Associations between recorded loneliness and adverse mental health outcomes among patients receiving mental healthcare in South London: a retrospective cohort study

PURPOSE

Loneliness disproportionately affects people with mental disorders, but associations with mental health outcomes in groups affected remain less well understood.

METHOD

A cohort of patients receiving mental healthcare on 30th June 2012 was assembled from a large mental health records database covering a south London catchment area. Recorded loneliness within the preceding 2 years was extracted using natural language processing and outcomes were measured between 30th June 2012 until 30th December 2019, except for survival which applied a censoring point of 6th December 2020 according to data available at the time of extraction. The following mental healthcare outcomes: (i) time to first crisis episode; (ii) time to first emergency presentation; (iii) all-cause mortality; (iv) days active to service per year; and (v) face-to-face contacts per year.

RESULTS

Loneliness was recorded in 4,483 (16.7%) patients in the study population and fully adjusted models showed associations with subsequent crisis episode (HR 1.17, 95% CI 1.07-1.29), emergency presentation (HR 1.30, 1.21-1.40), days active per year (IRR 1.04, 1.03-1.05), and face-to-face contacts per year (IRR 1.28, 1.27-1.30). Recorded loneliness in patients with substance misuse problems was particularly strongly associated with adverse outcomes, including risk of emergency presentation (HR 1.68, 1.29-2.18) and mortality (HR 1.29, 1.01-1.65).

CONCLUSION

Patients receiving mental healthcare who are recorded as lonely have a higher risk of several adverse outcomes which may require a need for higher service input.

HbA1c recording in patients following a first diagnosis of serious mental illness: the South London and Maudsley Biomedical Research Centre case register

OBJECTIVES

To investigate factors associated with the recording of glycated haemoglobin (HbA1c) in people with first diagnoses of serious mental illness (SMI) in a large mental healthcare provider, and factors associated with HbA1c levels, when recorded. To our knowledge this is the first such investigation, although attention to dysglycaemia in SMI is an increasing priority in mental healthcare.

DESIGN

The study was primarily descriptive in nature, seeking to ascertain the frequency of HbA1c recording in the mental healthcare sector for people following first SMI diagnosis.

SETTINGS

A large mental healthcare provider, the South London and Maudsley National Health Service Trust.

PARTICIPANTS

Using electronic mental health records data, we ascertained patients with first SMI diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder) from 2008 to 2018.

OUTCOME MEASURES

Recording or not of HbA1c level was ascertained from routine local laboratory data and supplemented by a natural language processing (NLP) algorithm for extracting recorded values in text fields (precision 0.89%, recall 0.93%). Age, gender, ethnic group, year of diagnosis, and SMI diagnosis were investigated as covariates in relation to recording or not of HbA1c and first recorded levels.

RESULTS

Of 21 462 patients in the sample (6546 bipolar disorder; 14 916 schizophrenia or schizoaffective disorder; mean age 38.8 years, 49% female), 4106 (19.1%) had at least one HbA1c result recorded from laboratory data, increasing to 6901 (32.2%) following NLP. HbA1c recording was independently more likely in non-white ethnic groups (black compared with white: OR 2.45, 95% CI 2.29 to 2.62), and was negatively associated with age (OR per year increase 0.93, 0.92-0.95), female gender (0.83, 0.78-0.88) and bipolar disorder (0.49, 0.45-0.52).

CONCLUSIONS

Over a 10-year period, relatively low level of recording of HbA1c was observed, although this has increased over time and ascertainment was increased with text extraction. It remains important to improve the routine monitoring of dysglycaemia in these at-risk disorders.

Antidepressant drug prescription and incidence of COVID-19 in mental health outpatients: a retrospective cohort study

BACKGROUND

Currently, the main pharmaceutical intervention for COVID-19 is vaccination. While antidepressant (AD) drugs have shown some efficacy in treatment of symptomatic COVID-19, their preventative potential remains largely unexplored. Analysis of association between prescription of ADs and COVID-19 incidence in the population would be beneficial for assessing the utility of ADs in COVID-19 prevention.

METHODS

Retrospective study of association between AD prescription and COVID-19 diagnosis was performed in a cohort of community-dwelling adult mental health outpatients during the 1st wave of COVID-19 pandemic in the UK. Clinical record interactive search (CRIS) was performed for mentions of ADs within 3 months preceding admission to inpatient care of the South London and Maudsley (SLaM) NHS Foundation Trust. Incidence of positive COVID-19 tests upon admission and during inpatient treatment was the primary outcome measure.

RESULTS

AD mention was associated with approximately 40% lower incidence of positive COVID-19 test results when adjusted for socioeconomic parameters and physical health. This association was also observed for prescription of ADs of the selective serotonin reuptake inhibitor (SSRI) class.

CONCLUSIONS

This preliminary study suggests that ADs, and SSRIs in particular, may be of benefit for preventing COVID-19 infection spread in the community. The key limitations of the study are its retrospective nature and the focus on a mental health patient cohort. A more definitive assessment of AD and SSRI preventative potential warrants prospective studies in the wider demographic.

Predictors of hospital readmission for patients diagnosed with delirium: An electronic health record data analysis

INTRODUCTION

Delirium is an acute and fluctuating change in attention and cognition that increases the risk of functional decline, institutionalisation and death in hospitalised patients. After delirium, patients have a significantly higher risk of readmission to hospital. Our aim was to investigate factors associated with hospital readmission in people with delirium.

METHODS

We carried out an observational retrospective cohort study using linked mental health care and hospitalisation records from South London. Logistic regression models were used to predict the odds of 30-day readmission and Cox proportional hazard models to calculate readmission risks when not restricting follow-up time.

RESULTS

Of 2814 patients (mean age 78.9 years SD ±11.8) discharged from hospital after an episode of delirium, 823 (29.3%) were readmitted within 30 days. Depressed mood (odds ratio (OR) 1.34 (95% confidence interval (CI) 1.08-1.66)), moderate-to-severe physical health problems (OR 1.67 (95% CI 1.18-2.2.36)) and a history of serious circulatory disease (OR 1.29 (95% CI 1.07-1.55)) were associated with higher odds of hospital readmission, whereas a diagnosis of delirium superimposed on dementia (OR 0.67 (95% CI 0.53-0.84)) and problematic alcohol/substance (OR 0.54 (95% CI 0.33-0.89)) use were associated with lower odds. Cox proportionate hazard models showed similar results.

CONCLUSION

Almost one-third of patients with delirium were readmitted within a short period of time, a more detailed understanding of the underlying risk factors could help prevent readmissions. Our findings indicate that the aetiology (as alcohol-related delirium), the recognition that delirium occurred in the context of dementia, as well as potentially modifiable factors, as depressed mood affect readmission risk, and should be assessed in clinical settings.

