Risk Factors for Depression in Long-Term Care: A Systematic Review

The prevalence of, and factors associated with, a risk of depression in residential aged care services residents: Findings from the FIRST study

OBJECTIVES

Depression is common amongst Australian residential aged care services (RACS) residents. This study aimed to estimate the risk of depression amongst residents and identify factors associated with this risk. In care settings such as RACS, time-efficient screening tools to identify depression risk may be a preferred tool.

METHODS

The two-item Patient Health Questionnaire (PHQ-2), derived from the nine-item PHQ-9 used commonly in the United States (US), was employed in this study. A resident was identified as being at risk of depression where the score was ≥3. Multivariable logistic regression analysis was used to identify independent factors associated with being at risk of depression.

RESULTS

Residents' mean age was 87.7 (standard deviation: 7.3) years and 73% were female. One-fifth of residents (n = 108 or 20%) were at risk of depression. Age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99); Pain Assessment in Advanced Dementia (PAINAD) score (OR 1.55, 95% CI 1.11-2.16); Epworth Sleepiness Scale (ESS) score (OR 1.08, 95% CI 1.03-1.13); and 38-item Frailty Index (FI) score (OR 1.07, 95% CI 1.03-1.10) were significantly associated with being at risk of depression, whilst sex, urinary incontinence, polypharmacy, Dementia Severity Rating Scale (DSRS) and Nursing Home Life Space Diameter (NHLSD) score were not.

CONCLUSIONS

One in five residents were at risk of depression. Younger age, higher pain, higher daytime sleepiness and higher frailty status were associated with depressive risk. Future studies focusing on interventions targeting these factors may contribute to improved health outcomes.

Prevalence and risk factors of depression among elderly people in nursing homes from 2012 to 2022: a systematic review and meta-analysis

OBJECTIVES

To determine a pooled prevalence of depression and its influencing factors among nursing home residents.

METHOD

PsycINFO, PubMed, Embase, and Web of Science were searched for studies investigating the prevalence and risk factors of late-life depression among nursing home residents between January 2012 and November 2022. Two reviewers independently completed the literature screening, data extraction and quality assessment. A random-effects model was utilized to pool the prevalence of depression and summarize the influencing factors.

RESULTS

This meta-analysis included 48 studies involving 28,501 participants. The pooled prevalence of depressive mood and major depressive disorder was 53% and 27%, respectively. The rate of depressive mood is higher in lower-middle-income countries (60.0%), compared with high- (53.0%) and upper-middle-income countries (44.0%). The rate of depressive mood (35.0%) is higher among females than male (19.0%). Depression was influenced by factors, including male (OR = 0.28), insufficient income (OR = 3.53), comorbidities (OR = 2.66), pain (OR = 2.67; r = 0.31), functional disability (r = 0.33), loneliness (r = 0.43), number of chronic health problems (r = 0.18), social support (r = -0.28), activities of daily living (r = -0.43), subjective health (r = -0.28), autonomy (r = -0.41), environment (r = -0.50) and physical (r = -0.57) and psychological health (r = -0.65).

CONCLUSION

The prevalence of depressive mood is high among nursing home residents, especially in lower-middle-income countries. It is influenced by factors including gender, income, social support, daily activities, environment, physical and psychological health and autonomy. Understanding those factors can provide evidence-based recommendations for improved awareness, prevention and better management of late-life depression.

Temporal trends and disparities of population attributable fractions of modifiable risk factors for dementia in China: a time-series study of the China health and retirement longitudinal study (2011-2018)

Background

In China, dementia poses a significant public health challenge, exacerbated by an ageing population and lifestyle changes. This study assesses the temporal trends and disparities in the population-attributable fractions (PAFs) of modifiable risk factors (MRFs) for new-onset dementia from 2011 to 2018.

Methods

We used data from the China Health and Retirement Longitudinal Study (CHARLS), covering 75,214 person-waves. We calculated PAFs for 12 MRFs identified by the Lancet Commission (including six early-to mid-life factors and six late-life factors). We also determined the individual weighted PAFs (IW-PAFs) for each risk factor. Subgroup analyses were conducted by sex, socio-economic status (SES), and geographic location.

