Two-Drug Combo Helps Older Adults with Hard-to-Treat Depression

Eric J. Lenze, MD, consults with patient Daniel Viehmann. Lenze led a multicenter study that found that adding a second drug can relieve depression in many older adults whose symptoms don’t resolve after treatment with a standard antidepressant drug.


September 28, 2015, Newswise — More than half of older adults with clinical depression don’t get better when treated with an antidepressant. But results from a multicenter clinical trial that included Washington University School of Medicine in St. Louis indicates that adding a second drug — an antipsychotic medication — to the treatment regimen helps many of those patients.

The findings, from a study of 468 people over age 60 and diagnosed with depression, are published in The Lancet. The study was sponsored by the National Institute of Mental Health and is the largest of its kind ever undertaken in older people with depression.

Previous research in younger patients with depression showed that adding a 

  

low dose of the antipsychotic drug aripiprazole (brand name Abilify) helped relieve symptoms of depression when an antidepressant alone wasn’t effective. 

But the new study is the first to show that the same strategy also works in older adults. The two-drug combination relieved depression in a significant number of patients and also reduced the likelihood that they would have suicidal thoughts.

“It’s important to remember that older adults may not respond to medications in the same way as younger adults,” said first author Eric J. Lenze, MD, a Washington University professor of psychiatry. 

“There are age-related changes in the brain and body that suggest certain treatments may work differently, in terms of benefits and side effects, in older adults. Even when a strategy works for patients in their 30s, it needs to be tested in patients in their 70s before it can be considered effective in older patients.”

A 2007 study estimated that about 7 million of the nation’s 39 million older Americans had clinical depression. Up to 90 percent did not receive necessary care, and 78 percent received no treatment at all.

The consequences are costly: Elderly patients with clinical depression use more health-care services, spending nearly twice as much on medical care as those without the disorder. 

Further, the suicide rate among people over 75 is higher than in any other age group, and depression is a risk factor for dementia.

Lenze, who directs the Healthy Mind Lab at Washington University School of Medicine, was the principal investigator in St. Louis. Patients also were treated at the University of Pittsburgh School of Medicine and at the Centre for Addiction and Mental Health (CAMH) in Toronto.

“This is a rare study because it looks at depression specifically in older adults,” said Benoit H. Mulsant, MD, a co-author of the study and a senior scientist at CAMH in Toronto. “It’s important to treat older adults for depression, especially given that adults with late-life depression are at an increased risk of developing dementia. But this research demonstrates that older adults do respond to depression therapy.”

Each study participant received an extended-release formulation of the antidepressant drug venlafaxine (brand name Effexor XR) for 12 weeks. About half of these patients still were clinically depressed after 12 weeks of treatment.

“We know that in older adults with depression, about half will not respond to medication,” Lenze said. “They may have a minimal response, but they’ll still be depressed. The question we wanted to answer was whether there was anything else we could do for them.”

So for the second phase of the study, patients who initially did not respond to the venlafaxine continued to receive the drug along with aripiprazole or a placebo. Aripiprazole often is prescribed to treat schizophrenia and manic episodes associated with bipolar disorder.

The two-drug combination led to a remission of depression in 44 percent of the treatment-resistant patients, compared with only 29 percent of those who had received the placebo.

“This study is a major advance in support of evidence-based care for older adults with depression,” said Charles F. Reynolds III, MD, a geriatric psychiatrist at the University of Pittsburgh, the coordinating site for the study. 

“By publishing our findings in The Lancet, we hope particularly to reach primary care physicians, who provide most of the treatment for depressed older adults. The excellent safety and tolerability profile of aripiprazole, as well as its efficacy, should support its use in primary care, with appropriate medical monitoring.”

Some patients who took the two-drug combination experienced restlessness. Others developed some stiffness, called mild Parkinsonism. But the side effects tended to be mild and short-lived.

“The potential benefits outweighed the side effects,” Lenze said, adding that side effects that investigators expected to see, such as weight gain and metabolic problems, never occurred.