Metabolic constraints on the body size scaling of extreme population densities

Pest outbreaks, harmful algal blooms and population collapses are extreme events with critical consequences for ecosystems. Therefore, understanding the ecological mechanisms underlying these extreme events is crucial. We evaluated theoretical predictions on the size scaling and variance of extreme population abundance by combining (i) the generalized extreme value (GEV) theory and (ii) the resource-limited metabolic restriction hypothesis for population abundance. Using the phytoplankton data from the L4 station in the English Channel, we showed a negative size scaling of the expected value of maximal density, whose confidence interval included the predicted metabolic scaling (α = -1) supporting theoretical predictions. The role of resources and temperature in the distribution of the size-abundance pattern and residuals was well characterized by the GEV distribution. This comprehensive modelling framework will allow to elucidate community structure and fluctuations and provide unbiased return times estimates, thereby improving the prediction accuracy of the timing of the population outbreaks.

Body mass index and mortality in patients with schizophrenia spectrum disorders: a cohort study in a South London catchment area

Background

People with schizophrenia have a high premature mortality risk. Obesity is a key potential underlying risk factor that is relatively unevaluated to date.

Aims

In this study, we investigated the associations of routinely recorded body size with all-cause mortality and deaths from common causes in a large cohort of people with schizophrenia spectrum disorders.

Methods

We assembled a retrospective observational cohort using data from a large mental health service in South London. We followed all patients over the age of 18 years with a clinical diagnosis of schizophrenia spectrum disorders from the date of their first recorded body mass index (BMI) between 1 January 2007 and 31 March 2018.

Results

Of 11 900 patients with a BMI recording, 1566 died. The Cox proportional hazards regression models, after adjusting for sociodemographic, socioeconomic variables and comorbidities, indicated that all-cause mortality was only associated with underweight status compared with healthy weight status (hazard ratio (HR): 1.33, 95% confidence interval (CI): 1.01 to 1.76). Obesity (HR: 1.24, 95% CI: 1.01 to 1.52) and morbid obesity (HR: 1.54, 95% CI: 1.03 to 2.42) were associated with all-cause mortality in the 18-45 years age range, and obesity was associated with lower risk (HR: 0.66, 95% CI: 0.50 to 0.87) in those aged 65+ years. Cancer mortality was raised in underweight individuals (HR: 1.93, 95% CI: 1.03 to 4.10) and respiratory disease mortality raised in those with morbid obesity (HR: 2.17, 95% CI: 1.02 to 5.22).

Conclusions

Overall, being underweight was associated with higher mortality in this disorder group; however, this was potentially accounted for by frailty in older age groups, and obesity was a risk factor for premature mortality in younger ages. The impact of obesity on life expectancy for people with schizophrenia spectrum disorders is clear from our findings. A deeper biological understanding of the relationship between these diseases and schizophrenia will help improve clinical practice.

The impact of the first UK COVID-19 lockdown on presentations with psychosis to mental health services for older adults: An electronic health records study in South London

OBJECTIVES

Social distancing restrictions in the COVID-19 pandemic may have had adverse effects on older adults' mental health. Whereby the impact on mood is well-described, less is known about psychotic symptoms. The aim of this study was to compare characteristics associated with psychotic symptoms during the first UK lockdown and a pre-pandemic comparison period.

METHODS

In this retrospective observational study we analysed anonymised records from patients referred to mental health services for older adults in South London in the 16-week period of the UK lockdown starting in March 2020, and in the comparable pre-pandemic period in 2019. We used logistic regression models to compare the associations of different patient characteristics with increased odds of presenting with any psychotic symptom (defined as hallucinations and/or delusion), hallucinations, or delusions, during lockdown and the corresponding pre-pandemic period.

RESULTS

1991 referrals were identified. There were fewer referrals during lockdown but a higher proportion of presentations with any psychotic symptom (48.7% vs. 42.8%, p = 0.018), particularly hallucinations (41.0% vs. 27.8%, p < 0.001). Patients of non-White ethnicity (adjusted odds ratio (OR): 1.83; 95% confidence interval (CI): 1.13-2.99) and patients with dementia (adjusted OR: 3.09; 95% CI: 1.91-4.99) were more likely to be referred with psychotic symptoms during lockdown. While a weaker association between dementia and psychotic symptoms was found in the pre-COVID period (adjusted OR: 1.55; 95% CI: 1.19-2.03), interaction terms indicated higher odds of patients of non-White ethnicity or dementia to present with psychosis during the lockdown period.

CONCLUSIONS

During lockdown, referrals to mental health services for adults decreased, but contained a higher proportion with psychotic symptoms. The stronger association with psychotic symptoms in non-White ethnic groups and patients with dementia during lockdown suggests that barriers in accessing care might have increased during the COVID-19 pandemic.

Cardiac surgery receipt and outcomes for people using secondary mental healthcare services: Retrospective cohort study using a large mental healthcare database in South London

BACKGROUND

Patients diagnosed with mental health problems are more predisposed to cardiovascular disease, including cardiac surgery. Nevertheless, health outcomes after cardiac surgery for patients with mental health problems as a discrete group are unknown. This study examined the association between secondary care mental health service use and postoperative health outcomes following cardiac surgery.

METHODS

We conducted a retrospective observational research, utilizing data from a large South London mental healthcare supplier linked to national hospitalization data. OPCS-4 codes were applied to classify cardiac surgery. Health results were compared between those individuals with a mental health disorder diagnosis from secondary care and other local residents, including the length of hospital stay (LOS), inpatient mortality, and 30-day emergency hospital readmission.

RESULTS

Twelve thousand three hundred and eighty-four patients received cardiac surgery, including 1,481 with a mental disorder diagnosis. Patients with mental health diagnosis were at greater risk of emergency admissions for cardiac surgery (odds ratio [OR] 1.60; 1.43, 1.79), longer index LOS (incidence rate ratio 1.28; 1.26, 1.30), and at higher risk of 30-day emergency readmission (OR 1.53; 1.31, 1.78). Those who underwent pacemaker insertion and major open surgery had worse postoperative outcomes during index surgery hospital admission while those who had major endovascular surgery had worse health outcomes subsequent 30-day emergency hospital readmission.

CONCLUSION

People with a mental health disorder diagnosis undertaking cardiac surgery have significantly worse health outcomes. Personalized guidelines and policies to manage preoperative risk factors require consideration and evaluation.

The Impact of Dementia on Diabetes Control: An Evaluation of HbA1c Trajectories and Care Outcomes in Linked Primary and Specialist Care Data

OBJECTIVES

Diabetes self-care may become increasingly challenging as cognition declines. We sought to characterize glycated hemoglobin A1c (HbA1c) trajectories, markers of diabetes-related management, health care utilization, and mortality in people with preexisting type 2 diabetes (T2D) with and without dementia and based on the extent of cognitive impairment at the time of dementia diagnosis.

DESIGN

Retrospective matched cohort study.

SETTING AND PARTICIPANTS

Using a linkage between a primary care (Lambeth DataNet) and a secondary mental healthcare database, up to 5 individuals aged ≥65 y with preexisting T2D without dementia were matched to each individual with dementia based on age, sex, and general practice.

METHODS

Comparisons were made for HbA1c trajectories (linear mixed effects models), markers of diabetes-related management and severity at dementia diagnosis (logistic regression), mortality (Cox regression), and health care utilization (multilevel mixed effects binomial regression).