Findings

The overall PAF for dementia MRFs had a slight increase from 45.36% in 2011 to 52.46% in 2018, yet this change wasn't statistically significant. During 2011-2018, the most contributing modifiable risk was low education (average IW-PAF 11.3%), followed by depression, hypertension, smoking, and physical inactivity. Over the eight-year period, IW-PAFs for risk factors like low education, hypertension, hearing loss, smoking, and air pollution showed decreasing trends, while others increased, but none of these changes were statistically significant. Sex-specific analysis revealed higher IW-PAFs for traumatic brain injury (TBI), social isolation, and depression in women, and for alcohol and smoking in men. The decline in IW-PAF for men's hearing loss were significant. Lower-income individuals had higher overall MRF PAFs, largely due to later-life factors like depression. Early-life factors, such as TBI and low education, also contributed to SES disparities. Rural areas reported higher overall MRF PAFs, driven by factors like depression, low education, and hearing loss. The study also found that the gap in MRF PAFs across different SES groups or regions either remained constant or increased over the study period.

Interpretation

The study reveals a slight but non-significant increase in dementia's MRF PAF in China, underscoring the persistent relevance of these risk factors. The findings highlight the need for targeted public health strategies, considering the demographic and regional differences, to effectively tackle and reduce dementia risk in China's diverse population.

Funding

This work was supported by the PKU Young Scholarship in Global Health and Development.

Bidirectional associations between hearing difficulty and cognitive function in Chinese adults: a longitudinal study

Background

Middle-aged and older adults frequently experience hearing loss and a decline in cognitive function. Although an association between hearing difficulty and cognitive function has been demonstrated, its temporal sequence remains unclear. Therefore, we investigated whether there are bidirectional relationships between hearing difficulty and cognitive function and explored the mediating role of depressive symptoms in this relationship.

Method

We used the cross-lagged panel model and the random-intercept cross-lagged panel model to look for any possible two-way link between self-reported hearing difficulty and cognitive function. To investigate depressive symptoms' role in this association, a mediation analysis was conducted. The sample was made up of 4,363 adults aged 45 and above from the China Health and Retirement Longitudinal Study (CHARLS; 2011-2018; 44.83% were women; mean age was 56.16 years). One question was used to determine whether someone had a hearing impairment. The tests of cognitive function included episodic memory and intelligence. The Center for Epidemiologic Studies Depression Scale, which consists of 10 items, was used to measure depressive symptoms.

Results

A bidirectional association between hearing and cognition was observed, with cognition predominating (Wald χ2 (1) = 7.241, p < 0.01). At the between-person level, after controlling for potential confounders, worse hearing in 2011 predicted worse cognitive function in 2013 (β = -0.039, p < 0.01) and vice versa (β = -0.041, p < 0.01) at the between-person level. Additionally, there was no corresponding cross-lagged effect of cognitive function on hearing difficulty; rather, the more hearing difficulty, the greater the cognitive decline at the within-person level. According to the cross-lagged mediation model, depressive symptoms partially mediates the impact of cognitive function on subsequent hearing difficulty (indirect effect: -0.003, bootstrap 95% confidence interval: -0.005, -0.001, p < 0.05), but not the other way around.

Conclusion

These results showed that within-person relationships between hearing impairment and cognitive function were unidirectional, while between-person relationships were reciprocal. Setting mental health first may be able to break the vicious cycle that relates hearing loss to cognitive decline. Comprehensive long-term care requires services that address depressive symptoms and cognitive decline to be integrated with the hearing management.

Grief, Social Support, Spirituality, and Depressive Symptoms Among Older Adults in Assisted Living in Kansas

PURPOSE

The purpose of this study was to explore the roles of grief, social support, as well as spirituality on the depressive symptoms of older adults in assisted living in Kansas. This study tested three hypotheses: a high level of grief will be related to a high level of depressive symptoms; high levels of social support (family, friends, and significant persons) will be associated with a low level of depressive symptoms; and high levels of spiritual experience and coping will be associated with a low level of depressive symptoms.