“Antipsychotic medications can cause increasing amounts of fat and thereby increase blood sugar, potentially contributing to diabetes,” Lenze said. 

“But compared with placebo, aripiprazole was no more likely to produce increased fat in these patients and had no effect on blood sugar, insulin or lipids.”

The key remaining question, Lenze explained, involves predicting which older depressed patients with depression are likely to benefit from the two-drug combination. Learning the answer is a goal for future research.

“One of the things we see as critical to our future research will be trying to better understand the factors that make some people respond to specific forms of treatment that may not work for others,” Lenze said.

This work was funded by the National Institute of Mental Health and the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). Additional funding was provided by the University of Pittsburgh Medical Center Endowment in Geriatric Psychiatry, the Taylor Family Institute for Innovative Psychiatric Research at Washington University, the Washington University Institute of Clinical and Translational Sciences, the Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health, Toronto. Bristol-Meyers Squibb contributed aripiprazole and placebo tablets, and Pfizer contributed venlafaxine extended-release capsules. NIH grant numbers R01 MH083660, P30 MH90333, R01 MH083648, R01 MH083643 and UL1 TR000448.

Lenze EJ, Mulsant BH, Blumberger DM, Karp JF, Newcomer JW, Anderson SJ, Dew MA, Butters MA, Stack JA, Begley AE, Reynolds CF. Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomized placebo-controlled trial. The Lancet, published online Sept. 28, 2015.

Washington University School of Medicine’s 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation, currently ranked sixth in the nation by U.S. News & World Report. 

Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.

Study Finds Significant Differences in Frailty by Region and by Race Among Older Americans

Substantial differences by income also found
Newswise, September 25, 2015 — A large-scale survey of older Americans living at home or in assisted living settings found that 15 percent are frail, a diminished state that makes people more vulnerable to falls, chronic disease and disability, while another 45 percent are considered pre-frail, or at heightened risk of becoming physically diminished.

The Johns Hopkins Bloomberg School of Public Health study found frailty to be more prevalent in older people and more common among women and the poor. In addition, the study found wide regional differences in the U.S., with older people in central southern states more than three times as likely to be frail than those in the western states. 

The researchers also found significant racial differences, with blacks and Hispanics nearly twice as likely to be frail as whites.

The study is published in the September 2015 issue ofJournals of Gerontology: Medical Sciences.

Frailty, once thought of as a generalized fragile state that befalls some people as they get older, is increasingly considered a medical process in and of itself. 

Frailty is thought to be exhibited by a set of symptoms including weakness, exhaustion and limited mobility. It often progresses separately from any underlying conditions, and is also common among patients with chronic diseases such as heart disease and diabetes, especially in their advanced stages.

Understanding frailty, and finding ways to prevent its onset or slow its progression, could improve older people’s quality of life by extending their so-called robust years. It could also increase their chances of surviving surgery, for example; previous research has suggested that older, frail patients are less likely to survive major surgical procedures. 

Reducing frailty could lower health care costs, since frail persons are prone to falls and falls often lead to hospitalization. Hospital care is the largest component of Medicare spending.

Of their findings, the authors were most surprised by the significant racial and regional differences, says study leader Karen Bandeen-Roche, PhD, the Frank Hurley and Catharine Dorrier Professor and Chair of the Department of Biostatistics at the Johns Hopkins Bloomberg School of Public Health. The study is believed to be the first that examines regional differences in frailty in the U.S.

“We can’t really explain the regional differences,” says Bandeen-Roche, who also co-directs the Johns Hopkins Older Americans Independence Center and is a Core Faculty member at the Johns Hopkins Center on Aging and Health. 

“We know there are health differences across the country, differences in diet and to some extent exercise habits. Observing the relatively low prevalence in the mountain west, you can imagine an active lifestyle might be a factor.” 

As for the racial differences, Bandeen-Roche says it’s too early to speculate, noting that they could be due to any number of factors, and merit further study.

