Aging of persons with schizophrenia: analysis of a national dataset.

OBJECTIVES: The number of older adults suffering from schizophrenia is increasing. Despite this, less than 1% of published studies about schizophrenia focus on those older than 65 years. Research indicates these individuals may age differently from the general population due to lifestyle, medication factors, and effects of the disease itself. We aimed to analyze whether schizophrenia was associated with a younger age at first assessment for social care as a proxy measure for accelerated aging. DESIGN: We analyzed the effect of schizophrenia diagnosis, demographics, mood, comorbidities, falls, cognition, and substance use on age at first assessment for social care using linear regression. PARTICIPANTS: We used data from 168,780 interRAI Home Care and Long-Term Care Facility (HC; LTCF) assessments completed from July 2013 to June 2020. RESULTS: When corrected for confounding factors, schizophrenia contributed to age at first assessment being 5.5 years younger (p = 0.0001 Cohen's D = 1.0) than in people free from schizophrenia. Its effect on age at first assessment was second only to smoking. People suffering from schizophrenia also required a higher level of care (long-term care facility rather than home care). People suffering from schizophrenia had significantly higher rates of diabetes mellitus and chronic obstructive pulmonary disease but otherwise had lower rates of comorbidity than people free from schizophrenia who required care. CONCLUSIONS: Aging with schizophrenia is associated with needing increased social care at a younger age. This has implications for social spending and developing policies to decrease frailty in this population.

The 2023 New Zealand psychiatry of old age services and workforce survey.

OBJECTIVE: The primary objective was to survey the Psychiatry of Old Age (POA) service resources in New Zealand: number of psychiatrists, inpatient beds, and community psychogeriatric beds. A secondary objective was to compare the POA service resources reported by frontline clinicians with official government data. METHODS: The New Zealand Branch of Faculty of POA collected information from a POA representative in each of the 20 districts, along with official government data. RESULTS: Information from 17 services were obtained. POA service resources varied greatly between districts. There were discrepancies between the New Zealand Branch of Faculty of POA and official government data. The number of old age psychiatrist FTEs per 10,000 older adults ranged from 0.3 to 1.1 (mean = 0.7). The number of inpatient beds per 10,000 older adults ranged from 0.0 to 4.1 (mean = 1.6); and the number of psychogeriatric beds per 10,000 older adults ranged from 0.0 to 22.7 (mean = 12.6). CONCLUSIONS: There is an urgent need to address the official government data discrepancies and POA service resource inequalities. This can ensure the "postcode" system that determines psychiatric care for older adults can be effectively eliminated. We also found the number of POA inpatient beds is below the internationally recommended level.

Sexual Assault in Older-Age Adults: Criminal Justice Response in New Zealand.

There is growing recognition that older persons, both male and female, may experience sexual assault. One clearly identified gap in the body of scientific literature is examination of the criminal justice response for older adults who have been sexually assaulted. This retrospective age-group comparative data analysis examines publicly available population and police statistics for 2018 to describe rates (per 100,000) of reported sexual assault across adult age categories (young adult, n = 748; adult, n = 1,478; middle age, n = 290; older adult, n = 58) and compare (using Chi-square bivariate analysis) the criminal justice response to sexual assault for these adult age categories in New Zealand (NZ). Sexual assault was perpetrated against victims across all age and sex groups examined. The rate of reported sexual assault against older adults was significantly lower after the age of 65 years (7.90 per 100,000) compared to younger adults aged 20-64 years (87.57 per 100,000). Across age categories no difference was found in the proportion of cases proceeded to court action. This study raises awareness of the topic of sexual assault perpetrated against older persons and shows that a substantial number of older adults experience sexual assault in cases that do not result in court action. It points to the need for policy-makers to consider the reporting of sexual assaults against older persons to justice services.

Creating opportunities to improve detection of older adult abuse: a national interRAI study.

