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

Association of dietary vitamin C intake with depression in adults: A cross-sectional study of NHANES from 2005 to 2020

BACKGROUND

The aim of this study was to evaluate the association between dietary vitamin C intake and depression in adults.

METHODS

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) during 2005 to 2020. Logistic regressions and restricted cubic spline (RCS) regression were used to assess the association between dietary vitamin C intake and depression. Additionally, we performed stratified and sensitivity analyses to evaluate the stability of the results.

RESULTS

This study included 38,157 participants, with 3448 (9.04 %) of them experiencing depression. The vitamin C intake was negatively associated with depression after adjusting for all covariates (OR = 0.91, 95%CI: 0.88-0.94, P < 0.001). Similar inverse associations were observed when vitamin C intake was transformed into categorical variables. Individuals in higher quartiles of dietary vitamin C intake (Q2, Q3, and Q4) had lower odds ratios (ORs) compared to those in the lowest quartile (Q1), as indicated by adjusted ORs of 0.78 (95 % CI: 0.71-0.87, P < 0.001), 0.74 (95 % CI: 0.67-0.82, P < 0.001), and 0.73 (95 % CI: 0.65-0.81, P < 0.001), respectively. The RCS analysis found an L-shaped nonlinear relationship between dietary vitamin C intake and depression, after adjusting for all covariates (P for non-linearity<0.001). Consumption of vitamin C was inversely associated with depression (OR = 0.994, 95%CI: 0.993-0.996, P < 0.001) for intakes below 93.61 mg, but there was no association between dietary vitamin C intake and depression (P = 0.980) for intakes of 93.61 mg or higher. The inverse associations between vitamin C intake and depression remained robust in stratified and sensitivity analyses.

LIMITATIONS

This study was a cross-sectional study, and therefore unable to establish a causal relationship between dietary vitamin C intake and depression. We are unable to fully eliminate the confounding effects resulted from other unmeasured or unknown factors.

CONCLUSION

The study revealed a negative association between dietary vitamin C intake and depression, as well as an L-shaped nonlinear relationship between vitamin C intake and depression.

Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER)

OBJECTIVES

To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents.

DESIGN

Modified stepped-wedge unit-level intervention.

SETTING AND PARTICIPANTS

Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs.

METHODS

Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2.

RESULTS

There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2.

CONCLUSIONS AND IMPLICATIONS

SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

Interaction between activities of daily living and cognitive function on risk of depression

Objective

There is a lack of literature about the joint effects of activities of daily living (ADL) limitation and cognitive impairment on depression. This study aimed to estimate the association of ADL limitation and cognitive impairment with depression among Chinese older adults aged 65 and above and to test their interaction on both additive and multiplicative scales.

Methods

Data was drawn from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), including 11,025 eligible participants. Logistic regression models were fitted, and both multiplicative and additive interactions for ADL limitation and cognitive impairment were tested.

Results

A total of 3,019(27.4%) participants reported depressive symptoms. After controlling for potential confounding factors, ADL limitation and cognitive impairment were both positively associated with depression. The adjusted additive interaction of basic and instrumental activities of daily living limitation were 2.47 (95%CI:1.92-3.19) and 3.67 (95%CI:2.88-4.66), respectively, but the multiplicative interaction items were both insignificant.

Conclusion

ADL limitation and cognitive impairment were both risk factors for depression among Chinese older adults. Moreover, the significant interaction of ADL limitation and cognitive impairment was found in the additive model, suggesting that improving ADL may be helpful in reducing the risk of depression among older people with cognitive impairment.

Health effects of social connectedness in older adults living in congregate long-term care settings: A systematic review of quantitative and qualitative evidence

BACKGROUND

The overall impact of social connectedness on health outcomes in older adults living in nursing homes and assisted living settings is unknown. Given the unclear health impact of social connectedness for older adults in congregate long-term care settings worldwide, a comprehensive systematic review is required to evaluate the overall relationship between social connectedness and health outcomes for them.

OBJECTIVES

The purpose of this article was to synthesize the literature regarding the health impact of social connectedness among older adults living in nursing homes or assisted living settings.

METHODS

Using PRISMA guidelines, we identified eligible studies from Scopus, MEDLINE, PsycINFO, CINAHL and Cochrane databases (1990-2021). Bias and quality reporting assessment was performed using standardized criteria for cohort, cross sectional and qualitative studies. At each stage, ≥ 2 researchers conducted independent evaluations.

