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Depression in older people with and without dementia: non-pharmacological interventions and associations between psychotropic drugs and mortality
Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.ORCID-id: 0000-0001-6480-8349
2016 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)Alternativ titel
Depression hos äldre människor med och utan demenssjukdom : icke-farmakologiska interventioner och associationer mellan psykofarmaka och död (Svenska)
Abstract [en]

The aim of this thesis was to investigate associations between psychotropic drug use and death, associations between functional capacity, dependency in ADL and depression, and to evaluate a non-pharmacological intervention to reduce depressive symptoms, among older people with and without dementia.

There is limited knowledge about the risk of death associated with psychotropic drug use among those aged ≥85 years, those with dementia, or those living in residential care facilities; groups that have a higher intake of psychotropic drugs and who are also more prone to adverse drug reactions. In a representative sample of people ≥85 years (n = 992), baseline antidepressant use was not associated with an increased 5-year mortality risk when adjusting for confounding factors. A significant interaction between gender and antidepressant use was found, with a higher mortality risk in women, than in men.  When analyzing men and women separately, no significant associations were found. In a sample of older people (i.e. ≥65 years) with dementia (n = 1037), there was a significant gender difference in 2-year mortality associated with the baseline use of antidepressant drugs, with a lower mortality risk in men, than in women. In men, the mortality risk was significantly reduced with antidepressant use, while there was no significant association in women. The association between baseline use of benzodiazepines and mortality had a tendency toward an increased risk during the first year of follow-up, although this became non-significant after adjustments. In this time period, the interaction term for sex was significant, with a higher mortality risk among men than women. When the sexes were analyzed separately, no significant associations were found. No significant associations were found between baseline use of antipsychotic drugs and mortality.

Drug treatment for depression seems to have a limited effect in older people and may have no effect in people with dementia. In order to find alternative ways of treating or preventing depression in older age, it is important to increase our knowledge about factors associated with this condition. Functional capacity and dependency in activities of daily living (ADL) are associated with depression in community-dwelling older people. However, it is uncertain whether the same associations are to be found in very old people (i.e. ≥80 years), including those with severe cognitive or physical impairments. In a heterogeneous sample (n = 392) with a high mean age, a large range of cognitive and functional capacity, a wide spectrum of dependency in ADL, and a high prevalence of comorbidities, depressive symptoms were significantly associated with functional balance capacity, but not with overall dependency in ADL. Among individual ADL tasks, dependency in transfer and dressing were associated with depressive symptoms.

Physical exercise has shown effect sizes similar to those of antidepressants in reducing depressive symptoms among older people without dementia, with moderate–high-intensity exercise being more effective than low-intensity exercise. However, these effects are unclear among older people with dementia. Care-facility residents with dementia (n = 186) were cluster-randomized to a high-intensity functional exercise program or a non-exercise control activity conducted for 45 minutes every other weekday for 4 months. No significant difference between the exercise and control activity was found in depressive symptoms at 4 or 7 months. Among participants with high levels of depressive symptoms, reductions were observed in both the exercise and control groups at 4 and 7 months.

In conclusion, ongoing treatment at baseline with any of the three psychotropic drug classes antidepressants, antipsychotics and benzodiazepines did not increase the risk of mortality in older people with dementia.  Neither did antidepressant drugs in very old people. In both samples, gender differences were found in the mortality risk due to antidepressant use. In those with dementia, the mortality risk due to benzodiazepine use also differed by gender. The potential risk from initial treatment and gender differences regarding mortality risk require further investigation in randomized controlled trials or in large cohort studies properly controlled for confounding factors. In older people, living in community and residential care facilities, functional capacity seems to be independently associated with depressive symptoms whereas overall ADL performance may not be associated. Dependency in the individual ADL tasks of transfer and dressing appear to be independently associated with depressive symptoms and may be an important focus for future interdisciplinary multifactorial intervention studies. Among older people with dementia living in residential care facilities, a 4-month high-intensity functional exercise program has no superior effect on depressive symptoms than a control activity. Both exercise and non-exercise group activities may reduce high levels of depressive symptoms. However, this finding must be confirmed in three-armed randomized controlled trials including control groups receiving standard care.

