To assess the risk of hip fracture associated with the use of four classes of psychotropic drugs, we performed a case-control study of 1021 patients with hip fractures and 5606 controls among elderly Medicaid enrollees. Persons treated with hypnotics-anxiolytics having short (less than or equal to 24 hours) elimination half-lives had no increased risk of hip fracture. By contrast, a significantly increased risk was associated with current use of hypnotics-anxiolytics having long (greater than 24 hours) elimination half-lives (odds ratio, 1.8; 95 percent confidence interval, 1.3 to 2.4), tricyclic antidepressants (odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8), and antipsychotics (odds ratio, 2.0; 95 percent confidence interval, 1.6 to 2.6). The risk increased in relation to the doses of drugs in these three classes. An analysis for possible confounding by dementia did not alter the results. Previous but noncurrent use of drugs in these classes conferred no increase in risk. Although a cause-and-effect relation was not proved, these data support the hypothesis that the sedative and autonomic effects of psychotropic drugs increase the risk of falling and fractures in elderly persons. The results suggest the need for studies of this association in other populations and for evaluation of newer psychotropic drugs with fewer undesirable sedative and autonomic effects.

https://www.nejm.org/doi/pdf/10.1056/NEJM198702123160702?listPDF=true

Psychotropic Drug Use and the Risk of Hip Fracture

Background: The vital role played by family caregivers in supporting dying cancer patients is well recognized, but the burden and economic impact on caregivers is poorly understood. We prospectively examined the psychosocial, occupational and economic impact of caring for a person with a terminal illness. Methods: We studied 89 caregivers of women with advanced breast cancer receiving care at either the Ottawa or Hamilton regional cancer centres in Ontario. Patients were followed until their death or study completion at 3 years. Patients identified a principal caregiver to participate in the study. The Karnofsky Performance Status (KPS) index, the Medical Outcomes Study 36-item Short Form (SF-36), the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, FAMCARE and the Medical Outcomes Study Social Support Survey were administered during follow-up. Economic data were collected by means of a questionnaire administered by an interviewer. Assessments were conducted every 3 months during the palliative period (KPS score > 50) and every 2 weeks during the terminal period (KPS score ≤ 50). Results: Over half of the caregivers were male (55%) and the patient9s spouse or partner (52%), with a mean age of 53 years. At the start of the palliative period, the caregivers9 mean physical functioning score was better than the patients9 (51.3 v. 35.1, 95% confidence interval [CI] 13.3–20.0); there were similar mean mental functioning scores (46.6 and 47.1 respectively); similar proportions were depressed (11% and 12%); and significantly more caregivers than patients were anxious (35% v. 19%, p = 0.009). More caregivers were depressed (30% v. 9%, p = 0.02) and had a higher level of perceived burden (26.2 v. 19.4, p = 0.02) at the start of the terminal period than at the start of the palliative period. Burden was the most important predictor of both anxiety and depression. Of employed caregivers, 69% reported some form of adverse impact on work. In the terminal period 77% reported missing work because of caregiving responsibilities. Prescription drugs were the most important component of financial burden. Interpretation: Caregivers9 depression and perceived burden increase as patients9 functional status declines. Strategies are needed to help reduce the psychosocial, occupational and economic burden associated with caregiving.

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Family caregiver burden: results of a longitudinal study of breast cancer patients and their principal caregivers

Violent offenders: Appraising and managing risk, 2nd ed.

Objective: to identify all published papers on risk factors and risk assessment tools for falls in hospital inpatients. To identify clinical risk assessment tools or individual clinical risk factors predictive of falls, with the ultimate aim of informing the design of effective fall prevention strategies. Design: systematic literature review (Cochrane methodology). Independent assessment of quality against agreed criteria. Calculation of odds ratios and 95% conWdence intervals for risk factors and of sensitivity, speciWcity, negative and positive predictive value for risk assessment tools (with odds ratios and conWdence intervals), where published data sufWcient. Results: 28 papers on risk factors were identiWed, with 15 excluded from further analysis. Despite the identiWcation of 47 papers purporting to describe falls risk assessment tools, only six papers were identiWed where risk assessment tools had been subjected to prospective validation, and only two where validation had been performed in two or more patient cohorts. Conclusions: a small number of signiWcant falls risk factors emerged consistently, despite the heterogeneity of settings namely gait instability, agitated confusion, urinary incontinence/frequency, falls history and prescription of ‘culprit’ drugs (especially sedative/hypnotics). Simple risk assessment tools constructed of similar variables have been shown to predict falls with sensitivity and speciWcity in excess of 70%, although validation in a variety of settings and in routine clinical use is lacking. Effective falls interventions in this population may require the use of better-validated risk assessment tools, or alternatively, attention to common reversible falls risk factors in all patients.

