Shortness of breath as a predictor of depressive symptoms in a community sample of older adults

Assessment and diagnosis of chronic dyspnoea: a literature review

Dyspnoea or breathlessness is a common presenting symptom among patients attending primary care services. This review aimed to determine whether there are clinical tools that can be incorporated into a clinical decision support system for primary care for efficient and accurate diagnosis of causes of chronic dyspnoea. We searched MEDLINE, EMBASE and Google Scholar for all literature published between 1946 and 2020. Studies that evaluated a clinical algorithm for assessment of chronic dyspnoea in patients of any age group presenting to physicians with chronic dyspnoea were included. We identified 326 abstracts, 55 papers were reviewed, and eight included. A total 2026 patients aged between 20–80 years were included, 60% were women. The duration of dyspnoea was three weeks to 25 years. All studies undertook a stepwise or algorithmic approach to the assessment of dyspnoea. The results indicate that following history taking and physical examination, the first stage should include simply performed tests such as pulse oximetry, spirometry, and electrocardiography. If the patient remains undiagnosed, the second stage includes investigations such as chest x-ray, thyroid function tests, full blood count and NT-proBNP. In the third stage patients are referred for more advanced tests such as echocardiogram and thoracic CT. If dyspnoea remains unexplained, the fourth stage of assessment will require secondary care referral for more advanced diagnostic testing such as exercise tests. Utilising this proposed stepwise approach is expected to ascertain a cause for dyspnoea for 35% of the patients in stage 1, 83% by stage 3 and >90% of patients by stage 4.

The mutual association between dyspnea and depressive symptoms in older adults: a 4-year prospective study

Objectives: dyspnea in daily living (DDL), night-time dyspnea (NTD) and depression are common symptoms in older people. However, how changes in dyspnea may influence and be influenced by modifications in depressive symptoms, so far has not been fully evaluated. We aimed to estimate the extent to which both DDL and NTD could be mutually associated to depressive symptoms in older adults with chronic conditions.Methods: this prospective study includes 2322 community-dwelling individuals aged ≥65 years enrolled in the Progetto Veneto Anziani (Pro.V.A.). At baseline and after 4.4 years, we evaluated the following parameters: DDL, assessed by the Medical Research Council dyspnea scale (MRC); self-reported NTD, assessed by personal interview; depressive symptoms, assessed using the Geriatric Depression Scale (GDS). The strength of the association between dyspnea and depression over the follow-up was evaluated through logistic regression and estimated by odds ratios and 95%Confidence Intervals (95%CI). Corrected risk ratios (RR) were then approximated from odds ratios.Results: GDS changes over the follow-up positively correlated with MRC changes (β = 0.938). Individuals with baseline DDL or NTD and those with incident/worsening DDL showed higher risk of developing or worsening depressive symptoms compared with their counterparts (RR = 3.36 [95%CI 2.11-5.06] for incident depression in people with worsening DDL). Incident or persistent depression increased more than twice the risk of developing DDL and NTD (for incident depression RR = 2.33 [95%CI 1.85-2.83] for DDL, and RR = 2.01 [95%CI 1.27-3.11] for NTD).Conclusions: older people may benefit from a comprehensive evaluation of respiratory and psychological symptoms, which seem to be related to each other in advanced age.

Mirtazapine for chronic breathlessness? A review of mechanistic insights and therapeutic potential

INTRODUCTION

Chronic breathlessness is a common and distressing symptom of advanced disease with few effective treatments. Central nervous system mechanisms are important in respiratory sensation and control. Consequently, drugs which may modify processing and perception of afferent information in the brain may have a role. Antidepressants have been proposed; however, current evidence is limited. Of potentially suitable antidepressants, mirtazapine is an attractive option given its tolerability profile, low cost, and wide availability, along with additional potential benefits. Areas covered: The paper provides an overview of the physiology of breathlessness, with an emphasis on central mechanisms, particularly the role of fear circuits and the associated neurotransmitters. It provides a potential rationale for how mirtazapine may improve chronic breathlessness and quality of life in patients with advanced disease. The evidence was identified by a literature search performed in PubMed through to October 2018. Expert opinion: Currently, there is insufficient evidence to support the routine use of antidepressants for chronic breathlessness in advanced disease. Mirtazapine is a promising candidate to pursue, with definitive randomized controlled trials required to determine its efficacy and safety in this setting.

