The body of evidence of late-life depression: the complex relationship between depressive symptoms, movement, dyspnea and cognition.

BACKGROUND: Physical symptoms play an important role in late-life depression and may contribute to residual symptomatology after antidepressant treatment. In this exploratory study, we examined the role of specific bodily dimensions including movement, respiratory functions, fear of falling, cognition, and physical weakness in older people with depression. METHODS: Clinically stable older patients with major depression within a Psychiatric Consultation-Liaison program for Primary Care underwent comprehensive assessment of depressive symptoms, instrumental movement analysis, dyspnea, weakness, activity limitations, cognitive function, and fear of falling. Network analysis was performed to explore the unique adjusted associations between clinical dimensions. RESULTS: Sadness was associated with worse turning and walking ability and movement transitions from walking to sitting, as well as with worse general cognitive abilities. Sadness was also connected with dyspnea, while neurovegetative depressive burden was connected with activity limitations. DISCUSSION: Limitations of motor and cognitive function, dyspnea, and weakness may contribute to the persistence of residual symptoms of late-life depression.

Physical exercise for late-life depression: Effects on symptom dimensions and time course.

BACKGROUND: Physical exercise is increasingly recognized as a treatment for major depression, even among older patients. However, it is still unknown which depressive symptoms exercise affects most, (e.g. somatic vs. affective) and the timing of its effects. Thus, the aim of this study was to examine the changes of depressive symptoms after treatment with exercise. METHODS: We analyzed data from the SEEDS study, a trial comparing the antidepressant effectiveness of sertraline (S) and sertraline plus exercise (S+EX). Exercise was delivered thrice weekly in small groups and monitored by heart rate meters. Patients with late life depression (n=121) were assessed at baseline, 4, 8, 12 and 24 weeks with the Hamilton Depression Scale. Scores of affective, vegetative, anxiety and agitation/insight factors were analyzed using Multilevel Growth Curve Models and sensitivity analyses (multiple imputation). RESULTS: Compared with the S group, patients in the S+EX group displayed significantly greater improvements of the affective symptom dimension (total effect size = 0.79) with largest changes in the first 4 weeks and last 12 weeks. Improvements were mainly driven by depressed mood and psychomotor retardation. LIMITATIONS: Sample size; lack of an exercise only treatment arm CONCLUSIONS: Adding exercise to antidepressant drug treatment may offer significant advantages over affective symptoms of depression, rather than somatic symptoms or other dimensions of depression. Compared with standard antidepressant treatment, clinical advantages should be expected both at an early (first 4 weeks) and later stage (after 12 weeks).

Antithrombotic prophylaxis of atrial fibrillation in an Italian real-world setting: a retrospective study.

OBJECTIVES: The aims of this study were to assess the prevalence of diagnosed atrial fibrillation (AF), the drug use in patients with AF in terms of antithrombotic (AT) strategies used and the compliance with treatment, and to describe the characteristics of patients affected by AF in relation to treatment. METHODS: The data collected were provided from databases of general practitioners (GPs) of the Local Health Unit of Bologna in Italy. From January 1, 2009, to December 31, 2012, all subjects aged ≥18 years followed by the 44 GPs enrolled in the study were evaluated, and the subjects with a diagnosis of AF were included in the analysis. RESULTS: From 2009 to 2012, we identified 1,413 patients with a diagnosis of AF (2.09% of 67,517 patients of the 44 GPs). A total of 1,413 patients with a diagnosis of AF (2.09% of 67,517 patients of the 44 GPs) were enrolled in the study. During the study, 14% of the enrolled patients did not receive any prescription of ATs, 30% and 39.56% were treated only with antiplatelet (AP) agents and oral anticoagulants (OACs), respectively, and 16.28% of the patients received prescriptions for both an OAC and an AP agent; of the patients receiving prescriptions for both, only 4.17% received these therapies at the same time. Among the OAC users, the percentage of patients still on treatment with the index drug during the last 3 months of observation was 76.9%. CONCLUSION: Our findings emphasize that in an Italian real-world setting, the burden of AF in general population from a public health point of view underscores the need for improvement in utilization of appropriate ATs in patients with known AF.

Physical Exercise for Late-Life Depression: Effects on Heart Rate Variability.

