Depressive symptoms and 3-year mortality in older hospitalized medical patients

Cognitive impairment, depressive symptoms, and functional decline in older people

OBJECTIVES

Although cognitive impairment and depressive symptoms are associated with functional decline, it is not understood how these risk factors act together to affect the risk of functional decline. The purpose of this study is to determine the relative contributions of cognitive impairment and depressive symptoms on decline in activity of daily living (ADL) function over 2 years in an older cohort.

DESIGN

Prospective cohort study.

SETTING

A U.S. national prospective cohort study of older people, Asset and Health Dynamics in the Oldest Old.

PARTICIPANTS

Five thousand six hundred ninety-seven participants (mean age 77, 64% women, 86% white) followed from 1993 to 1995.

MEASUREMENTS

Cognitive impairment and depressive symptoms were defined as the poorest scores: 1.5 standard deviations below the mean on a cognitive scale or 1.5 standard deviations above the mean on validated depression scales. Risk of functional decline in participants with depressive symptoms, cognitive impairment, and both, compared with neither risk factor, were calculated and stratified by baseline dependence. Analyses were adjusted for demographics and comorbidity.

RESULTS

Eight percent (n = 450) of subjects declined in ADL function. In participants who were independent in all ADLs at baseline, the relative risk (RR) of 2-year functional decline was 2.3 (95% confidence interval (CI) = 1.7-3.1) for participants with cognitive impairment, 1.9 (95% CI = 1.3-2.6) for participants with depressive symptoms, and 2.4 (95% CI = 1.4-3.7) for participants with cognitive impairment and depressive symptoms. In participants who were dependent in one or more ADLs at baseline, RR of 2-year functional decline was 1.9 (95% CI = 1.2-2.8) for participants with cognitive impairment, 0.6 (95% CI = 0.3-1.3) for participants with depressive symptoms, and 1.5 (95% CI = 0.8-2.6) for participants with cognitive impairment and depressive symptoms.

CONCLUSIONS

In participants with no ADL dependence at baseline, cognitive impairment and depressive symptoms are risk factors for decline, but that, in participants with dependence in ADL at baseline, cognitive impairment, but not depressive symptoms, is a risk factor for additional decline.

Mortality after hospitalization for COPD

OBJECTIVES

To identify variables associated with mortality in patients admitted to the hospital for acute exacerbation of COPD.

DESIGN

Prospective cohort study.

SETTING

Acute-care hospital in Barcelona (Spain).

PATIENTS

One hundred thirty-five consecutive patients hospitalized for acute exacerbation of COPD, between October 1996 and May 1997.

MEASUREMENTS AND RESULTS

Clinical, spirometric, and gasometric variables were evaluated at the time of inclusion in the study. Socioeconomic characteristics, comorbidity, dyspnea, functional status, depression, and quality of life were analyzed. Mortality at 180 days, 1 year, and 2 years was 13.4%, 22%, and 35.6%, respectively. Sixty-four patients (47.4%) were dead at the end of the study (median follow-up duration, 838 days). Greater mortality was observed in the bivariate analysis among the oldest patients (p < 0.0001), women (p < 0.01), and unmarried patients (p < 0.002). Hospital admission during the previous year (p < 0.001), functional dependence (Katz index) [p < 0.0004], greater comorbidity (Charlson index) [p < 0.0006], depression (Yesavage Scale) [p < 0.00001]), quality of life (St. George's Respiratory Questionnaire [SGRQ]) [p < 0.01], and PCO(2) at discharge (p < 0.03) were also among the significant predictors of mortality. In the multivariate analysis, the activity SGRQ subscale (p < 0.001; odds ratio [OR], 2.62; confidence interval [CI], 1.43 to 4.78), comorbidity (p < 0.005; OR, 2.2; CI, 1.26 to 3.84), depression (p < 0.004; OR, 3.6; CI, 1.5 to 8.65), hospital readmission (p < 0.03; OR, 1.85; CI, 1.26 to 3.84), and marital status (p < 0.0002; OR, 3.12; CI, 1.73 to 5.63) were independent predictors of mortality.

CONCLUSIONS

Quality of life, marital status, depressive symptoms, comorbidity, and prior hospital admission provide relevant information of prognosis in this group of COPD patients.

Does the presence of anxiety affect the validity of a screening test for depression in the elderly?

INTRODUCTION

Depression in the elderly is frequently detected by screening instruments and often accompanied by anxiety. We set out to study if anxiety will affect the ability to detect depression by a screening instrument.

OBJECTIVE

To validate the short Zung depression rating scale in Israeli elderly and to study the affect of anxiety on its validity.

DESIGN

The short Zung was validated against a psychiatric evaluation, in a geriatric inpatient and outpatient service. The overall validity was determined, as well as for subgroups of sufferers and non-sufferers of anxiety.

SETTING

An urban geriatric service in Israel.

PATIENTS

150 medical inpatients and outpatients, aged 70 years and older.

MEASURES

Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM-IV as criterion standard for anxiety and depression and short Zung instrument for depression.

