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srivastav P, K V, Bhat HV, Broadbent S. Effect of a pragmatic lifestyle modification intervention on physical activity levels and body mass index among obese and overweight adolescents in Udupi, India: a cluster randomized trial. F1000Res 2024; 13:859. [PMID: 39113943 PMCID: PMC11303949 DOI: 10.12688/f1000research.153483.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
Background Determine the effects of a multifactorial lifestyle intervention on physical activity (PA), BMI and health-related quality of life (QoL) in obese and overweight adolescents. Methods Nine schools in India were clustered randomly in a 12-month study with students allocated to a multifactorial intervention (MFI), or exercise only (EX) or control (CON) group. Participants were adolescents aged 11-16 years (n=671). In the MFI group, adolescents and their parents received lifestyle education using a validated booklet combined with a PA intervention for school students. The EX group received school-based PA only; the CON group continued regular activities. Primary outcomes were PA levels measured with the PAQ-A, and BMI; the secondary outcome was health-related QoL. A linear regression statistical model was used to analyse time, group effects and interactions, with Bonferroni correction for within-group differences at baseline (T0) and at 12-weeks (T1) (post-intervention), 6-month (T2) and 12-month (T3) follow-ups. Results Significant time and group effects observed for all groups with PA scores (p<0.001), with MFI group having largest increase in PA; with BMI (p<0.001) and MFI showing the least gain in BMI; and HRQOL (p<0.001), with MFI group showing greatest improvement in scores. There were significant increases in PA at T1 and T3 time-points with the EX group, and at T3 time-point only for MFI and CON, with MFI group showing largest increase in HRQOL scores. BMI increased significantly for all groups at T2 (MFI p=0.001, EX p<0.001) and T3 (p<0.001), while HRQOL increased significantly for both MFI and EX at both follow-ups (p<0.001). Conclusions School-based lifestyle MFI was more effective for improving PA, lifestyle behaviours and HRQOL than exercise alone for adolescents, although BMI was not reduced. MFI with PA could be an effective school-based approach for behaviour modification but BMI has limitations for measuring body composition changes. Registration CTRI/2019/04/018834 (30/04/2019).
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Affiliation(s)
- prateek srivastav
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Vaishali K
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - H Vinod Bhat
- The Apollo University, Chittoor, Andhra Pradesh, 517127, India
| | - Suzanne Broadbent
- School of Health, University of Sunshine Coast, Sippy Downs, Queensland, 4556, Australia
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Ahmed MS, Hasan T, Islam S, Ahmed N. Investigating Rhythmicity in App Usage to Predict Depressive Symptoms: Protocol for Personalized Framework Development and Validation Through a Countrywide Study. JMIR Res Protoc 2024; 13:e51540. [PMID: 38657238 PMCID: PMC11079771 DOI: 10.2196/51540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/27/2023] [Accepted: 01/11/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Understanding a student's depressive symptoms could facilitate significantly more precise diagnosis and treatment. However, few studies have focused on depressive symptom prediction through unobtrusive systems, and these studies are limited by small sample sizes, low performance, and the requirement for higher resources. In addition, research has not explored whether statistically significant rhythms based on different app usage behavioral markers (eg, app usage sessions) exist that could be useful in finding subtle differences to predict with higher accuracy like the models based on rhythms of physiological data. OBJECTIVE The main objective of this study is to explore whether there exist statistically significant rhythms in resource-insensitive app usage behavioral markers and predict depressive symptoms through these marker-based rhythmic features. Another objective of this study is to understand whether there is a potential link between rhythmic features and depressive symptoms. METHODS Through a countrywide study, we collected 2952 students' raw app usage behavioral data and responses to the 9 depressive symptoms in the 9-item Patient Health Questionnaire (PHQ-9). The behavioral data were retrieved through our developed app, which was previously used in our pilot studies in Bangladesh on different research problems. To explore whether there is a rhythm based on app usage data, we will conduct a zero-amplitude test. In addition, we will develop a cosinor model for each participant to extract rhythmic parameters (eg, acrophase). In addition, to obtain a comprehensive picture of the rhythms, we will explore nonparametric rhythmic features (eg, interdaily stability). Furthermore, we will conduct regression analysis to understand the association of rhythmic features with depressive symptoms. Finally, we will develop a personalized multitask learning (MTL) framework to predict symptoms through rhythmic features. RESULTS After applying inclusion criteria (eg, having app usage data of at least 2 days to explore rhythmicity), we kept the data of 2902 (98.31%) students for analysis, with 24.48 million app usage events, and 7 days' app usage of 2849 (98.17%) students. The students are from all 8 divisions of Bangladesh, both public and private universities (19 different universities and 52 different departments). We are analyzing the data and will publish the findings in a peer-reviewed publication. CONCLUSIONS Having an in-depth understanding of app usage rhythms and their connection with depressive symptoms through a countrywide study can significantly help health care professionals and researchers better understand depressed students and may create possibilities for using app usage-based rhythms for intervention. In addition, the MTL framework based on app usage rhythmic features may more accurately predict depressive symptoms due to the rhythms' capability to find subtle differences. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51540.