RESULTS

In 725 incident dementia and 3154 matched comparators, HbA1c trajectories differed by dementia status; HbA1c increased over time for mild dementia and non-dementia, but the increase was greater in the mild dementia group; for those with moderate-severe dementia, HbA1c decreased over time. Despite individuals with dementia having increased health care utilization around the time of dementia diagnosis, they were less likely to have had routine diabetes-related management. Patients with dementia had a higher prevalence of macrovascular complications and diabetes foot morbidity at dementia diagnosis and a higher mortality risk than those without dementia; these relationships were most marked in those with moderate-severe dementia.

CONCLUSIONS AND IMPLICATIONS

Our study has highlighted important differences in the monitoring, management, and control of diabetes in people with dementia. The effects of frailty and the extent of cognitive impairment on the ability to self-manage diabetes and on glycemic control may need to be considered in treatment guidelines and by primary care.

Centrally-acting anticholinergic drugs- associations with mortality, hospitalisation and cognitive decline following dementia diagnosis in people receiving antidepressant and antipsychotic drugs

OBJECTIVES

Long-term use of anticholinergic medication in older people is associated with increased risk of cognitive decline and mortality, but this relationship could be confounded by the underlying illness the drugs are treating. To investigate associations between central anticholinergic antidepressants or antipsychotics and mortality, hospitalisation and cognitive decline in people with dementia.

METHOD

In cohorts of patients with a dementia diagnosis receiving antidepressant and/or antipsychotic medication (N = 4,380 and N = 2,335 respectively), assembled from a large healthcare database, central anticholinergic burden scores were estimated using the Anticholinergic Effect on Cognition (AEC) scale. Data were linked to national mortality and hospitalisation data sources, and Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

There was a reduced mortality risk in people receiving agents with high central anticholinergic burden compared to those with no or low burden which was statistically significant in the antidepressant cohort (Hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.79-0.98; p = 0.023) but not the antipsychotic one (HR: 0.91; 95% CI: 0.82-1.02; p = 0.105). Patients on antidepressants with no central anticholinergic burden had accelerated cognitive decline compared with other groups, whereas no differences were found in the antipsychotic cohort. No significant associations were detected between antidepressant or antipsychotic-related central anticholinergic burden and hospitalisation.

CONCLUSION

These counter-intuitive findings may reflect factors underlying the choice of psychotropics rather than the agents themselves, although do not support a strong role for central anticholinergic drug actions on dementia outcomes. Further studies, including randomized switching of agents are needed to clarify this relationship.

Unsupervised Machine Learning to Identify Depressive Subtypes

OBJECTIVES

This study evaluated an unsupervised machine learning method, latent Dirichlet allocation (LDA), as a method for identifying subtypes of depression within symptom data.

METHODS

Data from 18,314 depressed patients were used to create LDA models. The outcomes included future emergency presentations, crisis events, and behavioral problems. One model was chosen for further analysis based upon its potential as a clinically meaningful construct. The associations between patient groups created with the final LDA model and outcomes were tested. These steps were repeated with a commonly-used latent variable model to provide additional context to the LDA results.

RESULTS

Five subtypes were identified using the final LDA model. Prior to the outcome analysis, the subtypes were labeled based upon the symptom distributions they produced: psychotic, severe, mild, agitated, and anergic-apathetic. The patient groups largely aligned with the outcome data. For example, the psychotic and severe subgroups were more likely to have emergency presentations (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.17-1.43 and OR = 1.16; 95% CI, 1.05-1.29, respectively), whereas these outcomes were less likely in the mild subgroup (OR = 0.86; 95% CI, 0.78-0.94). We found that the LDA subtypes were characterized by clusters of unique symptoms. This contrasted with the latent variable model subtypes, which were largely stratified by severity.

CONCLUSIONS

This study suggests that LDA can surface clinically meaningful, qualitative subtypes. Future work could be incorporated into studies concerning the biological bases of depression, thereby contributing to the development of new psychiatric therapeutics.

Potentially avoidable causes of hospitalisation in people with dementia: contemporaneous associations by stage of dementia in a South London clinical cohort

OBJECTIVES

To estimate the frequency of all-cause and ambulatory care sensitive condition (ACSCs)-related hospitalisations among individuals with dementia. In addition, to investigate differences by stage of dementia based on recorded cognitive function.

SETTING

Data from a large London dementia care clinical case register, linked to a national hospitalisation database.

PARTICIPANTS

Individuals aged ≥65 years with a confirmed dementia diagnosis with recorded cognitive function.

OUTCOME MEASURES

Acute general hospital admissions were evaluated within 6 months of a randomly selected cognitive function score in patients with a clinical diagnosis of dementia. To evaluate associations between ACSC-related hospital admissions (overall and individual ACSCs) and stage of dementia, an ordinal regression was performed, modelling stage of dementia as the dependant variable (to facilitate efficient model selection, with no implication concerning the direction of causality).

RESULTS

Of the 5294 people with dementia, 2993 (56.5%) had at least one hospitalisation during a 12-month period of evaluation, and 1192 (22.5%) had an ACSC-related admission. Proportions with an all-cause or ACSC-related hospitalisation were greater in the groups with more advanced dementia (all-cause 53.9%, 57.1% and 60.9%, p 0.002; ACSC-related 19.5%, 24.0% and 25.3%, p<0.0001 in the mild, moderate and severe groups, respectively). An ACSC-related admission was associated with 1.3-fold (95% CI 1.1 to 1.5) increased odds of more severe dementia after adjusting for demographic factors. Concerning admissions for individual ACSCs, the most common ACSC was urinary tract infection /pyelonephritis (9.8% of hospitalised patients) followed by pneumonia (7.1%); in an adjusted model, these were each associated with 1.4-fold increased odds of more severe dementia (95% CI 1.2 to 1.7 and 1.1 to 1.7, respectively).

CONCLUSIONS

Potentially avoidable hospitalisations were common in people with dementia, particularly in those with greater cognitive impairment. Our results call for greater attention to the extent of cognitive status impairment, and not just dementia diagnosis, when evaluating measures to reduce the risk of potentially avoidable hospitalisations.

Predictors of falls and fractures leading to hospitalisation in 36 101 people with affective disorders: a large representative cohort study

OBJECTIVES

To investigate predictors of falls and fractures leading to hospitalisation in people with affective disorders.

DESIGN

Cohort study.

SETTING

The South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register.

PARTICIPANTS

A large cohort of people with affective disorders (International Classification of Diseases- 10th version [ICD-10] codes F30-F34) diagnosed between January 2008 and March 2016 was assembled using data from the SLaM BRC Case Register.

PRIMARY AND SECONDARY OUTCOME MEASURES

Falls and fractures leading to hospitalisation were ascertained from linked national hospitalisation data. Multivariable Cox proportional hazards analyses were administrated to identify predictors of first falls and fractures.

RESULTS

Of 36 101 people with affective disorders (mean age 44.4 years, 60.2% female), 816 (incidence rate 9.91 per 1000 person-years) and 1117 (incidence rate 11.92 per 1000 person-years) experienced either a fall or fracture, respectively. In multivariable analyses, older age, analgesic use, increased physical illness burden, previous hospital admission due to certain comorbid physical illnesses and increase in attendances to accident and emergency services following diagnosis were significant risk factors for both falls and fractures. Having a history of falls was a strong risk factor for recurrent falls, and a previous fracture was also associated with future fractures.