RESULTS

By criterion validity, 60% suffered from depression. The overall validity of the short Zung was high (sensitivity 71.1%, specificity 88.3%, PPV 90.1%, NPV 67.1%). The validity for those not suffering from anxiety was good (sensitivity 71.1%, specificity 90.2%, PPV 84.4%, NPV 80.7%). In those with anxiety, sensitivity, specificity and PPV were high (71.2%, 77.8%, 94.9% respectively), although the specificity was less than in non-suffers. However major difference was in the NPV rate being much lower (31.8%).

CONCLUSION

The short Zung, an easily administered instrument for detecting depression, is also valid in the Israeli elderly. However, anxiety limits the usefulness of this instrument in correctly ruling out depression. The clinician must be aware, therefore, that those suffering from anxiety may score negatively for depression on a screening instrument, such as the short Zung.

Depression and anxiety in older women

The recommended shift in paradigm for assessment and treatment of depression and anxiety in the primary care setting includes a more holistic medical care approach, one that pays attention to the patient's mental health status and her functional level of social role recovery in addition to symptom relief. Practice Guidelines of professional specialities should be expanded to include attention to initializing mental health care in primary care practice and parameters for early referral and, if indicated, later follow-up. Our medical education system, at all levels, needs to become considerably more inclusive of issues of aging, gender, and mental health. Ongoing attention must be given to the health care cost burden of under recognition and under treatment of anxiety and depression, alleviation of stigma, treatment to functional recovery, and alleviation of caregiver burden.

Psychoneuroimmunology of depression: clinical implications

Psychoneuroimmunology is a field that investigates the interactions between the brain and the immune system. One important goal of this field of research is to translate basic research in order to understand how behavior affects health and resistance to disease in humans. This review evaluates the impact of depression on morbidity and mortality risk and asks whether neuroimmune mechanisms contribute to this association. Examples are drawn from three diseases: cardiovascular disease, infectious disease, and rheumatoid arthritis. Finally, the potential for biobehavioral interventions to impact psychological adaptation and the course of immune related disease is discussed.

Health literacy and performance on the Mini-Mental State Examination

The objectives of the study were to determine the relationship between functional health literacy and performance on the Mini-Mental State Examination (MMSE). New Medicare managed-care enrollees aged 65 years and older, living independently in the community in four US cities (Cleveland, Houston, Tampa, and Fort Lauderdale/Miami), were eligible to participate. In-home interviews were conducted to determine demographics and health status, and interviewers then administered the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the MMSE. We then determined the relationship between functional health literacy and the MMSE, including total scores, subscale scores (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction), and individual items. Functional health literacy was linearly related to the total MMSE score across the entire range of S-TOFHLA scores (R(2) = 0.39, p < 0.001). This relationship between health literacy and MMSE was consistent across all MMSE subscales and individual items. Adjustment for chronic conditions and self-reported overall health did not change the relationship between health literacy and MMSE score. Health literacy was related to MMSE performance even for subscales of the MMSE that were not postulated to be directly dependent on reading ability or education (e.g. delayed recall). These results suggest that the lower MMSE scores for patients with low health literacy are only partly due to 'test bias' and also result from true differences in cognitive functioning. 'Adjusting' MMSE scores for an individual's functional health literacy may be inappropriate because it may mask true differences in cognitive functioning.

The psychological impact of end-stage lung disease

STUDY OBJECTIVES

End-stage lung disease is associated with poor quality of life and increased risk for psychological distress. Despite the significant number of individuals with end-stage lung diseases, the emotional health of these patients, as compared with those with other chronic organ diseases, is not well-known. The purpose of this article is to elucidate personality styles and the presence of psychopathology in a clinical sample of patients with end-stage lung disease presenting for possible lung transplantation.

DESIGN

Cross-sectional survey.

SETTING

Two academic medical center transplant programs.

PARTICIPANTS

Two hundred forty-three consecutively referred transplant candidates.

RESULTS

Cluster analysis of the Minnesota Multiphasic Personality Inventory (MMPI)-2 indicated five different personality styles. The majority of patients evidenced mild somatic and depressive symptoms. Approximately one fourth of the sample exhibited marked anxiety and mood disturbances. A small cluster also evidenced features consistent with an antisocial personality style.

CONCLUSIONS

Separate and distinct personality styles that could affect quality of life, the need for adjunct treatments, and medical compliance emerged from this sample of individuals with end-stage lung disease. Results are discussed in light of prior research on other end-stage organ conditions and in relation to personality and coping theories.

Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration

OBJECTIVE

To examine (1) the prevalence of depressive disorders in community-dwelling adults with advanced age-related macular degeneration (AMD) and (2) the relationship in this population between depression, visual acuity, the number of comorbid medical conditions, disability caused by vision loss as measured by the National Eye Institute-Vision Function Questionnaire (NEI-VFQ) and the vision-specific Sickness Impact Profile (SIPV), and disability caused by overall health status as measured by the Sickness Impact Profile-68 (SIP).