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Affiliation(s)
- Md Sabbir Ahmed
- Design Inclusion and Access Lab, North South University, Dhaka, Bangladesh
| | - Tanvir Hasan
- Design Inclusion and Access Lab, North South University, Dhaka, Bangladesh
| | - Salekul Islam
- Department of Computer Science and Engineering, United International University, Dhaka, Bangladesh
| | - Nova Ahmed
- Design Inclusion and Access Lab, North South University, Dhaka, Bangladesh
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Gaba A, Li P, Xi Z, Gao C, Ruixue C, Hu K, Gao L. Associations between depression symptom burden and delirium risk: a prospective cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.21.23295926. [PMID: 37790485 PMCID: PMC10543040 DOI: 10.1101/2023.09.21.23295926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Delirium and depression are increasingly common in aging. There is considerable clinical overlap, including shared symptoms and comorbid conditions, including Alzheimer's disease (AD), functional decline, and mortality. Despite this, the long-term relationship between depression and delirium remains unclear. This study assessed the associations of depression symptom burden and its trajectory with delirium risk in a 12-year prospective study of older individuals during hospitalization. RESEARCH DESIGN AND METHODS 319,141 UK biobank participants between 2006-2010 (mean 58y [range 37-74, SD=8], 54% female) reported frequency (0-3) of four depressive symptoms (mood, disinterest, tenseness, or lethargy) in the preceding 2 weeks, and aggregated into a depressive symptom burden score (0-12). New-onset delirium was obtained from hospitalization records during 12y median follow-up. 40,451 (mean age 57±8; range 40-74y) had repeat assessment on average 8y after their first. Cox proportional hazard models examined whether depression symptom burden and trajectory predicted incident delirium during hospitalization. RESULTS 5,753 (15 per 1000) newly developed delirium during follow-up. Increased risk for delirium was seen for mild (aggregated scores 1-2, hazards ratio, HR=1.16, [95% confidence interval 1.08-1.25], p<0.001), modest (scores 3-5, 1.30 [1.19-1.43], p<0.001) and severe (scores ≥ 5, 1.38 [1.24-1.55], p<0.001) depressive symptoms, versus none in the fully adjusted model. These findings were independent of the number of hospitalizations and consistent across hospitalization settings (e.g., surgical, medical, or critical care) and specialty (e.g., neuropsychiatric, cardiorespiratory or other). Worsening depression symptoms (≥1 point increase), compared to no change/improved score, were associated with an additional 39% increased risk (1.39 [1.03-1.88], p=0.03) independent of baseline depression burden. The association was strongest in those over 65y at baseline (p for interaction <0.001). DISCUSSION AND IMPLICATIONS Depression symptom burden and worsening trajectory predicted delirium risk during hospitalization. Increased awareness of subclinical depression symptoms may be warranted for delirium prevention.
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Affiliation(s)
- Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Zheng Xi
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Cai Ruixue
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Ahmed MS, Ahmed N. A Fast and Minimal System to Identify Depression Using Smartphones: Explainable Machine Learning-Based Approach. JMIR Form Res 2023; 7:e28848. [PMID: 37561568 PMCID: PMC10450542 DOI: 10.2196/28848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Existing robust, pervasive device-based systems developed in recent years to detect depression require data collected over a long period and may not be effective in cases where early detection is crucial. Additionally, due to the requirement of running systems in the background for prolonged periods, existing systems can be resource inefficient. As a result, these systems can be infeasible in low-resource settings. OBJECTIVE Our main objective was to develop a minimalistic system to identify depression using data retrieved in the fastest possible time. Another objective was to explain the machine learning (ML) models that were best for identifying depression. METHODS We developed a fast tool that retrieves the past 7 days' app usage data in 1 second (mean 0.31, SD 1.10 seconds). A total of 100 students from Bangladesh participated in our study, and our tool collected their app usage data and responses to the Patient Health Questionnaire-9. To identify depressed and nondepressed students, we developed a diverse set of ML models: linear, tree-based, and neural network-based models. We selected important features using the stable approach, along with 3 main types of feature selection (FS) approaches: filter, wrapper, and embedded methods. We developed and validated the models using the nested cross-validation method. Additionally, we explained the best ML models through the Shapley additive explanations (SHAP) method. RESULTS Leveraging only the app usage data retrieved in 1 second, our light gradient boosting machine model used the important features selected by the stable FS approach and correctly identified 82.4% (n=42) of depressed students (precision=75%, F1-score=78.5%). Moreover, after comprehensive exploration, we presented a parsimonious stacking model where around 5 features selected by the all-relevant FS approach Boruta were used in each iteration of validation and showed a maximum precision of 77.4% (balanced accuracy=77.9%). Feature importance analysis suggested app usage behavioral markers containing diurnal usage patterns as being more important than aggregated data-based markers. In addition, a SHAP analysis of our best models presented behavioral markers that were related to depression. For instance, students who were not depressed spent more time on education apps on weekdays, whereas those who were depressed used a higher number of photo and video apps and also had a higher deviation in using photo and video apps over the morning, afternoon, evening, and night time periods of the weekend. CONCLUSIONS Due to our system's fast and minimalistic nature, it may make a worthwhile contribution to identifying depression in underdeveloped and developing regions. In addition, our detailed discussion about the implication of our findings can facilitate the development of less resource-intensive systems to better understand students who are depressed and take steps for intervention.
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Affiliation(s)
- Md Sabbir Ahmed
- Design Inclusion and Access Lab, North South University, Dhaka, Bangladesh
| | - Nova Ahmed
- Design Inclusion and Access Lab, North South University, Dhaka, Bangladesh
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El-Sabawi B, Cloud H, Patel JN, Bell SP, Elmariah S, Fearon WF, Kim JB, Piana RN, Kapadia SR, Kumbhani DJ, Gillam LD, Whisenant BK, Quader N, Zajarias A, Welt FG, Bavry AA, Coylewright M, Vatterott A, Jackson N, Huang S, Lindman BR. Association of Depression and Cognitive Dysfunction With Patient-Centered Outcomes After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2023; 16:e012875. [PMID: 37503662 DOI: 10.1161/circinterventions.123.012875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Depression and cognitive dysfunction (CD) are not routinely screened for in patients before transcatheter aortic valve replacement (TAVR) and their association with postprocedural outcomes is poorly understood. The objectives of this study are to determine the prevalence of depression and CD in patients with aortic stenosis undergoing TAVR and evaluate their association with mortality and quality of life. METHODS We analyzed a prospective, multicenter TAVR registry that systematically screened patients for preexisting depression and CD with the Patient Health Questionnaire-2 and Mini-Cog, respectively. The associations with mortality were assessed with Cox proportional hazard models and quality of life (Kansas City Cardiomyopathy Questionnaire and EuroQol visual analogue scale) were evaluated using multivariable ordinal regression models. RESULTS A total of 884 patients were included; median follow-up was 2.88 years (interquartile range=1.2-3.7). At baseline, depression was observed in 19.6% and CD in 31.8%. In separate models, after adjustment, depression (HR, 1.45 [95% CI, 1.13-1.86]; P<0.01) and CD (HR, 1.27 [95% CI, 1.02-1.59]; P=0.04) were each associated with increased mortality. Combining depression and CD into a single model, mortality was greatest among those with both depression and CD (n=62; HR, 2.06 [CI, 1.44-2.96]; P<0.01). After adjustment, depression was associated with 6.6 (0.3-13.6) points lower on the Kansas City Cardiomyopathy Questionnaire 1-year post-TAVR and 6.7 (0.5-12.7) points lower on the EuroQol visual analogue scale. CD was only associated with lower EuroQol visual analogue scale. CONCLUSIONS Depression and CD are common in patients that undergo TAVR and are associated with increased mortality and worse quality of life. Depression may be a modifiable therapeutic target to improve outcomes after TAVR.