Despite being recognized as a major global health issue, older adult abuse (OAA) remains largely undetected and under-reported. Most OAA assessment tools fail to capture true prevalence. Follow up of patients where abuse exposure is not easily determined is a necessity. The interRAI-HC (International Resident Assessment Instrument-Home Care) currently underestimates the extent of abuse. We investigated how to improve detection of OAA using the interRAI-HC. Analysis of 7 years of interRAI-HC data from an Aotearoa New Zealand cohort was completed. We identified that through altering the criteria for suspicion of OAA, capture rates of at-risk individuals could be nearly doubled from 2.6% to 4.8%. We propose that via adapting the interRAI-HC criteria to include the "unable to determine" whether abuse occurred (UDA) category, identification of OAA sufferers could be substantially improved. Improved identification will facilitate enhanced protection of this vulnerable population.

Strategies to Prevent Elderly Suicide: A Delphi Consensus Study.

OBJECTIVES: In the next decades, many countries will become 'ageing societies'. This combined with the current high rates of suicide in later life suggests that many older adults may die by suicide before clinical trials can be conducted to demonstrate the best approaches to prevent late-life suicide. METHODS: A New Zealand (NZ) 'expert panel' has reviewed key considerations for suicide prevention interventions in older adults based on existing evidence, where available, and expert opinion. The key considerations were extracted from the current literature. The Delphi survey method was used to reach consensus for identifying interventions to be recommended as part of a national strategy for older adults' suicide prevention. RESULTS: A set of 20 key recommended considerations are presented. The major addition to existing recommendations is the need for 'A suicide prevention strategy for the elderly…' to enhance the national all-ages suicide prevention strategy. CONCLUSION: The recommended statements are offered for consideration by stakeholder groups preparing new interventions, large-scale public healthcare planning and governmental policy.

The Great Escape. Centenarians' exceptional health.

BACKGROUND: Centenarians escapers are those who reached 100 years of age without the diagnosis of any of the common age-related diseases and exploring their characteristics will inform about successful ageing. No previous study has examined centenarians free of common chronic diseases amongst New Zealand centenarians. METHODS: Retrospective observational cross-sectional review of a national dataset determining the prevalence of depression, dementia, diabetes and hypertension, smoking, physical activity and social relationships among older adults (aged 60-99 years) and centenarians. Participants were all older New Zealanders living independently in the community who completed the international Residential Assessment Instrument-Home Care (interRAI-HC) assessment during the study's 5-year period (July 2013-June 2018). RESULTS: The assessments of 292 centenarians (mean age 101.03, SD 1.27 years) and 103,377 elderly (mean age 81.7, SD 5.7 years) were analysed. Compared to the elderly, centenarians were more likely to be female (74.7%, compared with 59.3% elderly, p < 0.001). Centenarians free of common chronic diseases did not differ from other centenarians on any of the analysed variables. Reduction in smoking rates and steady high rates of social engagement were associated with reaching a centenarian status free of common chronic diseases compared with older adults. CONCLUSIONS: Not smoking and being socially engaged throughout older age were associated with being a centenarian free of common chronic diseases. This study adds to our understanding the complexities of attaining exceptional longevity.

Progesterone loading as a strategy for treating postpartum depression.

Postpartum depression (PPD) is a severe disorder that adversely impacts both mothers and infants. It is associated with significant morbidity and mortality and reported prevalence is 11.5% (Ko, Rockhill, Tong, Morrow, & Farr. (2017). MMWR Morbidity and Mortality Weekly Report, 66(6), 153-158). Although PPD's fundamental pathophysiology remains to be fully illuminated, the influence of changes in perinatal hormones such as allopregnanolone (an endogenous progesterone metabolite) are most promising avenues of research. Conventional treatments for PPD are aligned with treatment strategies for depressive disorders. Brexanolone is a small molecule, neuroactive steroid GABAA receptor allosteric modulator consisting of synthetic allopregnanolone and a solubilizing agent. In early 2019, brexanolone received approval in the United States for the treatment of PPD. Brexanolone is only available through a restricted program and is costly. Animal models demonstrate that progesterone prevents depression-like behaviors. However, studies of progesterone's effects in women suffering from PPD are few and inconclusive. We hypothesize that orally dosed progesterone will increase concentrations of allopregnanolone in the central nervous system, which should relieve symptoms of PPD.