DESIGN

Analysis of cross-sectional baseline data from a randomized clinical trial.

PARTICIPANTS

Participants were 151 adults aged 60 and older (mean age, 80 years) with advanced macular degeneration whose vision was 20/60 or worse in their better eye.

METHODS

Subjects were interviewed using measures of depression, disability, and chronic medical conditions. Visual acuity was obtained. Nonparametric correlation analyses and linear regression analyses were performed.

MAIN OUTCOME MEASURES

Structured Clinical Interview for DSM-IV (SCID-IV), Geriatric Depression Scale (GDS), NEI-VFQ, SIPV, and SIP.

RESULTS

Of the participants, 32.5% (n = 49) met SCID-IV criteria for depressive disorder, twice the rate observed in previous studies of community-dwelling elderly. Over and above depression (GDS), visual acuity aided in prediction of the level of vision-specific disability (NEI-VFQ and SIPV).

CONCLUSIONS

Depressive disorder is a significant problem for the elderly afflicted with advanced macular degeneration. Further research on psychopharmacologic and psychotherapeutic interventions for depressed AMD patients is warranted to improve depression and enhance functioning. Over and above depression, visual acuity aided in predicting vision-specific disability. Treatment strategies that teach patients to cope with vision loss should be developed and evaluated.

Identifying physicians likely to benefit from depression education: a challenge for health care organizations

BACKGROUND

Few methods exist to identify physicians who might benefit from depression education.

OBJECTIVES

To develop a measure of physicians' confidence or self-efficacy in caring for depressed patients and assess it's reliability and validity.

RESEARCH DESIGN

A national sample of primary care physicians were surveyed and exploratory factor analysis (EFA) was used to identify factors underlying physicians' responses to 26 items. We named the factors, selected items with factor loadings > or = 0.50 for final scales, and tested a priori hypotheses about self-efficacy.

SUBJECTS

1) Random cross-sectional sample of family physicians, internists, obstetrician-gynecologists, and pediatricians (n = 5,369) and 2) 49 general internists and family physicians participating in a prepost evaluation of a depression workshop.

RESULTS

In the national sample, 3,712 physicians were eligible and 2,104 responded. Forty-six percent were female, and 51% were family physicians and general internists. EFA identified 5 factors, the first of which was called Self-Efficacy (4 items, alpha = 0.86). More family physicians (64%) had confidence (self-efficacy) in caring for depressed patients compared with general internists (33%), obstetrician-gynecologists (16%), and pediatricians (6%) (P < 0.001). Few physicians intended to change their care of depressed patients (10%) or take CME on depression (24%). Of the 49 physicians attending a depression workshop, 76% reported high self-efficacy after the workshop versus 50% before it (P = 0.013).

CONCLUSIONS

This study supports the reliability and validity of the Self-Efficacy scale as one method to identify physicians who might benefit from interventions. New approaches are needed because physicians are unlikely to change.

The association of depression and mortality in elderly persons: a case for multiple, independent pathways

BACKGROUND

The evidence for an association between depression and mortality among community-dwelling elderly persons remains inconclusive, although it is well established for younger individuals. Extant studies suggest that this association weakens when adjusted for potential confounding factors, especially functional impairment. A cohort of elderly subjects followed for 3 years was analyzed to determine the association of depression and 3-year mortality, controlling for the major known risk factors for mortality in the elderly population.

METHODS

Information on depression (CES-D scores), mortality, demographics, body mass index, chronic disease, smoking history, cognitive impairment, functional impairment, self-rated health, and social support was obtained from a stratified probability-based sample of community-dwelling elderly persons, with equal distribution between African Americans and whites in the Piedmont of North Carolina. Descriptive statistics were calculated, and logistic regression was used for a series of models with progressively more control variables.

RESULTS

The unadjusted relative odds of mortality among depressed subjects at baseline was 1.98 over 3 years of follow-up. Inclusion of age, gender, and race into the model did not reduce the relative odds. When chronic disease and health habits, cognitive impairment, functional impairment, and social support were added to the model, the odds ratios for mortality with depression were 1.74, 1.69, 1.29, and 1.21, respectively. This decrease in odds ratios was not observed for other variables in the model when additional variables were added.

CONCLUSIONS

The estimated odds of dying if depressed moved toward unity as other risk factors for mortality were controlled. Unlike other known risk factors for mortality in the elderly population, depression appears to be associated with mortality through a number of independent mechanisms, perhaps through complex feedback loops.

Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients

OBJECTIVE

To determine the independent effects of depressed mood and markers of medical disease severity on mortality in consecutive medical inpatients.

METHODS

Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study endpoint was mortality from all causes at 1 year.

RESULTS

The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. In multivariate analyses, physicians' rating of prognosis was the best predictor of mortality [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI), 2.5--5.4]. Other independent predictors included a principal diagnosis of hemato-oncological disease, comorbidity scores, and HADS depression (adjusted OR 1.75; 95% CI, 1.10--2.79).