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Affiliation(s)
- Bassim El-Sabawi
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Harrison Cloud
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Jay N Patel
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Susan P Bell
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Sammy Elmariah
- Department of Medicine, Division of Cardiology, University of California San Francisco (S.E.)
| | - William F Fearon
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Juyong B Kim
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Robert N Piana
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Samir R Kapadia
- Department of Medicine, Division of Cardiology, Cleveland Clinic Foundation, OH (S.R.K.)
| | - Dharam J Kumbhani
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Linda D Gillam
- Department of Cardiovascular Medicine, Morristown Medical Center, NJ (L.D.G.)
| | - Brian K Whisenant
- Department of Medicine, Division of Cardiology, Intermountain Heart Institute, Murray, UT (B.K.W.)
| | - Nishath Quader
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Alan Zajarias
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Frederick G Welt
- Department of Medicine, Division of Cardiology, University of Utah Hospital, Salt Lake City (F.G.W.)
| | - Anthony A Bavry
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Megan Coylewright
- Department of Internal Medicine, Division of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN (M.C.)
| | - Anna Vatterott
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Natalie Jackson
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN (S.H.)
| | - Brian R Lindman
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
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Sajjad MU, Blennow K, Knapskog AB, Idland AV, Chaudhry FA, Wyller TB, Zetterberg H, Watne LO. Cerebrospinal Fluid Levels of Interleukin-8 in Delirium, Dementia, and Cognitively Healthy Patients. J Alzheimers Dis 2020; 73:1363-1372. [DOI: 10.3233/jad-190941] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | | | - Ane-Victoria Idland
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
| | - Farrukh Abbas Chaudhry
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
| | - Leiv Otto Watne
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
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Reichardt LA, van Seben R, Aarden JJ, van der Esch M, van der Schaaf M, Engelbert RHH, Twisk JWR, Bosch JA, Buurman BM. Trajectories of cognitive-affective depressive symptoms in acutely hospitalized older adults: The hospital-ADL study. J Psychosom Res 2019; 120:66-73. [PMID: 30929710 DOI: 10.1016/j.jpsychores.2019.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify trajectories of cognitive-affective depressive symptoms among acutely hospitalized older patients and whether trajectories are related to prognostic baseline factors and three-month outcomes such as functional decline, falls, unplanned readmissions, and mortality. METHODS Prospective multicenter cohort of acutely hospitalized patients aged ≥ 70. Depressive trajectories were based on Group Based Trajectory Modeling, using the Geriatric Depression Scale-15. Outcomes were functional decline, falls, unplanned readmission, and mortality within three months post-discharge. RESULTS The analytic sample included 398 patients (mean age = 79.6 years; SD = 6.6). Three distinct depressive symptoms trajectories were identified: minimal (63.6%), mild persistent (25.4%), and severe persistent (11.0%). Unadjusted results showed that, compared to the minimal symptoms group, the mild and severe persistent groups showed a significantly higher risk of functional decline (mild: OR = 3.9, p < .001; severe: OR = 3.0, p = .04), falls (mild: OR = 2.0, p = .02; severe: OR = 6.0, p < .001), and mortality (mild: OR = 2.2, p = .05; severe: OR = 3.4, p = .009). Patients with mild or severe persistent symptoms were more malnourished, anxious, and functionally limited and had more medical comorbidities at admission. CONCLUSION Nearly 40% of the acutely hospitalized older adults exhibited mild to severe levels of cognitive-affective depressive symptoms. In light of the substantially elevated risk of serious complications and the fact that elevated depressive symptoms was not a transient phenomenon identification of these patients is needed. This further emphasizes the need for acute care hospitals, as a point of engagement with older adults, to develop discharge or screening procedures for managing cognitive-affective depressive symptoms.
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Affiliation(s)
- Lucienne A Reichardt
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health research institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Rosanne van Seben
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health research institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jesse J Aarden
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
| | - Martin van der Esch
- ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands; Reade, Center for Rehabilitation and Rheumatology/Amsterdam Rehabilitation Research Center, Amsterdam, The Netherlands.
| | - Marike van der Schaaf
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Raoul H H Engelbert
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Jos A Bosch
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands; Department of Psychology, Section of Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health research institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
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Shastri A, Aimola L, Tooke B, Quirk A, Corrado O, Hood C, Crawford MJ. Recognition and treatment of depression in older adults admitted to acute hospitals in England. Clin Med (Lond) 2019; 19:114-118. [PMID: 30872291 PMCID: PMC6454375 DOI: 10.7861/clinmedicine.19-2-114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Levels of awareness and treatment of depression in older adults admitted to acute hospitals are unclear. This study aims to examine the proportion of older adults diagnosed with depression in acute hospitals, treatment, referral, and communication between secondary and primary healthcare services following discharge. Retrospective examination of records of 766 older adults admitted to 27 acute hospitals in England was carried out. Ninety-eight (12.7%, 95% confidence interval (CI) = 10.6-15.3) records included a diagnosis of depression of which eight (1.0%, 95% CI = 0.5-2.0) had a new diagnosis made during their hospital admission. All newly diagnosed and 76 (84.4%, 95% CI = 75.5-90.5) of those with an existing diagnosis of depression were prescribed antidepressant medication. Six (75.0%, 95% CI = 40.9-92.8) of those with a new diagnosis, and 21 (23.3%, 95% CI = 15.8-33.0) with an existing diagnosis of depression were referred to liaison psychiatry. References to mental health were made in 50 (51.0%, 95% CI = 41.2-60.6) discharge letters sent to primary care. Very few older adults admitted to acute hospitals in this study were diagnosed with depression during their inpatient stay. Opportunities for improving the mental and physical health of such patients appear to be being missed.