Abstract [sv]

Syftet med avhandlingen var att utreda sambandet mellan risken för död och användningen av psykofarmaka (läkemedel som används vid olika psykiatriska tillstånd) och att utforska samband mellan funktionell kapacitet, hjälpberoende i aktiviteter i det dagliga livet (ADL) och depression hos äldre personer med och utan demenssjukdom. Syftet var även att utvärdera effekten av högintensiv funktionell träning på depressiva symtom hos äldre människor med demenssjukdom som bor på särskilt boende.

Kunskapen är begränsad om risken för död vid psykofarmakaanvändning hos de som är 85 år eller äldre, har demenssjukdom eller bor på särskilt boende. Människor i dessa grupper får oftare utskrivet psykofarmaka och är mer benägna att drabbas av biverkningar än yngre och friskare människor. I ett representativt urval av personer som var 85 år eller äldre (n = 992) hade inte antidepressiv medicinering vid baslinjen (d.v.s. studiestarten) något signifikant samband med risken att dö under en uppföljning på 5 år, kontrollerat för störfaktorer. Sambandet mellan risken för död och användningen av antidepressiva läkemedel skiljde sig mellan kvinnor och män, med en relativt högre risk för död hos kvinnor jämfört med män. I separata analyser av män och kvinnor hittades dock inga signifikanta samband. I ett annat urval, där äldre personer med demenssjukdom (n = 1037) följdes i upp till 2 år, hittades också en skillnad mellan män och kvinnor i risken att dö relaterad till antidepressiv användning vid studiestarten. Risken för död var relativt lägre hos män jämfört med kvinnor. När män analyserades separat hittades ett signifikant samband mellan en lägre risk för död och användning av antidepressiva läkemedel, samtidigt som inget samband kunde ses hos kvinnor. Det fanns en tendens mot en ökad risk för död relaterad till användning av bensodiazepiner under det första årets uppföljning. Detta samband försvann dock, när analyserna justerades för störfaktorer. Under det första årets uppföljning fanns det också en könsskillnad i risken för död vid användning av bensodiazepiner. Denna risk var relativt högre hos män jämfört med kvinnor. När män och kvinnor analyserades separat fanns dock inga samband. Inga signifikanta samband hittades heller mellan användning av antipsykotiska läkemedel vid studiestarten och risken för död.

Läkemedelsbehandling vid depression verkar ha en begränsad effekt hos äldre människor och kan möjligtvis sakna effekt hos personer med demens. För att hitta alternativa sätt att behandla eller förebygga depression hos äldre är det därför viktigt att öka kunskapen om faktorer som har samband med depression. Nedsatt funktionell kapacitet och hjälpberoende i ADL är associerat med depression hos relativt friska äldre människor som bor i ordinärt boende. Det är dock osäkert om dessa samband också finns hos personer som är 80 år eller äldre, inklusive de med gravt nedsatt kognitiv eller fysisk funktion och inklusive de som bor på särskilt boende. I ett heterogent urval (n = 392) med hög medelålder, stor variation av kognitiv och fysisk funktion, mycket varierat hjälpbehov i ADL och hög förekomst av sjukdomar, var depressiva symptom signifikant associerade med nedsatt funktionell balanskapacitet, men inte med övergripande beroende i ADL. Bland enskilda ADL-uppgifter var depressiva symtom relaterade till hjälpberoende i överflyttning och påklädning.

Fysisk träning har haft effekter liknande antidepressiva läkemedel i att minska depressiva symtom hos äldre personer utan demenssjukdom, med bättre effekt av måttlig-högintensiv träning än lågintensiv träning. Hos äldre personer med demenssjukdom är det osäkert om fysisk träning kan minska depressiva symtom. Äldre personer med demenssjukdom (n = 186) som bodde på särskilt boende lottades till att delta i ett högintensivt funktionellt träningsprogram eller till en stillasittande kontrollaktivitet, under 45 minuter varannan vardag i 4 månader. Ingen signifikant skillnad hittades mellan träningen och kontrollaktiviteten i förändring av depressiva symtom vid 4 eller 7 månaders uppföljning. Bland deltagarna med höga nivåer av depressiva symtom sågs signifikanta minskningar i både tränings- och kontrollgruppen vid 4 och 7 månader.