METHODS

This study recruited 316 older adult residents aged 65 or over from seven assisted living facilities in Kansas. This cross-sectional survey was done by face-to-face interviews using the purposive sampling method. Hierarchical multiple regression was used to test the three sets of variables in relation to depressive symptoms: socio-demographics, social support factors, and spiritual factors.

RESULTS

Participants' mean age was 82.6 years, ranging from 65 to 102; 70.9% were female. Married participants consisted of 18.7%, and over 64% were widowed. Hierarchical multivariate regression results indicated that a high level of grief was significantly related to a high level of depressive symptoms. On the other hand, high levels of social support from friends and spiritual coping were significantly associated with a low level of depressive symptoms.

DISCUSSION AND CONCLUSION

Assisted living facilities may consider developing appropriate bereavement, social support, and spiritual intervention programs, which will alleviate the depression issues of older adult residents after the COVID-19 pandemic.

Family visits and depression among residential aged care residents: An integrative review

BACKGROUND

Depression in older people living in residential aged care is a serious and highly prevalent health issue, with loneliness and social isolation being major contributors. The COVID-19 pandemic underscored the harm visiting restrictions have on the mental wellbeing of older people in residential aged care. However, there is a need to systematically review the relationship between family visits and depression in this population.

OBJECTIVE

This literature review seeks to explore the association between family visits and depression among those living in residential aged care.

METHODS

An integrative review was conducted in March 2022, based on a search of seven databases from inception to 2022. Papers were included if the studies were situated in a residential aged care facility and explored the impact of in-person family visits on depression of residents. Those that examined impact of family visits on community-dwelling older people and papers examining virtual family visits were excluded. The quality of the included papers was assessed using appropriate critical appraisal tools. Guided by the aim of this study, the included papers were narratively synthesised and presented thematically (PROSPERO ID CRD42022325895).

RESULTS

Ten papers, published between 1991 and 2022, were included in the final synthesis. Multiple categorisations of frequency of visits and different scales were used to assess depression. Depression among residents in aged care facilities varied from 20 % to 58.7 % with 40 % of studies showing a positive association between the frequency of family visits and lower rate of depression. Three themes influencing the association between family visits and depression in residential aged care were identified. These were: (i) intersection of culture, filial values, and depression; (ii) resident-related factors including whether admission was voluntary and presence of functional impairment; and (iii) non-resident-related factors such as social activities for residents and staff involvement.

CONCLUSION

Family visits ameliorated loneliness and depression among residents in aged care however, other factors such as culture, comorbidities and functional impairment, opportunities for socialisation and the social involvement of facility staff also influenced depression. Whilst the low number of studies reviewed limited comparison and generalisation of results, the review highlighted the broader and crucial role of healthcare staff in facilitating socialisation and promoting mental wellbeing of residents especially those who are not visited by families.

TWEETABLE ABSTRACT

Family visits ameliorate depression in institutionalised older people but may not be the "silver bullet" as depression is multifactorial.

Trajectory and Predictors of Mental Health Symptoms and Wellbeing in Newly Admitted Nursing Home Residents

OBJECTIVES

This study determined changes in multiple aspects of mental health and wellbeing in newly admitted nursing home residents, and identified risk and protective factors.

METHODS

Participants were 204 residents recently admitted to one of 42 nursing homes in Melbourne, Australia. A subgroup of 82 participants were followed up eight months post-admission. Depression, anxiety, stress, adjustment, and quality of life were assessed at baseline and follow-up. Predictive factors (demographics, health, transition factors, nursing home characteristics) were examined in multiple regression analyses.

RESULTS

Rates of depression and anxiety were high at both baseline and follow-up. Low self-rated health and medical comorbidity predicted poor wellbeing at baseline. Higher perceived control in the relocation to the nursing home and engagement in meaningful activities were associated with better post-admission outcomes. Baseline psychotropic medication use predicted lower anxiety at follow-up but did not impact depressive symptoms.

CONCLUSIONS

There were no significant changes in mental health and wellbeing from one to eight months post-admission. The negative effect of residing in a for-profit nursing home requires further investigation.

CLINICAL IMPLICATIONS

Individual activity scheduling and an opportunity to participate in relocation decision-making and planning may support resident wellbeing post-admission.