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Affiliation(s)
| | | | | | - Alan Quirk
- Royal College of Psychiatrists, London, UK
| | | | - Chloe Hood
- Royal College of Psychiatrists, London, UK
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Biella MM, Borges MK, Strauss J, Mauer S, Martinelli JE, Aprahamian I. Subthreshold Depression Needs A Prime Time In Old Age Psychiatry? A Narrative Review Of Current Evidence. Neuropsychiatr Dis Treat 2019; 15:2763-2772. [PMID: 31576131 PMCID: PMC6765057 DOI: 10.2147/ndt.s223640] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/06/2019] [Indexed: 11/23/2022] Open
Abstract
This study aims to carry out a narrative review, aiming to update the literature on subsyndromic depression (SD), which is the most prevalent depressive disorder in older adults, and no formal guidelines or consensus are dedicated to this topic. We carried out an electronic search for articles on SD. Relevant articles were retrieved from Pubmed, EMBASE and Web of Science using the search terms "subthreshold depression," "prevalence," "treatment" and "older adults" in several combinations. Original articles in English were included from inception to 1st March 2019. No clear consensus exists in the literature on its nosologic classification, diagnostic tools, causes, course, outcomes or management. SD diagnosis should base in depressive symptoms scales and DSM criteria. Treatment relies mainly on collaborative care and psychotherapy. SD is relevant in clinical practice and research in geriatric psychiatry. Given the negative outcomes and potential benefits of treatment, we recommend brief psychotherapy as first-line treatment and use of psychotropic agents in cases with greater severity and/or functional impairment in association with psychotherapy. SD can precede major depressive disorder, but it also may consist of a primary depressive disorder in older adults. Furthermore, adequate treatment of SD can prevent or reduce negative outcomes associated with depressive symptoms such as worsening of clinical comorbidities, loss of functionality, increased demand for health services, and increased mortality.
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Affiliation(s)
- Marina Maria Biella
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marcus Kiiti Borges
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jason Strauss
- Geriatric Psychiatry, Cambridge Health Alliance, Harvard Medical School, Boston, MA, USA
| | - Sivan Mauer
- Department of Psychiatry, Tufts Medical Center, Tufts University Scholl of Medicine, Boston, MA, USA
| | - José Eduardo Martinelli
- Geriatrics & Psychiatry Division, Department of Internal Medicine, Faculty of Medicine of Jundiaí, Jundiaí, Brazil
| | - Ivan Aprahamian
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.,Geriatrics & Psychiatry Division, Department of Internal Medicine, Faculty of Medicine of Jundiaí, Jundiaí, Brazil
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Ghesquiere AR, Pepin R, Kinsey J, Bartels SJ, Bruce ML. Factors associated with depression detection in a New Hampshire mental health outreach program. Aging Ment Health 2018; 22:1471-1476. [PMID: 28812372 PMCID: PMC5815953 DOI: 10.1080/13607863.2017.1364346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES For mental health outreach programs for older adults, accurately detecting depression is key to quality service provision. Multiple factors, including gender, cognitive impairment, or recent bereavement may affect depression detection, but this is under-studied. Therefore, we sought to both establish rates of depressive symptom detection and to examine factors associated with inaccuracies of detecting depression among participants in a mental health outreach program serving older adults. METHOD We conducted a chart review of 1126 cases in an older adult-focused mental health outreach program in New Hampshire, the Referral Education Assistance & Prevention (REAP) program. Accuracy of depression detection was identified by comparing screen-positive scores for depressive symptoms on the 15-item Geriatric Depression Scale (GDS) to depression identification by counselors on a 'presenting concerns' list. RESULTS Inaccurate depression detection (positive on the GDS but depression not identified by counselors) occurred in 27.6% of cases. Multivariate regression analyses indicated that anxiety, cognitive concerns, and rurality were all associated with detection innaccuracy. CONCLUSION This study appears to be the first to examine factors influencing depression detection in a mental health outreach program. Future efforts should help ensure that all older mental health outreach clients have depression detected at optimal rates.
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Affiliation(s)
- Angela R Ghesquiere
- a Brookdale Center for Healthy Aging, Hunter College , City University of New York , NY , USA
| | - Renee Pepin
- b Dartmouth Centers for Health and Aging , Lebanon , NH , USA
| | | | - Stephen J Bartels
- d The Dartmouth Institute, Geisel School of Medicine at Dartmouth, and Dartmouth Centers for Health and Aging , Lebanon , NH , USA
| | - Martha L Bruce
- d The Dartmouth Institute, Geisel School of Medicine at Dartmouth, and Dartmouth Centers for Health and Aging , Lebanon , NH , USA
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Deschodt M, Van Grootven B, Jeuris A, Devriendt E, Dierckx de Casterlé B, Dubois C, Fagard K, Herregods MC, Hornikx M, Meuris B, Rex S, Tournoy J, Milisen K, Flamaing J. Geriatric CO-mAnagement for Cardiology patients in the Hospital (G-COACH): study protocol of a prospective before-after effectiveness-implementation study. BMJ Open 2018; 8:e023593. [PMID: 30344179 PMCID: PMC6196878 DOI: 10.1136/bmjopen-2018-023593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Although the majority of older patients admitted to a cardiology unit present with at least one geriatric syndrome, guidelines on managing heart disease often do not consider the complex needs of frail older patients. Geriatric co-management has demonstrated potential to improve functional status, and reduce complications and length of stay, but evidence on the effectiveness in cardiology patients is lacking. This study aims to determine if geriatric co-management is superior to usual care in preventing functional decline, complications, mortality, readmission rates, reducing length of stay and improving quality of life in older patients admitted for acute heart disease or for transcatheter aortic valve implantation, and to identify determinants of success for geriatric co-management in this population. METHODS AND ANALYSIS This prospective quasi-experimental before-and-after study will be performed on two cardiology units of the University Hospitals Leuven in Belgium in patients aged ≥75 years. In the precohort (n=227), usual care will be documented. A multitude of implementation strategies will be applied to allow for successful implementation of the model. Patients in the after cohort (n=227) will undergo a comprehensive geriatric assessment within 24 hours of admission to stratify them into one of three groups based on their baseline risk for developing functional decline: low-risk patients receive proactive consultation, high-risk patients will be co-managed by the geriatric nurse to prevent complications and patients with acute geriatric problems will receive an additional medication review and co-management by the geriatrician. ETHICS AND DISSEMINATION The study protocol was approved by the Medical Ethics Committee UZ Leuven/KU Leuven (S58296). Written voluntary (proxy-)informed consent will be obtained from all participants at the start of the study. Dissemination of results will be through articles in scientific and professional journals both in English and Dutch and by conference presentations. TRIAL REGISTRATION NUMBER NCT02890927.