Older adults abuse: analysis of a New Zealand national dataset.

Older adult abuse (OAA), defined as abuse, neglect, or mistreatment of persons aged 65 years or older, is a globally pervasive concern, with severe consequences for its victims. While internationally reported rates of OAA are in the range of 5-20% per annum, New Zealand lacks the necessary data to quantify the issue. However, with a growing aging population, an increase in the prevalence of OAA is predicted. We investigated the extent of OAA in New Zealand, utilizing the mandatory interRAI-HC (International Resident Assessment Instrument-home care assessment) dataset, which included 18,884 interviewees from the Southern District Health Board between 2013 and 2019. Findings confirmed our hypothesis that the interRAI assessment is neither sufficiently sensitive nor specific capturing only 3% from a population of increased frailty and thus at higher risk of abuse. We characterized OAA victims as relatively younger males, depressed, and with impaired decision-making capacity. If the interRAIs were to serve as a preliminary screening tool for OAA in New Zealand, it would be germane to implement changes to improve its detection rate. Further studies are urgently called for to test changes in the interRAI that will aid in identifying often missed cases of OAA better and thus offer protection to this vulnerable population.

The Dunedin dementia risk awareness project: pilot study in older adults.

AIMS: The USA and UK governmental and academic agencies suggest that up to 35% of dementia cases are preventable. We canvassed dementia risk and protective factor awareness among New Zealand older adults to inform the design of a larger survey. METHOD: The modified Lifestyle for Brain Health scale quantifying dementia risk was introduced to a sample of 304 eligible self-selected participants. RESULTS: Two hundred and sixteen older adults (≥50 years), with mean ± standard deviation age 65.5 ± 11.4 years (50-93 years), completed the survey (71% response rate). Respondents were mostly women (n = 172, 80%), European (n = 207, 96%), and well educated (n = 100, 46%, with a tertiary qualification; including n = 17, 8%, with a postgraduate qualification). Around half of the participants felt that they were at a future risk of living with dementia (n = 101, 47%), and the majority felt that this would change their lives significantly (n = 205, 95%), that lifestyle changes would reduce their risk (n = 197, 91%), and that they could make the necessary changes (n = 189, 88%) and wished to start changes soon (n = 160, 74%). Only 4 of 14 modifiable risk or protective factors for dementia were adequately identified by the participants: physical exercise (81%), depression (76%), brain exercises (75%), and social isolation (83%). Social isolation was the commonly cited risk factor for dementia, while physical exercise was the commonly cited protective factor. Three clusters of brain health literacy were identified: psychosocial, medical, and modifiable. CONCLUSION: The older adults in our study are not adequately knowledgeable about dementia risk and protective factors. However, they report optimism about modifying risks through lifestyle interventions.

Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no.

OBJECTIVE: Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legalised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that currently have legalised this. In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revision of legislation or changes in practice. CONCLUSIONS: We suggest that this dynamic can be halted by international agreements of medical societies to shun involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have in the past, need to work collectively to meet this ethical challenge.

No country for older men: ageing male suicide in New Zealand.

OBJECTIVE: Suicide rates increase in late life. There is, however, a gap in understanding suicide in the very old. We aimed to underscore the evidence for high rates of death by suicide in the oldest-old men (age 85+) in New Zealand and to provide a conjectural discussion about factors driving these rates. METHOD: Provisional suicide data were obtained from the New Zealand Coronial Services website for the period 2011-2019. Yearly suicide rates for those aged 85+ were plotted over time. Mean suicide rates were calculated for three youth and young adult male cohorts, identified by the Coroner as having very high rates, and compared with the 85+ age cohort. RESULTS: Between 2011 and 2019, rates of death by suicide of older males remained consistently high never overlapping female suicide rates. Mean suicide deaths/100,000 population for all four age cohorts were comparable; 15-19 years: 23.5; 20-24 years: 29.0; 25-29 years: 27.0; 85+ years: 27.9. CONCLUSIONS: Deaths by suicide are very high for older males. In addition to established risk factors, psychosocial adversity as reflected by loneliness, poverty and shift to residential care may be major reasons for the high suicide rates. Research to inform about this vulnerable population and prevention are urgently needed.