A Scoping Review of the Measurement of Depression in Older Adults with Cognitive Impairment

OBJECTIVES

Depression and cognitive impairment are disabling conditions that commonly occur together in older adults. The interaction is challenging when choosing appropriate measurement scales. This review aimed to summarize the scales to measure depression symptoms in older people with cognitive impairment, investigating how cognitive impairment is related to the choice of measurement, and how the setting may affect the choice of measurement.

METHODS

A scoping review of literature published between 2015 and 2021.

RESULTS

After screening 1580 articles, 26 were included in the review with 11 different measures of depression symptoms identified. The measures mostly commonly used were the Geriatric Depression Scale (GDS), Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory (NPI-Q). Most studies did not report on the usability of depression scales used with people with cognitive impairment and only two scales (CSDD and NPI-Q, not GDS) have been validated for use with this population.

CONCLUSIONS

Severe cognitive impairment was under-represented in the identified studies, and no association was detected between study setting, cognitive impairment and type of measure used.

CLINICAL IMPLICATIONS

Clinicians and researchers should consider both the cognitive status of participants and the setting they live in when choosing a measure of depression symptoms.

The Course of Depressive Symptoms Over 36 Months in 696 Newly Admitted Nursing Home Residents

OBJECTIVES

To investigate the course of depressive symptoms in newly admitted nursing home (NH) residents and how resident characteristics were associated with the symptoms. To identify groups of residents following the same symptom trajectory.

DESIGN

An observational, multicenter, longitudinal study over 36 months with 7 biannual assessments.

SETTING AND PARTICIPANTS

Representing 47 Norwegian NHs, 696 residents were included at admission to a NH.

METHODS

Depressive symptoms were assessed with the Cornell Scale for Depression in Dementia (CSDD). We selected severity of dementia, functional impairment, physical health, pain, use of antidepressants, age, and sex as covariates. Time trend in CSDD score was assessed by a linear mixed model adjusting for covariates. Next, a growth mixture model was estimated to investigate whether there were groups of residents following distinct trajectories in CSDD scores. We estimated a nominal regression model to assess whether the covariates at admission were associated to group membership.

RESULTS

There was a nonlinear trend in CSDD score. More severe dementia, a lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher CSDD scores. Growth mixture model identified 4 groups: (1) persistent mild symptoms (32.6%), (2) persistent moderate symptoms (50.8%), (3) increasing symptoms (5.1%), and (4) severe but decreasing symptoms (11.6%). A lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher odds for belonging to the severe but decreasing symptoms group compared with the persistent mild symptoms group.

CONCLUSIONS AND IMPLICATIONS

Most NH residents were in trajectory groups with persistent mild or moderate depressive symptoms. Residents with more severe dementia, lower levels of functioning, poor physical health, severe pain, younger age at admittance, and who are using antidepressants should be monitored closely and systematically with respect to depression. Taking actions toward a more personalized treatment for depression in NHs is a priority and should be investigated in future studies.

Perceived availability of home- and community-based services and self-reported depression among Chinese older adults: A cross-sectional study

Few studies have assessed the association between perceived availability of home- and community-based services (HCBSs) and self-reported depression among Chinese older adults, which the present study attempts to rectify. This cross-sectional study enrolled 11,941 participants aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey 2018 wave. The 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) was used to evaluate depression, and perceived availability was measured for four categories of HCBSs: daily life assistance, medical care services, emotional support and social services, and other. These four categories and the number of services in each were used to represent the perceived availability of service provision. Binary logistic models were used to explore the relationship between perceived availability of HCBSs and depression in older adults. Perceived daily life assistance was found to be negatively associated with depression symptoms among Chinese older adults in both urban and rural areas [rural: OR (95%CI) = 0.66 (0.55-0.78), p < 0.001; urban: OR (95% CI) = 0.69(0.60-0.79), p < 0.001], while perceived levels of medical care services, emotional support and social services, and other were not associated with depression symptoms in rural or urban areas. Our primary finding was that providing daily life assistance at the community level may help to meet more older adults' daily needs, thus potentially decreasing the risk of depression.