For the study, researchers drew on interviews with 7,439 participants in the 2011 National Health and Aging Trends Study, a longitudinal study of people age 65 and older drawn from Medicare records. 

Participants, who resided either at home or in an assisted living facility, completed a two-hour, in-person interview that assessed frailty using several criteria: exhaustion, weakness, low physical activity, shrinking and low walking speed. 

Participants were also asked about their medical history and ability to perform daily tasks such as meal preparation and other household activities. The researchers assessed probable dementia with a combination of questions and cognitive tests.

Among the survey’s other findings: Residents of assisted living facilities were more than twice as likely to be frail than those living in private homes. 

Prevalence increased with age, with 9 percent of those ages 65 to 69 found to be frail compared to 38 percent of those aged 90 or older. Among the frail, more than half had fallen in the previous year, and more than one-third had fallen several times, with 40 percent of those who had fallen being hospitalized.

As frailty becomes better understood, the researchers hope clinicians will develop recommendations that specifically address risks associated with frailty, for instance, having people engage in strengthening activities before major surgery. 

Such recommendations, if adapted by older people who had not yet slipped into advanced frailty, could help delay or even prevent its onset.

Aside from the 15 percent found to be frail, the researchers also found that 45 percent were what the authors deemed “pre-frail,” or older people who have begun to experience the same symptoms of frailty, but to a lesser extent. “It’s a question of degree,” Bandeen-Roche says. 

The so-called pre-frail are a prime target of study in order to help researchers understand the progression of frailty so doctors can develop recommendations – for instance, changes in diet or exercise – that could extend a person’s robust years.

“We would love for frailty assessment to become a standard component of assessment of older Americans,” Bandeen-Roche says. “Understanding frailty could potentially help us extend people’s quality of life into their later years.”

“Frailty in Older Adults: A Nationally Representative Profile in the United States” was written by Karen Bandeen-Roche, Christopher L. Seplaki, Jin Huang, Brian Buta, Rita R. Kalyani, Ravi Varadhan, Qian-Li Xue, Jeremy D. Walston and Judith D. Kasper.

Senior Home Equity Reaches $4.08 Trillion, Reverse Mortgage Market Index Hits Record High

 September 23, 2015--NRMLA/RiskSpan Reverse Mortgage Market Index (RMMI), a quarterly measure that analyzes trends in the home values, home equity, and mortgage debt of homeowners 62 and older, reached an all-time high of 195.29 in the second quarter of 2015, surpassing the prior record of 192.03 set in Q4 2006.

On a quarter-over-quarter basis, the index rose 3.0% in the second quarter, as senior home equity increased by $117.1 billion.

"The strong gains in housing wealth among America's seniors are an encouraging economic indicator for the millions of boomers who weathered the recession on the cusp of their retirement years," said NRMLA PresidentPeter Bell.

"The home equity they've worked so hard to build up can serve as a valuable financial management tool for years to come."

The increase in senior home equity relative to the first quarter was driven by an estimated $122.8 billionincrease in the aggregate value of senior housing, which was offset by a $5.7 billion increase in senior-held mortgage debt.

The second quarter of 2015 was the thirteenth consecutive quarter in which the index has risen, and the current estimate of $4.08 trillion for the aggregate value of senior home equity represents a 38% recovery from the post-Recession trough in Q2 2011, when senior equity levels had fallen to an estimated $3.0 trillion.

The RMMI is updated quarterly and tracks back to the start of 2000. Release dates for 2015 – 2016 are:
Q3 2015: 12/22/2015
Q4 2015: 3/22/2016
Q1 2016: 6/21/2016
Q2 2016: 9/20/2016
Q3 2016: 12/20/2016

About Reverse Mortgages
Reverse mortgages are available to homeowners age 62 and older with significant home equity. They are a safe financial tool seniors can use to borrow against the equity in their home without having to make monthly payments as with a traditional "forward" mortgage or a home equity loan. Under a reverse mortgage, funds are advanced to the borrower and interest accrues, but the outstanding balance is not due until the last borrower leaves the home, sells, or passes away.