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Affiliation(s)
- Mieke Deschodt
- Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven—University of Leuven, Leuven, Belgium
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Bastiaan Van Grootven
- Research Foundation, Flanders, Belgium
- Department of Public Health and Primary Care, University of Leuven - KU Leuven, Leuven, Belgium
| | - Anthony Jeuris
- Department of Public Health and Primary Care, University of Leuven - KU Leuven, Leuven, Belgium
| | - Els Devriendt
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Christophe Dubois
- Department of Cardiovascular Diseases, KU Leuven—University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Katleen Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Christine Herregods
- Department of Cardiovascular Diseases, KU Leuven—University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Miek Hornikx
- Department of Cardiovascular Diseases, KU Leuven—University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Diseases, KU Leuven—University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Koen Milisen
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Johan Flamaing
- Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
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McCusker J, Yaffe M, Sussman T, Cole M, Sewitch M, Strumpf E, Freeman E, Lambert S, de Raad M. La gestion de la dépression chez les aînés et leurs aidants naturels : résultats d’un programme de recherche au Québec. SANTE MENTALE AU QUEBEC 2017. [DOI: 10.7202/1040254ar] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
La dépression est un problème répandu, sérieux, et souvent chronique chez les aînés, qui sont souvent atteints de maladies physiques chroniques, et affecte de façon négative leurs traitements et leurs soins. Malheureusement, le taux de détection et de suivi adéquat de la dépression est faible dans cette population. Au cours des deux dernières décennies, notre équipe a mené une série d’études pour mieux comprendre et améliorer la gestion de la dépression chez les aînés. Nous présentons une revue narrative et synthèse de 25 articles qui incluent : 4 revues systématiques, 10 études observationnelles, 9 essais d’interventions, et 2 conférences de consensus. Nous proposons en conclusion nos recommandations pour 1) la détection de la dépression dans les soins de santé primaires ; 2) les soins collaboratifs de la dépression ; 3) des interventions d’autogestion de la dépression ; 4) le rôle des aidants naturels dans les interventions d’autogestion de la dépression.
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Affiliation(s)
- Jane McCusker
- Centre de recherche de St. Mary, Montréal, Canada
- Département d’épidémiologie, biostatistique et santé au travail, Université McGill, Montréal, Canada
| | - Mark Yaffe
- Département de médecine familiale, Centre hospitalier de St. Mary, Montréal, Canada
- Département de médecine de famille, Université McGill, Montréal, Canada
| | - Tamara Sussman
- École de travail social, Université McGill, Montréal, Canada
| | - Martin Cole
- Centre de recherche de St. Mary, Montréal, Canada
- Département de psychiatrie, Centre hospitalier de St. Mary, Montréal, Canada
- Département de psychiatrie, Université McGill, Montréal, Canada
| | - Maida Sewitch
- Département d’épidémiologie, biostatistique et santé au travail, Université McGill, Montréal, Canada
- Institut de recherche du Centre universitaire de santé McGill, Montréal, Canada
- Centre universitaire de santé McGill, Divisions de gastroentérologie et d’épidémiologie clinique, Montréal, Canada
| | - Erin Strumpf
- Département d’économie, Université McGill, Montréal, Canada
| | - Ellen Freeman
- Centre de recherche, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Sylvie Lambert
- Centre de recherche de St. Mary, Montréal, Canada
- École des sciences infirmières Ingram, Université McGill, Montréal, Canada
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13
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Canuto A, Gkinis G, DiGiorgio S, Arpone F, Herrmann FR, Weber K. Agreement between physicians and liaison psychiatrists on depression in old age patients of a general hospital: influence of symptom severity, age and personality. Aging Ment Health 2016; 20:1092-8. [PMID: 26155954 DOI: 10.1080/13607863.2015.1063103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Comorbid depressive episodes are common among general hospital inpatients. However, existing evidence shows that depression is often poorly recognized in patients aged over 60 years. The aim of the study was first to determine the degree of agreement between primary care physicians' and liaison psychiatrists' evaluation of depression, and second, to analyze how patients' clinical presentation and personality traits influence this degree of agreement. METHODS Agreement was defined as the matching of the physicians' initial referral for depressive mood and the actual diagnosis of a major depressive disorder evaluated by the consultation-liaison service in 148 inpatients aged 60+ years. Nature and severity of psychiatric symptoms were rated on the HoNOS65+ scale and patients' personality traits were assessed with the Big Five Inventory. RESULTS Forty percent of the patients referred for depressive mood were indeed diagnosed with major depression. Agreement between physicians and psychiatrists was most likely in patients with more severe depressive symptoms and younger age. In contrast, risk for non-agreement was increased for patients with more open personalities, yet lower levels of neuroticism, who were referred for depressive mood even though they presented another or even no psychiatric disorder. CONCLUSION These data reveal that the detection of late-life depression in general hospitals may be critically influenced by age, symptoms severity and personality traits.