Cognitive abilities of institutionalized older persons with depressive symptoms

ABSTRACT Objective To determine the level of association between depressive symptoms and cognitive abilities of institutionalized older adults. Methods This is a cross-sectional study that enrolled 69 older adults, living in a long-term care facility. Investigation of depressive symptoms in all individuals was performed using the geriatric depression scale. Cognitive verbal fluency, digit span forward (DSF) and backward (DSB) tests, and two-minute stationary gait, sit-to-stand test, and six-minute walk test were performed to assess their association with depressive symptoms. Results Depressive symptoms were identified in 35 individuals. Worse cognition and physical performances were associated with the presence of depressive symptoms – Mini-Mental State Examination [t (61) = 2.36; p < 0.05] and Stationary gait test of two minutes [t (53) = 3.12; p < 0.05]. Short-term memory and working memory tests presented worse results in individuals with depressive symptoms (DSF: U = 402.00; p < 0.05 e DSB: U = 341,00; p < 0.05). Older adults with scores below normal in DSF were 5 times more likely to exhibit depressive symptoms. Conclusion The importance of physical, cognitive and social intervention strategies in long-term care facilities for the older adults is highlighted, in order to privilege autonomy. Notably, there is an association between deficits in short-term memory and the presence of depressive symptoms in older adults. Therefore, prospective studies are suggested to investigate the cause-effect relationship of this association with the institutionalization of older adults.

Risk factors for depression in the elderly: An umbrella review of published meta-analyses and systematic reviews

BACKGROUND

Depression has been identified as one of the leading causes of the disease burden worldwide. Identification of the potential factors that increased or decreased the risk of depression could be important to provide prevention strategies. We aimed to conduct an umbrella review of risk factors for depression in the elderly and assessed the credibility of evidence of the association between each factor and depression.

METHODS

We searched PubMed and Web of Science from 1990 to April 11, 2021 for articles investigating associations between potential factors and depression. For each association, we recalculated the summary effect size and 95% confidence intervals using random effects models. The 95% prediction interval and between-heterogeneity were also reported. For publication bias, small-study effect and excess of significance bias were assessed.

RESULTS

Twenty-five publications met the inclusion criteria, including twenty-two meta-analyses and three qualitative systematic reviews. Approximately 1,199,927 participants and 82 unique factors were reported. Two factors were rated as convincing evidence and four factors showed highly suggestive evidence. These risk factors were aspirin use, individuals aged 80 years and above, sleep disturbances and persistent sleep disturbances, hearing problem, poor vision, and cardiac disease.

LIMITATIONS

Most studies that we included were of low quality.

CONCLUSIONS

We found several risk factors for depression with different levels of evidence, in which aspirin use and individuals aged 80 years and above presented the strongest evidence. Further research is warranted to support other findings from this umbrella review using a large, well-designed cohort study.

Needs and Needs Communication of Nursing Home Residents with Depressive Symptoms: A Qualitative Study

Nursing home residents are affected by depressive symptoms more often than elders living at home. There is a correlation between unmet needs and depression in nursing home residents, while met needs positively correlate with greater satisfaction and well-being. The study aims to examine the needs of nursing home residents with depressive symptoms and the communication of those needs, as no previous study has explicitly addressed the needs of this group of people and the way they are communicated. We conducted semi-structured interviews with 11 residents of three nursing homes and analyzed them using content-structuring content analysis. The residents reported diverse needs, assigned to 12 categories. In addition, barriers such as health impairments prevented the fulfillment of needs. As to the communication of needs, various interlocutors, facilitators, and barriers were identified. The findings reveal that residents can express their needs and are more likely to do so if the interlocutors are patient and take them seriously. However, lack of confidants, missing or non-functioning communication tools, impatience and perceived lack of understanding on the part of caregivers, and residents’ insecurities limit communication of needs.

The Roles of Life Satisfaction and Community Recreational Facilities in the Relationship between Loneliness and Depression in Older Adults

OBJECTIVES

This study examined the mediating effect of life satisfaction and the moderating effect of the availability of community recreational facilities (CRF) in the association between loneliness and depression in rural older adults and urban older adults, respectively.