To date, more than 920,000 senior households have utilized an FHA-insured reverse mortgage. More than 625,000 senior households are currently using a reverse mortgage to help meet their financial needs. For more information, please visit www.ReverseMortgage.org 

About the National Reverse Mortgage Lenders Association
The National Reverse Mortgage Lenders Association (NRMLA) is the national voice for the industry and represents the lenders, loan servicers, credit unions, and housing counseling agencies responsible for more than 90 percent of reverse mortgage transactions in the United States. All NRMLA member companies commit themselves to a Code of Ethics & Professional Responsibility. 

30 Million Americans Used Retirement Savings for an Emergency Over Past Year21 Million Americans Aren't Saving for Retirement

NEW YORK, Sept. 23, 2015 /PRNewswire/ -- 30 million Americans tapped their retirement savings for an emergency within the past year, according to a new Bankrate.com (NYSE: RATE) report.  The report also found that 21 million Americans aren't saving for retirement at all.

Surprisingly, millennials were the least likely to dip into their retirement funds prematurely (only 8% did so over the past 12 months).

In fact, millennials are the most likely age group to note an improved overall financial situation over the past year (40% say they're better off and just 11% say they're doing worse).

The numbers tell a more troubling story for 50-64 year-olds. 26% say their financial situation has deteriorated over the past year (more than any other age group) and 17% recently dipped into their retirement savings to pay for an emergency.

"Using retirement savings to cover an emergency is a permanent setback to retirement planning, with the possibility of taxable distributions, early withdrawal penalties, loss of tax efficiency, and the inability to replace withdrawn funds in future years," said Greg McBride, CFA, Bankrate.com's chief financial analyst.

• The Bankrate.com Financial Security Index rebounded after sliding the past two months and now stands at 102.6 – the best since June.
• Job security is a particular strength: people who feel more secure than a year ago outnumber those who feel less secure by more than two-to-one.
• Savings is the one major area where Americans note deterioration, with 30% saying they feel less comfortable with their savings now compared to one year ago against 18% that feel more comfortable.
•  

The survey was conducted by Princeton Survey Research Associates International (PSRAI) and can be seen in its entirety here:

http://www.bankrate.com/finance/consumer-index/financial-security-charts-0915.aspx  

PSRAI obtained telephone interviews with a nationally representative sample of 1,004 adults living in the continental United States. Telephone interviews were conducted by landline (501) and cell phone (503, including 311 without a landline phone) in English and Spanish by Princeton Data Source from September 3-6. Statistical results are weighted to correct known demographic discrepancies. The margin of sampling error for the complete set of weighted data is plus or minus 3.7 percentage points.

Can Your Sense of Smell Predict When You’ll Die?

Newswise, September 21, 2015--By measuring how worms move toward an appealing, food-like scent, researchers at the Salk Institute were able to predict whether the worms would be long-lived.

The finding, publishing September 22, 2015 in the journal eLife, shows how nematodes (Caenorhabditis elegans) process information about the environment and how circuits in the brain change as an animal ages.

“We’re not saying that your ability to smell is going to make you live longer,” says Sreekanth Chalasani, an assistant professor in Salk’s Molecular Neurobiology Laboratory.

“But this odor behavior is likely indicative of some kind of underlying physiology.”

The small C. elegans has 12 pairs of specialized neurons in its brain that detect stimuli in the environment. Scientists had previously identified individual pairs of these neurons as required for the animals to respond to attractive odors.

Chalasani and his colleagues wanted to understand this entire process in more detail. In their new work, the researchers measured the responses of all 24 neurons asC. elegans was exposed to benzaldehyde—a chemical that gives off a pleasant, almond-like smell. Surprisingly, rather than the individual pairs that had been previously shown, they found that additional neurons were also involved.

