Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review.

PURPOSE: Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing. METHODS: A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium. RESULTS: Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication. CONCLUSIONS: Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.

Specialized Care Resources for Diagnosis and Management of Patients Who Have Suffered Falls: Results of a National Survey in Geriatric Units.

INTRODUCTION: Clinical guidelines recommend comprehensive multifactorial assessment and intervention to prevent falls and fractures in older populations. METHODS: A descriptive study was conducted by the Falls Study Group of the Spanish Geriatric Medicine Society (SEMEG) to outline which types of healthcare-specific resources were assigned for fall assessment in Spanish geriatric departments. A self-reported seven-item questionnaire was delivered from February 2019 to February 2020. Where geriatric medicine departments were not available, we tried to contact geriatricians working in those areas. RESULTS: Information was obtained regarding 91 participant centers from 15 autonomous communities, 35.1% being from Catalonia and 20.8% from Madrid. A total of 21.6% reported a multidisciplinary falls unit, half of them in geriatric day hospitals. Half of them reported fall assessment as part of a general geriatric assessment in general geriatric outpatient clinics (49.5%) and, in 74.7% of cases, the assessment was based on functional tests. A total of 18.7% reported the use of biomechanical tools, such as posturography, gait-rides or accelerometers, for gait and balance analysis, and 5.5% used dual X-ray absorptiometry. A total of 34% reported research activity focused on falls or related areas. Regarding intervention strategies, 59% reported in-hospital exercise programs focused on gait and balance improvement and 79% were aware of community programs or the pathways to refer patients to these resources. CONCLUSIONS: This study provides a necessary starting point for a future deep analysis. Although this study was carried out in Spain, it highlights the need to improve public health in the field of fall prevention, as well as the need, when implementing public health measures, to verify that these measures are implemented homogeneously throughout the territory. Therefore, although this analysis was at the local level, it could be useful for other countries to reproduce the model.

[An opportunity to identify and prevent frailty through falls intervention.] / Oportunidad para la detección y manejo precoz de la fragilidad a través del abordaje de las caídas.

Falls are one of the classic giant geriatric syndromes with a multifactorial etiopathogenesis and closely related to frailty, being this relationship bidirectional. The Consensus Document on the Prevention of Frailty and Falls approved by the Interterritorial Council of the National Health System in 2014 provides recommendations for the screening of frailty and falls in all older adults in order to develop a management plan in high risk older adults so to prevent disability. This review describes the intrinsic relationship between frailty and falls, falls assessment and screening instruments to use and detect frailty and finally gives evidence-based recommendations to reduce falls impact.

Las caídas son uno de los grandes síndromes geriátricos, con una etiopatogenia multifactorial y con una estrecha relación con la fragilidad, siendo esta relación bidireccional. El Documento de Consenso sobre Prevención de Fragilidad y Caídas aprobado por el Consejo Interterritorial del Sistema Nacional de Salud en 2014, propone un cribado universal de fragilidad y riesgo de caídas, con el objetivo de intervenir en aquellos ancianos de alto riesgo y por tanto prevenir discapacidad. Esta revisión evalúa la relación intrínseca entre caídas y fragilidad, describe las herramientas de valoración del paciente que presenta caídas, incidiendo en aquellos aspectos que detectan fragilidad y finalmente propone intervenciones que han demostrado reducir su impacto.

Endothelin-1 induces cellular senescence and fibrosis in cultured myoblasts. A potential mechanism of aging-related sarcopenia.

Endothelial dysfunction, with increased endothelin-1 (ET-1) synthesis, and sarcopenia, characterized by the loss of muscular mass and strength, are two aging-related conditions. However, a relationship between them has not been already established. The aim of this study was to determine whether ET-1 induces senescence and fibrosis in cultured murine myoblasts, which could be involved in the development of sarcopenia related to aging. For this purpose, myoblasts were incubated with ET-1 to assess cellular senescence, analyzed by senescence associated ß-galactosidase activity and p16 expression; and fibrosis, assessed by fibronectin expression. ET-1 induced myoblast senescence and fibrosis through ETA receptor. The use of antioxidants and several antagonists revealed that ET-1 effect on senescence and fibrosis depended on ROS production and activation of PI3K-AKT-GSK pathway. To stress the in vivo relevance of these results, circulating ET-1, muscular strength, muscular fibrosis and p16 expression were measured in male C57Bl6 mice from 5-18-24-months-old. Old mice shown high levels of ET-1 correlated with muscular fibrosis, muscular p16 expression and loss of muscle strength. In conclusion, ET-1 promotes fibrosis and senescence in cultured myoblasts, similar results were found in old mice, suggesting a potential role for ET-1 in the development of sarcopenia related to aging.