Aging of Holocaust Survivors: Discrepancies Between Subjective and General Health in the greater Tel Aviv Area.

BACKGROUND: Aging has been associated with perceived lowering of health, especially in post-traumatic individuals. The effects may be more complex or even different for Holocaust survivors as they age due to their inherited resilience and life perspective. A cross-sectional study was conducted of Holocaust survivors and a matched comparison group recruited from the general Israeli population. All participants underwent a personal interview and completed the Cumulative Illness Rating Scale and a survey of subjective Likert-scale questions about perceived health. The study comprised 214 older adults: 107 Holocaust survivors and 107 comparison participants; 101 women and 113 men. The mean age for the participants was 80.7 ± 4.7 years (range 68-93). Holocaust survivors did not differ from comparison subjects in general health measures (mean 51.50 ± 3.06 vs. 52.27 ± 3.24, respectively). However, the Holocaust survivors' subjective health was significantly lower, F (2,211) = 4.18, P < 0.05, and associated with decreased quality of life. The present study demonstrates the complex interplay between general and subjective health and suggests that future interventions need to focus on improving the psychological and social well-being of Holocaust survivors to achieve successful aging.

Deliberate Self-Harm in Older Adults: A General Hospital Emergency Department Survey.

BACKGROUND: Deliberate self-harm (DSH) increases the danger of future suicide death and the risk increases with age. Self-harm in older adults is often associated with greater suicidal intent and lethality. OBJECTIVES: To investigate clinical and psychosocial variables of older patients (age ≥ 65 years) assessed due to DSH, compared with younger adults. METHODS: Patients admitted to the Emergency Department following DSH during an 8 year period were included. RESULTS: Of 1149 participants, 187 (16.6%) were older adults (age ≥ 65) and 962 (83.4%) were younger adults (< 65). The older adults reported DSH closer to mid-day (P < 0.01) and suffered more frequently from adjustment disorder and depression. Personality disorders and schizophrenia were less commonly diagnosed (P < 0.001). Prescription medication (sedatives and hypnotics) were a more frequent means (88% vs. 71%) of DSH among older patients. Younger patients with DSH used over-the-counter medications (21.9% vs. 6.4%) three times more than did the older patients (P < 0.01). Past DSH was significantly more frequent in younger adults. Following DSH the older patients were frequently admitted for further general hospitalization (P < 0.001). CONCLUSIONS: Older adults with DSH are a unique group with different clinical characteristics. There is a need for targeted prevention strategies and education of caregivers regarding DSH in older adults.

Effect of Alfacalcidol on multiple sclerosis-related fatigue: A randomized, double-blind placebo-controlled study.

CONTEXT: Fatigue is one of the most common and disabling symptoms of multiple sclerosis (MS); however, there is no medication that has been approved specifically to treat MS-related fatigue. OBJECTIVE: We aimed to evaluate the effect of vitamin D analogue, Alfacalcidol, on MS-related fatigue. DESIGN, SETTINGS, PARTICIPANTS: This was a randomized, double-blind, parallel group, placebo-controlled trial in patients with clinically definite MS by McDonald criteria conducted in a single university-affiliated medical center in Israel. Randomly selected patients from the Sheba MS Registry computerized database (N=600) were assessed using the self-report Fatigue Severity Scale (FSS). Patients with clinically meaningful fatigue (N=259) were further assessed for trial eligibility, and MS patients with significant fatigue (N=158; 61%, 118 females, mean age 41.1 ± 9.2 years and mean disease duration of 6.2 ± 5.5 years) were included in the study and randomized to receive treatment or placebo. INTERVENTION: Alfacalcidol (1 mcg/d, N=80) or placebo (N=78) was administered for six consecutive months. MAIN OUTCOME MEASURE: The primary endpoint of the study was the change between Alfacalcidol and placebo-treated patients in the Fatigue Impact Scale (FIS) score; the cut-off point for improvement was defined as 30% decrease. All analyses followed the intention-to-treat principle and were performed for all participants based on the group they were randomly allocated regardless of whether or not they dropped out. RESULTS: Alfacalcidol decreased the mean relative FIS score as compared with placebo (-41.6% vs. -27.4%, p=0.007, respectively). This advantage was further emphasized when the modified FIS (MFIS) relative change was calculated. Quality of Life (QoL) improved in Alfacalcidol-treated patients as compared with placebo in the RAYS psychological (p=0.033) and social (p=0.043) sub-scales. The Alfacalcidol-treated group had reduced number of relapses (p=0.006) and higher proportion of relapse-free patients (p=0.007). Reduction of relapses by Alfacalcidol became significant at 4 months of treatment, was sustained at 6 months and decayed 2 months after drug discontinuation. Alfacalcidol treatment was safe and no serious adverse events were recorded. CONCLUSION: Alfacalcidol is a safe and effective treatment strategy to decrease fatigue and improve QoL in patients with MS.