Sammanfattningsvis hittades ingen ökad risk för död hos äldre personer med demens som vid studiestarten behandlades med bensodiazepiner, antidepressiva läkemedel eller antipsykotiska läkemedel. Inte heller hos mycket gamla människor hittades något samband mellan en ökad risk för död och behandling med antidepressiva läkemedel. I båda urvalen hittades könsskillnader i risken för död vid användning av antidepressiva läkemedel. Hos de med demenssjukdom hittades också en könsskillnad i risken för död i samband med användning av bensodiazepiner. Den potentiella risken med initial behandling, samt könsskillnader i risken för död, bör utforskas vidare i randomiserade kontrollerade studier eller i stora kohortstudier med noggranna justeringar för störfaktorer. Hos äldre människor som bor i ordinärt boende eller särskilt boende verkar funktionell kapacitet vara oberoende associerat med depressiva symtom, samtidigt som övergripande ADL-beroende inte verkar vara det. Beroende i de enskilda ADL-uppgifterna överflyttning och påklädning verkar ha oberoende samband med depressiva symtom och kan vara ett viktigt fokus i framtida studier. Bland äldre personer med demenssjukdom som bor på särskilt boende har 4 månaders högintensiv funktionell träning inte bättre effekt på depressiva symtom än en stillasittande aktivitet. Både gruppträning och andra gruppaktiviteter skulle kunna minska höga nivåer av depressiva symtom, men det behöver bekräftas i interventionsstudier som även inkluderar en kontrollgrupp som får sedvanlig vård.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet , 2016. , s. 89
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 1797
Nyckelord [en]
Depression, Dementia, Exercise, Randomized controlled trial, Psychotropic drugs, Mortality, Gender, Residential facilities, Frail elderly, Epidemiology, Cohort study
Nationell ämneskategori
Geriatrik Sjukgymnastik
Forskningsämne
geriatrik; sjukgymnastik
Identifikatorer
URN: urn:nbn:se:umu:diva-119016ISBN: 978-91-7601-452-3 (tryckt)OAI: oai:DiVA.org:umu-119016DiVA, id: diva2:917782
Disputation
2016-05-04, Aulan, Vårdvetarhuset, Umeå, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2016-04-13 Skapad: 2016-04-07 Senast uppdaterad: 2018-06-07Bibliografiskt granskad
Delarbeten
1. Antidepressant use and mortality in very old people
Öppna denna publikation i ny flik eller fönster >>Antidepressant use and mortality in very old people
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2016 (Engelska)Ingår i: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 28, nr 7, s. 1201-1210Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Antidepressant treatment may increase the risk of death. The association between antidepressants and mortality has been evaluated in community-dwelling older people, but not in representative samples of very old people, among whom dementia, multimorbidity, and disability are common.

METHODS: Umeå 85+/GERDA study participants (n = 992) aged 85, 90, and ≥95 years were followed for up to five years. Cox proportional hazard regression models were used to analyze mortality risk associated with baseline antidepressant treatment, adjusted for potential confounders.

RESULTS: Mean age was 89 years; 27% of participants had dementia, 20% had stroke histories, 29% had heart failure, and 16% used antidepressants. In age- and sex-adjusted analyses, antidepressant use was associated with a 76% increased mortality risk (hazard ratio [HR] = 1.76; 95% confidence interval [CI], 1.41-2.19). Adding adjustment for Geriatric Depression Scale score, HR was 1.62 (95% CI, 1.29-2.03). The association was not significant when adjusting for additional confounding factors (HR = 1.08; 95% CI, 0.85-1.38). Interaction analyses in the fully adjusted model revealed a significant interaction between sex and antidepressant use (HR: 1.76; 95% CI, 1.05-2.94). Among male and female antidepressant users, the HRs for death were 0.76 (95% CI, 0.47-1.24) and 1.28 (95% CI, 0.97-1.70), respectively.