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Affiliation(s)
- Alessandra Canuto
- a Division of liaison psychiatry and crisis intervention , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Geneva , Switzerland
| | - Georgios Gkinis
- a Division of liaison psychiatry and crisis intervention , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Geneva , Switzerland
| | - Sergio DiGiorgio
- a Division of liaison psychiatry and crisis intervention , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Geneva , Switzerland
| | - Francesca Arpone
- a Division of liaison psychiatry and crisis intervention , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Geneva , Switzerland
| | - François R Herrmann
- b Department of Internal Medicine, Rehabilitation and Geriatrics , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Thônex , Switzerland
| | - Kerstin Weber
- a Division of liaison psychiatry and crisis intervention , University Hospitals of Geneva and Faculty of Medicine of the University of Geneva , Geneva , Switzerland
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Examining functional and social determinants of depression in community-dwelling older adults: implications for practice. Geriatr Nurs 2015; 35:236-40. [PMID: 24942525 DOI: 10.1016/j.gerinurse.2014.04.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coping with declining health, physical illnesses and complex medical regimens, which are all too common among many older adults, requires significant lifestyle changes and causes increasing self-management demands. Depression occurs in community-dwelling older adults as both demands and losses increase, but this problem is drastically underestimated and under-recognized. Depressive symptoms are often attributed to physical illnesses and thus overlooked, resulting in lack of appropriate treatment and diminished quality of life. The purpose of this study is to assess prevalence of depressive symptoms in community-dwelling older adults with high levels of co-morbidity and to identify correlates of depression. In this sample of 533 homebound older adults screened (76.1% female, 71.8% white, mean age 78.5 years) who were screened using the Geriatric Depression Scale (SF), 35.9% scored greater than 5. Decreased satisfaction with family support (p << 0.001) and functional status (p ≤ 0.001) and increased loneliness (p < 0.001) were significant independent predictors of depression status in this sample; thus, these factors should be considered when planning care.
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15
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Wald HL, Leykum LK, Mattison MLP, Vasilevskis EE, Meltzer DO. A patient-centered research agenda for the care of the acutely ill older patient. J Hosp Med 2015; 10:318-27. [PMID: 25877486 PMCID: PMC4422835 DOI: 10.1002/jhm.2356] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/28/2015] [Accepted: 03/09/2015] [Indexed: 12/11/2022]
Abstract
Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.
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Affiliation(s)
- Heidi L. Wald
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO
| | - Luci K. Leykum
- South Texas Veterans Health Care System and Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio TX
| | - Melissa L. P. Mattison
- Department of Medicine, Division of General Medicine and Primary Care, Section of Hospital Medicine Beth Israel Deaconess Medical Center, Boston, MA
| | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health and Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, TN
| | - David O. Meltzer
- Section of Hospital Medicine, University of Chicago Department of Medicine, Chicago, IL
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16
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Vasilevskis EE, Simmons SF. Simple solutions may not work for complex patients: A need for new paradigms in geriatric hospital medicine. J Hosp Med 2015; 10:343-4. [PMID: 25641782 PMCID: PMC4412786 DOI: 10.1002/jhm.2327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 01/21/2023]
Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Center for Health Services Research, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee; Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
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17
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Poulsen KM, Pachana NA, McDermott BM. Health professionals' detection of depression and anxiety in their patients with diabetes: The influence of patient, illness and psychological factors. J Health Psychol 2014; 21:1566-75. [PMID: 25512198 DOI: 10.1177/1359105314559618] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study examines how often depression and anxiety, in patients with diabetes, are detected by health professionals; and whether detection is influenced by patient characteristics (age, gender), illness factors (duration of illness, diabetes control), and self-reported levels of depression and anxiety. Prevalence rates of clinically significant depression and anxiety were high (57% and 36%, respectively); however, of those identified, only 44 and 36 per cent, respectively, were detected by staff as depressed or anxious. The only significant predictors of detection were severity of depressive and anxious symptoms. Patient and illness characteristics did not influence whether professionals identified emotional problems in their patients.
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Affiliation(s)
- Kellee M Poulsen
- Mater Child and Youth Mental Health Service, Brisbane, Australia
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Radinovic KS, Markovic-Denic L, Dubljanin-Raspopovic E, Marinkovic J, Jovanovic LB, Bumbasirevic V. Effect of the overlap syndrome of depressive symptoms and delirium on outcomes in elderly adults with hip fracture: a prospective cohort study. J Am Geriatr Soc 2014; 62:1640-8. [PMID: 25243678 DOI: 10.1111/jgs.12992] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture. DESIGN Prospective cohort study. SETTING University hospital. PARTICIPANTS Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study. MEASUREMENTS Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded. RESULTS Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002). CONCLUSION Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.
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O'Sullivan R, Inouye SK, Meagher D. Delirium and depression: inter-relationship and clinical overlap in elderly people. Lancet Psychiatry 2014; 1:303-11. [PMID: 26360863 PMCID: PMC5338740 DOI: 10.1016/s2215-0366(14)70281-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Delirium and depression are complex neuropsychiatric syndromes common in the elderly and are associated with poor health-care outcomes. Accurate diagnosis is essential to the provision of optimum health care for individuals with these conditions but is complicated by substantial clinical overlap in symptoms and comorbidities. A careful assessment of the patient's symptoms, including their context and time course, is needed for accurate diagnosis. Previous depression is common in patients with delirium and depressive illness is a recognised sequelae of delirium. The two syndromes seem to be caused by similar pathophysiological mechanisms, involving disturbances in stress and inflammatory responses, monoaminergic and melatonergic signalling, which point to new avenues for therapeutic intervention. Improved methods to assess delirium and depression in populations at high risk by virtue of their age, diminished cognitive reserve and physical frailty is a key target to achieve improved health-care outcomes in elderly individuals.
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Affiliation(s)
- Roisin O'Sullivan
- Department of Adult Psychiatry, University Hospital Limerick and University of Limerick Medical School, and Cognitive Impairment Research Group, 4i institute, Limerick, Ireland
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife and Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Meagher
- Department of Adult Psychiatry, University Hospital Limerick and University of Limerick Medical School, and Cognitive Impairment Research Group, 4i institute, Limerick, Ireland.
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Polyakova M, Sonnabend N, Sander C, Mergl R, Schroeter ML, Schroeder J, Schönknecht P. Prevalence of minor depression in elderly persons with and without mild cognitive impairment: a systematic review. J Affect Disord 2014; 152-154:28-38. [PMID: 24103852 DOI: 10.1016/j.jad.2013.09.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/08/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Minor depression (MinD) and mild cognitive impairment (MCI) are common disorders in late life that often coexist. The aim of the present review is to demonstrate prevalence rates of minor depression in older patients with and without MCI. METHODS Electronic database searches were performed through Medline, ISI Web of Knowledge, Psycinfo, and Cochrane library. Two independent reviewers extracted the original studies based on inclusion criteria: representative study population aged 55 and older, diagnostics of MinD according to DSM. Data on prevalence rates, risk factors, comorbidity and health care usage were analyzed. RESULTS Point prevalence for MinD is higher in medical settings (median 14.4%) than in the community-based settings (median 10.4%) and primary care patients (median 7.7%). Although minor depression is rarely investigated in elderly persons with MCI, nearly 20% of patients with MCI seem to suffer from MinD. No data was found on the prevalence of MCI in patients with MinD. Risk factors associated with MinD include female gender, history of cerebrovascular diseases, generalized anxiety disorder, loneliness, and long-term institutional care. LIMITATIONS Methodological differences of included studies resulted in a broad range of prevalence rates. No data is shown regarding the prevalence of MCI in MinD group due to insufficient evidence. CONCLUSIONS Our review indicates that MinD is frequent in elderly population. MCI among those subjects has not been sufficiently investigated. Future studies based on clinical structured interviews should be performed in longitudinal design in order to differentiate late-life depression from progressive MCI or early manifestation of Alzheimer's disease.