METHODS

Quantitative data collected from 7547 Chinese older adults were analyzed using the SPSS macro PROCESS to test a moderated mediation model with life satisfaction as the mediator and CRF availability and residency type (rural vs. urban) as moderators.

RESULTS

Loneliness negatively predicted life satisfaction, life satisfaction negatively predicted depression, and loneliness positively predicted depression. The interaction of loneliness and CRF availability had a significant effect on depression for urban older adults but not for rural older adults. The direct impact of loneliness on depression differed significantly between rural and urban older adults.

CONCLUSIONS

Life satisfaction mediated the association between loneliness and depression in both rural and urban older adults; CRF availability unexpectedly boosted the effect of loneliness on depression in urban older adults but not in rural older adults. Given the same level of loneliness, urban older adults were more likely to be depressed than rural older adults.

CLINICAL IMPLICATIONS

Psychogeriatric practitioners may embed life satisfaction into intervention programs to minimize depression among older adults. Public administrators should examine the utilization of public facilities to avoid wasted resources and counterproductive effects on older adults. Lonely urban older adults deserve special attention.

Detecting depression in persons living in long-term care: a systematic review and meta-analysis of diagnostic test accuracy studies

OBJECTIVE

Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings.

METHODS

We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias.

RESULTS

We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%-76.5%), specificity was 76.5% (95% CI 62.9%-86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%-90.0%) for persons in LTC living with dementia.

CONCLUSIONS

There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses.

Influence of Attachment Anxiety on the Relationship between Loneliness and Depression among Long-Term Care Residents

BACKGROUND

Attachment styles influence an individual's ability to maintain relationships throughout their lifespan. Insecure attachment has been associated with many aspects of mental health. The study aimed to explore the influence of attachment on loneliness and depression among old-age residents in long-term care facilities.

METHODS

A survey was conducted among residents from long term care facilities (LTC) in Thailand during the COVID-19 pandemic; 221 older people participated in the study. The mean aged was 73.60 ± 7.45 years old, and 57.5% female. All participants completed the Geriatric Depression Scale, the six-item revised version of the University of California Los Angeles Loneliness Scale, and the Revised Experience of Close Relationships questionnaire to measure depressive symptoms, loneliness, and attachment style. Hierarchical multiple regression analysis was performed to find the predictors for depressive symptoms.

RESULTS

In all, 40.7% of residents in LTC facilities experienced depression. Male sex, education, loneliness, and attachment anxiety predicted the increased level of depressive symptoms.

CONCLUSION

Loneliness was confirmed to be significantly associated with depressive symptoms, and attachment anxiety was found to be a strong predicting factor of depressive symptoms. Intervention and research regarding reducing loneliness and attachment anxiety should be promoted in LTC settings.

The effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in newly admitted nursing home residents

BACKGROUND

Depression is common in nursing homes, particularly among newly admitted residents. This cluster randomised controlled trial evaluated the effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in this group.

METHODS

Participants were 219 newly-admitted residents (mean of 4.4 weeks since admission) in 42 nursing homes in Melbourne, Australia, with a mean age of 85.5 years (SD = 7.3). Nursing homes were randomly allocated to the intervention or standard care condition. Level of depressive symptoms was evaluated at baseline (T1), one week post- intervention (T2), 2 months post-intervention (T3, primary end point), and 6 months post-intervention (T4). Changes in depressive symptoms in the intervention and control groups over time were compared using a multilevel model, with nursing homes modelled as random intercept.

RESULTS

In intention to treat analyses, depressive symptoms reduced from T1 to T3 to a greater degree in the intervention condition (M_change=2.56, SD_change=5.71) than in the control (M_change=0.63, SD_change=5.25), with a significant, small-medium treatment effect size (p=.035; Cohen's d=0.36). The reduction in depressive symptoms from T1 to T4 was not significant (p=.369; Cohen's d=0.32).

LIMITATIONS

The findings require replication, particularly comparing PEARL with an active control condition.

CONCLUSIONS

PEARL is a simple, brief program that was effective in reducing symptoms of depression in newly admitted nursing home residents.

