BGS Falls Severe mental illness, poor bone health and falls: The potential role for physical activity

Transcription

1 Severe mental illness, poor bone health and falls: The potential role for physical activity Brendon Stubbs MCSP, PhD Head of Physiotherapy South London and Maudsley NHS Foundation Trust Post Doctoral Research Physiotherapist

2 Talk outline Background about SMI Poorer physical health Bone health Falls Potential role of physical activity Conflict of interest None

3 Background Older people mental health and falls Dominated by dementia/cognitive impairment (Bunn et al 2014, Narayanan et al 2016). Serious mental illness (SMI) typically refers to people with a diagnosis of schizophrenia spectrum/ psychosis, bipolar disorder & Major depressive disorder (MDD).

4 Schizophrenia/ psychosis Lifetime incidence 5.5 per 1,000 persons (McGrath et al 2008) 220,000 people with schizophrenia treated by NHS in UK (NICE 2014) Accounts for 30% mental health budget (NICE 2014) Onset typically in late adolescence/ early adulthood (Murray et al 2004) Multifactorial aetiology (Murray et al 2004) Characterised positive symptoms e.g. hallucinations or delusions negative symptoms e.g. emotionless, flat and apathetic Marked cognitive impairment. (Pichinno & Murray 2007) Evidence of sensorimotor impairments from prodrome (Murray et al 1998) Increasing emphasis on physical health and parity of esteem.

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6 Scandal of premature mortality among people with serious mental illnesses Nielsen et al. Increasing mortality gap for patients diagnosed with schizophrenia over the last three decades--a Danish nationwide study from 1980 to Schiz Res 2013; 146(1-3):22-7 6

7 Increased focus on physical healthcare

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9 At risk population: Psychotropic medication Psychotropic medication -cornerstone treatment (Leucht et al 2013) Prolactin raising AP medication (De Hert et al 2016) Polypharmacy common > 60% patients Antipsychotic polypharmacy 20% (Correll et al 2012)

10 Poor bone health Behavioural risk Fx 70% people with SMI smoke (McNeil et al 2013) Physical inactivity (Stubbs et al 2016) 49% people with established illness have vitamin D deficiency (Lally et al 2016) Poor nutritional intake (Teeasdale et al 2017) High levels alcohol use disorder Medical/ functional risk factors 15% have T2DM (Vancampfort et al 2016) and 35% have MeTs Increased C-Reactive Protein (Miller et al 2016) 20% have multimorbidity (Stubbs et al 2017) High levels poor lower limb performance and earlier onset frailty

11 19 studies and 3038 people schizophrenia Mean 44 years (24-58) 40% had osteopenia on DXA 13.2% had osteoporosis Meta regression Increasing age and BMI influenced results OR 2.5 osteoporosis elevated risk at hip and lumbar spine

12 (Inter)national falls guidance and research Missing people with SMI (e.g. NICE 2013) Excluded from mainstream RCTs Compounded by diagnostic overshadowing (Thornicroft 2013)

13 8 studies 43,500 people schizophrenia (45-79 yrs) RR 1.72 (95% CI ) versus age/sex matched controls No UK data on falls and fractures

14 Fractures and deleterious outcomes in SMI High risk contralateral fracture Higher risk post operative infections Longer stay in hospital Difficulty engaging in rehabilitation Deterioration of mental health Worse post op mobility Holt 2010

15 Lower limb # in US National Hospital Discharge Survey database 10,669,449 lower limb fractures 0.6% had schizophrenia Discharge to long term care: Schizophrenia OR 5.6 (95% CI ) Dementia: OR, 1.3, (95% CI, ) Length of stay: Schizophrenia 11 ± 21 days Dementia 7.9 ± 7.1 day Adverse events People schizophrenia at greatest risk of acute renal failure, pneumonia, and deep venous thrombosis

16 Objectives Predictors of hospital admissions for falls and/ or fractures in people with schizophrenia. Predictors include; Socio-demographic factors Mental health information Physical health ailments Hospital admissions (ICD-10 diagnosis)

17 SLAM Biomedical Research Centre (BRC) Case Register King s College London (KCL) South London and Maudsley (SLAM) London United Kingdom South London