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Affiliation(s)
- M Polyakova
- Department of Psychiatry, University of Leipzig, Leipzig, Germany; LIFE-Leipzig Research Center for Civilization Diseases, University of Leipzig, Germany; Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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Struble LM, Sullivan BJ, Hartman LS. Psychiatric disorders impacting critical illness. Crit Care Nurs Clin North Am 2013; 26:115-38. [PMID: 24484928 DOI: 10.1016/j.ccell.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An astounding 30% to 50% of older patients who are hospitalized for a medical condition also have a psychiatric disorder. The intent of this article is to prepare acute care nurses to meet the mental health needs of older adults with a critical illness and prevent untoward sequelae of medical events. The authors discuss the importance of baseline assessment data, issues related to informed consent, manifestations of common psychiatric disorders that may be seen in older adults in the acute care setting, as well as strategies to improve patient outcomes.
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Affiliation(s)
- Laura M Struble
- Division of Acute, Critical and Long-Term Care, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109, USA.
| | - Barbara J Sullivan
- Division of Acute, Critical and Long-Term Care, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109, USA
| | - Laurie S Hartman
- University of Michigan Hospitals and Health System, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109, USA
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Gregg JJ, Fiske A, Gatz M. Physicians' detection of late-life depression: the roles of dysphoria and cognitive impairment. Aging Ment Health 2013; 17:1030-6. [PMID: 23767897 PMCID: PMC3797862 DOI: 10.1080/13607863.2013.805403] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine factors that impede or facilitate physicians' detection of depression in later life, including cognitive impairment and patients' endorsement of dysphoria. METHODS A population-based sample of 344 adults from the Swedish Adoption/Twin Study of Aging (SATSA) was utilized. Physician detection of depression was determined by (1) outpatient medical records, (2) antidepressant prescription, and/or (3) inpatient hospitalization. Depressive symptoms were measured by highest score on the Center for Epidemiologic Studies - Depression Scale (CES-D), administered on six occasions between 1986 and 1994. Endorsement of dysphoria was examined using two items on the CES-D. The Mini-Mental State Examination (MMSE) was used to indicate cognitive impairment. RESULTS One-hundred thirty-six individuals were above the cut-off on the CES-D on at least one occasion; however, only 14 of these individuals (10%) were detected as depressed by a physician. Higher CES-D total score was significantly related to physician detection. Furthermore, physicians were most likely to detect depression if the individual endorsed the single CES-D item regarding feeling depressed. A significant interaction was found, such that overall CES-D score was only associated with physician detection among those with higher endorsement of the depressed item. The association between total CES-D and physician detection was not affected by presence of cognitive impairment. CONCLUSIONS Depression in later life often goes undetected by physicians. Factors associated with detection include the frequency/severity of symptoms and patients' endorsement specifically of feeling depressed. Results suggest that physicians should routinely assess for other symptoms associated with late-life depression besides dysphoria (e.g., appetite loss, crying spells).
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Affiliation(s)
- Jeffrey J. Gregg
- Department of Psychology, West Virginia University, Morgantown, West Virginia
| | - Amy Fiske
- Department of Psychology, West Virginia University, Morgantown, West Virginia
| | - Margaret Gatz
- Department of Psychology, University of Southern California, Los Angeles, California,Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Pierluissi E, Mehta KM, Kirby KA, Boscardin WJ, Fortinsky RH, Palmer RM, Landefeld CS. Depressive symptoms after hospitalization in older adults: function and mortality outcomes. J Am Geriatr Soc 2012. [PMID: 23176725 DOI: 10.1111/jgs.12008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes. DESIGN Secondary analysis of a prospective cohort study. SETTING General medical service of two urban, teaching hospitals in Ohio. PARTICIPANTS Hospitalized individuals aged 70 and older. MEASUREMENTS Ten depressive symptoms, instrumental activities of daily living (IADLs), and basic activities of daily living (ADLs) were measured at hospital discharge and 1, 3, 6, and 12 months later. Participant-specific changes in depressive symptoms (slopes) were determined using all data points. Four groups were also defined according to number of depressive symptoms (≤3 symptoms, low; 4-10 symptoms, high) at discharge and follow-up: low-low, low-high, high-low, and high-high. Mortality was measured 3, 6, and 12 months after hospital discharge. RESULTS Participant-specific discharge depressive symptoms and change in depressive symptoms over time (slopes) were associated (P < .05) with functional and mortality outcomes. At 1 year, more participants in the low-low depressive symptom group (49%) were alive and independent in IADLs and ADLs than in the low-high group (37%, P = .02), and more participants in the high-low group (39%) were alive and independent in IADLs and ADLs than in the high-high group (19%, P < .001). CONCLUSION Number of depressive symptoms and change in number of depressive symptoms during the year after discharge were associated with functional and mortality outcomes in hospitalized older adults. Fewer participants with persistently high or increasing depressive symptoms after hospitalization were alive and functionally independent 1 year later than participants with decreasing or persistently low symptoms, respectively.
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Affiliation(s)
- Edgar Pierluissi
- Division of Geriatrics, University of California at San Francisco, San Francisco, California 94110, USA.