CONCLUSION

Our data demonstrate an independent prognostic effect of depressed mood on mortality in general medical inpatients. Screening for depression may improve risk stratification in these patients over and above that obtained by routinely available physical parameters and physicians' clinical judgement.

Does satisfaction with abilities mediate the relationship between the impact of rheumatoid arthritis on valued activities and depressive symptoms?

OBJECTIVE

Both impact of rheumatoid arthritis (RA) on valued life activities and dissatisfaction with abilities have been linked to depression among individuals with RA. We integrated these concepts by examining the hypothesis that satisfaction with one's abilities may explain the mechanism by which the impact of RA on valued activities leads to depression.

METHODS

Data were collected over 2 years (1997 and 1998) through interviews with the University of California, San Francisco, RA panel. Analyses examined whether activity impairment in 1997 predicted later (1998) dissatisfaction with abilities and depression.

RESULTS

Greater impact on activities predicted dissatisfaction with abilities, which in turn was associated with higher depression scores. There was no direct relationship between activity impact and depression when satisfaction with abilities was considered.

CONCLUSION

Satisfaction with abilities mediated the relationship between the impact of RA on valued activities and an increase in depressive symptoms, suggesting a need to assess not only physical decline but also individuals' interpretation of the decline.

Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis

Depression is the most commonly encountered psychological problem in patients with end-stage renal disease (ESRD). Depression has recently been shown to significantly impact on the morbidity and mortality of patients undergoing therapy for ESRD. The present study was designed as a pilot study to evaluate the feasibility of screening a large cohort of patients maintained on chronic peritoneal dialysis (CPD) for depression and then pharmacologically treating those patients assessed to have clinical depression. One hundred thirty-six patients maintained on CPD in our CPD unit were screened for depression using the Beck Depression Inventory (BDI), a self-administered questionnaire. Patients with scores of 11 or greater were referred to a trained psychiatric interviewer for further evaluation to confirm the diagnosis of clinical depression and determine whether the patient was a candidate for antidepressant medication. Sixty-seven patients had BDI scores of 11 or greater, and 60 of these patients were asked to participate in further evaluation and possible therapy. Only 27 patients agreed to further study and were evaluated by a trained psychiatric interviewer for clinical depression. Twenty-three of these patients were assessed to have clinical depression, and 22 patients were eligible for antidepressant medication based on their scores on the Hamilton Depression Scale and psychiatric interview. Eleven patients completed a 12-week course of therapy with antidepressant medication, and their BDI scores decreased from a mean of 17.1 +/- 6.9 (SD) to a mean of 8.6 +/- 3.2. Seven patients were treated with sertraline, 2 patients with bupropion, and 2 patients with nefazodone. It is concluded that (1) depression is commonly present in patients maintained on CPD, (2) the BDI is a useful tool to use to screen for clinical depression, and (3) clinical depression is treatable with medication in this patient population.

History and mobility exam index to identify community-dwelling elderly persons at risk of falling

BACKGROUND

Falls are common in community-dwelling elderly persons and are a frequent source of morbidity. Simple indices to prospectively stratify people into categories at different fall-risk would be useful to health care practitioners. Our goal was to develop a fall-risk index that discriminated between people at high and low risk of falling.

METHODS

We evaluated the risk of falling over a one-year period in 557 elderly persons (mean age 81.6) living in a retirement community. On the baseline interview, we asked subjects if they had fallen in the previous year and evaluated risk factors in six additional conceptual categories. On the follow-up interview one year later, we again asked subjects if they had fallen in the prior year. We evaluated risk factors in the different conceptual categories and used logistic regression to determine the independent predictors of falling over a one-year period. We used these independent predictors to create a fall-risk index. We compared the ability of a prior falls history with other risk factors and with the combination of a falls history and other risk factors to discriminate fallers from nonfallers.

RESULTS

A fall in the previous year (OR = 2.42, 95% CI = 1.49-3.93), a symptom of either balance difficulty or dizziness (OR = 1.83, 95% CI = 1.16-2.89), or an abnormal mobility exam (OR = 2.64, 95% CI = 1.64-4.26) were independent predictors of falling over the subsequent year. These three risk factors together (c statistic =.71) discriminated fallers from nonfallers better than previous history of falls alone (c statistic =.61) or the symptomatic and exam risk factors alone (c statistic =.68). When combined into a risk index, the three independent risk factors stratify people into groups whose risk for falling over the subsequent year ranges from 10% to 51%.

CONCLUSION

A history of falling over the prior year, a risk factor that can be obtained from a clinical history (balance difficulty or dizziness), and a risk factor that can be obtained from a physical exam (mobility difficulty) stratify people into groups at low and high risk of falling over the subsequent year. This risk index may provide a simple method of assessing fall risk in community-dwelling elderly persons. However, it requires validation in other subjects before it can be recommended for widespread use.