CONCLUSIONS

Over a mean 5 years' follow-up, approximately 8% of people with affective disorders were hospitalised with a fall or fracture. Several similar factors were found to predict risk of falls and fracture, for example, older age, comorbid physical disorders and analgesic use. Routine screening for bone mineral density and fall prevention programmes should be considered for this clinical group.

Associations between loneliness and acute hospitalisation outcomes among patients receiving mental healthcare in South London: a retrospective cohort study

PURPOSE

It is well known that loneliness can worsen physical and mental health outcomes, but there is a dearth of research on the impact of loneliness in populations receiving mental healthcare. This study aimed to investigate cross-sectional correlates of loneliness among such patients and longitudinal risk for acute general hospitalisations.

METHOD

A retrospective observational study was conducted on the data from patients aged 18 + receiving assessment/care at a large mental healthcare provider in South London. Recorded loneliness status was ascertained among active patients on the index date, 30th Jun 2012. Acute general hospitalisation (emergency/elective) outcomes were obtained until 31st Mar 2018. Length of stay was modelled using Poisson regression models and time-to hospitalisation and time-to mortality were modelled using Cox proportional hazards regression models.

RESULTS

The data from 26,745 patients were analysed. The prevalence of patients with recorded loneliness was 16.4% at the index date. In the fully adjusted model, patients with recorded loneliness had higher hazards of emergency (HR 1.15, 95% CI 1.09-1.22) and elective (1.05, 1.01-1.12) hospitalisation than patients who were not recorded as lonely, and a longer duration of both emergency (IRR 1.06, 95% CI 1.05-1.07) and elective (1.02, 1.01-1.03) general hospitalisations. There was no association between loneliness and mortality. Correlates of loneliness included having an eating disorder (OR 1.67, 95% CI 1.29-2.25) and serious mental illnesses (OR 1.44, 1.29-1.62).

CONCLUSION

Loneliness in patients receiving mental healthcare is associated with higher use of general hospital services. Increased attention to the physical healthcare of this patient group is therefore warranted.

Centrally Acting Anticholinergic Drugs Used for Urinary Conditions Associated with Worse Outcomes in Dementia

OBJECTIVES

To investigate the associations between central anticholinergic burden and mortality, hospitalization, and cognitive impairment in people with dementia prescribed anticholinergic drugs for urinary symptoms.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients diagnosed with dementia receiving anticholinergic medication for bladder conditions (N = 540), assembled from a large healthcare database.

METHODS

Central anticholinergic burden related to bladder drugs was estimated using the anticholinergic effect on cognition scale. Data were linked to national mortality and hospitalization data sources, and serially recorded Mini-Mental State Examination scores were used to investigate cognitive decline.

RESULTS

Patients had a median survival of 4.1 years. Urinary drugs with a high anticholinergic effect on cognition score (tolterodine, oxybutynin) were associated with a 55% increased mortality risk (hazard ratio 1.55; 95% confidence interval 1.19‒2.01; P = .001) compared with drugs with low or no central anticholinergic burden (darifenacin, fesoterodine, trospium, mirabegron, solifenacin). Cognitive decline over a 24-month period around diagnosis was only detectable in the high central anticholinergic group, but there was no significant difference in cognitive trajectories between the high and low/no anticholinergic bladder drug groups. No increase of emergency hospitalization risk was seen in relation to central anticholinergic burden.

CONCLUSIONS AND IMPLICATIONS

Urinary drugs with high central anticholinergic burden cause more harm than those acting peripherally and should be avoided in people with dementia. Further research is needed to test whether centrally acting anticholinergic agents in general cause worse outcomes in dementia.

Identifying subtypes of depression in clinician-annotated text: a retrospective cohort study

Current criteria for depression are imprecise and do not accurately characterize its distinct clinical presentations. As a result, its diagnosis lacks clinical utility in both treatment and research settings. Data-driven efforts to refine criteria have typically focused on a limited set of symptoms that do not reflect the disorder's heterogeneity. By contrast, clinicians often write about patients in depth, creating descriptions that may better characterize depression. However, clinical text is not commonly used to this end. Here we show that clinically relevant depressive subtypes can be derived from unstructured electronic health records. Five subtypes were identified amongst 18,314 patients with depression treated at a large mental healthcare provider by using unsupervised machine learning: severe-typical, psychotic, mild-typical, agitated, and anergic-apathetic. Subtypes were used to place patients in groups for validation; groups were found to be associated with future outcomes and characteristics that were consistent with the subtypes. These associations suggest that these categorizations are actionable due to their validity with respect to disease prognosis. Moreover, they were derived with automated techniques that might theoretically be widely implemented, allowing for future analyses in more varied populations and settings. Additional research, especially with respect to treatment response, may prove useful in further evaluation.

What gets recorded, counts: dementia recording in primary care compared with a specialist database

BACKGROUND

databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care.

METHODS

a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared.

RESULTS

3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06).

DISCUSSION

there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Loneliness in older adult mental health services during the COVID-19 pandemic and before: Associations with disability, functioning and pharmacotherapy

OBJECTIVES

Loneliness is associated with psychiatric morbidity. Restrictions placed on the population during the first COVID-19 lockdown may have disproportionately affected older adults, possibly through increasing loneliness. We sought to investigate this by examining loneliness in referrals to mental health of older adults (MHOA) services during the first UK COVID-19 lockdown.

METHODS

Referrals to MHOA services from a large South London catchment area were identified for the 16-week period of the UK lockdown starting in March 2020 and for the corresponding period in 2019. A natural language processing algorithm identified loneliness in the patients' records. We applied logistic regression models adjusted for age, gender, ethnicity and diagnosis, to examine associations of loneliness in the study population.

RESULTS

1991 referrals were identified, 56.9% of whom were female, with a mean age of 77.9 years. Only 26.9% occurred during the 2020 lockdown, but with a higher prevalence of loneliness (22.0 vs. 17.7%, p = 0.028). In the whole sample, loneliness was associated with non-accidental self-injury (Odds ratio [OR]: 1.65), depressed mood (OR: 1.73), psychotic symptoms (OR: 1.65), relationship problems (OR: 1.49), problems with daytime activities (OR: 1.36), and antidepressant use (OR: 2.11). During lockdown, loneliness was associated with non-accidental self-injury (OR: 2.52), problem drinking or drug-taking (OR 2.33), and antidepressant use (OR 2.10).

CONCLUSIONS

Loneliness is associated with more severe symptoms of affective illness, worse functional problems and increased use of antidepressant medication in older adults. During lockdown, loneliness in referrals to MHOA services increased and was associated with increased risk-taking behaviour. Loneliness is a potential modifiable risk factor for mental illness, and efforts to minimise it in older adults should be prioritised as we emerge from the pandemic.

Effect of trazodone on cognitive decline in people with dementia: Cohort study using UK routinely collected data

OBJECTIVES

Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants.

METHODS

Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis.

RESULTS

We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses.

CONCLUSIONS

There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.

Risk of hospitalised falls and hip fractures in working age adults receiving mental health care

OBJECTIVE

This retrospective cohort study investigates risks of hospitalised fall or hip fractures in working age adults receiving mental health care in South London.