CONCLUSION: Among very old people, baseline antidepressant treatment does not seem to be independently associated with increased mortality risk. However, the risk may be different in men and women. This difference and the potential risk of initial treatment require further investigation in future cohort studies of very old people.

Ort, förlag, år, upplaga, sidor
Cambridge University Press, 2016
Nyckelord
depression, antidepressants, age 80 and over, dementia, residential facilities, frail elderly, epidemiology, mortality
Nationell ämneskategori
Geriatrik
Forskningsämne
geriatrik
Identifikatorer
urn:nbn:se:umu:diva-119010 (URN)10.1017/S104161021600048X (DOI)000382387500016 ()26987958 (PubMedID)2-s2.0-84961217608 (Scopus ID)
Tillgänglig från: 2016-04-07 Skapad: 2016-04-07 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
2. Psychotropic drug use and mortality in old people with dementia: investigating sex differences
Öppna denna publikation i ny flik eller fönster >>Psychotropic drug use and mortality in old people with dementia: investigating sex differences
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2017 (Engelska)Ingår i: BMC Pharmacology & Toxicology, E-ISSN 2050-6511, Vol. 18, artikel-id 36Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Psychotropic drugs are common among old people with dementia, and have been associated with increased mortality. Previous studies have not investigated sex differences in this risk. This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein.

Methods: In total, 1037 participants (74% women; mean age, 89 years) with dementia were included from four cohort studies and followed for 2 years. Data were collected through home visits and medical records. Cox proportional hazard regression models were used to analyse associations between ongoing baseline drug use and mortality. Multiple possible confounders were evaluated and adjusted for.

Results: In fully adjusted models including data from the whole population, no association between baseline psychotropic drug use and increased 2-year mortality was seen. Significant sex differences were found in mortality associated with antidepressant use, which was protective in men, but not in women (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40–0.92 and HR 1.09, 95% CI 0.87–1.38, respectively). The interaction term for sex was significant in analyses of benzodiazepine use, with a higher mortality risk among men than among women.

Conclusions: Among old people with dementia, ongoing psychotropic drug use at baseline was not associated with increased mortality in analyses adjusted for multiple confounders. Sex differences in mortality risk associated with antidepressant and benzodiazepine use were seen, highlighting the need for further investigation of the impact of sex.

Nyckelord
Alzheimer’s disease, antidepressants, antipsychotics, benzodiazepines, cohort study, dementia, gender, mortality, old age, psychotropic drugs, vascular dementia
Nationell ämneskategori
Geriatrik
Forskningsämne
geriatrik
Identifikatorer
urn:nbn:se:umu:diva-119011 (URN)10.1186/s40360-017-0142-9 (DOI)000402184000001 ()28545507 (PubMedID)2-s2.0-85019695950 (Scopus ID)
Anmärkning

Originally published in manuscript form with title "Psychotropic drug use and mortality in old people with dementia: a gender-sensitive analysis"