Psicofármacos inadecuados, pero no psicofármacos adecuados, cambian las carácterísticas de la marcha / No disponible

Los factores que modifican la marcha son los que clásicamente han sido identificados como factores de riesgo de caídas y su tratamiento una de las bases de la prevención de caídas y mejora en la estabilidad de la marcha. La velocidad de la marcha ha demostrado ser un buen predictor de caídas. Siendo común en el tratamiento de inestabilidades de la marcha el ejercicio físico, la reducción de polifarmacia y la retirada de psicofármacos. Sin embargo, en la práctica clínica diaria debido a la alta prevalencia de trastornos afectivos y ansiedad en las personas mayores, no siempre es posible la retirada de los psicofármacos. Por otro lado, a la hora de hablar de fármacos en las personas mayores hay criterios bien definidos que categoriza a los fármacos según sus características farmacocinéticas en inadecuados y adecuados, pero a la hora de analizar los psicofármacos y la marcha, pocos son los artículos que hace la distinción entre psicofármacos adecuados e inadecuados. El objetivo de este estudio es analizar si los sujetos que toman psicofármacos inadecuados tienen velocidades de la marcha inferiores de los sujetos que toman psicofármacos adecuados y de los que no los toman. Métodos: Estudio observacional transversal. Se seleccionaron 120 personas con marcha independiente, libres de discapacidad. Los criterios de exclusión fueron discapacidad mental o física, enfermedades que pudieran modificar la marcha, enfermedad aguda en los últimos 6 meses o mal pronóstico a corto plazo. La velocidad de la marcha fue lanzada medida a los 6 metros. El análisis estadístico fue una regresión lineal, la variable dependiente fue la velocidad de la marcha y la independiente la edad, el sexo, los psicofármacos adecuados e inadecuados. Resultados: En el modelo multivariante ajustado por edad (B = 0,025, p<0,001) y sexo (ser hombre B = 0,226 y p = 0,047), los sujetos que tomaban psicofármacos inadecuados tenían medias de velocidad de la marcha disminuidas en 0,1 m/seg (B= 0,114, p=0,040) respecto los que no los tomaban, sin embargo los sujetos que tomaban psicofármacos adecuados no tenían cambios estadísticamente significativos en las medias de su velocidad de la marcha (B= 0,023, p=0,672).Conclusiones: Este estudio es un análisis preliminar, que abre una nueva línea de investigación. Los sujetos que tomaban psicofármacos inadecuados tenían medías de velocidad de la marcha clínica y estadísticamente inferiores que los que no los tomaban. Sin embargo, en las personas que tomaban psicofármacos adecuados no presentaban cambios estadísticamente significativos. Dada la alta prevalencia de enfermedad ansiosa depresiva en las personas mayores, sería conveniente realizar nuevos estudios para comprobar si a las personas que tomaban psicofármacos inadecuados y tienen problemas en la estabilidad de su marcha, si al cambiarles a un psicofármaco adecuado ven disminuida dicha inestabilidad

The factors that modify gait are those that have been classically identified as risk factors for falls and their treatment is one of the bases for preventing falls and improving gait stability. The speed of walking has proven to be a good predictor of falls. Physical exercise, the reduction of polypharmacy and the withdrawal of psychotropic drugs are common in the treatment of gait instabilities. However, in daily clinical practice due to the high prevalence of affective disorders and anxiety in the elderly, the withdrawal of psychotropic drugs is not always possible. On the other hand, when talking about drugs in older people there are well-defined criteria that categorize drugs according to their pharmacokinetic characteristics in inadequate and appropriate, but when analysing psychotropic drugs and walking, there are few articles that make the distinction between appropriate and inadequate psychotropic drugs. The aim of this study is to analyse whether subjects who take inappropriate psychotropic drugs have lower gait speeds of subjects who take appropriate psychotropic drugs and those who do not. Methods: Cross-sectional observational study. 120 people were selected with independent march, free of disability. Exclusion criteria were mental or physical disability, diseases that could modify the gait, acute illness in the last 6 months or poor shortterm prognosis. The speed of the march was released measured at 6 meters. The statistical analysis was a linear regression, the dependent variable was the speed of the march and the independent age, sex, the appropriate and inadequate psychotropic drugs. Results: In the multivariate model adjusted for age (B = 0.025, p <0.001) and sex (being male B = 0.226 and p = 0.047), the subjects taking inappropriate psychotropic drugs had gait speed averages decreased by 0.1 m / sec (B = 0.114, p = 0.040) with respect to those who did not take them; however, the subjects who took adequate psychotropic drugs did not have statistically significant changes in the means of their gait speed (B = 0.023, p = 0.672). Conclusions: This study is a preliminary analysis, which opens a new line of research. Subjects who took inappropriate psychotropic drugs had gait velocity medically and statistically lower than those who did not. However, in people who took adequate psychotropic drugs, they did not show statistically significant changes. Given the high prevalence of anxious depressive illness in the elderly, it would be advisable to carry out further studies to check whether people who took inappropriate psychotropic drugs and have problems in the stability of their march, if changing them to a suitable psychotropic drug, this instability is diminished