METHODS

Patients aged 18 to 64, who received a first mental illness diagnosis between 2008 and 2016 were included. Primary outcome was hospitalised falls, secondary outcome was hip fractures. Age- and gender-standardised incidence rates and incidence rate ratios (IRRs) compared to local general population were calculated. Multivariate Cox proportionate hazard models were used to investigate which mental health diagnoses were most at risk.

RESULTS

In 50,885 patients incidence rates were 8.3 and 0.8 per 1,000 person-years for falls and hip fractures respectively. Comparing mental health patients to the general population, age-and-gender-adjusted IRR for falls was 3.6 (95% CI: 3.3-4.0) and for hip fractures 7.5 (95% CI: 5.2-10.4). The falls IRR was highest for borderline personality and bipolar disorder and lowest for schizophreniform and anxiety disorder. After adjusting for multiple confounders in the sample of mental health service users, borderline personality disorder yielded a higher and anxiety disorder a lower falls risk.

CONCLUSION

Working age adults using mental health services have almost four times the incidence of hospitalised falls compared to general population. Targeted interventions are warranted.

Vascular surgery receipt and outcomes for people with serious mental illnesses: Retrospective cohort study using a large mental healthcare database in South London

OBJECTIVE

Vascular surgery can be common among people with serious mental illness (SMI) given the high prevalence of cardiovascular disease. However, post-operative outcomes following vascular surgery have received little investigation, particularly in a subpopulation of SMI.

METHODS

We conducted a retrospective observational study using data from the South London and Maudsley NHS Foundation Trust (SLaM) via its Clinical Record Interactive Search (CRIS) platform and linkage with Hospital Episode Statistic (HES). Vascular surgery recipients were identified using OPCS version 4 codes. Length of stay (LOS) was modelled using Incidence Rate Ratios (IRRs), and 30-day emergency hospital readmissions using Odds Ratios (ORs) for people with SMI compared with the general population.

RESULTS

Vascular surgery was received by 152 patients with SMI diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder) and 8821 catchment residents without any mental health conditions. People with active SMI symptoms more likely to be admitted to hospital via emergency route OR: 1.80 (95% CI: 1.06, 3.07) and more likely to stay longer in the hospital for vascular surgery IRR: 1.35 (1.01, 1.80) and more likely to be readmitted to hospital via emergency route within 30 days OR: 1.53 (1.02, 2.67). People with SMI who had major open vascular surgery and peripheral endovascular surgery more likely to have worse post-operative outcomes.

CONCLUSION

Our study highlights the risks faced by people with SMI following vascular surgery. These suggest tailored guidelines and policies are needed, based on the identification of pre-operative risk factors, allowing for focused post-vascular surgery care to minimise adverse outcomes.

Aspirin in people with dementia, long-term benefits, and harms: a systematic review

PURPOSE

People with dementia may have indications for aspirin prescription and clinicians are asked to balance the potential risks against benefits. This review examines the evidence for the risk and benefit of long-term aspirin use in people with dementia aged over 65 years, including randomised controlled trials and observational studies.

METHODS

We searched three databases for research published between 2007 and 2020. Each eligible article was assessed for risk of bias, and confidence in findings was rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Four papers met inclusion criteria: one randomised controlled trial, two cohort studies, and one with pooled data. All looked only at dementia of Alzheimer's type, and none addressed myocardial or cerebral infarction as outcomes. Dementia progression was reported by two studies, with conflicting results. The trial found no significant effect of aspirin on mortality (odds ratio aspirin vs. no aspirin 1.07, 95% confidence interval 0.58-1.97) but found more events of severe bleeding with aspirin (OR aspirin vs. no aspirin 6.9, 1.5-31.2). An excess in intracranial haemorrhage in the aspirin group was judged plausible based on two non-randomised studies.

CONCLUSIONS

The review findings are limited because studies include only people with Alzheimer's-type dementia and lack confirmatory studies, although an increased risk of bleeding events is recognised. Further research that addresses the benefits and risks of aspirin in more representative groups of people with dementia is needed to guide prescribing decisions.

The association between an early diagnosis of dementia and secondary health service use

Background

dementia policy suggests diagnosing dementia early can reduce the risk of potentially harmful hospital admissions or emergency department (ED) attendances; however, there is little evidence to support this. A diagnosis of mild cognitive impairment (MCI) before dementia is a helpful proxy to explore early diagnosis. This study investigated the association between an early diagnosis of dementia and subsequent hospitalisations and ED attendances.

Method

a retrospective cohort study of electronic health care records from 15,836 patients from a large secondary care database in South London, UK. Participants were divided into two groups: those with a diagnosis of MCI before dementia, an early diagnosis, and those without. Cox regression models were used to compare the risk of hospitalisation and ED attendance after dementia diagnosis and negative binomial regression models were used to compare the average length of stay and average number of ED attendances.

Results

participants with an early diagnosis were more likely to attend ED after their diagnosis of dementia (HR = 1.09, CI = 1.00–1.18); however, there was no difference in the number of ED attendances (IRR = 1.04, CI = 0.95–1.13). There was no difference in the risk of hospitalisation (HR = 0.99, CI = 0.91–1.08) or length of stay between the groups (IRR = 0.97, CI = 0.85–1.12).

Conclusion

the findings of this study do not support the assumption that an early diagnosis reduces the risk of hospitalisation or ED attendance. The patterns of health service use in this paper could reflect help-seeking behaviour before diagnosis or levels of co-morbidity.

Motor signs in Alzheimer's disease and vascular dementia: Detection through natural language processing, co-morbid features and relationship to adverse outcomes

BACKGROUND

Motor signs in patients with dementia are associated with a higher risk of cognitive decline, institutionalisation, death and increased health care costs, but prevalences differ between studies. The aims of this study were to employ a natural language processing pipeline to detect motor signs in a patient cohort in routine care; to explore which other difficulties occur co-morbid to motor signs; and whether these, as a group and individually, predict adverse outcomes.

METHODS

A cohort of 11,106 patients with dementia in Alzheimer's disease, vascular dementia or a combination was assembled from a large dementia care health records database in Southeast London. A natural language processing algorithm was devised in order to establish the presence of motor signs (bradykinesia, Parkinsonian gait, rigidity, tremor) recorded around the time of dementia diagnosis. We examined the co-morbidity profile of patients with these symptoms and used Cox regression models to analyse associations with survival and hospitalisation, adjusting for twenty-four potential confounders.

RESULTS

Less than 10% of patients were recorded to display any motor sign, and tremor was most frequently detected. Presence of motor signs was associated with younger age at diagnosis, neuropsychiatric symptoms, poor physical health and higher prescribing of psychotropics. Rigidity was independently associated with a 23% increased mortality risk after adjustment for confounders (p = 0.014). A non-significant trend for a 15% higher risk of hospitalisation was detected in those with a recorded Parkinsonian gait (p = 0.094).

CONCLUSIONS

With the exception of tremor, motor signs appear to be under-recorded in routine care. They are part of a complex clinical picture and often accompanied by neuropsychiatric and functional difficulties, and thereby associated with adverse outcomes. This underlines the need to establish structured examinations in routine clinical practice via easy-to-use tools.

