Falls risk assessment outcomes and factors associated with falls for older Indigenous Australians.

OBJECTIVE: To describe the prevalence of falls and associated risk factors in older Indigenous Australians, and compare the accuracy of validated falls risk screening and assessment tools in this population in classifying fall status. METHOD: Cross-sectional study of 289 Indigenous Australians aged ≥45 years from the Kimberley region of Western Australia who had a detailed assessment including self-reported falls in the past year (n=289), the adapted Elderly Falls Screening Tool (EFST; n=255), and the Falls Risk for Older People-Community (FROP-Com) screening tool (3 items, n=74) and FROP-Com falls assessment tool (n=74). RESULTS: 32% of participants had ≥1 fall in the preceding year, and 37.3% were classified high falls risk using the EFST (cut-off ≥2). In contrast, for the 74 participants assessed with the FROP-Com, only 14.9% were rated high risk, 35.8% moderate risk, and 49.3% low risk. The FROP-Com screen and assessment tools had the highest classification accuracy for identifying fallers in the preceding year (area under curve >0.85), with sensitivity/specificity highest for the FROP-Com assessment (cut-off ≥12), sensitivity=0.84 and specificity=0.73. CONCLUSIONS: Falls are common in older Indigenous Australians. The FROP-Com falls risk assessment tool appears useful in this population, and this research suggests changes that may improve its utility further.

Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability.

OBJECTIVES: Frailty represents a loss of homeostasis, markedly increasing the risk of death and disability. Frailty has been measured in several ethnic groups, but not, to our knowledge, in Aboriginal Australians. We aimed to determine the prevalence and incidence of frailty, and associations with mortality and disability, in remote-living Aboriginal people. STUDY DESIGN: Between 2004 and 2006, we recruited 363 Aboriginal people aged ≥ 45 years from 6 remote communities and one town in the Kimberley region of Western Australia (wave 1). Between 2011 and 2013, 182 surviving participants were followed-up (wave 2). We assessed frailty with an index, comprising 20 health-related items. Participants with ≥ 4 deficits (frailty index ≥ 0.2) were considered frail. Disability was assessed by family/carer report. Those unable to do ≥ 2 of 6 key or instrumental activities of daily living were considered disabled. We investigated associations between frailty, and disability and mortality, with logistic regression and Cox proportional hazards models. RESULTS: At wave 1 (W1), 188 participants (65.3%) were frail, and of robust people at W1 who participated in wave 2, 38 (51.4%) had become frail. Frailty emerged at a younger age than expected. A total of 109 people died (30.0%), of whom 80 (73.4%) were frail at W1. Frailty at W1 was not associated with becoming disabled, but was associated with mortality (HR = 1.9; 95% CI 1.2, 3.0). CONCLUSIONS: Frailty in remote-living Aboriginal Australians is highly prevalent; substantially higher than in other populations. Research to understand the underlying causes of frailty in this population, and if possible, reverse frailty, is urgently needed.

Incidence and predictors of cognitive impairment and dementia in Aboriginal Australians: A follow-up study of 5 years.

INTRODUCTION: Aboriginal Australians are reported to develop dementia earlier than the general population. The causes remain unknown. METHODS: This was a longitudinal study of 363 participants aged ≥45 years. Consensus diagnoses were established for cognitive impairment or dementia. RESULTS: At follow-up, 189 people (mean ± standard deviation age, 65.4 ± 10.3 years) participated, as 109 (30%) had died and 65 (18%) were unavailable. The incidence of cognitive impairment or dementia was 52.6 (95% confidence interval 33.9, 81.5) per 1000 person-years (380.3 total person-years) and for dementia was 21.0 (10.5, 42.1) per 1000 person-years (380.3 person-years total) over the age 60 years. Longitudinal risk factors associated with a decline from normal cognition to impairment were age and head injury. Other associations with cognitive decline were stroke, head injury, nonaspirin analgesics, lower BMI, and higher systolic BP. DISCUSSION: Dementia incidence in Aboriginal Australians is among the highest in the world, and is associated with age and head injury.

The Kimberley assessment of depression of older Indigenous Australians: prevalence of depressive disorders, risk factors and validation of the KICA-dep scale.

