Mental Health

Introduction: Severe Mental Illness (SMI), particularly schizophrenia, has been associated with reduced bone mineral density and increased risk of fractures, although some studies have shown inconsistent results. We aimed to examine the effect of SMI on recorded diagnosis of osteoporosis and fragility fracture in older people in the UK, accounting for age, sex, social deprivation and lifestyle factors (smoking, alcohol and Body Mass Index (BMI)).

Methods: We used de-identified data provided as part of routine primary care (IQVIA Medical Research Database). Patients with a diagnosis of SMI (schizophrenia, bipolar disorder, other psychosis) aged 50-99y between 1/1/2000-31/12/2018 were matched 1:8 to age- and sex-adjusted controls without SMI, using Exposure Density Sampling (EDS). We estimated Hazard Ratios (HR) and 95% Confidence Intervals (95%CI) based on Cox Proportional Hazards model. We stratified the analysis by sex, accounting for age, social deprivation, year (model 1), and the above plus smoking, alcohol, and BMI (model 2). We imputed missing lifestyle data using Multiple Imputation.

Results: In total 444,480 people aged ≥50 years were included in the analysis (SMI N=50,006; controls N=394,474). In men, prior diagnosis of SMI increased the risk of osteoporosis diagnosis by 64% (HR 1.64; 95%CI 1.44-1.88) and the risk of fragility fractures by 87% (HR 1.87; 95%CI 1.70-2.06) in model 1. SMI also increased osteoporosis risk by 49% (HR=1.49; 95%CI 1.30-1.71) and fragility fracture risk by 82% (HR=1.82; 95%CI 1.65-2.00) in model 2 in men. In contrast, prior diagnosis of SMI had no significant effect on recorded osteoporosis risk in women. Prior SMI in women increased fragility fracture risk by 53% (HR 1.53; 95%CI 1.45-1.61) in model 1 and by 51% (HR=1.51; 95%CI 1.43-1.58) in model 2.

Conclusions: SMI is associated with increased risk of osteoporosis in men, and fragility fractures in both men and women, with a greater effect in men. 

Background

Older adults were more likely to be socially isolated during the COVID-19 pandemic, with increased risk of depression and loneliness. The Behavioural Activation in Social Isolation (BASIL+) trial investigated whether a Behavioural Activation (BA) intervention delivered remotely could mitigate depression and loneliness in at-risk older people during the COVID-19 pandemic.

Methods

We undertook a multicentre randomised controlled trial [ISRCTN63034289] of BA to mitigate depression and loneliness among older adults (65+) with multiple long-term health conditions, including low mood or depression. BA was delivered remotely (telephone or video call) with intervention participants (n=218). Control participants received usual care, with existing COVID wellbeing resources (n=217). 

Results

Participants engaged with an average of 5.2 (SD 2.9) of 8 remote BA sessions. Adjusted mean difference (AMD) for depression (Patient Health Questionnaire-9, PHQ-9) at 3 months [primary outcome] was -1.65 (95% CI -2.54 to -0.75, p<0.001). There was an effect for BA on emotional loneliness at 3 months (AMD -0.37, 95% CI -0.68 to -0.06, p=0.02), but not social loneliness (AMD -0.05, 95% CI -0.33 to 0.23, p=0.72). For participants with lower severity depression symptoms (5-9 on the PHQ-9) at baseline, there was an effect AMD PHQ9 1.13 (95% CI –2.26 to 0.01, p=0.051), though this was less pronounced than for those scoring 10 or more at baseline (-2.48, 95% CI -3.81 to 1.16, p=0.0002).

Conclusion

Behavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by frightening or traumatic events. Delirium is a state of acute confusion associated with acute illness, surgery, and hospitalisation. Delirium is known to be associated with a risk of PTSD in patients in the Intensive Care (ICU) setting. However, there is limited information on the prevalence of delirium in older adults outside of Intensive Care. Therefore we undertook a systematic review to ascertain the prevalence of PTSD in elderly patients after an episode of delirium on a general ward.