Early revisit, hospitalization, or death among older persons discharged from the ED

The purpose of this study to determine predictors of revisit, hospital admission, or death among older patients discharged from the emergency department (ED). We performed a prospective study of patients aged 65 or older in an urban ED. The primary outcomes were ED revisit, hospital admission, or death 30 or 90 days after discharge from an index ED visit. Of the 463 eligible patients, 75 (16%) experienced ED revisit, hospitalization, or death within 30 days, and 125 (27%) within 90 days. In multivariate proportional hazards models, physical functioning and mental health in the lowest tertile, and lack of supplemental insurance predicted revisit, hospitalization, or death within 30 days after ED discharge. Poor physical functioning, missing mini-mental state examination, comorbidity, and ambulance transport to the initial ED visit predicted 90-day outcome. Problems with physical functioning, mental health and supplemental insurance are potentially remediable precursors of early morbidity among older patients after ED discharge. Future research should examine whether addressing these issues among the elderly population will lessen ED return visits, hospitalization, and mortality.

Persistence of impaired functioning and psychological distress after medical hospitalization for men with co-occurring psychiatric and substance use disorders

OBJECTIVE

To measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans.

DESIGN

A random sample followed observationally for 1 year after study enrollment.

SETTING

Inpatient medical and surgical wards at 3 university-affiliated Department of Veterans Affairs Medical Centers.

PATIENTS/PARTICIPANTS

A random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%).

MEASUREMENTS AND MAIN RESULTS

All participants were administered a computerized structured psychiatric diagnostic interview for 13 psychiatric (include substance use) disorders and received longitudinal assessments at 3 and 12months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P <.05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P <.001) except physical functioning (P <.05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services.

CONCLUSIONS

General medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated posthospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time.

Activity loss and the onset of depressive symptoms: Do some activities matter more than others?

OBJECTIVE

This study continues an investigation into the role of decline in performance of valued life activities in the development of depressive symptoms among persons with rheumatoid arthritis (RA). We examined whether declines in specific types of activities are important in the onset of depressive symptoms or whether the important factor is simply the overall burden of activity decline.

METHODS

Data from a longitudinal study of persons with RA, for which individuals are interviewed annually, were used. Two analyses (n = 344 and 310) were conducted because of differences in the way life activities were assessed over time. Each analysis covered 4 interviews (1989-1992 and 1995-1998). Analyses were structured so that the decline in performance of life activities clearly preceded the development of depressive symptoms. The outcome variable was the presence of depressive symptoms at time 4; primary independent variables were activity decline between time 2 and time 3. Individuals with high levels of depressive symptoms prior to time 4 were excluded from the analyses.

RESULTS

In both analyses, total decline in performance of life activities was an important predictor of subsequent high levels of depressive symptoms. However, some activity domains were more closely linked to the onset of new depressive symptoms than others. In particular, declines in the ability to perform recreational activities and engage in social interactions were linked to the onset of new depressive symptoms.

CONCLUSION

Declines in the ability to engage in recreational activities and social interactions appear to significantly increase the risk of new depressive symptoms. These findings can give direction to both clinical inquiries into patients' functioning and interventions intended to enhance functioning.

Gender differences in morbidity and mortality related to depression: a review of the literature

In this review of the existing evidence regarding a gender-specific association of depression with major health outcomes in older adults, we were unable to confirm that relative risk of morbidity and/or mortality due to depression varies with respect to gender. Future researchers may wish to concentrate their efforts in the identification of possible biophysiologic mechanisms underlying the association between depression and a variety of health outcomes.

The protective effect of emotional vitality on adverse health outcomes in disabled older women

OBJECTIVE

Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women.

DESIGN

A community-based study, The Women's Health and Aging Study.

PARTICIPANTS

A total of 1002 moderately to severely disabled women aged 65 years and older living in the community.

MEASUREMENTS

Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. The onset of new disability was determined by semiannual assessments of disability in performing activities of daily living (ADLs), walking across a room, walking 1/4 mile, and lifting/carrying 10 pounds. Mortality status was determined by proxy interviews and linkage with death certificates. Survival analyses with time to onset of specific disabilities (among those not disabled at baseline) and time to mortality were performed and adjusted for age, baseline level of difficulty, physical performance, and chronic conditions.

RESULTS

Three hundred fifty-one of the 1002 older disabled women studied were emotionally vital. Among women without the specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking one-quarter mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression since protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed.

CONCLUSIONS

Emotional vitality in older disabled women reduces the risk for subsequent new disability and mortality. Our findings suggest that positive emotions can protect older persons against adverse health outcomes.

Maximizing life's potentials in AIDS: a psychopharmacologic update

Psychiatric factors play a major role in the AIDS pandemic. They have an impact on transmission, morbidity, coping, adherence, and quality of life and of death. Substance-related disorders are associated with HIV transmission through needle sharing, sexual transmission, exchange of sex for drugs, and perinatal transmission. Persons with AIDS have a high prevalence of substance-related disorders, mood disorders, dementia, mania, and delirium. Persons with AIDS require complex medications, including combination antiretroviral therapy and prophylaxis and treatment for opportunistic infections and cancers. Recognition and treatment of distressing symptoms can maximize life's potentials and enhance adherence with risk prevention and with care. We describe an integrated approach to the use of psychotropic medications in the care of persons with AIDS. With the new antiretroviral therapies available, psychotropic medications can be helpful in alleviating distressing symptoms, promoting less risk taking, and adhering to complex medical care. The intricacies and complexities of new medical and psychopharmacological issues are delineated in order to enable caregivers help persons with AIDS to maximize life's potentials.