OBJECTIVES: Late-life major depression is associated with increased cardiovascular risk and impaired autonomic control of the heart, as evident from reduced heart rate variability (HRV). Moreover, antidepressant drug therapy also might be associated with further reductions of HRV. In the SEEDS study, we investigated whether sertraline associated with physical exercise protocols led to improvements of HRV, compared with antidepressant drug therapy alone. DESIGN: Single-blind randomized controlled trial. SETTING: Psychiatric consultation-liaison program for primary care. PARTICIPANTS: Patients aged 65-85 years with major depression, recruited from primary care. INTERVENTIONS: Sertraline plus structured, tailored group physical exercise (S + EX) versus sertraline alone (S) for 24 weeks. MEASUREMENTS: HRV indices (RR, percentage of NN intervals greater than 50 msec [pNN50], square root of the mean squared differences of successive NN intervals [RMSSD], standard deviation of heart rate [SDHR], standard deviation of the NN interval [SDNN], high-frequency band [HF], low-frequency band [LF], and their ratio [LF/HF]) were measured at baseline, week 12, and week 24. Psychiatric and medical assessments. RESULTS: Participants displayed significant improvements of most HRV indices over time, irrespective of the group assignment (pNN50, RMSSD, SDHR, SDNN, HF, LF, and LF/HF). Moreover, patients in the S + EX group displayed greater increases of different HRV indices(RR, pNN50, RMSSD, SDHR, SDNN, HF, and LF) compared with those in the S group. CONCLUSIONS: The combination of structured physical exercise and sertraline might exert positive effects on the autonomic control of the heart among older patients with major depression.

Stroke prophylaxis in high-risk patients with atrial fibrillation: rhythm vs. rate control strategy.

PURPOSE: "Rhythm" and "Rate" control strategies require partially different organization, and a different involvement of Specialists and General Practitioners; we verified whether the strategy assignment modified the approach to stroke prophylaxis. METHODS: Survey in general practice: 233 GPs identified all patients with codified atrial fibrillation (AF) diagnosis, checked the diagnosis (ECG/hospital discharge document), and filled a structured questionnaire on stroke risk-factors, prophylactic therapy, and reasons for warfarin non prescription in CHADS ≥2 patients. Data were collected as an "aggregate." RESULTS: Population observed: 295,906 patients aged >14; 6,036 with confirmed AF; 5,888 with complete data about anti-thrombotic prophylaxis are analyzed here. In the "rhythm strategy" group 45.6% of the CHADS score ≥2 patients (594) were on warfarin, vs. 73.2% (1,741) in the "rate strategy" group (p<0.0001). Overall reasons for warfarin non-use were significantly different in the two groups: clinical contraindications (12.3% vs. 19.7%), side effects (5.5% vs. 8.5%), patients' refusal (12.2% vs. 15.2%), unreliable patient/care-giver (14.4% vs. 25.9%); reasons were unknown to the GP in 55.6% in rhythm control vs. 30.9% in rate control group. CONCLUSIONS: Anti-thrombotic prophylaxis in CHADS ≥2 patients is different in subjects assigned to the Rhythm vs. the Rate control strategy, as well as reported reasons for warfarin non use. GPs do not know why warfarin is not used in a large percentage of cases, mainly in the rhythm control strategy group. Improving efforts should probably be differently tailored for patients assigned to the "rhythm" or the "rate" control strategy.

Frequency, patient characteristics, treatment strategies, and resource usage of atrial fibrillation (from the Italian Survey of Atrial Fibrillation Management [ISAF] study).

Atrial fibrillation (AF) is 1 of the most important healthcare issues and an important cause of healthcare expenditure. AF care requires specific arrhythmologic skills and complex treatment. Therefore, it is crucial to know its real affect on healthcare systems to allocate resources and detect areas for improving the standards of care. The present nationwide, retrospective, observational study involved 233 general practitioners. Each general practitioner completed an electronic questionnaire to provide information on the clinical profile, treatment strategies, and resources consumed to care for their patients with AF. Of the 295,906 patients screened, representative of the Italian population, 6,036 (2.04%) had AF: 20.2% paroxysmal, 24.3% persistent, and 55.5% permanent AF. AF occurred in 0.16% of patients aged 16 to 50 years, 9.0% of those aged 76 to 85 years, and 10.7% of those aged ≥85 years. AF was symptomatic despite therapy in 74.6% of patients and was associated with heart disease in 75%. Among the patients with AF, 24.8% had heart failure, 26.8% renal failure, 18% stroke/transient ischemic attack, and 29.3% had ≥3 co-morbidities. The rate control treatment strategy was pursued in 55%. Of the 6,036 patients with AF, 46% received anticoagulants. The success rate of catheter ablation of the AF substrate was 50%. In conclusion, in our study, the frequency of AF was 2 times greater than previously reported (approximately 0.90%), rate control was the most pursued treatment strategy, anticoagulants were still underused, and the success rate of AF ablation was lower than reported by referral centers.