Factors associated with slow progression of cognitive impairment following first dementia diagnosis

OBJECTIVES

To investigate the extent to which slow progression of dementia after diagnosis might be predicted from routine longitudinal healthcare data, in order to clarify characteristics of people who experience this outcome.

METHODS

A retrospective observational study was conducted using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register. This study included all patients receiving a first dementia diagnosis between 2006 and 2017, restricted to those with a baseline Mini-Mental State Examination (MMSE) score within 6 months of initial diagnosis of dementia and at least one MMSE score after 3 years post-diagnosis. Slow progression was defined as a change in MMSE score of -1, 0 or an increase at the follow-up point. This group was compared to the remainder with an MMSE decline of -2 or more.

RESULTS

Overall, 682 patients with slow progression were compared to 1045 with faster progression. In the confounder-adjusted multivariate logistic regression model, slow progression was more likely in younger patients (age 65-74 years; odds ratio: 1.18; 95% confidence intervals: 1.04-1.37), males (1.24; 1.01-1.53), those with moderate or severe dementia according to MMSE, patients with mixed-type dementia (2.06; 1.11-3.82) compared to Alzheimer's disease and less likely in those receiving acetylcholinesterase inhibitor (AChEI) treatment (0.57; 0.46-0.71).

CONCLUSION

Slow dementia progression after diagnosis was common in patients with mixed Alzheimer's and vascular dementia, younger age, males and non-receipt of AChEIs, possibly suggesting non-Alzheimer pathologies and clarifying such predictors is important, as there is currently very limited information on which to base prognosis estimates in post-diagnosis counselling.

A prospective investigation of depression and adverse outcomes in patients undergoing vascular surgical interventions: A retrospective cohort study using a large mental health database in South London

BACKGROUND

Patients with depression are more susceptible to cardiovascular illness including vascular surgeries. However, health outcomes after vascular surgery among patients with depression is unknown. This study aimed to investigate associations of depression with post-operative health outcomes for vascular surgical patients.

METHODS

A retrospective observational study was conducted using data from a large mental healthcare provider and linked national hospitalization data for the same south London geographic catchment. OPCS-4 codes were used to identify vascular procedures. Health outcomes were compared between those with/without depression including length of hospital stay (LOS), inpatient mortality, and 30 day emergency hospital readmissions. Predictors of these health outcomes were also assessed.

RESULTS

Vascular surgery was received by 9,267 patients, including 446 diagnosed with depression. Patients with depression had a higher risk of emergency admission for vascular surgery (odds ratio [OR] 1.28; 1.03, 1.59), longer index LOS (IRR 1.38; 1.33-1.42), and a higher risk of 30-day emergency readmission (OR 1.82; 1.35-2.47). Patients with depression had higher inpatient mortality after adjustment for sociodemographic status (1.51; 1.03, 2.23) but not on full adjustment, and had longer emergency readmission LOS (1.13; 1.04, 1.22) after adjustment for sociodemographic factors and cardiovascular disease. Correlates of vascular surgery hospitalization among patients with depression included admission through emergency route for longer LOS, inpatient mortality, and 30-day hospital readmission.

CONCLUSION

Patients with depression undergoing vascular surgery have substantially poorer health outcomes. Screening for depression prior to surgery might be indicated to target preventative measures.

Antipsychotic use in dementia: the relationship between neuropsychiatric symptom profiles and adverse outcomes

Antipsychotic treatments are associated with safety concerns in people with dementia. The authors aimed to investigate whether risk of adverse outcomes related to antipsychotic prescribing differed according to major neuropsychiatric syndromes-specifically psychosis, agitation, or a combination. A cohort of 10,106 patients with a diagnosis of dementia was assembled from a large dementia care database in South East London. Neuropsychiatric symptoms closest to first dementia diagnosis were determined according to the Health of the Nation Outcome Scales' mental and behavioural problem scores and the sample was divided into four groups: 'agitation and psychosis', 'agitation, but no psychosis', 'psychosis, but no agitation', and 'neither psychosis nor agitation'. Antipsychotic prescription in a one-year window around first dementia diagnosis was ascertained as exposure variable through natural language processing from free text. Cox regression models were used to analyse associations of antipsychotic prescription with all-cause and stroke-specific mortality, emergency hospitalisation and hospitalised stroke adjusting for sixteen potential confounders including demographics, cognition, functioning, as well as physical and mental health. Only in the group 'psychosis, but no agitation' (n = 579), 30% of whom were prescribed an antipsychotic, a significant antipsychotic-associated increased risk of hospitalised stroke was present after adjustment (adjusted hazard ratio (HR) 2.16; 95% confidence interval (CI) 1.09-4.25). An increased antipsychotic-related all-cause (adjusted HR 1.14; 95% CI 1.04-1.24) and stroke-specific mortality risk (adjusted HR 1.28; 95% CI 1.01-1.63) was detected in the whole sample, but no interaction between the strata and antipsychotic-related mortality. In conclusion, the adverse effects of antipsychotics in dementia are complex. Stroke risk may be highest when used in patients presenting with psychosis without agitation, indicating the need for novel interventions for this group.

The Association Between a Previous Diagnosis of Mild Cognitive Impairment as a Proxy for an Early Diagnosis of Dementia and Mortality: A Study of Secondary Care Electronic Health Records

BACKGROUND

Dementia policy states that the early diagnosis of dementia can keep people living well for longer; however, there is little robust evidence to support this. Mild cognitive impairment (MCI) is considered a prodrome to dementia and can aid with the earlier diagnosis of dementia.

OBJECTIVE

The objective of this study was to use a previous diagnosis of MCI, before dementia, as a proxy for early diagnosis to investigate the relationship between an early diagnosis and mortality.

METHODS

A retrospective cohort study of electronic health care records from South London and Maudsley NHS. Patients aged 50+, diagnosed with dementia between January 2008 and November 2018, were divided into two groups: those with a previous diagnosis of MCI (early diagnosis) and those without. Cox regression models used to compare the risk of mortality between groups.

RESULTS

Of 18,557 participants, 5.6%(n = 1,030) had an early diagnosis; they had fewer cognitive, psychiatric, and functional problems at dementia diagnosis. The early diagnosis group had a reduced hazard of mortality (HR = 0.86, CI = 0.77-0.97). However, the magnitude of this effect depended on the scale used to adjust for cognitive difficulties.

CONCLUSION

A previous diagnosis of MCI is a helpful proxy for early diagnosis. There is some evidence that an early diagnosis is associated with a reduced risk of mortality; however, it is not clear how Mini-Mental State Exam scores affect this relationship. While these findings are promising, we cannot be conclusive on the relationship between an early diagnosis and mortality.

Vascular and metabolic risk factor differences prior to dementia diagnosis: a multidatabase case-control study using European electronic health records

OBJECTIVE

The objective of the study is to compare body mass index (BMI), systolic/diastolic blood pressure (SBP/DBP) and serum total cholesterol levels between dementia cases and controls at multiple time intervals prior to dementia onset, and to test time interval as a modifying factor for these associations.

DESIGN

Case-control study.

SETTING

Six European electronic health records databases.

PARTICIPANTS

291 780 cases at the date of first-recorded dementia diagnosis, compared with 29 170 549 controls randomly selected from the same databases, age matched and sex matched at this index date.