Association between depressive symptoms and mortality in medical inpatients

The authors interviewed a consecutive series of medical inpatients (N = 241) using the Schedule for Affective Disorders and Schizophrenia to determine which depressive symptoms are associated with in-hospital mortality. Fifteen depressive symptoms, pain, and physical discomfort were assessed along with medical comorbidity. Twenty patients died in-hospital (8.3%). Logistic regression showed that anhedonia, hopelessness, worthlessness, indecisiveness, and insomnia predicted in-hospital death after adjusting for physical comorbidity and age. Clinicians should be aware that these depressive symptoms may predict mortality in medical inpatients. Future studies should address which treatment modalities lead to better outcomes.

Geriatric oncology: challenges for the new century

The management of cancer in the older aged person represents one of the major immediate challenges of medicine. The response to this challenge involves answers to the following questions: I. Who is old? Currently. 70 years of age may he considered the lower limit of senescence because the majority of age-related changes occur after this age. Individual estimates of life expectancy and functional reserve may be obtained by a comprehensive and time-consuming multidimensional geriatric assessment. The current instrument may be fine-tuned and new instruments, including laboratory tests of ageing. may be developed. 2. Why do older persons develop more cancer? It is clear that ageing tissues are more susceptible to late-stage carcinogen. Older persons may represent a natural monitor system for new environmental carcinogens, and may also represent a fruitful ground to study the late stages of carcinogenesis. 3. Is cancer different in younger and older persons? Clearly. the behaviour of some tumors. including acute myeloid leukaemia, non-Hodgkin's lymphoma and breast cancer change with the age of the patient. The mechanisms of these changes that may involve both the tumour cell and the tumour host are poorly understood. 4. Can cancer he prevented in older individuals? Chemoprevention offers a new horizon of possibilities for cancer prevention: older persons may benefit most from chemoprevention due to increased susceptibility to environmental carcinogens. Screening tests may become more accurate in older individuals due to increased prevalence of cancer. hut may he less beneficial due to more limited patient life expectancy. 5. Do older persons benefit from cytotoxic treatment? The answer to this question partly stands on proper patient selection. partly on the development of safer forms of cancer treatment and prudent use of antidotes to chemotherapy toxicity. 6. What is the cost of treating older cancer patients? The treatment of older patients is generally more costly. This cost should be assessed against the cost of not treating cancer and promoting functional dependence. which by itself is extremely costly. 7. What are the endpoints of clinical trials in older cancer patients? With more limited life expectancy. the effect of treatment on quality of life is paramount. Reliable assessment of quality of life is essential for interpreting clinical trials in older individuals. 2000 Elsevier Science Ltd. All rights reserved.

Measurement and impact of comorbidity in older cancer patients

As the world population ages, oncologists are increasingly confronted with the problem of comorbidity in cancer patients. This has stemmed an increasing interest into approaching comorbidity in a systematic way, in order to integrate it in treatment decisions. So far, data on the subject have been widely scattered through the medical literature. This article is aimed at reviewing the available data on the interaction of comorbidity and prognosis. This overview should provide an accessible source of references for oncological investigators developing research in the field. Various methods have been used to sum comorbidity. However, a major effort remains to be done to analyze how various diseases combine in influencing prognosis. The main end-point explored so far is mortality, with which comorbidity globally is reliably correlated. A largely open challenge remains to correlate comorbidity with treatment tolerance, and functional and quality of life outcomes, as well as to integrate it in clinical decision-making.

Management of cancer in the older person: a practical approach

The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is the treatment producing more benefits than harm? This article explores a practical, albeit evolving, approach to these questions including a multidimensional assessment of the older person and simple pharmacologic interventions that may ameliorate the toxicity of antineoplastic agents. Age may be construed as a progressive loss of stress tolerance, due to decline in functional reserve of multiple organ systems, high prevalence of comorbid conditions, limited socioeconomic support, reduced cognition, and higher prevalence of depression. Aging is highly individualized: chronologic age may not reflect the functional reserve and life expectancy of an individual. A comprehensive geriatric assessment (CGA) best accounts for the diversities in the geriatric population. The advantages of the CGA include:Recognition of potentially treatable conditions such as depression or malnutrition, that may lessen the tolerance of cancer treatment and be reversed with proper intervention; Assessment of individual functional reserve; Gross estimate of individual life expectancy; and Adoption of a common language to classify older cancer patients. The CGA allows the practitioner to recognize at least three stages of aging:People who are functionally independent and without comorbidity, who are candidates for any form of standard cancer treatment, with the possible exception of bone marrow transplant. People who are frail (dependence in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are a candidate only for palliative treatment; and People in between, who may benefit from some special pharmacological approach, such as reduction in the initial dose of chemotherapy with subsequent does escalations. The pharmacological changes of age include decreased renal excretion of drugs and increased susceptibility to myelosuppression, mucositis, cardiotoxicity and neurotoxicity. Based on these findings, the proposal was made that all persons aged 70 and older, treated with cytotoxic chemotherapy of dose intensity comparable to CHOP, receive prophylactic growth factor treatment, and that the hemoglobin of these patients be maintained >/=12 gm/dl.