Risk Factors for Depression in Long-term Care: A Prospective Observational Cohort Study

Objectives: Depression among older adults in long-term care remains a problem, despite the uptake of antidepressants and the development of intervention programs. A better understanding of the risk factors for depression is much needed. Guided by a systematic assessment of the evidence, this prospective observational cohort study sought to clarify existing evidence, identify modifiable risk factors and explore novel variables. Methods: Adults aged ≥65 (T1 n=147, T2 n= 81) were recruited from 15 long-term-care facilities in Melbourne, Australia. Cognitive impairment, functional impairment, pain, sleep disturbance, social support, and person-environment fit were investigated as risk factors. Outcomes were depressive symptoms and indicated Major Depressive Episode. Results: Generalized Estimating Equations (GEE) identified that changes in pain (b= 0.06, p<.05), sleep disturbance (b= 0.02, p< .001), social support (b= -0.02, p< .001) and person-environment fit (b= -0.02, p= <.01) were significantly associated with changes in depression score. Conclusions: Pain, sleep disturbance, social support, and person-environment fit are modifiable risk factors, making them strongly positioned to strategically inform prevention and intervention strategies. Clinical Implications: Individuals with clinically significant symptoms on these risk factors for depression should be selected for interventions that target these risk factors. For depressed individuals, psychotherapy should prioritize the potential role of these risk factors. Finally, these risk factors should be used as screening and monitoring variables: clinically significant changes in symptoms warrant investigation.

Evaluating the Effect of COVID-19 Pandemic Lockdown on Long-Term Care Residents' Mental Health: A Data-Driven Approach in New Brunswick

Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the interRAI LTC facility (LTCF) assessment can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behavior problems in a network of 7 LTC homes in New Brunswick, Canada, where mitigative strategies were deployed to minimize poor mental health outcomes (eg, virtual visits and increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modeled the change within and between residents for depression, delirium, and behavioral problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, P < .001), the number of residents experiencing delirium (4.5%-3.5%, P = .51) and behavioral problems (35.5%-30.2%, P = .19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (P < .002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioral problems. Our analyses demonstrate that poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment, and researchers can examine the data to identify better management strategies for when pandemic strikes again.

The clinical characterization of the adult patient with depression aimed at personalization of management

Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.

A social robot intervention on depression, loneliness, and quality of life for Taiwanese older adults in long-term care

OBJECTIVES

To investigate the effect of a social robot intervention on depression, loneliness, and quality of life of older adults in long-term care (LTC) and to explore participants' experiences and perceptions after the intervention.

DESIGN

A mixed-methods approach consisting of a single group, before and after quasi-experimental design, and individual interview.

PARTICIPANTS

Twenty older adults with depression from four LTC facilities in Taiwan were recruited.

INTERVENTION

Each participant participated in 8 weeks of observation and 8 weeks of intervention. In the observation stage, participants received usual care or activities without any research intervention. In the intervention stage, each participant was given a Paro (Personal Assistive RobOt) to keep for 24 hours, 7 days a week.

MEASUREMENTS

The Geriatric Depression Scale, the UCLA Loneliness Scale Version 3, and the World Health Organization Quality of Life Questionnaire for older adults were administered at four time points. Individual qualitative interviews with thematic analysis followed.

RESULTS

A repeated multivariate analysis of variance and Friedman's test showed no significant changes during the observation stage between T1 and T2 for depression and quality of life (p >.5). For the intervention stage, statistically significant changes in decreasing depression and loneliness and improving quality of life over time were identified. Three themes emerged from the interviews: (i) humanizing Paro through referring to personal experiences and engagement; (ii) increased social interaction with other people; and (iii) companionship resulting in improved mental well-being.

CONCLUSIONS

There were significant improvements in mental well-being in using Paro. Further research may help us to understand the advantages of using a Paro intervention as depression therapy.

Depression Severity, but Not Cognitive Impairment or Frailty, is Associated with Disability in Late-Life Depression

OBJECTIVES

Assess the relationship of cognitive impairment to disability, accounting for depression severity and frailty, among older adults with late-life depression (LLD).