EXPOSURE

The following measures were extracted whenever recorded within each dataset: BMI (kg/m2), SBP and DBP (mm Hg) and serum total cholesterol (mmol/L). Levels for each of these variables were defined within six 2-year time intervals over the 12 years prior to the index date.

MAIN OUTCOMES

Case-control differences in exposures of interest were modelled for each time period and adjusted for demographic and clinical factors (ischaemic/unspecified stroke, type 2 diabetes mellitus, acute myocardial infarction, hypertension diagnosis, antihypertensive medication, cholesterol-lowering medication). Coefficients and interactions with time period were meta-analysed across the six databases.

RESULTS

Mean BMI (coefficient -1.16 kg/m2; 95% CI -1.38 to 0.93) and SBP (-2.83 mm Hg; 95% CI -4.49 to -1.16) were lower in cases at diagnosis, and case-control differences were greater in more recent time periods, as indicated by significant case-x-time interaction and case-x-time-squared interaction terms. Time variations in coefficients for cholesterol levels were less consistent between databases and those for DBP were largely not significant.

CONCLUSION

Routine clinical data show emerging divergence in levels of BMI and SBP prior to the diagnosis of dementia but less evidence for DBP or total cholesterol levels. These divergences should receive at least some consideration in routine dementia risk screening, although underlying mechanisms still require further investigation.

The anticholinergic effect on cognition (AEC) scale-Associations with mortality, hospitalisation and cognitive decline following dementia diagnosis

OBJECTIVES

To investigate associations between central anticholinergic burden (determined through the anticholinergic effect on cognition [AEC] scale) and mortality, hospitalisation and cognitive decline in patients with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) Clinical Records Interactive Search (CRIS) application was used to identify patients with a first diagnosis of dementia. Medication exposure was extracted through a natural language processing algorithm, allowing for calculations and comparisons of AEC scores. Data were linked to national mortality and hospitalisation data sources, and serially recorded Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

We identified 14 093 patients with dementia, 60.7% were female and the mean age at diagnosis was 79.8 years. Patients for whom a review of their medication was indicated (AEC score ≥ 2 for any individual drug or total AEC score ≥ 3) had an increased risk of mortality (hazard ratio 1.07; 95% confidence interval [CI]: 1.01-1.15) and emergency hospitalisation (1.10; 95% CI: 1.04-1.17), but there were no associations with duration of hospitalisation. Cognitive trajectory analyses showed that this exposure group had lower MMSE scores at diagnosis and a sharper increase in MMSE scores over the subsequent 6 months, but similar slopes for the 6 to 36 months period compared to the remainder of the sample.

CONCLUSIONS

Patients with dementia receiving medication with high central anticholinergic activity appear to have worse prognosis in terms of mortality and hospitalisation risk, but have, primarily, acutely impaired cognitive function, rather than longer-term differences in cognitive decline. J Am Geriatr Soc 68:-, 2020.

Dementia in People from Ethnic Minority Backgrounds: Disability, Functioning, and Pharmacotherapy at the Time of Diagnosis

OBJECTIVES

Increasingly, older populations in the United Kingdom and other well-resourced settings are ethnically diverse. Despite a concern that the prevalence of dementia is expected to rise, very little is known about the association of ethnicity and dementia among aging older adults. The current study aimed to compare ethnic group differences in symptom profile, functioning and pharmacotherapy at dementia diagnosis.

DESIGN

Cross-sectional study of patient characteristics at the point of dementia diagnosis.

SETTING AND PARTICIPANTS

In total, 12,154 patients aged 65 years or older diagnosed with dementia in Southeast London between 2007 and 2015.

METHODS

Data were extracted from the Clinical Record Interactive Search system, which provides anonymized access to the electronic health records of a large mental healthcare provider in Southeast London. Patients from ethnic minority backgrounds were compared with white British individuals on mental and physical well-being, functional scales and medications prescribed at dementia diagnosis, as well as subtype of dementia documented anywhere in the record.

RESULTS

Compared with white British patients, Black African and Black Caribbean patients were more likely to present with psychotic symptoms and were less likely to have an antidepressant prescribed; white Irish patients had higher rates of substance/alcohol use and depressive symptoms were more prevalent in South Asian patients; all ethnic minority groups had higher odds of polypharmacy; and vascular dementia diagnoses were more common in Black and Irish ethnic minority groups.

CONCLUSIONS AND IMPLICATIONS

At dementia diagnosis, there are substantial differences in noncognitive mental health symptoms and pharmacotherapy across ethnic minority groups and compared with the white British majority population. Some of these differences might reflect access/treatment inequalities or implicit unconscious bias related to ethnicity, influencing both. They need to be taken into consideration to optimize pathways into care and personalize assessment and management.

Clinical factors associated with progression to dementia in people with late-life depression: a cohort study of patients in secondary care

OBJECTIVES

Depression can be a prodromal feature or a risk factor for dementia. We aimed to investigate which clinical factors in patients with late-life depression are associated with a higher risk of developing dementia and a more rapid conversion.

DESIGN

Retrospective cohort study.

SETTING

South London and Maudsley NHS Foundation Trust (SLaM) secondary mental healthcare services.

PARTICIPANTS

The SLaM Clinical Record Interactive Search was used to retrieve anonymised data on 3659 patients aged 65 years or older who had received a diagnosis of depression in mental health services and had been followed up for at least 3 months.

OUTCOME MEASURES

Predictors of development of incident dementia were investigated, including demographic factors, health status rated on the Health of the National Outcome scale for older people (HoNOS65+), depression recurrence and treatments including psychotropic drugs and cognitive behavioural therapy (CBT).

RESULTS

In total, 806 (22.0%) patients developed dementia over a mean follow-up time of 2.7 years. Significant predictors of receiving a dementia diagnosis in fully adjusted models and after accounting for multiple comparisons were older age (adjusted HR=1.04, 95% CI 1.03 to 1.06 per year difference from sample mean) and the HoNOS65+ subscale measuring cognitive problems (HR=4.72, 95% CI 3.67 to 6.06 for scores in the problematic range). Recurrent depressive disorder or past depression (HR=0.65, 95% CI 0.55 to 0.77) and the receipt of CBT (HR=0.73 95% CI 0.61 to 0.87) were associated with a lower dementia risk. Over time, hazards related to age increased and hazards related to cognitive problems decreased.

CONCLUSIONS

In older adults with depression, a higher risk of being subsequently diagnosed with dementia was predicted by higher age, new onset depression, severity of cognitive symptoms and not receiving CBT. Further exploration is needed to determine whether the latter risk factors are responsive to interventions.

The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register

OBJECTIVES

To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment.

SETTING

We used data from a large London mental healthcare case register linked to a national hospitalisation database.

PARTICIPANTS

Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography.

OUTCOME MEASURES

We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population.

RESULTS

Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis.

CONCLUSIONS

Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.

Methotrexate and relative risk of dementia amongst patients with rheumatoid arthritis: a multi-national multi-database case-control study

Background

Inflammatory processes have been shown to play a role in dementia. To understand this role, we selected two anti-inflammatory drugs (methotrexate and sulfasalazine) to study their association with dementia risk.