Depressed mood in a cohort of elderly medical inpatients: prevalence, clinical correlates and recognition rate

The objectives of this prospective cohort study were to 1) determine the prevalence of depressed mood, 2) identify the characteristics associated with it, and 3) evaluate the recognition rate of depressed mood by clinicians. The study population was a cohort of 401 elderly patients, aged 75 years and older, admitted to the internal medicine service of a tertiary care academic medical center in Western Switzerland over six months. We excluded patients with severe cognitive impairment, terminal disease or those living in a nursing home. Data on demographics, medical, physical, social and mental status were collected upon admission. Presence of depressed mood was defined as a score > or = 6 on the Geriatric Depression Scale (GDS), short form (15-item). An independent reviewer performed a discharge summary abstraction to assess recognition rate. Subjects' mean age was 82.4 years, 60.9% were women. Overall, 90 patients (22.40%) had an abnormal GDS score (> or =6). Compared to those without a depressed mood, these subjects were (all p<0.05) older (83.5 vs 82.0 years), more frequently living alone (66.7 vs 55.0%), dependent in both basic activities of daily living (BADL) and instrumental ADL (48.9 vs 36.0%, and 91.1 vs 84.9%, respectively), and cognitively impaired (47.8 vs 27.7% with MMSE score<24). In addition, they had more comorbidities (Charlson index 1.6 vs 1.2). In multivariate analysis, an independent association remains for subjects living alone (OR 1.8, 95%CI 1.1-3.0), with cognitive impairment (OR 1.9, 95%CI 1.1-3.2), and comorbidities (OR 1.3 per point, 95%CI 1.1-1.5). Detection rate during the index hospitalization was only 16.7% (15/90). In conclusion, depressed mood was frequent but rarely detected in this population. These findings emphasize the need to improve screening efforts, and to develop additional strategies such as using a pre-screening question to enhance clinical recognition.

Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients

BACKGROUND

The medical risk factors associated with increased mortality in hemodialysis (HD) patients are well known, but the psychosocial factors that may affect outcome have not been clearly defined. One key psychosocial factor, depression, has been considered a predictor of mortality, but previous studies have provided equivocal results regarding the association. We sought to determine whether depressive affect is associated with mortality in a longitudinal study of end-stage renal disease (ESRD) patients treated with HD, using multiple assessments over time.

METHODS

Two hundred ninety-five outpatients with ESRD treated with HD were recruited from three outpatient dialysis units in Washington D.C. to participate in a prospective cohort study with longitudinal follow-up. Patients were assessed every six months for up to two years using the Beck Depression Inventory (BDI), age, serum albumin concentration, Kt/V, and protein catabolic rate (PCR). A severity index, previously demonstrated to be a mortality marker, was used to grade medical comorbidity. The type of dialyzer with which the patient was treated was noted. Patient mortality status was tracked for a minimum of 20 and a maximum of 60 months after the first interview. Cox proportional hazards models, treating depression scores as time-varying covariates in a univariable analysis, and controlling for age, medical comorbidity, albumin concentration, and dialyzer type and site in multivariable models, were used to assess the relative mortality risk.

RESULTS

The mean (+/- SD) age of our population at initial interview was 54.6 +/- 14.1 years. The mean PCR was 1.06 +/- 0.27 g/kg/day, and the mean Kt/V was 1.2 +/- 0.4 at baseline, suggesting that the patients were well nourished and dialyzed comparably to contemporary U.S. patients. The patients' mean BDI at enrollment was 11.4 +/- 8.1, in the range of mild depression. Patients' baseline level of depression was not a significant predictor of mortality at 38.6 months of follow-up. In contrast, when depression was treated as a time-varying covariate based on periodic follow-up assessments, the level of depressive affect was significantly associated with mortality in both single variable and multivariable analyses.

CONCLUSIONS

Higher levels of depressive affect in ESRD patients treated with HD are associated with increased mortality. The effects of depression on patient survival are of the same order of magnitude as medical risk factors. Our findings using both controls for factors possibly confounded with depressive affect in patients with ESRD and time-varying covariate analyses may explain the inconsistent results of previous studies of depression and mortality in ESRD patients. Time-varying analyses in longitudinal studies may add power to defining and sensitivity to establishing the association of psychosocial factors and survival in ESRD patients. The mechanism underlying the relationship of depression and survival and the effect of interventions to improve depression in HD outpatients and general medical inpatients should be studied.