OBJECTIVE: This study aimed to develop a culturally acceptable and valid scale to assess depressive symptoms in older Indigenous Australians, to determine the prevalence of depressive disorders in the older Kimberley community, and to investigate the sociodemographic, lifestyle and clinical factors associated with depression in this population. METHODS: Cross-sectional survey of adults aged 45 years or over from six remote Indigenous communities in the Kimberley and 30% of those living in Derby, Western Australia. The 11 linguistic and culturally sensitive items of the Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep) scale were derived from the signs and symptoms required to establish the diagnosis of a depressive episode according to the DSM-IV-TR and ICD-10 criteria, and their frequency was rated on a 4-point scale ranging from 'never' to 'all the time' (range of scores: 0 to 33). The diagnosis of depressive disorder was established after a face-to-face assessment with a consultant psychiatrist. Other measures included sociodemographic and lifestyle factors, and clinical history. RESULTS: The study included 250 participants aged 46 to 89 years (mean±SD = 60.9±10.7), of whom 143 (57.2%) were women. The internal reliability of the KICA-dep was 0.88 and the cut-point 7/8 (non-case/case) was associated with 78% sensitivity and 82% specificity for the diagnosis of a depressive disorder. The point-prevalence of a depressive disorder in this population was 7.7%; 4.0% for men and 10.4% for women. Heart problems were associated with increased odds of depression (odds ratio = 3.3, 95% confidence interval = 1.2,8.8). CONCLUSIONS: The KICA-dep has robust psychometric properties and can be used with confidence as a screening tool for depression among older Indigenous Australians. Depressive disorders are common in this population, possibly because of increased stressors and health morbidities.

Patient perceptions of the potential lethality associated with deliberate self-poisoning.

INTRODUCTION: Little is known about patient perceptions of the lethality of their overdose. Our aim was to compare patient perceptions with the risk assessment of clinical toxicologists. METHODS: A prospective observational study of overdose patients presenting to a tertiary hospital. Eligible patients were surveyed once they were medically fit for psychiatric evaluation. Descriptive data were collected, including the Pierce Suicide Intent Scale (SIS). In response to 'how dangerous did you think this overdose was when you took the tablets?' patients marked a 10 cm VAS, with 0 = would be harmless, 10 = certain to cause death. A panel of clinical toxicologists independently made a risk assessment on a 10 cm VAS, with 0 = non-toxic ingestion and 10 = uniform lethality even with full medical intervention. RESULTS: Of 202 patients enrolled, 118 (58.4%, 95% CI 51-65) were female; median age 33 years (interquartile range [IQR] 24-42). One hundred and three (51%, 95% CI 44-58) stated it was their intention to kill themselves and 44 (21.8%, 95% CI 16-28) wrote a suicide note. They most commonly used their own prescription medications (141, 69.8%, 95% CI 63-76). The median patient visual analog scale (VAS) was 5.8 (IQR 2.3-8.3) and median toxicology VAS was 1.4 (IQR 0.6-2.8); this difference was statistically significant (P < 0.0001). The correlation between the patient visual analog scale (VAS) and Pierce SIS (median 8.5/25 [IQR 4-12]) was strong (r= 0.73, P < 0.0001). CONCLUSIONS: Patient perceptions of the lethality of their overdose are correlated with their suicidal intent as measured on the Pierce SIS, with a significant mismatch between patient perceptions and the toxicological risk assessment.

The B-VITAGE trial: a randomized trial of homocysteine lowering treatment of depression in later life.

BACKGROUND: Depression is a leading cause of disability worldwide and depressive symptoms are common in later life. Observational evidence suggests that depression is more prevalent among people with high plasma homocysteine (tHcy), but the results of randomized trials to date have been unable to show that lowering tHcy through the supplementation of vitamins B6, B12 and folate benefits depressive symptoms. We designed the B-VITAGE trial to determine whether adjunctive treatment with vitamins B6, B12 and folate increases the efficacy of standard antidepressant treatment. METHODS/DESIGN: The B-VITAGE trial is a 12-month randomized, double-blind, placebo-controlled trial of daily citalopram (20 to 40 mg) plus B12(0.5 mg), B6 (25 mg) and folic acid (2 mg) or citalopram (20 to 40 mg) plus placebo for the treatment of depression in later life. The trial aims to recruit over 300 older adults with major depression (DSM-IV) and has been powered to detect the impact of an intervention associated with moderate effect size. Depressive symptoms will be rated with the Montgomery-Asberg Depression Rating Scale (MADRS). The trial has two main outcomes of interest: a reduction of 50% or more in the MADRS total score between baseline and week 12 and the remission of the depressive episode at weeks 12, 26 and 52 according to DSM-IV criteria. We hypothesize that subjects randomly allocated to the vitamin arm of the study will be more likely to show a clinically significant improvement and achieve and maintain remission of symptoms at 12, 26 and 52 weeks. Secondary outcomes of interest include compliance with treatment, reduction in the severity of depressive symptoms, switching to different antidepressants, the use of non-pharmacological antidepressant treatments, response to treatment according to MTHFRC677T genotype, and changes in cognitive function over 52 weeks. CONCLUSIONS: The results of this trial will clarify whether the systematic use of B-vitamins improves the response of older adults to standard antidepressant treatment. We anticipate that our findings will have implications for clinical practice and health policy development. TRIAL REGISTRATION: The trial is registered with the Australian Clinical Trials Registry, trial number (())ACTRN12609000256279.