RESULTS

Of the 7350 articles identified, 25 cohort (follow-up range: 1 month-11 years; with two also contributing to cross sectional), 86 cross sectional, eight qualitative and two mixed methods were eligible. Despite different instruments used, many residents living in nursing homes and assisted living settings had reduced social engagement. Quantitative evidence supports a link between higher social engagement and health outcomes most studied (e.g. depression, quality of life). Few studies evaluated important health outcomes (e.g. cognitive and functional decline). Most cohort studies showed that lack of social connectedness accelerated time to death.

CONCLUSIONS

Social connectedness may be an important modifiable risk factor for adverse health outcomes for older adults living in nursing homes and assisted living facilities. Most studies were cross sectional and focused on quality of life and mental health outcomes. Longitudinal studies suggest that higher social engagement delays time to death. Evidence regarding other health outcomes important to older adults was scant and requires further longitudinal studies.

Social Support and Commitment to Life and Living: Bidirectional Associations in Late Life over Time

OBJECTIVES

This study aims to enhance the understanding of longitudinal associations between two important facets of well-being in late life: social support and commitment to life and living (CTL).

METHODS

Structured home interviews were conducted with 824 Israelis ≥75 years of age, with three annual data collection timepoints. We hypothesized and tested a cross-lagged, longitudinal structural equation model (SEM) in which CTL and social support were assumed to predict each other over time, covarying for previously reported CTL and social support.

RESULTS

Social support has a positive, contemporaneous effect, predicting commitment to living at T1 and T3, while CTL predicts social support the following year (i.e., T1-T2 & T2-T3). Satisfaction with relationships significantly contributes to measurement of both latent constructs at each point of data collection.

DISCUSSION

Commitment to life and living and social support are intertwined phenomena. Whereas social support has a concomitant effect on CTL, the effect of CTL on social support emerges over time. This suggests that greater social support fosters greater CTL, leading older adults to nurture social networks and relationships; the effect of which is greater social support in the future. The implications of these results warrant further research over longer periods and across cultures.

Geriatric symptoms associated with healthy life expectancy in older people in Japan

BACKGROUND

We investigated the relationship between characteristic geriatric symptoms and healthy life expectancy in older adults in Japan. Additionally, we determined relationship predictors that would help formulate effective approaches toward promoting healthy life expectancy.

METHODS

The Kihon Checklist was used to identify older people at high risk of requiring nursing care in the near future. We evaluated the association of geriatric symptoms with healthy life expectancy while considering risk factors (frailty, poor motor function, poor nutrition, poor oral function, confinement, poor cognitive function, and depression). Data from the 2013 and 2019 Japan Gerontological Evaluation Studies were used. Healthy life expectancy was assessed using the multistate life table method.

RESULTS

Overall, 8,956 individuals were included. For both men and women, healthy life expectancy was shorter in the symptomatic group than in the asymptomatic group for several domains of the Kihon Checklist. For men, the difference between individuals with risk factors and those with no risk factors was the maximum for confinement (3.83 years) and the minimum for cognitive function (1.51 years). For women, the difference between individuals with risk factors and those with no risk factors was the maximum for frailty (4.21 years) and the minimum for cognitive function (1.67 years). Healthy life expectancy tended to be shorter when the number of risk factors was higher. Specifically, the difference between individuals with ≥3 risk factors and those with no risk factors was 4.46 years for men and 5.68 years for women.

CONCLUSIONS

Healthy life expectancy was negatively associated with characteristic geriatric symptoms, with strong associations with frailty, physical functional decline, and depression. Therefore, comprehensive assessment and prevention of geriatric symptoms may increase healthy life expectancy.

Nurse Practitioners Navigating the Consequences of Directives, Policies, and Recommendations Related to the COVID-19 Pandemic in Long-Term Care Homes

Objectives

New models for the workforce are required in long-term care (LTC) homes, as was made evident during the Coronavirus Disease 2019 (COVID-19) pandemic. Nurse Practitioner (NP)-led models of care represent an effective solution. This study explored NPs’ roles in supporting LTC homes as changes in directives, policies, and recommendations related to COVID-19 were introduced.

Design

Qualitative exploratory study.