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Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review

The authors reviewed 30 studies on Alzheimer's disease to determine the prevalence and phenomenology of affective and psychotic symptoms in patients with this disorder. Depressive and psychotic symptoms occurred in 30%-40% of the Alzheimer's disease patients. Isolated symptoms were two to three times as frequent as diagnosable affective or psychotic disorders. Paranoid delusions were the most common psychotic symptoms reported. Implications of the relationship of psychiatric symptoms to the clinical presentation of Alzheimer's disease, patterns of cognitive dysfunction, clinical management, and areas for future research are discussed.

Overview of depression and psychosis in Alzheimer's disease.

Objective: To measure and compare perceived financial burden, use of services, and perceived unmet service needs of supporters of demented and non-demented elderly people Design: Comparison study of age and sex matched demented and non-demented elderly people and their supporters Setting: 25 primary health care teams in Dundee Subjects: 114 community resident elderly (age over 65) people with dementia, 114 age and sex matched comparators, and the main informal supporter of each elderly person Main outcome measures: Carers9 perceptions of financial impact of looking after an old person, service use (from a list of locally available services), unmet service needs, and needs for three types of generic service (help with supervision, housework, or personal care) Results: Financial impact was low, except for extra household expense in the dementia group There was significantly greater use of mainstream domiciliary and day care services in the dementia group Dementia was nevertheless associated with a high level of unmet need, mainly for more mainstream support and help with supervision of the elderly person Conclusion: Supervisory care for demented elderly people should be further developed within an expanded domiciliary service to meet supporters needs Key messages Key messages Community care for demented elderly people is thought to pose special problems for carers but comparison studies with non-demented elderly people are rare The financial impact on family carers of demented elderly people in a Scottish city was not as high as expected The use of mainstream domiciliary and day care services was significantly higher for demented than non-demented elderly people Family carers of demented elderly people need more support in caring for these people

/pdf/community-care-for-demented-and-non-demented-elderly-people-r9l761sbvd.pdf

Community care for demented and non-demented elderly people: a comparison study of financial burden, service use, and unmet needs in family supporters

All inpatients aged greater than 55 years with dementia in the Dundee Psychiatric Service were surveyed for seizure occurrence by interviewing staff and reviewing records. Of 208 patients, 19 (9.1%) were recorded as having seizures. The seizures were major in 92% and occurred at a rate of approximately 2.3 seizures per patient per year. Patients with epilepsy were significantly younger than a control group of dementia inpatients and were significantly more cognitively impaired on the survey Clifton Assessment Procedure for the Elderly (CAPE), but not on the Mini Mental State Examination. Of 111 reported accidents, only 5 appeared to be associated with epilepsy. Although epileptic seizures are relatively common in patients with severe dementia, they rarely caused severe problems.

Epileptic seizures in elderly patients with dementia.

A survey was made of self-injury in patients in a mental subnormality hospital and a psychiatric hospital. Ninety-three out of 626 subnormals (14.9 per cent) and 20 out of 584 psychiatric patients (3.4 per cent) had injured themselves in the previous month. The relationship of self-injury to other characteristics of the patients is considered. It is suggested that individual attention, recreation and constructive occupations may be more important than drug treatment in the alleviation of these symptoms.

Minor Self-Injury

Very little is known about psychiatric disorders in severely and profoundly retarded adults. We have investigated these disorders by systematically recording and collecting data about the behaviour of 100 severely and profoundly retarded hospitalized adults and subjecting the data thus derived to cluster analysis. Eight clusters were isolated. The clinical psychiatric significance of these clusters is discussed and their relationship to cause retardation, duration of stay in hospital and visiting is considered. A diagnostic framework for psychiatric disorder in severely and profoundly retarded adults is put forward and some possible treatment approaches are suggested.

Behavioural syndromes identified by cluster analysis in a sample of 100 severely and profoundly retarded adults.

100 randomly selected mildly or moderately mentally retarded adults were assessed for personality disorder using the Standardized Assessment of Personality devised by Mann et al. (1981). By the terms of this instrument 56% of patients showed features of abnormal personality, and in 22% this abnormality was marked, suggesting the presence of personality disorder. Personality problems may be a more significant factor in assessing a mentally retarded person's acceptability in a community setting than has hitherto been realized.

Brian R. Ballinger

Papers

Community care for demented and non-demented elderly people: a comparison study of financial burden, service use, and unmet needs in family supporters

Epileptic seizures in elderly patients with dementia.

Minor Self-Injury

Behavioural syndromes identified by cluster analysis in a sample of 100 severely and profoundly retarded adults.

Personality disorder in mental handicap.