Recruitment and baseline characteristics of the Community of Voices choir study to promote the health and well-being of diverse older adults

Objective

To describe the recruitment and baseline results of the Community of Voices study that aims to examine the effect of a community choir intervention on the health and well-being of older adults from diverse racial/ethnic and socioeconomic backgrounds.

Method

Using community-based participatory research methods, we recruited adults age 60 and over from 12 Administration on Aging-supported senior centers in San Francisco into a 2-arm cluster-randomized controlled trial of the community choir intervention. Multiple outreach methods were used. We tracked outreach, screening, and recruitment metrics and collected demographics and baseline outcomes via community-based, interviewer-administered surveys and performance measures of cognition, physical function, and psychosocial variables.

Results

The study contacted 819 individuals, screened 636, and enrolled 390 diverse older adults over a 42-month, phased recruitment period. The mean age was 71.2 (SD = 7.3), and the majority were women. Two-thirds of the sample are non-white, and 20% of participants reported having financial hardship.

Discussion

Outreach and recruitment methods used in the Community of Voices trial facilitated enrollment of a large proportion of minority and lower-SES older adults in the final sample. Similar recruitment approaches could serve as a model for recruiting diverse racial/ethnic and socioeconomic older adults into research.

Ageing and trajectories of depressive symptoms in community-dwelling men and women

OBJECTIVE

The aim of this study was to investigate age-related patterns of depressive symptoms in older men and women and to identify their determinants.

METHODS

The Center for Epidemiological Studies Depression Scale was used to prospectively assess depressive symptoms in 1059 men and 1531 women, enrolled in a French representative population-based cohort (PAQUID study) and followed over a period of 20 years. Using a group-based trajectory method with an accelerated longitudinal design, we modelled the course of depressive symptoms between 65 and 104 years of age and examined associations between trajectory patterns and baseline socio-demographic and health variables.

RESULTS

In men, we identified three rising trajectories: 'never depressed' including 65% of the sample, 'emerging depression' (28%) and 'increasing depression' (7%). Compared with the membership of the never-depressed trajectory, that of the two higher trajectories was significantly associated with a history of depression and dyspnoea. In women, we identified two slightly rising trajectories (never depressed, 56%, and 'rising subclinical', 33%) and one stable high trajectory ('persistent depression', 11%). Membership of the two higher trajectories was significantly associated with the use of benzodiazepine, polymedication and dyspnoea. A history of nondepressive psychiatric disorder was a risk factor for membership of the persistent-depression group, whereas being widowed seemed to be a protective factor for membership of this group.

CONCLUSION

High-risk groups for later-life depression should be targeted differently in older men and women in order to implement appropriate interventions to prevent chronicity and disability.

Predictors of Cognitive/Affective and Somatic Depression in Heart Failure Patients

The effects of depression on patients with heart failure (HF) are substantial, yet the predictors remain unclear. The predictors of cognitive/affective and somatic depression in stable HF patients were studied. Using a cross-sectional design, 150 HF outpatients were recruited at two mid-Western HF clinics. Predictors included dyspnea with activities of daily living, family and friend social support, and loneliness; age and gender were control variables. All constructs were measured using standardized instruments. Structural equation modeling (SEM) showed that cognitive/affective depression was predicted by greater dyspnea and loneliness, whereas somatic depression was predicted by more dyspnea and friend support. Also, greater dyspnea was related to more loneliness and less friend support; less friend support was related to loneliness. Women reported more dyspnea and loneliness. Since cognitive/affective and somatic depression have different predictors, further study is warranted to identify HF patients at risk for depression and to establish interventions targeted at improving depression.