Interestingly, these cells were divided into primary and secondary neurons. Primary neurons showed activity in response to the benzaldehyde, while secondary neurons responded to signals sent by the primary neurons. By having a neural circuit structured like this, the team hypothesizes, the worm can get better information on the strength or concentration of a smell.

“If you have multiple different cells that are all detecting a stimulus, you can use the combination of them to get more dynamic information,” says Sarah Leinwand, a graduate student in the Chalasani lab and first author of the new paper.

“Using this strategy allows an animal to generate flexible behavioral responses to its environment.” For instance, some behaviors could only be triggered when a smell is strong enough to cause activity in particular combinations of neurons.

The researchers speculate that other species with larger brains may use similarly structured neural circuits to represent sensory information and fine-tune their behaviors.

Since they knew that worms (like other animals and people) often begin to lose their sense of smell with age, Chalasani and Leinwand next measured how the circuit composed of primary and secondary neurons changes as C. elegansgets older.

While the primary neurons don’t show a decline in activity, they found, secondary neurons become less active with age. This suggests that communication between neurons could be degraded as animals age, Chalasani says, a phenomenon which might also hold true in other neural circuits in many different species.

The scientists went on to show a correlation between poor performance on a smell-based test (moving toward a point source of benzaldehyde), the activity of secondary neurons and the animal’s lifespan. Older animals that were more successful in finding the odor lived about 16% longer than animals that were less good at moving toward the smell.

“Even though all these animals are siblings and have similar genomes, if you look at neuron activity, behavioral performance, or lifespan, there are significant differences,” says Chalasani. “Perhaps that’s because some animals have better signaling between primary and secondary cells.”

If the signaling between neurons ends up being important in how other organisms —including humans — age, then manipulating the nervous system may prove a fruitful way to minimize the effects of aging or rejuvenate brain functions, he says.

“There are a lot of questions that remain about what exactly is changing as an animal ages,” says Leinwand. “We want to keep looking at what is changing to cause some animals to have better functioning nervous systems and to live longer.”

Other researchers on the study were Claire Yang of the Salk Institute, Daphne Bazopoulou and Nikos Chronis of the University of Michigan, and Jagan Srinivasan of the Worcester Polytechnic Institute.

The work and the researchers involved were supported by the Rita Allen Foundation, the W.M. Keck Foundation, the National Institutes of Health, Achievements Rewards for College Scientists and the National Science Foundation.

About the Salk Institute for Biological Studies:
The Salk Institute for Biological Studies is one of the world's preeminent basic research institutions, where internationally renowned faculty probes fundamental life science questions in a unique, collaborative and creative environment.

Focused both on discovery and on mentoring future generations of researchers, Salk scientists make groundbreaking contributions to our understanding of cancer, aging, Alzheimer's, diabetes and infectious diseases by studying neuroscience, genetics, cell and plant biology and related disciplines.

Faculty achievements have been recognized with numerous honors, including Nobel Prizes and memberships in the National Academy of Sciences. Founded in 1960 by polio vaccine pioneer Jonas Salk, MD, the Institute is an independent nonprofit organization and architectural landmark.

Solo Grandparents Raising Grandchildren at Greater Risk Than Parents for Serious Health Problems

Newswise, September 16, 2015 — Single grandparents raising grandchildren are more vulnerable to poor physical and mental health than are single parents, according to a study recently published in Current Gerontology and Geriatrics Research.

These caregivers may be at greater risk for diminished physical capacity and heightened prevalence of depression, researchers found.

Researchers at Georgia State University and the University of Toronto found that solo grandparents caring for grandchildren fare worse than single parents across four critical health areas: physical health, mental health, functional limitations and health behaviors. 

Their research looked at a sample of solo grandparents from 36 U.S. states using the 2012 Behavioral Risk Factor Surveillance System, a survey from the U.S. Centers for Disease Control and Prevention.

“The burden of chronic illness among solo grandparents was very worrying,” said study co-author Deborah Whitley, a professor of social work in the Andrew Young School of Policy Studies’ School of Social Work at Georgia State. 