METHODS: The systematic review was conducted using MEDLINE (1946-10/01/2024), Embase (1974- 10/01/2024), and PsycINFO (1806- 10/01/2024) to identify studies. Studies were eligible if they included adults aged ≥ 65 years, admitted to an acute hospital, diagnosed with delirium using a validated screening tool, (e.g. 4AT, CAM-ICU) and subsequently screened for PTSD at any point following discharge with a validated screening tool (e.g. the PTSS-14). The exclusion criteria excluded ICU cohorts and terminal illness with < 3 months life expectancy. Two researchers (SM, NM) independently reviewed all studies with any disparities resolved though a 3rd researcher (AM)

RESULTS: After removal of duplicates, the search identified 1042 titles from which only 3 eligible studies were identified. All 3 studies were in older patients after surgical procedures (n=132 participants in total). Two of the studies reported no association between delirium and the subsequent risk of PTSD. However, the largest study (n=77) reported a significant independent association between delirium and the 3-month risk of PTSD.

CONCLUSION: The current body of research on the prevalence of PTSD following episodes of in-patient delirium in older adults is limited. The findings of this review highlight the need for further research. A prospective cohort study on Geriatric Medicine wards is being planned.

Introduction

Symptoms of depression and anxiety, with and without dementia, are common in older care home residents. It is postulated that that watching films can help residents to share emotions, enhance social connectedness and engage in reminiscence. As such, films can ameliorate depression and promote well-being. This scoping review summarises the evidence for the therapeutic benefits of film-based interventions in care homes.

Methods

Electronic databases MEDLINE, Embase, EMCare and CINAHL were searched for quantitative and qualitative studies in English including adults aged 65 years and older in years 2005-2023. The search terms were: older adults, dementia, depression, carers, caregivers, care homes, and film. 

Results 

Five studies met our criteria: Campbell-Sills, 2006, USA; Kim, 2014, Korea; Davison et al., 2016, Australia; Bjornskov et al., 2018, Denmark; and Breckenridge et al., 2020, UK. All subjects were care home residents except for Bjornskov et al., who included 63 institutional caregivers. The number of study participants ranged from 11 to 120. There was a female predominance throughout the studies, and all residents had dementia of varying severity. Study designs included: direct comparison of participants with mood/anxiety disorder versus controls (Campbell-Sills); non-equivalent control group pretest/posttest (Kim); randomised single-blind crossover (Davison); qualitative focus-group caregiver interviews (Bjornskov); and cross-sectional observation (Breckenridge). Observation/follow up periods ranged from 6 -10 weeks. Findings were as follows: Campbell-Sills: residents with mood/anxiety disorders were identified by suppressing negative emotions induced by films; Kim: group reminiscence therapy using cinema increased ego integrity and reduced depression severity; Davison et al: using a personal computer platform that included films resulted in reductions in anxiety, depression and agitation; Bjornskov et al.: caregivers reported that films can evoke reminiscence; Breckenridge et al.: small-group film viewing enhanced social connectivity.

Conclusion

Film screenings for ageing care home residents have the potential for improving mood and encouraging social connections.

• Frailty is an important consideration in the health and wellbeing of older adults, particularly as it is associated with a risk of falls, and mental health difficulties such as depression.

• After Option appraisal of various frailty assessment tools we chose Edmonton frail scale which consists of 9 domains ( Ref: ROLFSON DB, ET AL, VALIDITY AND RELIABILITY OF THE EDMONTON FRAIL SCALE, AGE AND AGEING 2006; 35 (5): 526–529 DOI: 10.1093/AGEING/AFL041​).

Abstract

• This was a feasibility study exploring the use of the Edmonton frail scale (EFS) among patients with highly complex mental health needs within a Psychiatric Inpatient Setting with a view to develop a service integration process leading to further research.

• Completion rate of the assessment was 55% as the domains requiring patient participation for cognitive and physical performance assessment were difficult to complete for this cohort of patients.

• It is feasible to use EFS in this setting but older adults with psychiatric disorders may benefit from having an adapted assessment of the cognitive and functional domains to promote complete administration of EFS Results

• 118 assessments were administered to 45 patients, over a 12-month period (months 1, 6 and 12).

• There was a 55% assessment completion rate.