Effectiveness and safety of clozapine in elderly patients with chronic resistant schizophrenia.

UNLABELLED: ABSTRACT Background: Recommendations for the treatment of elderly schizophrenia patients are largely based on data extrapolated from studies of antipsychotic medications in younger patient populations. We aimed to evaluate the effectiveness and safety of clozapine monotherapy in a diagnostically homogeneous group of elderly patients suffering from schizophrenia (DSM-IV-TR criteria). METHODS: A retrospective analysis of computerized medical charts of elderly inpatients suffering from schizophrenia treated at our center during the period January 2007-December 2012 was undertaken. Inclusion criteria were: (1) 60 years and older, (2) unsuccessful treatment with at least three different antipsychotic compounds during the last five years prior to the study period. Mortality and re-hospitalization over a five-year period were the pre-defined outcome measures. RESULTS: Of 527 elderly patients suffering from schizophrenia 43 patients, mean age 69.4 ± 8.7 years, were treated with clozapine. There were 19 women and 24 men, mean disease duration was 38.8 years. All had been exposed to at least three first- and second-generation antipsychotics prior to clozapine treatment. Clozapine was very well tolerated by the patients and mortality rate (8/43 (18.6% vs. 87/484 (18%)) was equal to that of other first- and second-generation antipsychotics (p < 0.18). Re-hospitalization rates with clozapine were significantly lower than rates for the five-year period prior to exposure to clozapine (0.41 vs. 3.8; p < 0.001). CONCLUSION: The present study demonstrates that clozapine is efficacious and safe for the treatment of elderly schizophrenia patients. Prospective studies are needed to support these findings.

Acute electroconvulsive therapy followed by maintenance electroconvulsive therapy decreases hospital re-admission rates of older patients with severe mental illness.

OBJECTIVES: Electroconvulsive therapy (ECT) is a highly effective treatment for patients with severe mental illness (SMI). Maintenance ECT (M-ECT) is required for many elderly patients experiencing severe recurrent forms of mood disorders, whereas M-ECT for schizophrenia patients is a poorly studied treatment. We report on the outcomes in aged patients with SMI: schizophrenia and severe affective disorders treated by M-ECT of varying duration to prevent relapse after a successful course of acute ECT. The study measured the effectiveness of M-ECT in preventing hospital readmissions and reducing admission days. METHOD: A retrospective chart review of 42 consecutive patients comparing the number and length of psychiatric admissions before and after the start of M-ECT was used. We analyzed diagnoses, previous ECT treatments, number of ECT treatments, and number and length of psychiatric admissions before and after M-ECT. RESULTS: Mean age in our sample was 71.5 (6.9) years. Twenty-two (52%) patients experienced severe affective disorders and 20 (48%) experienced schizophrenia. Patients were administered 92.8 (85.9) M-ECT treatments. Average duration of the M-ECT course was 34 (29.8) months. There were on average 1.88 admissions before M-ECT and only 0.38 admissions in the M-ECT period (P < 0.001). Duration of mean hospitalization stay decreased from 215.9 to 12.4 days during the M-ECT (P < 0.01). CONCLUSIONS: Our findings suggest that acute ECT followed by M-ECT is highly effective in selected elderly patients with SMIs.