“One in four solo grandparents reported they had diabetes and one in five had chronic obstructive pulmonary disease and asthma. One in six had a heart attack. With this level of illness, it is not surprising that 32 percent reported that their physical health was not good more than one week in the past month.”

An estimated 920,000 American children are being raised by solo grandparents without a parent in the home.

“Many solo grandparents are quite elderly, yet they are raising some of the nation’s most vulnerable children with shockingly limited resources,” said co-author Esme Fuller-Thomson, a professor in Toronto's Factor-Inwentash Faculty of Social Work and the Institute for Life Course & Aging. 

“One-quarter of solo grandparents were over age 70. More than a quarter of these households reported incomes of less than $15,000 per year. And more than one-third were raising more than one child, and half the children were less than 12 years of age.”

As America celebrates Grandparents Day on Sept. 13, the authors believe their findings signal the need for policies that will foster the delivery of health services that effectively address the physical and mental health needs of this population.

They point to health professionals from multiple disciplines as an important resource in reducing their health problems and helping to increase their physical and emotional capacity to support and nurture the grandchildren in their care.

A copy of the study, “Health Characteristics of Solo Grandparent Caregivers and Single Parents: A Comparative Profile Using the Behavior Risk Factor Surveillance Survey,” can be downloaded athttp://www.hindawi.com/journals/cggr/2015/630717/. 

New Survey By FTD Reveals Top 10 Life Lessons From GrandparentsFTD Grandparent's Day survey reveals that Grandma and Grandpa profoundly influence lives

September 14, 2015/PRNewswire/ -- We're often told that "Grandma knows best" and now a new study from FTD® (Nasdaq: FTD), the iconic floral and gifting company, has revealed exactly how true those words are. To celebrate Grandparent's Day this month, FTD identified the most valuable nuggets of a grandparent's wisdom, with lessons like "A watched kettle never boils," and "A minute on the lips, a lifetime on the hips," making the shortlist.

The research questioned 1,500 grandchildren and was commissioned to help FTD brands celebrate Grandparents' Day—Sunday, Sept. 13 in the U.S. and Oct. 5 in the UK—and better understand the great impact grandparents have on our lives.

Nearly two thirds of respondents (64%) acknowledged grandparents have influenced their lives profoundly, while more than half (53%) say they would confide in their grandparents over their friends or immediate family. A further 56 percent pass on their grandparent's wisdom to their own children, friends (42%) or colleagues (17%).

The study also explored the specific pieces of wisdom, advice and phrases grandparents have passed on from generation to generation. The list – which includes health, relationship and life advice – has been broken down into the 10 most common nuggets of wisdom.

1.      A leopard never changes its spots.

2.    A minute on the lips, a lifetime on the hips.

3.    A watched kettle never boils.

4.    Treat others as you would like to be treated.

5.     An apple a day keeps the doctor away.

6.    An hour before midnight is worth two after.

7.     Be nice to people on the way up as you will meet them on the way down.

8.    Cleanliness is next to godliness.

9.    Don't leave until tomorrow what you can do today.

10.                        Don't let the sun go down on your anger.

Additional phrases rounding out the top 20 include: "If you can't say anything nice, don't say anything at all," "Live life as though every day could be your last," and "Don't drink alcohol on an empty stomach."

"It's clear that grandparents play a significant role in our lives, and it's important to take the time to show them just how much they are loved and appreciated this Grandparent's Day," said FTD President and CEO Robert Apatoff.

"FTD is honored to help our customers recognize and help celebrate these important figures who have helped shape us and taught us valuable life lessons."

FTD is offering gourmet gifts, flower arrangements and plants to help celebrate Grandparent's Day and Grandparent's Week in both the U.S. (Sept. 13-19) and UK (Oct. 5).  Customers can send their love, appreciation and thanks with a special gift.

Visit www.ftd.com orwww.interflora.co.uk for more information.