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Cherubini A, Nisticò G, Rozzini R, Liperoti R, Di Bari M, Zampi E, Ferrannini L, Aguglia E, Pani L, Bernabei R, Marchionni N, Trabucchi M. Subthreshold depression in older subjects: an unmet therapeutic need. J Nutr Health Aging 2012; 16:909-13. [PMID: 23208031 DOI: 10.1007/s12603-012-0373-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Major depression, defined according to DSM IV TR criteria, is less common in older subjects, while other types of depression are two to three times more prevalent. This heterogeneous group of disturbances has received different names: depression not otherwise specified, minor depression, subthreshold or subsyndromal depression. Moreover, each condition has been defined using heterogeneous criteria by different authors. The term of subthreshold depression will be adopted in this position statement. Subthreshold depression has been associated with the same negative consequences of major depression, including reduced well being and quality of life, worsening health status, greater disability, increased morbidity and mortality. Nevertheless, there is a dearth of clinical trials in this area, and therefore older patients with subthreshold depression are either not treated or they are treated with the same non pharmacological and pharmacological therapies used for major depression, despite the lack of supporting scientific evidence. There is an urgent need to reach a consensus concerning the diagnostic criteria for subthreshold depression as well as to perform clinical trials to identify effective and safe therapies in this too long neglected patient group.
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Affiliation(s)
- A Cherubini
- Department of Geriatrics, Research Hospital of Ancona, Italian National Research Center on Aging (INRCA), Ancona, Italy.
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Abstract
Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007).
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Su JA, Tsai CS, Hung TH, Chou SY. Change in accuracy of recognizing psychiatric disorders by non-psychiatric physicians: five-year data from a psychiatric consultation-liaison service. Psychiatry Clin Neurosci 2011; 65:618-23. [PMID: 22176280 DOI: 10.1111/j.1440-1819.2011.02272.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM Psychiatric disorders are easily underestimated and under-recognized by physicians. The aim of the present study was to investigate the change in accuracy of recognizing psychiatric symptoms. METHODS Consecutive 5-year consultation-liaison data were collected and patients with one of the five common psychiatric diagnoses, including depressive disorders, substance use disorders, delirium, anxiety disorders and psychotic disorders, were chosen for analysis. The primary care physician's initial impression of a psychiatric diagnosis was recorded based on their reason for referral on the referral sheets. Accurate recognition was defined as matching of the physician's initial impression with the psychiatrist's final diagnosis. Mentioning the core symptoms of psychiatric diagnostic criteria or common synonyms would be considered as correct recognition. RESULTS The overall accuracy of recognition was 41.5% and there was no significant change during this 5-year period. Substance use disorders were the one diagnosis with the highest agreement, followed by delirium, depressive disorders, anxiety disorders, and psychotic disorders. As for the factors associated with accurate recognition, male patients or those with multiple physical illnesses were more likely to have their psychiatric symptoms recognized correctly. CONCLUSIONS Without comprehensive postgraduate psychiatric education, the accuracy of recognizing psychiatric symptoms does not improve year by year. Education should focus on common psychiatric problems among medical inpatients, especially those easily misdiagnosed, such as depression and delirium.
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Affiliation(s)
- Jian-An Su
- Department of Psychiatry, Chang Gung Memorial Hospital at Chiayi, Taiwan
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Mitchell AJ, Kakkadasam V. Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy. Int J Nurs Stud 2010; 48:359-68. [PMID: 20580001 DOI: 10.1016/j.ijnurstu.2010.05.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 05/15/2010] [Accepted: 05/17/2010] [Indexed: 11/17/2022]
Abstract
PURPOSE To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies. METHODS Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data. RESULTS Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed. CONCLUSIONS Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.
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Affiliation(s)
- Alex J Mitchell
- Liaison Psychiatry, Leicester General Hospital, Leicester LE5 4PW, United Kingdom.
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Givens JL, Jones RN, Inouye SK. The overlap syndrome of depression and delirium in older hospitalized patients. J Am Geriatr Soc 2009; 57:1347-53. [PMID: 19558475 DOI: 10.1111/j.1532-5415.2009.02342.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients. DESIGN Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial. SETTING General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge. PARTICIPANTS Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission. MEASUREMENTS Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year. RESULTS Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57-18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14-9.56) than patients with neither condition. CONCLUSION The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients.
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Affiliation(s)
- Jane L Givens
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA.
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Désy PM, Prohaska TR. The Geriatric Emergency Nursing Education (GENE) Course: An Evaluation. J Emerg Nurs 2008; 34:396-402. [DOI: 10.1016/j.jen.2007.08.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 08/09/2007] [Accepted: 08/28/2007] [Indexed: 10/22/2022]
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McCusker J, Cole M, Latimer E, Sewitch M, Ciampi A, Cepoiu M, Belzile E. Recognition of depression in older medical inpatients discharged to ambulatory care settings: a longitudinal study. Gen Hosp Psychiatry 2008; 30:245-51. [PMID: 18433656 DOI: 10.1016/j.genhosppsych.2008.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 01/21/2008] [Accepted: 01/23/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to examine the recognition of depression in older medical inpatients by nonpsychiatric physicians over a 2-year period. METHODS A cohort of medical inpatients aged 65 and above was recruited at two university-affiliated hospitals, with oversampling of depressed patients. Participants were assessed with research diagnoses of major or minor depression (DSM-IV) at admission and at 3, 6 and 12 months. Indicators of recognition during the 12 months before and the 12 months after admission, derived from administrative databases, included the following: depression diagnosis, antidepressant prescription and psychiatric referral. Multiple logistic regression analyses were used to identify factors associated with recognition. RESULTS Among 185 patients with at least one research diagnosis of depression during the study, recognition rates ranged up to 56% during the 12 months before admission among patients with major depression lasting at least 6 months and up to 61% during the 12 months after admission among patients with persistent major depression. In both study periods, a greater number of physician visits and prescription of a psychotropic medication (non-antidepressant) were independently associated with recognition. CONCLUSIONS A longitudinal approach to measuring recognition of late-life depression in ambulatory care settings indicates that persistent major depression is more likely to be recognized than previously reported.
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Affiliation(s)
- Jane McCusker
- Department of Clinical Epidemiology and Community Studies, St Mary's Hospital, Montreal, Quebec, Canada.
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Affiliation(s)
- Leonard E. Egede
- Division of General Internal Medicine, Center for Health Disparities Research, Medical University of South Carolina, 135 Rutledge Avenue, Room 280H, Charleston, SC 29425 USA
- Charleston VA TREP, Ralph H. Johnson VA Medical Center, Charleston, SC USA
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