Methods

A retrospective matched case-control study of patients over 50 with rheumatoid arthritis (486 dementia cases and 641 controls) who were identified from electronic health records in the UK, Spain, Denmark and the Netherlands. Conditional logistic regression models were fitted to estimate the risk of dementia.

Results

Prior methotrexate use was associated with a lower risk of dementia (OR 0.71, 95% CI 0.52–0.98). Furthermore, methotrexate use with therapy longer than 4 years had the lowest risk of dementia (odds ratio 0.37, 95% CI 0.17–0.79). Sulfasalazine use was not associated with dementia (odds ratio 0.88, 95% CI 0.57–1.37).

Conclusions

Further studies are still required to clarify the relationship between prior methotrexate use and duration as well as biological treatments with dementia risk.

Predictors of mortality in people with late-life depression: A retrospective cohort study

OBJECTIVES

Late-life depression (LLD) is associated with an increased mortality risk in the general older population. It remains however unclear which signs or symptoms are predictive of mortality in those suffering from LLD.

SETTING AND PARTICIPANTS

Patients aged 65 years or older with depressive disorder diagnosed in Southeast London between January 2008 and December 2017.

METHODS

We assembled patients diagnosed with late-life depression from the Maudsley Biomedical Research Centre Case Register, which is linked to national mortality data. Using depression diagnosis as index date, we followed patients until death or censoring point. Sociodemographic data, scores of Health of the Nation Outcome Scales (HoNOS65+), which include a physical illness scale, profiles of depressive symptoms, and psychotropic medications were extracted and modeled in multivariable survival analyses to determine predictors of mortality.

RESULTS

Of 4,243 patients with LLD (mean age 77.0 years; 61.2% female), 2,327 (54.8%) died over a median follow-up time of 3.5 years. In multivariable Cox regression models, an increased risk of all-cause mortality was associated with older age, cognitive problems, physical illness/disability, impaired activities of daily living, apathy, lack of appetite and mirtazapine prescription; conversely, female gender, non-white ethnicity, guilt feelings, tearfulness, impaired concentration, disturbed sleep and delusions were associated with lower mortality risk.

CONCLUSIONS

Besides demographic factors, physical health, functioning and cognition, different depressive symptoms were significantly associated with the prognosis of LLD. Elderly patients presenting with depressive symptoms predicting higher mortality risk should be examined and followed more closely.

'Real time' monitoring of antipsychotic prescribing in patients with dementia: a study using the Clinical Record Interactive Search (CRIS) platform to enhance safer prescribing

BACKGROUND

The use of antipsychotic drugs in dementia has been reported to be associated with increased risk of cerebrovascular events and mortality. There is an international drive to reduce the use of these agents in patients with dementia and to improve the safety of prescribing and monitoring in this area.

OBJECTIVES

The aim of this project was to use enhanced automated regular feedback of information from electronic health records to improve the quality of antipsychotic prescribing and monitoring in people with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) incorporated antipsychotic monitoring forms into its electronic health records. The SLaM Clinical Record Interactive Search (CRIS) platform provides researcher access to de-identified health records, and natural language processing is used in CRIS to derive structured data from unstructured free text, including recorded diagnoses and medication. Algorithms were thus developed to ascertain patients with dementia receiving antipsychotic treatment and to determine whether monitoring forms had been completed. We used two improvement plan-do-study-act cycles to improve the accuracy of the algorithm for automated evaluation and provided monthly feedback on team performance.

RESULTS

A steady increase in antipsychotic monitoring form completion was observed across the study period. The percentage of our sample with a completed antipsychotic monitoring form more than doubled from October 2017 (22%) to January 2019 (58%).

CONCLUSION

'Real time' monitoring and regular feedback to teams offer a time-effective approach, complementary to standard audit methods, to enhance the safer prescribing of high risk drugs.

Late-life depression in people from ethnic minority backgrounds: Differences in presentation and management

BACKGROUND

An elevated risk of late-life depression has been suggested in older adults from minority ethnic groups, but little is known about ethnic group differences in symptom and treatment profiles. The current study aimed to compare symptoms and types of treatment between ethnic groups in patients with late-life depression.

METHODS

Data were extracted from the Clinical Record Interactive Search (CRIS) system , which provides access to the anonymised electronic health records of a large mental health care provider in South London. In total, 5,546 individuals aged 65 years and older, and diagnosed with late-life depression between 2006 and 2017, were included. Patients from ethnic minority backgrounds were compared to White British individuals on the following features recorded at depression diagnosis: mental and physical wellbeing,functional scales, individual depressive symptoms recorded, and treatments administered.

RESULTS

Black Africans and Black Caribbeans more frequently presented with psychotic problems and were significantly less likely to have antidepressant treatment prescribed post diagnosis compared to White British. White Irish had higher rates of substance use and sleep disturbance. Depressive symptoms of hopelessness, guilt feelings, and suicidal thoughts were less common in Black Caribbeans, Black Africans, and South Asians compared to White British.

LIMITATIONS

Only patients with depression under a specialist mental health care provider were included in the study.

CONCLUSIONS

Ethnic minority elders have significantly different presentations and undertake different types of treatment both across groups and relative to their White British counterparts. These differences need to be taken into consideration to optimise pathways into care and to personalise treatment.

Benefits and Harms of Statins in People with Dementia: A Systematic Review and Meta-Analysis

OBJECTIVES

More people with dementia also fall into the category of high vascular risk, for which a statin is usually prescribed. However, these recommendations are based on studies in people without dementia. We aimed to evaluate the evidence for the long-term effectiveness and harm of statin therapy in patients with dementia.

DESIGN

Systematic review of randomized controlled trials and observational research.

SETTING

Publications from developed countries indexed in the PubMed, Web of Science, and Cochrane trial database between 2007 and 2019.

PARTICIPANTS

Trials including people with all types of dementia with a mean age older than 65 years.

INTERVENTION

Treatment with a statin for 6 months or longer.

MEASUREMENTS

Major adverse cardiovascular events, dementia progression, and general health at 2 years, or medication adverse events (AEs) at any time. Each article was assessed for bias using the Newcastle-Ottawa or Cochrane Collaboration tools. A narrative synthesis and pooled analyses are reported.

RESULTS

Five articles met the inclusion criteria. They reported only on dementia of the Alzheimer's type. There was no evidence regarding cardiovascular events or general health. We made a very low confidence finding that statins reduce dementia progression based on three cohort studies of heterogeneous design. We made a very low confidence finding of no significant difference in AEs based on two randomized controlled trials of 18 months: odds ratios of any AE = 1.21 (95% confidence interval [CI] = .83-1.77), serious AE = 1.03 (95% CI = .76-1.87), and death = 1.69 (95% CI = .79-3.62).

CONCLUSION

Evidence was insufficient to fully evaluate the efficacy of statins in people with dementia. We found that statins may have a small benefit delaying progression in Alzheimer's dementia, although this conflicted with previous findings from shorter randomized trials. For safety, the trial data lacked power to show clinically important differences between the groups. We recommend that clinical data be leveraged for further observational studies to inform prescribing decisions. J Am Geriatr Soc 68:650-658, 2020.