18 Methods 2007 Jan March 2013 Diagnosis psychosis Outcome: Hospital admissions due to falls/ fractures 6 months after diagnosis of psychosis Covariates: -Socio-demographic factors at diagnosis -Measures within 6 months before or after psychosis diagnosis: Medications prescribed, Other psychiatric conditions, HoNoS status, MMSE scores, Hospital admissions Census date or date of death

19 Statistical Methods Survival analysis: Cox proportional-hazards regression Univariate analysis Multivariate backward stepwise (elimination) method

20 Sociodemographics fallers: v non fallers Presence of falls Presence of fractures Characteristics of sample No (n= 11,105) Yes (n= 462) No (n= 11,174) Yes (n= 393) Age (98.2) 79 (1.8) 4336 (97.9) 91 (2.1) (98) 79 (2) 3853 (97.7) 92 (2.3) (94.2) 102 (5.8) 1687 (95.6) 77 (4.4) (87) 138 (13) 970 (91.6) 89 (8.4) 80 & over 308 (82.8) 64 (17.2) 328 (88.2) 44 (11.8) Gender Female 4736 (95.2) 239 (4.8) 4791 (96.3) 184 (3.7) Marital status Cohabiting 2384 (96.6) 85 (3.4) 2398 (97.1) 71 (2.9) Living status Living alone 2382 (94.6) 136 (5.4) 2409 (95.7) 109 (4.3) Falls Median LOS Fall 10.8 days Fracture 14.4 days Total days in hospital Fall 6,977 Fracture 11,327BGS 2017

21 Multivariable predictors of first hospital admission due to falls or fracture Falls Fractures Characteristics HR (95% CI) P value HR (95% CI) P value 10 year increase in age 1.59 (1.48, 1.7) < (1.13, 1.32) <0.001 Living alone 1.29 (1.01, 1.65) Antidepressants received 1.97 (1.49, 2.61) <0.001 F30- F39 (Mood [affective ] disorders) present 1.57 (1.26, 1.94) < (1.28, 1.99) <0.001 Diabetes 2.25 (1.53, 3.32) (1.39, 3.37) Hypotension 2.27 (1.52, 3.37) <0.001 Diseases of genitourinary system including UTI 4.81 (3.24, 7.12) <0.001 Osteoporosis 1.79 (1.17, 2.73) (9.15, 26.57) <0.001 Hearing Loss 3.14 (1.12, 8.82) 0.03 Syncope or Collapse 0.33 (0.11, 0.97) Parkinson's Disease 2.74 (1.67, 4.48) <0.001 Falls or fractures before psychosis diagnosis 3.57 (2.08, 6.13) <0.001

22 17 RCTs & 4 CCTs all dementia/cognitive impairment Most nursing/care home None in mental health hospital setting Some evidence for multifactorial/ exercise/ environmental changes

23 Current state of play and major inequities Plethora of increased risk factors for poor bone health People with SMI at +++ increased risk of fractures People with SMI excluded from RCTs Have worse outcomes Difficulty engaging in current falls/fracture rehabilitation models No evidence to guide clinical care

24 Next steps Conduct cohort study investigate lower limb function and falls in people psychosis Qualitative interviews with people with schizophrenia who have had a fall/fracture Qualitative interviews with HCPs in general hospitals Collect information to consider how improve bone health and prevent falls/fractures If you are interested in collaborating and sharing your wisdom, please get in touch.

25 Opportunities Physical activity and outcomes in SMI Improve negative symptoms (Firth et al 2015) Cognition (Firth et al 2016) Cardiometabolic markers (Firth et al 2015) Falls prevention generally Gillespie et al 2012/ Sherrington et al 2014 exercise is effective

26 Acknowledgements Authors: Robert Stewart 1,2, Gayan Perera 1,2 Fiona Gaughran 1,2 1 South London and Maudsley NHS Foundation Trust 2 Institute of Psychiatry, Psychology and Neuroscience, King s College London, London, United Kingdom CRIS team (Members of of SLAM BRC Nucleus) Funding: The data resource and researcher are funded by the National Institute for Health Research (NIHR) Biomedical Research Centre and Dementia Biomedical Research Unit and King's College London. The views expressed are those of the researchers and not necessarily those of the NHS, the NIHR or the Department of Health in the United Kingdom. Contact: brendon.stubbs@kcl.ac.uk Thank you