Measuring comorbidity in older cancer patients

The aim of this article was to provide oncology researchers with adequate tools and practical advice to integrate comorbidity into clinical studies. Open research questions are also discussed. Commonly used comorbidity indexes were identified and a detailed literature search was done by MEDLINE and cross-referencing. Expert opinion was sought on each index. A common scheme exploring the description of the index, clinical experience, metrological performance, easiness of use, cross-compatibility and preservation of data was followed. The actual indexes are included in the Appendix. Four commonly used indexes were identified: the Charlson Comorbidity Index (Charlson), the Cumulative Illness Rating Scale (CIRS), the Index of Coexistent Disease (ICED), and the Kaplan-Feinstein index. The Charlson is the most commonly used whereas the performance of the first two indexes is best characterised. Most studies are retrospective and focus on mortality as an outcome and a base of grading. All indexes are easy to use and require a maximum of 10 min to be filled. Inter-rater and test-retest reliability is generally good. Little is known about other outcomes and the way various diseases cumulate in influencing prognosis. Thus, several reliable indexes are available to measure comorbidity in cancer patients. They show that globally comorbidity is a strong predictor of outcome. Since little is still known about the importance of individual comorbidities for various outcomes and the way comorbidity cumulates in influencing cancer treatment, a wide integration of comorbidity in prospective studies is essential.

Exercise and older patients: guidelines for the clinician

Sedentary persons who improve their physical fitness are less likely to die of all causes and of cardiovascular disease than are those who remain sedentary. There now exists a wealth of data demonstrating that physical activity and exercise may ameliorate disease and delay decline in function in the geriatric population. We review evidence that exercise can improve body composition, diminish falls, increase strength, reduce depression, reduce arthritis pain, reduce risks for diabetes and coronary artery disease, and improve longevity. However, many healthcare professionals do not feel adequately prepared to design and prescribe exercise programs for their patients. This review provides a basic overview of the benefits of exercise in the geriatric population and guidelines indicating how to prescribe and facilitate adherence to an exercise program. Healthcare providers are strongly encouraged to promote a less sedentary life style for their older patients, which may augment quality of life in these older individuals.

Antineoplastic chemotherapy of the older cancer patient

Cancer chemotherapy may be effective and safe in older patients if some proper provisions are made. Doses of chemotherapy should be adjusted to the patient's glomerular filtration rate, and his or her hemoglobin should be maintained for the duration of the therapy. For patients who are 70 years of age or older and who are receiving moderately toxic chemotherapy, growth factors should be used. The risk of mucositis increases with the age of the patient, so it is important to treat it aggressively at the first signs of the complication.

Cancer and aging. An evolving panorama

This article illustrates how the nosology of cancer evolves with the patient's age. If the current trends are maintained, 70% of all neoplasms will occur in persons aged 65 years and over by the year 2020, leading to increased cancer-related morbidity among older persons. Cancer control in the older person involves chemoprevention, early diagnosis, and timely and effective treatment that entails both antineoplastic therapy and symptom management. These interventions must be individualized based on a multidimensional assessment that can predict life expectancy and treatment complications and that may evaluate the quality of life of the older person. This article suggests a number of interventions that may improve cancer control in the aged. Public education is needed to illustrate the benefits of health maintenance and early detection of cancer even among older individuals, to create realistic expectations, and to heighten awareness of early symptoms and signs of cancer. Professional education is needed to train students and practitioners in the evaluation and management of the older person. Of special interest is the current initiative of the Hartford Foundation offering combined fellowships in oncology and geriatrics and incorporating principles of geriatric medicine in medical specialty training. Prudent pharmacologic principles must be followed in managing older persons with cytotoxic chemotherapy. These principles include adjusting the dose according to the patient's renal function, using epoietin to maintain hemoglobin levels of 12 g/dL or more, and using hemopoietic growth factors in persons aged 70 years and older receiving cytotoxic chemotherapy of moderate toxicity (e.g., CHOP). To assure uniformity of data, a cooperative oncology group should formulate a geriatric package outlining a common plan for evaluating function and comorbidity. This article also suggests several important areas of research items: Molecular interactions of age and cancer Host-tumor interactions in the older tumor host Chemoprevention of cancer and aging Laboratory evaluation of aging Development of shorter forms of geriatric assessment Management of the frail cancer patients Clinical trials of tumor-specific issues.

Cancer in the frail patient. A coming epidemic

With the aging of the population, frailty has emerged as a new clinical entity. The frail person has exhausted any functional reserve. Current criteria for the recognition of frailty include age of over 85 years, dependence in one or more activities of daily living, three or more comorbid conditions, and the presence of one or more geriatric syndromes. It is calculated that there are approximately 6 million frail patients in the United States and approximately 400,000 of them have cancer. Management of cancer in the frail person is mainly comprised of palliation, which may include some forms of chemotherapy, such as navelbine, gemcitabine, or low-dose taxanes.