METHODS

Data were analyzed from 78 community-dwelling older adults with LLD and without dementia (age M = 71.9; SD = 6.1). Cognitive functioning was assessed using a comprehensive neuropsychological battery. Depression severity was measured using the 17-item Hamilton Depression Rating Scale (HDRS; cutoff ≥15). Frailty was assessed using several motor tests. The World Health Organization Disability Assessment Schedule (WHO-DAS) measured disability status. A linear regression analysis was performed to identify relationships of cognition, frailty and depression severity with disability.

RESULTS

The average number of impaired cognitive tests was 2.0 (SD = 1.9), with 28.2% of participants showing no impaired scores. On average participants reported depression severity of 17.3 (SD = 3.6), and disability total score of 15.1 (SD = 6.9). The regression model accounted for 25.1% of the variance in disability, with only depression severity significantly predicting disability status. Burden of cognitive impairment and frailty were not predictive of disability in this sample.

CONCLUSIONS

In this sample, only depression severity was associated with increased disability.

CLINICAL IMPLICATIONS

These findings have implications for intervention in LLD, as depression severity may represent a more modifiable risk factor for disability.

Risk indicators for depression in aged care: The contribution of a meaningful life, mastery and environmental fit

OBJECTIVES

Depression is a pernicious, growing problem in the aged care population. Knowledge about the risk factors for depression focuses on unchangeable, medical factors; therefore, a deeper, systematic understanding of modifiable psychological risk indicators is needed.

METHODS

This secondary analysis used data from an observational cohort study (T1, n = 147; T2, n = 81) of adults aged ≥65 years recruited from 15 aged care facilities in Melbourne, Australia. Meaningful existence, mastery, social support and person-environment fit were investigated as risk indicators.

RESULTS

Generalised estimating equation analysis identified that changes in meaningful existence (b = -0.06, P < .05), mastery (b = -0.05, P < .05) and person-environment fit (b = -0.02, P < .05) were significantly associated with change in depression score. These remained significant controlling for socio-demographic variables, cognitive impairment and functional impairment.

CONCLUSION

Because these psychological risk factors-meaningful existence, mastery and person-environment fit-are suitable therapeutic targets, they are well positioned to inform prevention and intervention programs.

The course of depressive symptoms with decline in cognitive function - a longitudinal study of older adults receiving in-home care at baseline

Background

Depressive symptoms in old age are common, but the prevalence, persistence, and incidence of depressive symptoms in older adults with and without dementia receiving in-home care is less well studied, and descriptions of the relationship between severity of cognitive decline and depressive symptoms over time is, to our knowledge, lacking. The aim of the present study was to describe the prevalence, incidence and persistence of depressive symptoms over a 36-month follow-up period among older adults receiving in-home care at baseline, and to explore the association between cognitive function and the course of depressive symptoms over time.

Methods

In all, 1001 older people (≥ 70 years) receiving in-home care were included in a longitudinal study with three assessments over 36 months. Depressive symptoms were assessed using the Cornell Scale for Depression in Dementia. Clinical Dementia Rating Scale, diagnosis of dementia and mild cognitive impairment, general medical health, personal and instrumental activities of daily living, neuropsychiatric symptoms and the use of psychotropic medication were evaluated during the three assessments. Baseline demographic characteristics and information on nursing home residency at follow-up were recorded. Linear mixed models were estimated.

Results

The baseline prevalence and cumulative incidence of single depressive symptoms were higher in those with dementia at baseline than in those without dementia. The persistence of depressive symptoms did not differ between those with or without dementia at baseline. The severity of cognitive impairment and mean depressive symptom score assessed simultaneously were positively associated, but the strength of the association changed over time and was not significant at the last assessment. Furthermore, being younger, female, in very poor physical health, with neuropsychiatric symptoms and not becoming a nursing home resident were associated with more depressive symptoms when assessed simultaneously.

Conclusion

The baseline prevalence and cumulative incidence of depressive symptoms in those with and without dementia at baseline, as well as the relationship we found between the degree of cognitive decline and depressive symptoms over time show that depression and dementia are interconnected. Nurses and clinicians should pay attention to cognitive status when observing or evaluating depression among older adults receiving in-home care.