Bipolar disorder: similarities and differences between patients with illness onset before and after 65 years of age.

BACKGROUND: Recent reports have suggested that bipolar disorder beginning in late life is strongly associated with organic brain disease whereas early-onset cases are more likely to be associated with a family history of mood disorder. It is not yet clear whether late-onset bipolar disorder is therefore a "phenocopy" of the classic early-onset disorder, sharing symptoms but having a different etiology, or whether people with early- and late-onset bipolar disorder have a common underlying vulnerability that interacts with age-specific triggering factors. AIM: The present study examines the administrative records of patients treated for bipolar disorder, to establish whether differences between early- and late-onset cases might be consistent with their having distinct etiological processes. METHODS: We used a file containing administrative data for all patients with a diagnosis of bipolar disorder who were in contact with the health services of Western Australia between 1980 and 1998. For each contact with psychiatric services, the file provided the patient's age, gender, marital status, educational achievement, employment, ethnic origin, postcode of residence, primary and secondary diagnoses, and the duration of the (administrative) episode. Subjects were designated "late-onset" when their first contact with psychiatric services occurred at or after 65 years of age. RESULTS: Between 1980 and 1998 there were 33,004 service contacts involving 6,182 individuals whose primary or secondary clinical diagnosis was bipolar disorder. This indicates that the prevalence of bipolar disorder in Western Australia is approximately 0.4%. Most patients had an onset of illness between 15 and 45 years of age, but 492 patients (8%) were aged 65 years or over at the time of first contact with mental health services. We observed that the relative frequency of late-onset bipolar disorder increased between 1980 and 1998 (1% to 11%). There was an excess of women in our cohort (3:2), but no difference in the age of onset between males and females. Early onset was associated with a subsequently lower socioeconomic status, aboriginal ethnicity, and a higher frequency of mixed affective episodes, other mood disorders, schizophrenia, and schizoaffective disorder. Patients with late-onset bipolar disorder were more likely to have a diagnosis of organic mental disorder recorded (2.8% vs. 1.2%). There was no evidence of a bimodal pattern of age-specific incidence. CONCLUSION: The observed differences between early- and late-onset bipolar disorders are small and most likely attributable to differences in the duration of illness. Only a small proportion of patients with bipolar disorder were ever diagnosed with an organic mental disorder, which suggests that the reported association between late onset of illness and organic factors may be of limited clinical relevance.

Successful treatment of behavioural problems in dementia using a cholinesterase inhibitor: the ethical questions.

OBJECTIVE: To review the effect of cholinesterase inhibitors on the behavioural and neuropsychiatric symptoms of dementia and discuss the current clinical guidelines for the prescription of cholinesterase inhibitors in Australia. METHOD: This paper reports the case of a patient with clinical diagnosis of dementia with lewy bodies (DLB) who was referred to an old age psychiatry service for the treatment of severe visual hallucinations and behavioural problems. RESULTS: Pharmacological treatment with olanzapine produced marked parkinsonism, agitation and confusion. A cholinesterase inhibitor, donepezil, was introduced. The introduction of donepezil was associated with cognitive improvement (mini-mental state examination [MMSE] increased from 23 to 27) and complete remission of behavioural symptoms. CONCLUSION: That cholinesterase inhibitors may have a role in the management of behavioural symptoms of dementia and the current Australian PBS guidelines for prescribing cholinesterase inhibitors are clinically restrictive. This has clinical and ethical implications that need to be addressed by consumers, the medical community and regulating authorities.