Personality disorders in the community

Just under half of all people with psychiatric disorders, have a co-existing chronic physical illness. However, less attention has been paid the physical health outcomes of
individuals living with these disorders in the general population, or their
treatment seeking behaviors. In absence of these data, we do know those living
with PD encounter disability and suffer significantly. The aims of this thesis,
were to investigate the prevalence of PDs, and associations with physical
health comorbidities, and health service utilization, in population-based
samples (≥20 years), from Australia, and the United States (US).

The microbiome: a biological mechanism underpinning the social gradient of musculoskeletal conditions?

We read with interest the article by Steves et al, published in J Bone Miner Res, 2016; 31(2):261-269 (1). The authors review available evidence and suggest that the modifiable nature of the gut microbiome (GM) provides a potential therapeutic target to intervene in musculoskeletal conditions of aging.

Depression as a risk factor for fracture in women: a 10 year longitudinal study

BACKGROUND: Previous research has demonstrated deficits in bone mineral density (BMD) among individuals with depression. While reduced BMD is a known risk for fracture, a direct link between depression and fracture risk is yet to be confirmed. METHODS: A population-based sample of women participating in the Geelong Osteoporosis Study was studied using both nested case-control and retrospective cohort study designs. A lifetime history of depression was identified using a semi-structured clinical interview (SCID-I/NP). Incident fractures were identified from radiological reports and BMD was measured at the femoral neck using dual energy absorptiometry. Anthropometry was measured and information on medication use and lifestyle factors was obtained via questionnaire. RESULTS: Among 179 cases with incident fracture and 914 controls, depression was associated with increased odds of fracture (adjusted odds ratio (OR) 1.57, 95%CI 1.04-2.38); further adjustment for psychotropic medication use appeared to attenuate this association (adjusted OR 1.52, 95%CI 0.98-2.36). Among 165 women with a history of depression at baseline and 693 who had no history of depression, depression was associated with a 68% increased risk of incident fracture (adjusted hazard ratio (HR) 1.68, 95%CI 1.02-2.76), with further adjustment for psychotropic medication use also appearing to attenuate this association (adjusted HR 1.58, 95%CI 0.95-2.61). LIMITATIONS: Potential limitations include recall bias, unrecognised confounding and generalizability. CONCLUSIONS: This study provides both cross-sectional and longitudinal evidence to suggest that clinical depression is a risk factor for radiologically-confirmed incident fracture, independent of a number of known risk factors. If there is indeed a clinically meaningful co-morbidity between mental and bone health, potentially worsened by psychotropic medications, the issue of screening at-risk populations needs to become a priority.

Effects of antidepressants on postmenopausal bone loss - a 5-year longitudinal study from the OSTPRE cohort

BACKGROUND: Osteoporosis and depression are major health problems worldwide. The association between antidepressants, a treatment for depression, and bone health needs more detailed exploration. OBJECTIVE: The present study investigates antidepressant medication use and postmenopausal bone loss over time. METHODS: A total of 1988 women (aged 57-67) participating in the Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) cohort responded to a postal enquiry and had their femoral neck bone mineral density (BMD) measured in 1999 and again in 2004. Data on antidepressant use was obtained from the National Prescription Register. Multiple regression techniques were used to test the associations, before and after adjustment for anthropometric, medical, physical and lifestyle factors. RESULTS: Over the five years of follow-up, 319 (16.0%) women purchased antidepressants. Mean baseline femoral neck BMD for the entire study group was 881mg/cm(2) (SD 123) and mean 5-year bone loss was 6.0mg/cm(2) (SD 4.7). After adjustments, users of tricyclic antidepressants (TCA) had greater annual BMD loss than non-users (-3.6mg/cm(2) vs. -1.1mg/cm(2); P=0.031). Accelerated bone loss was also associated with selective serotonin reuptake inhibitor's (SSRI) use (P=0.001) and use of other antidepressants in a dose-response way, with the latter only among women of low-weight and normal-weight women who had lost weight over the study period. CONCLUSIONS: In conclusion, the use of SSRIs seems to accelerate postmenopausal bone loss in a dose-response manner. Associations between TCA and other antidepressant use and bone loss may also exist. Thus, the possibility of increased risk of osteoporosis should be considered when prescribing antidepressants for postmenopausal women.

Changes in bone mineral density in the year after critical illness

RATIONALE: Critical illness may be associated with increased bone turnover and loss of bone mineral density. Prospective evidence describing long-term changes in bone mineral density after critical illness is needed to further define this relationship.

OBJECTIVES: To measure the change in bone mineral density and bone turnover markers in patients one year after critical illness compared to population-based controls.