• This was largely attributed to the challenges of administering two components of the EFS; the cognitive domain (Clock Drawing test) whose completion rate was 32%, and the Functional Performance Domain (Timed Get Up and Go Test).

• It was quite difficult for patients with highly complex mental health needs to understand and comply with the assessment instructions in the above domains

. • Average age was 73.5 years​ and 29 out of 45 patients were found to have moderate or severe frailty.

• 24 out of 29 patients with moderate or severe frailty had documentation of DNACPR discussions in their clinical records.

• Falls incidences did not change significantly during the year of implementation.

Conclusions

• It is feasible to use EFS in an inpatient psychiatric facility, particularly one where the patients have highly complex mental health needs​.

• The findings also indicate that this population has a high prevalence of moderate to severe frailty​.

• The continued use of the EFS as a holistic assessment tool would enable the MDT to focus on the areas/domains in which a patient is identified to be deteriorating​.

• To improve the tool’s completion rate alternative assessments for cognition and functional ability (Clock drawing test and timed get up and go test) need to be explored.

Acknowledgements This project could not have been done without engagement of staff and patients, and support of Dr Muthusamy Natarajan, CD of Neuropsychiatry division and Agnieszka

Septum pellucidum is a double-membrane separating the frontal horns of the lateral ventricles of the brain. [1] Cavum septum pellucidum (CSP) refers to a potential space between these membranes. CSP is associated with some psychiatric disorders. [2] Radiological CSP has been evaluated as a possible in-vivo biomarker for chronic traumatic encephalopathy (CTE), a neurodegenerative condition affecting, particularly, retired athletes who experienced repetitive, low impact head trauma. [3]

Our study evaluated the incidence of radiological CSP among a cohort undergoing investigation for cognitive impairment in memory clinic. A list of patient Community Health Index (CHI) numbers corresponding to patients referred to CT brain from a community memory clinic in North West Glasgow between October 2019 and March 2020 was generated. Approval for use of imaging for research purposes was granted by local imaging department.

Images were viewed by first author following a session from second author on basic relevant anatomy. Positive cases were defined as those with a visible CSP. There were twenty-eight (n=28) cases in total. CSP was observed in one (n=1) case.

Radiological CSP has been suggested as a potential biomarker for CTE. While this study does not involve review of the clinical or personal history of the subjects, it does include a cohort with clinically-relevant symptoms. We included CT only, while current evidence makes observations on MRI [3]. Locally CT is more available and the initial assessment of such patients uses CT in the first instance. Further evidence is required to establish CSP as a reliable in vivo biomarker of CTE.

[1] Das et al, in StatPearls [Internet], 2022 [2] Wang et al, J Neuropsychiatry Clin Neurosci. 2020; 32(2):175-184 [3] Alosco et al Neurotherapeutics. 2021; 18(2):772-791

Introduction

People with frailty (Rockwood Frailty Score of 4 or more) represents 43% of the medical take at Withybush Hospital. There was a lack of front door frailty and comprehensive geriatric assessments (CGA). It was postulated that this was leading to delays in discharge and limiting the number of patients receiving a CGA by teams led by a geriatrician

Methods

In mid-November 2022, the acute medical take was adapted to stream stable patients with frailty through a frailty assessment unit. Prior to this, the area was being used as a surge ward for short stay acute medical patients. On the frailty unit, patients receive a CGA creating a problem list and plan. The patients are then streamed into either short stay and discharged from the unit itself or to an appropriate ward area. Number of discharges was the main outcome measure.

Results

In the 2 months preceding the intervention the number of discharges from the short stay assessment unit was 16% of total medical discharges. The percentage of patient’s discharged from frailty wards was also 16% of medical discharges. In the 2 months after the intervention, discharges from the frailty unit accounted for 21% of medical discharges. Discharges from the frailty wards accounted for 16% of medical discharges. In the post intervention months, the frailty team discharges accounted for 37% of total medical discharges. 

Conclusions

Adoption of frailty unit model improved rates of short stay discharges and allowed frailty team to assess a greater proportion of the hospital patients. Using assessment by the frailty teams as a surrogate for a CGA this has significantly improved the proportion of patients receiving CGA to more fit our patient demographics.