An observational study of psychotropic drug use and initiation in older patients resident in their own home or in care.

OBJECTIVE: to compare the prescription of psychotropic medications for patients living in care homes with that for patients living at home. DESIGN AND SETTING: retrospective population database study in the Tayside region of Scotland. SUBJECTS: 70,297 patients aged ≥65 and followed until death or the end of the study. METHODS: examining registered addresses for all people aged 65-99 identified those in care. The prescriptions for a 12-week period was examined and psychotropic drug use compared by their place of residence. Comparisons of prescriptions pre- and post-admission were performed for people admitted to a care home from Jan 2005 to Dec 2006. RESULTS: people living in care (4.1%) received 9.80 more prescribed items (P < 0.001) from 1.63 more British National Formulary (BNF) categories (P < 0.001) than people living at home over a 12-week period. They were more likely to receive any psychotropic medication (42 versus 16%, odds ratio (OR) 3.09, 95% CI: 2.79-3.41). Over 70% of 1,715 people admitted to care homes during the study who received psychotropic medication commenced the medication prior to admission. Patients who started anti-psychotics in the 30 days prior to admission were less likely to have stopped them (OR: 0.53, 95% CI: 0.30-0.94). CONCLUSION: prolonged prescription of psychotropic medications is commonplace in care home residents. Almost half of the people prescribed antipsychotic drugs received them for a minimum of 6 months. Systematic medication reviews must be established in all care homes to promote safe and effective prescription to this at-risk population.

The burden of psychotropic drug prescribingin people with dementia: a populationdatabase study.

OBJECTIVE: to compare psychotropic prescribing in older people with dementia and the general elderly population. DESIGN AND SETTING: retrospective population database study in 315 General Practices. SUBJECTS: there were 271,365 patients aged > or = 65, of which 10,058 (3.7%) recorded as having dementia. METHODS: epidemiology of psychotropic prescribing in older people with and without dementia; multilevel modelling of patient and practice characteristics associated with antipsychotic prescribing. RESULTS: people with dementia were currently prescribed an antipsychotic drug (17.7%), an antidepressant (28.7%) and a hypnotic/anxiolytic (16.7%). Compared to the general elderly population, antipsychotic prescribing was 17.4 [95% confidence interval (CI) 16.4-18.4], antidepressant prescribing 2.7 (95% CI 2.6-1.8) and hypnotic/anxiolytics 2.2 (95% 2.1-2.3) times more likely in people with dementia. Most antipsychotic prescribing in people with dementia was prolonged (> 16 weeks). Patients living in more deprived areas and registered with larger and more remote practices were more likely to be prescribed prolonged antipsychotics. CONCLUSIONS: over one in six patients are currently prescribed antipsychotic drugs known to be of little benefit and causing significant harm, with other psychotropics equally commonly used. Changing this will require investment in services to support alternative management strategies for people with behavioural and psychological disturbance associated with dementia.

Psychosocial, psychopharmacological and demographic predictors of changes in psychological distress over a course of computerised cognitive behavioural therapy (cCBT).

Social group identification, socioeconomic deprivation, and a number of other clinical and demographic factors have been found to predict severity of psychological distress prior to treatment in those referred to receive computerised cognitive behavioural therapy (cCBT) as an intervention for mild to moderate depression. The aim of the current study is to investigate whether the same key factors are able to predict magnitude of change in psychological distress across treatment in a sample receiving cCBT. Participants (N = 1158) consisted of individuals completing the 'Beating the Blues' (BtB) programme. Participants completed three versions of the group identifications scale (GIS), one for each of three groups: family, community, and a social group of choice. Changes in psychological distress showed statistically significant improvements between pre- and post-treatment assessment in all outcome measure subscales. Significantly greater changes (reductions) in psychological distress were found in those who had more severe pre-treatment psychological distress, those who lived in a lesser state of socioeconomic deprivation, those who identified with more social groups, and those taking antidepressant medication (ADM) concurrently. These findings provide valuable information on the likely course of treatment in those receiving cCBT, and highlight both the potential of social group identification as a 'social cure' for poor psychological health and the inequalities of the socioeconomic health gradient.

Activation of PI 3-kinase by the hexosamine biosynthesis pathway.

It has been shown that hyperglycaemia-induced defects in glucose transport and insulin action are mediated by increased flux of excess glucose through the hexosamine biosynthesis pathway (HBP). We have previously demonstrated that in rat adipocytes, increased flux through the HBP activates protein kinase C (PKC). The aim of the present study was to explore the mechanism for HBP-mediated activation of PKC. We show that activation of the HBP by either high glucose or glucosamine causes the translocation of PKC-zeta/lambda and PKC-epsilon but not other PKC isoforms tested (alpha, beta, delta). This translocation was inhibited by wortmannin, a PI 3-kinase inhibitor. Both high glucose and glucosamine caused widespread cellular activation of PI 3-kinase. We demonstrate that HBP-mediated activation of PI 3-kinase has an insulin-like effect to translocate GLUT4. We conclude that an acute increase of glucose flux through the HBP activates PI 3-kinase.

Differential impact of two risk communications on antipsychotic prescribing to people with dementia in Scotland: segmented regression time series analysis 2001-2011.