METHODS: We studied adult patients admitted to a tertiary intensive care unit (ICU) and requiring mechanical ventilation for at least 24 hours. We measured clinical characteristics, bone turnover markers and bone mineral density during admission and one year after ICU discharge. We compared change in bone mineral density to age and sex-matched controls from the Geelong Osteoporosis Study.

MEASUREMENTS AND MAIN RESULTS: Sixty-six patients completed bone mineral density testing. Bone mineral density decreased significantly in the year after critical illness at both femoral neck and anterior-posterior spine site. The annual decrease was significantly greater in the ICU cohort compared to matched controls (anterior-posterior spine -1.59%, 95% CI -2.18, -1.01, p< 0.001, femoral neck -1.20%, 95% CI -1.69, -0.70, p <0.001). There was a significant increase in 10-year fracture risk for major fractures (4.85+5.25 vs 5.50+5.52, p<0.001) and hip fractures (1.57+2.40 vs 1.79+2.69, p=0.001). The pattern of bone resorption markers was consistent with accelerated bone turnover.

CONCLUSIONS: Critically ill patients experience a significantly greater decrease in bone mineral density in the year after admission compared to population-based controls. Their bone turnover biomarkers pattern is consistent with increased rate of bone loss.

A conduit between epidemiological research and regional health policy

OBJECTIVE: To transform data from a research setting into a format that could be used to support strategies encouraging healthy lifestyle choices and service planning within local government. METHODS: Details of the health status and lifestyle behaviours of the Geelong, Victoria, population were generated independently by the Geelong Osteoporosis Study (GOS), a prospective population-based cohort study. Recent GOS follow-up phases provided evidence about patterns of unhealthy diet, physical inactivity, smoking and harmful alcohol use. These factors are well-recognised modifiable risk factors for chronic disease; the dataset was complemented with prevalence estimates for musculoskeletal disease, obesity, diabetes, cardiovascular disease, asthma and cancer. RESULTS: Data were provided to Healthy Together Geelong in aggregate form according to age, sex and suburb. A population statistics company used the data to project health outcomes by suburb for use by local council. This data exchange served as a conduit between epidemiological research and policy development. CONCLUSION AND IMPLICATIONS: Regional policy makers were informed by local evidence, rather than national or state health survey, thereby optimising potential intervention strategies.

Anxiety disorders and falls among older adults

BACKGROUND: Falls are common among older adults and can lead to serious injuries, including fractures. We aimed to determine associations between anxiety disorders and falls in older adults. METHODS: Participants were 487 men and 376 women aged ≥60 years enrolled in the Geelong Osteoporosis Study, Australia. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Non-patient edition (SCID-I/NP), lifetime history of anxiety disorders was determined. Falls were determined by self-report. In men, a falls-risk score (Elderly Falls Screening Test (EFST)) was also calculated. RESULTS: Among fallers, 24 of 299 (8.0%) had a lifetime history of anxiety disorder compared to 36 of 634 (5.7%) non-fallers (p=0.014). Examination of the association between anxiety and falls suggested differential relationships for men and women. In men, following adjustment for psychotropic medications, mobility and blood pressure, lifetime anxiety disorder was associated with falling (OR 2.96; 95%CI 1.07-8.21) and with EFST score (OR 3.46; 95%CI 1.13-10.6). In women, an association between lifetime anxiety disorder and falls was explained by psychotropic medication use, poor mobility and socioeconomic status. LIMITATIONS: Sub-group analyses involving types of anxiety and anxiety disorders over the past 12-months were not performed due to power limitations. CONCLUSION: Although anxiety disorders were independently associated with a 3-fold increase in likelihood of reported falls and high falls risk among men, an independent association was not detected among women. These results may aid in prevention of falls through specific interventions aimed at reducing anxiety, particularly in men.

Maternal nutrition during pregnancy: intake of nutrients important for bone health