Tillgänglig från: 2016-04-07 Skapad: 2016-04-07 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
3. Functional capacity and dependency in transfer and dressing are associated with depressive symptoms in older people
Öppna denna publikation i ny flik eller fönster >>Functional capacity and dependency in transfer and dressing are associated with depressive symptoms in older people
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2014 (Engelska)Ingår i: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 9, s. 249-257Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: This study examined associations between depressive symptoms and functional capacity, overall dependency in personal activities of daily living (ADLs), and dependency in individual ADL tasks, respectively, in people with a high mean age, large range of functional capacity, and wide spectrum of dependency in ADLs. Methods: Cross-sectional data from three studies were used. A total of 392 individuals living in community and residential care facilities were included. Mean age was 86.2 years, 72% were women, 75% were dependent in ADLs, 42% had depression, and 39% had dementia. Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS-15), functional capacity with the Berg Balance Scale (BBS), and ADLs with the Barthel ADL Index. Multiple linear regression analyses with comprehensive adjustments were performed between GDS-15 and BBS, GDS-15 and Barthel ADL Index, and GDS-15 and each individual ADL task, separately. Results: GDS-15 score was associated with BBS score (unstandardized b=-0.03, P=0.008), but not with Barthel ADL Index score (unstandardized b=-0.07, P=0.068). No significant interaction effects of sex, dementia, or living conditions were found in these associations. Among individual ADL tasks, dependency in transfer (unstandardized b=-1.03, P=0.007) and dressing (unstandardized b=-0.70, P=0.035) were associated with depressive symptoms. Conclusion: Functional capacity seems to be independently associated with depressive symptoms in older people living in community and residential care facilities, whereas overall ADL performance may not be associated. Dependency in the individual ADL tasks of transfer and dressing appear to be independently associated with depressive symptoms and may be an important focus of future interdisciplinary multifactorial intervention studies.

Ort, förlag, år, upplaga, sidor
Dove Medical Press Ltd., 2014
Nyckelord
aged 80 and over, residential facilities, independent living, depression, activities of daily living
Nationell ämneskategori
Geriatrik
Identifikatorer
urn:nbn:se:umu:diva-86336 (URN)10.2147/CIA.S57535 (DOI)000330634700001 ()2-s2.0-84893679690 (Scopus ID)
Forskningsfinansiär
Vetenskapsrådet, K2009-69P-21298-01-4, K2009-69X-21299-01-1, K2009-69P-21298-04-4
Tillgänglig från: 2014-02-24 Skapad: 2014-02-24 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
4. Effects of a high-intensity functional exercise program on depressive symptoms among people with dementia in residential care: a randomized controlled trial
Öppna denna publikation i ny flik eller fönster >>Effects of a high-intensity functional exercise program on depressive symptoms among people with dementia in residential care: a randomized controlled trial
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2016 (Engelska)Ingår i: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 31, nr 8, s. 868-878Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

OBJECTIVES: The aim of this study is to evaluate the effect of a high-intensity functional exercise program on depressive symptoms among older care facility residents with dementia.

METHODS: Residents (n = 186) with a diagnosis of dementia, age ≥ 65 years, Mini-Mental State Examination score ≥ 10, and dependence in activities of daily living were included. Participants were randomized to a high-intensity functional exercise program or a non-exercise control activity conducted 45 min every other weekday for 4 months. The 15-item Geriatric Depression Scale (GDS) and the Montgomery-Åsberg Depression Rating Scale (MADRS) were administered by blinded assessors at baseline, 4, and 7 months.

RESULTS: No difference between the exercise and control activity was found in GDS or MADRS score at 4 or 7 months. Among participants with GDS scores ≥ 5, reductions in GDS score were observed in the exercise and control groups at 4 months (-1.58, P = 0.001 and -1.54, P = 0.004) and 7 months (-1.25, P = 0.01 and -1.45, P = 0.007). Among participants with MADRS scores ≥ 7, a reduction in MADRS score was observed at 4 months in the control group (-2.80, P = 0.009) and at 7 months in the exercise and control groups (-3.17, P = 0.003 and -3.34, P = 0.002).

CONCLUSIONS: A 4-month high-intensity functional exercise program has no superior effect on depressive symptoms relative to a control activity among older people with dementia living in residential care facilities. Exercise and non-exercise group activities may reduce high levels of depressive symptoms.

Nyckelord
dementia, residential facilities, depression, exercise, randomized controlled trial, frail elderly
Nationell ämneskategori
Annan hälsovetenskap Sjukgymnastik Geriatrik
Forskningsämne
geriatrik; sjukgymnastik
Identifikatorer
urn:nbn:se:umu:diva-113681 (URN)10.1002/gps.4401 (DOI)000382959400004 ()26644304 (PubMedID)2-s2.0-84977676446 (Scopus ID)
Tillgänglig från: 2015-12-22 Skapad: 2015-12-22 Senast uppdaterad: 2023-03-24Bibliografiskt granskad

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