BACKGROUND: Regulatory risk communications are an important method for disseminating drug safety information, but their impact varies. Two significant UK risk communications about antipsychotic use in older people with dementia were issued in 2004 and 2009. These varied considerably in their content and dissemination, allowing examination of their differential impact. METHODS: Segmented regression time-series analysis 2001-2011 for people aged ≥65 years with dementia in 87 Scottish general practices, examining the impact of two pre-specified risk communications in 2004 and 2009 on antipsychotic and other psychotropic prescribing. RESULTS: The percentage of people with dementia prescribed an antipsychotic was 15.9% in quarter 1 2001 and was rising by an estimated 0.6%/quarter before the 2004 risk communication. The 2004 risk communication was sent directly to all prescribers, and specifically recommended review of all patients prescribed relevant drugs. It was associated with an immediate absolute reduction in antipsychotic prescribing of 5.9% (95% CI -6.6 to -5.2) and a change to a stable level of prescribing subsequently. The 2009 risk communication was disseminated in a limited circulation bulletin, and only specifically recommended avoiding initiation if possible. There was no immediate associated impact, but it was associated with a significant decline in prescribing subsequently which appeared driven by a decline in initiation, with the percentage prescribed an antipsychotic falling from 18.4% in Q1 2009 to 13.5% in Q1 2011. There was no widespread substitution of antipsychotics with other psychotropic drugs. CONCLUSIONS: The two risk communications were associated with reductions in antipsychotic use, in ways which were compatible with marked differences in their content and dissemination. Further research is needed to ensure that the content and dissemination of regulatory risk communications is optimal, and to track their impact on intended and unintended outcomes. Although rates are falling, antipsychotic prescribing in dementia in Scotland remains unacceptably high.

Cost (non)-recovery by platform technology facilities in the Bio21 Cluster.

Platform technologies (PT) are techniques or tools that enable a range of scientific investigations and are critical to today's advanced technology research environment. Once installed, they require specialized staff for their operations, who in turn, provide expertise to researchers in designing appropriate experiments. Through this pipeline, research outputs are raised to the benefit of the researcher and the host institution. Platform facilities provide access to instrumentation and expertise for a wide range of users beyond the host institution, including other academic and industry users. To maximize the return on these substantial public investments, this wider access needs to be supported. The question of support and the mechanisms through which this occurs need to be established based on a greater understanding of how PT facilities operate. This investigation was aimed at understanding if and how platform facilities across the Bio21 Cluster meet operating costs. Our investigation found: 74% of platforms surveyed do not recover 100% of direct operating costs and are heavily subsidized by their home institution, which has a vested interest in maintaining the technology platform; platform managers play a major role in establishing the costs and pricing of the facility, normally in a collaborative process with a management committee or institutional accountant; and most facilities have a three-tier pricing structure recognizing internal academic, external academic, and commercial clients.

Predictors of discharge destination for 234 patients admitted to a combined geriatric medicine/old age psychiatry unit.

OBJECTIVE: To examine the factors that predicted discharge destinations of all patients admitted to a combined geriatric medicine/old age psychiatry unit over a 4-year period. METHOD: Data regarding discharge destinations, active medical problems and demographics of 234 patients admitted to the unit were analysed using non-parametric bivariate correlation and logistic regression analysis. RESULTS: Independence for activities of daily living (ADL) was the key predictor of discharge destination. In combination with the number of active medical problems and dementia severity, independence for activities of daily living (ADL) defined three distinct groups: patients discharged home, patients discharged to a nursing home and patients who died in hospital. CONCLUSIONS: The findings suggest that although the key precipitants of admission to joint geriatric medicine/old age psychiatric care are behavioural and psychiatric, these factors are intercurrent, can be successfully treated in an appropriate environment, and do not play a major role in determining discharge outcome. These findings confirm the broad spectrum of need among older patients admitted to acute medical care identified in previous research and support the case for specialised joint provision to address their physical and mental health needs.

A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression.

OBJECTIVES: This study provides an empirical evaluation of Cognitive Behaviour Therapy (CBT) alone vs Treatment as usual (TAU) alone (generally pharmacotherapy) for late life depression in a UK primary care setting. METHOD: General Practitioners in Fife and Glasgow referred 114 Participants to the study with 44 meeting inclusion criteria and 40 participants providing data that permitted analysis. All participants had a diagnosis of mild to moderate Major Depressive Episode. Participants were randomly allocated to receive either TAU alone or CBT alone. RESULTS: Participants in both treatment conditions benefited from treatment with reduced scores on primary measures of mood at end of treatment and at 6 months follow-up from the end of treatment. When adjusting for differences in baseline scores, gender and living arrangements, CBT may be beneficial in levels of hopelessness at 6 months follow-up. When evaluating outcome in terms of numbers of participants meeting Research Diagnostic Criteria for depression, there were significant differences favouring the CBT condition at the end of treatment and at 3 months follow-up after treatment. CONCLUSIONS: CBT alone and TAU alone produced significant reductions in depressive symptoms at the end of treatment and at 6 months follow-up. CBT on its own is shown to be an effective treatment procedure for mild to moderate late life depression and has utility as a treatment alternative for older people who cannot or will not tolerate physical treatment approaches for depression.