Objectives Maternal nutrition during pregnancy plays an important role in predisposing offspring to the development of chronic disease in adulthood, including osteoporosis. Our aim was to investigate maternal dietary intakes during pregnancy, with a focus on nutrients important for skeletal development in the offspring. Methods In this case-control study, cases were pregnant women recruited for the Vitamin D in Pregnancy Study (n = 350, age 20-40 years) and controls were non-pregnant peers participating in the Geelong Osteoporosis Study (n = 305, age 20-40 years). Dietary intakes of nutrients were quantified using a validated food frequency questionnaire. Results Compared to controls, cases consumed more energy [median (interquartile range): 7831 (6506-9461) vs. 7136 (6112-8785) kJ/day]; median intakes for cases were greater for carbohydrates [206.2 (172.5-249.9) vs. 188.2 (147.7-217.5) g/day], fat [77.9 (60.3-96.6) vs. 72.1 (53.3-87.4) g/day], potassium [2860 (2363-3442) vs. 2606 (2166-3442) mg/day] and calcium [1022 (819-1264) vs. 918 (782-1264) mg/day] (all p ≤ 0.05). However, pregnant women were not consuming greater amounts of those nutrients which had an increased demand (protein, magnesium, phosphorus and zinc). Similarly, this translated to the likelihood of achieving national recommendations for corresponding nutrients. Conclusions for Practice Compared to their non-pregnant peers, pregnant women were more likely to meet dietary recommendations for calcium and potassium; however, this was not the pattern observed for protein, magnesium and zinc. Future public health messages should perhaps focus on increasing awareness of the importance of all these nutrients during pregnancy.

Non-hip and non-vertebral fractures : the neglected fracture sites

Summary: Non-hip, non-vertebral fractures (NHNVF) were compared with hip, vertebral and controls. NHNVF were younger and heavier than controls and hip/vertebral fractures in both men and women, respectively. Falls and prior fractures were less common in NHNVF than hip fractures. Glucocorticoid use was lower in NHNVF compared to vertebral fracture (VF) in men. Introduction: Although hip fracture (HF) and vertebral fractures (VF) receive the most attention in the literature and are the targeted sites for fracture prevention, non-hip, non-vertebral fracture (NHNVF) sites account for a greater proportion of fractures than the hip or vertebrae. This study aimed to assess risk factors for NHNVF and compare them with those for HF, VF and controls. Methods: Incident fractures during 2005–2007 for men and 1994–1996 for women were identified using computerised keyword searches of radiological reports, and controls were selected at random from electoral rolls for participation in the Geelong Osteoporosis Study. Participants aged 60+ years were included in this study. Results: Compared to controls, men and women with NHNVF were younger (ORs, 0.90, 95 % CI 0.86–0.94; and 0.96, 0.93–0.98, respectively) and had a lower femoral neck bone mineral density (BMD) T-score (age-adjusted; difference [men] 0.383, P = 0.002; [women] 0.287, P = 0.001). Compared to HF, men and women with NHNVF were heavier (difference [men] 9.0 kg, P = 0.01; [women] 7.6 kg, P < 0.001). Heavier weight was also a risk factor for women with NHNVF compared to VF (1.03, 1.01–1.06). In men with NHNVF, falls (0.37, 0.14–0.97) and prior fractures (0.38, 0.15–0.98) were less common compared to HF; and glucocorticoid use was less common for NHNVF (0.30, 0.11–0.85) compared to VF. Conclusions: Given the high numbers of NHNVF sustained by men and women in this study, fracture prevention strategies should focus on individuals with high risk of sustaining these types of fractures, as well as on individuals who are more likely to sustain a HF or VF.

Low lean tissue mass and physical performance as markers of sarcopenia in older men and women

Background: While declines in muscle mass and function occur in all individuals with advancing age, the extent and rate of decline vary in the general population. We aimed to determine the prevalence of low lean tissue mass combined with poor physical function as an indicator of sarcopenia among older men and women residing in southeastern Australia.

Methods: The study involved men and women aged 60+ years from the Geelong Osteoporosis Study (GOS). Skeletal muscle mass was measured as total lean tissue mass by dual energy x-ray absorptiometry (DXA) and expressed as a percentage of body weight to generate the skeletal mass index (SMI); low lean mass was defined as SMI T-score <-1. Low muscle function was based on performance using “timed up-and-go” scores >10s. Physical activity scores were determined using a validated questionnaire for the elderly and falls were self-reported for the previous year. Associations between sarcopenia, physical activity and falls were determined using multivariable regression techniques.

Results: Among 624 men, 233 had low SMI, 169 had low muscle performance and 81 had both, thus meeting criteria for sarcopenia. Among 436 women, 143 had low SMI, 179 had low muscle performance and 70 had both. A general age-related increase in the observed prevalence of sarcopenia appeared to be driven by an age-related increase in low performance. Sarcopenia was associated with lower physical activity scores. No association was detected between sarcopenia and falls for men but an association was observed for women (age-adjusted OR 1.87, 95% CI 1.11, 3.14).

Conclusion: In our population, the prevalence of sarcopenia was 10.6% (95% CI 7.7, 13.4) for men and 14.5% (95% CI 10.8, 18.3) for women. Men and women with sarcopenia were habitually less active and, for women, sarcopenia was associated with increased likelihood of falls.