (95% CI, 1.25 to 2.46) times higher odds of having lower MMSE scores compared with those receiving daily doses less than 80 mg. Other risk factors for cognitive dysfunction were older age, low Karnofsky performance status (KPS), time since diagnosis (< 15 months), and absence of breakthrough pain (BTP).

CONCLUSION

One third of opioid-treated patients with cancer had possible or definite cognitive dysfunction. Lung cancer, daily opioid doses of 400 mg or more (oral morphine equivalents), older age, low KPS, shorter time since cancer diagnosis, and absence of BTP were predictors for cognitive dysfunction.

Neuromodulation approaches for the treatment of major depression: challenges and recommendations from a working group meeting

The use of neuromodulation as a treatment for major depressive disorder (MDD) has recently attracted renewed interest due to development of other non-pharmacological therapies besides electroconvulsive therapy (ECT) such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). METHOD: We convened a working group of researchers to discuss the updates and key challenges of neuromodulation use for the treatment of MDD. RESULTS: The state-of-art of neuromodulation techniques was reviewed and discussed in four sections: [1] epidemiology and pathophysiology of MDD; [2] a comprehensive overview of the neuromodulation techniques; [3] using neuromodulation techniques in MDD associated with non-psychiatric conditions; [4] the main challenges of neuromodulation research and alternatives to overcome them. DISCUSSION: ECT is the first-line treatment for severe depression. TMS and tDCS are strategies with a relative benign profile of side effects; however, while TMS effects are comparable to antidepressant drugs for treating MDD; further research is needed to establish the role of tDCS. DBS and VNS are invasive strategies with a possible role in treatment-resistant depression. In summary, MDD is a chronic and incapacitating condition with a high prevalence; therefore clinicians should consider all the treatment options including invasive and non-invasive neuromodulation approaches.

Psychotropic medication use among older adults: what all nurses need to know

Psychotropic medications are commonly administered to elderly clients to manage behavior and psychiatric symptoms. These drugs are known to have potentially serious side effects, to which older adults are more vulnerable. Nurses care for older adults in many different practice settings but have varying degrees of knowledge about these kinds of medications. The purposes of this article are to (a) provide information to geriatric nurses in all settings about how the most commonly prescribed psychotropic medications (i.e., anxiolytic, antidepressant, and antipsychotic drugs) differentially affect older adults; (b) examine recent concerns about the use of psychotropic medications with older adults; and (c) discuss nursing implications for those administering psychotropic medications to older adults.

Potentially inappropriate medication use in older adults with mild cognitive impairment

BACKGROUND

Patients with mild cognitive impairment (MCI) may be especially vulnerable to the side effects of potentially inappropriate medications (PIMs), especially those that impair cognition.

METHODS

We conducted a cross-sectional study to determine the prevalence of PIM use among 689 patients with MCI. We used the 2003 Beers Criteria for cognitive impairment to identify PIMs. We then determined if certain patients were more likely to use PIMs.

RESULTS

There were 143 (20.8%) patients with MCI taking a PIM: 108 (15.7%) patients were taking one PIM and 35 (5.1%) patients were taking two or more PIMs. The most common PIMs were anticholinergics (35.7%) and benzodiazepines (31.5%). Patients were more likely to be taking PIMs if they were women and were taking a greater number of medications and less likely if they had a history of myocardial infarction.

CONCLUSIONS

Patients with MCI are frequently taking PIMs that may negatively affect cognition. Future research is needed to assess whether cognitive impairment symptoms are improved if PIM use is reduced.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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