Journals Watch: Antipsychotics in intellectual disability, harmful drinking and trans fat intake

PSYCHOTROPIC DRUGS IN INTELLECTUAL DISABILITY¹

Approximately 1% of the population have intellectual disability. There is concern that antipsychotics are overused in these patients, and might often be prescribed for challenging behaviour rather than diagnosed mental illness, despite lack of evidence of efficacy.

Study design
This UK-based cohort study looked at 571 general practices contributing data to The Health Improvement Network clinical database.

A total of 33,016 adults with intellectual disability were included, or 0.9%, comparable to population prevalence.

Mental illness, dementia, autism and epilepsy code lists were included. Time trends of recording mental illness, challenging behaviour and new prescriptions for psychotropic drugs were examined.

Key findings
Of the adults studied, 21% had a record of mental illness, 25% had a record of challenging behaviour and 49% had a prescription for psychotropic drugs.

The rate of new antipsychotic prescribing was significantly higher in those with challenging behaviour, autism and dementia, and in older people. Most were prescribed to people without a record of severe mental illness.

Implications for GPs
The proportion of people with intellectual disability treated with psychotropics exceeds the proportion with recorded mental illness.

Limited evidence suggests that certain antipsychotics might be effective in treating behavioural disturbances in intellectual disability comorbid with autism, but no evidence supports antipsychotic use in challenging behaviours outside this context.

Antipsychotics are associated with side-effects that can impair quality of life and diminish health outcomes, further implicated by possible lack of capacity to consent to the prescription. Reducing reliance on drugs will require investment in a multidisciplinary team to provide evidence-based management strategies for challenging behaviour.

OLDER PEOPLE AND RISKS OF HARMFUL DRINKING²

Harmful alcohol drinking among people aged 50 or over is a middle-class phenomenon, according to research into the socioeconomic determinants of harmful drinking in those aged 50 years and over in England.

Study design
This study used data from the English Longitudinal Study of Ageing. The sample size was 9,251 and levels of risk were set using NICE guidelines. The variables included were age, income, education, smoking, physical activity, depression, loneliness, self-reported health, ethnicity, gender, marital status, caring responsibilities, children in household, religion, economic activity, social detachment and healthy diet.

Key findings
The probability of being in a higher-risk category decreases with age for both sexes. Caring responsibilities reduce the probability for women.

A higher income and retirement are positively associated for women. Higher educational attainment, number of cigarettes consumed and reporting better health are positively associated for both sexes. Higher-risk drinking is more likely in single, separated or divorced men.

Women who are lonely, younger, and those with a higher income are more at risk of becoming higher-risk drinkers.

Transition into higher-risk categories in men is associated with not eating healthily, being younger and having a higher income.

Implications for GPs
The findings suggest that harmful drinking in later life is more prevalent among people who exhibit a lifestyle associated with affluence and a ‘successful’ ageing process, in terms of better self-rated health, greater physical activity and more social contacts. We should be alert to these hidden health and social problems.

TRANS FAT INTAKE AND INCREASE IN MORTALITY³

Saturated fats contribute about 10% to the North American diet. Trans fats, contributing about 1-2%, are produced industrially and occur naturally in meat and dairy products.

Recent systematic reviews have called for a re-evaluation of dietary guidelines for the intake and effects of saturated fat on health.

Study design
This systematic review and meta-analysis of 41 prospective cohort studies reviewed the association between intake of saturated fat and trans unsaturated fat and all-cause mortality, cardiovascular disease and CHD and associated mortality, ischaemic stroke and type 2 diabetes.

Key findings
Saturated fat intake was not associated with all-cause mortality, cardiovascular disease mortality, total CHD, ischaemic stroke or type 2 diabetes, but a trend of association with CHD mortality was found.

Total trans fat intake was associated with a 34% increase in all-cause mortality, 28% increase in CHD mortality and 21% increase in risk of CHD, but not ischaemic stroke or type 2 diabetes.

Implications for GPs
Although saturated fats have not been found to be associated with the above health outcomes, foods high in saturated fats, particularly processed and red meats, have been associated with increased mortality and risk of cancer.

Dietary guidelines recommend that saturated fats should be limited to <10% and trans fats to <1% of energy, primarily to reduce the risk of IHD and stroke.

Advice to reduce the consumption of industrially produced trans fats will reduce all-cause mortality, total CHD and CHD mortality.

WELLS MOST EFFICIENT SCORE IN SUSPECTED PE⁴

A diagnosis of pulmonary embolism (PE) can be easily missed, resulting in a low threshold for referral for further diagnostics. Only 10-15% of all suspected cases are confirmed emboli.

This study indicates that the Wells score with point-of-care testing for D-dimer can be used by GPs to exclude suspected PE.

Study design
This systematic review looked at 598 patients across 300 general practices in the Netherlands. An independent external validation study assessed the transportability of retrieved prediction models to primary care.

The original, modified and simplified Wells, revised Geneva and simplified revised Geneva models were assessed.

Key findings
Efficiency was comparable for all five models. The simplified revised Geneva model was the most efficient, but was also associated with the highest failure rate. The three Wells rules gave the best performance, with lower failure rates of 1.2-1.5%.

Implications for GPs
Risk stratification is valuable in deciding which patients with suspected PE to refer for diagnostic investigations. A diagnostic model should classify as many patients as possible in the non-referral group, but not at the expense of an increase in missed diagnoses.

The recommendation is that GPs use the simplified Wells rule combined with a point-of-care D-dimer test, to enable the exclusion of suspected PE with an acceptably low failure rate of below 2%. Point-of-care D-dimer tests have a relatively lower sensitivity than laboratory-based quantitative tests, leading to a higher number of false negative results. However, the specificity of point-of-care tests is higher, contributing to the efficiency of the test.

CLASSIFYING BODILY DISTRESS SYNDROME⁵

GPs play a key part in the detection and management of medically unexplained symptoms. Bodily distress syndrome (BDS) is a newly proposed diagnosis for moderate to severe functional disorders, and may replace the numerous overlapping categories of functional somatic syndromes and somatoform disorders.

Study design
In this cross-sectional study of 1,356 primary care patients in urban and rural areas in Denmark, data were obtained from GP one-page registration forms, patient questionnaires (including a BDS checklist) and national registers.

It aimed to estimate the frequency and describe the characteristics of patients fulfilling the BDS criteria in general practice.

Key findings
A total of 17% fulfilled the BDS criteria. BDS was more common among primary care patients aged 41-65 years and was equally frequent among males and females.

Patients with BDS were characterised by poor health-related quality of life (HRQOL) and were more likely to have high scores on the symptom checklist for anxiety and depression.

Implications for GPs
BDS is defined by specific physical symptom patterns in four main groups – cardiopulmonary, GI, musculoskeletal and general symptoms (see box). BDS criteria have been included in the draft of the WHO International Classification of Diseases, but are still the subject of debate.

BDS will be a clinical diagnosis tool in the future, after full approval by WHO, and may provide a basis for future therapeutic pathways for this group of patients in primary care.

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References

1. BMJ 2015; 351: h4326
2. BMJ Open 2015; 5: e007684
3. BMJ 2015; 351: h3978
4. BMJ 2015; 351: h4438
5. Br J Gen Pract 2015; DOI: 10.3399/bjgp15X686545