Context

Thirteen NPs working in LTC homes in Ontario, Canada.

Methods

Semi-structured interviews were conducted in March/April 2021. A five-step inductive thematic analysis was applied.

Findings

Analysis generated four themes: leading the COVID-19 vaccine rollout; promoting staff wellbeing related to COVID-19 fatigue; addressing complexities of new admissions; and negotiating evolving collaborative relationships.

Conclusions

Nurse practitioners were instrumental in supporting LTC homes through COVID-19 regulatory changes producing unintended consequences. The NPs’ leadership in transforming care is equally essential in LTC homes as in other established healthcare settings, such as primary and acute care.

Prevalence of depression and its potential contributing factors in patients with enterostomy: A meta-analytical review

OBJECTIVE

In patients with intestinal pathologies, the placement of a stoma bag affects multiple aspects of their perceived quality of life. This meta-analysis aims to evaluate the prevalence of depression among patients with enterostomy and to determine the underlying factors that could explain the potential heterogeneity of this prevalence.

METHODS

Relevant published studies were identified by searching PubMed, Embase, PsycINFO, Cochrane, CINAHL, Scopus, and Web of Science until May 2022. The random-effects model was used to determine the pooled prevalence of depression among patients with enterostomy using cross-sectional studies from various countries. Meta-regression and subgroup analysis were performed to identify factors contributing to heterogeneity. Quality assessment of the included studies was conducted using the Newcastle-Ottawa scale for nonrandomized studies.

RESULTS

The pooled prevalence of depressive symptoms among patients with enterostomy, as calculated using the random-effects model, was 41.6% (95% confidence interval [CI]: 25.4-59.7%, Q-value = 145.794, df = 8, p < 0.001, tau^∧2 = 1.124, I^∧2 = 94.513). The meta-regression found that mean age and gender were not significant moderators for the observed heterogeneity in prevalence. Subgroup analysis according to the indications for enterostomy formation showed that the prevalence of depression was highest in patients with colorectal cancer, at 34.4% (95% CI: 27.2-42.4%). Subgroup analysis by region showed that patients in Africa had the highest prevalence of depression, at 88.2% (95% CI: 76.1-94.6%), compared to other regions. Subgroup analysis by stoma indication was not significant.

CONCLUSION

This meta-analysis reports that the pooled prevalence of depression among patients with enterostomy is 41.6%. Indications for enterostomy formation, as well as geographical region, were identified as potential sources of heterogeneity. These findings highlight the need for appropriate psychosocial support and interventions at different stages of enterostomy placement.

Use of antidepressant medications among older adults in European long-term care facilities: a cross-sectional analysis from the SHELTER study

Background

Late-life depression is common among older adults living in nursing homes (NHs). Over the last 30 years there has been an increase in the rates of prescription of antidepressant medications across all ages, with the largest rise reported in older adults. This study aimed to describe the pattern of antidepressant medication use among NH residents from 7 European countries and Israel and to examine patient and facilities characteristics that may account for it.

Methods

We conducted a cross-sectional analysis of data from the SHELTER study, an observational longitudinal cohort study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument in 7 European Countries and Israel.

Descriptive statistics were used to examine sample characteristics. Potential correlates of antidepressant medication use were identified using multiple logistic regression modeling.

Results

Among 4023 residents entering the study, 32% had depressive symptoms and nearly half of these individuals used antidepressants. Antidepressant medication use varied by country, with a prevalence in the overall sample of 35.6% (n = 1431). Among antidepressant users, 59.9% were receiving selective serotonin reuptake inhibitors (SSRI). The strongest correlates of antidepressant use included reported diagnosis of anxiety, depression, bipolar disorder, pain, falls and high level of social engagement. Age over 85 years, living in facilities located in rural areas and a diagnosis of schizophrenia reduced the likelihood of being prescribed with an antidepressant.

Conclusions

A large proportion of residents in European long-term care facilities receive antidepressant medications. The decision to prescribe antidepressants to NH residents seems to be influenced by both patient and facility characteristics. Future longitudinal studies should evaluate the efficacy and safety of antidepressant use in NHs thus providing evidence for recommendations for clinical practice.

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.

Depressive symptoms in long term care facilities in Western Canada: a cross sectional study

BACKGROUND

The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC.

METHODS

11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80-120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers.

RESULTS

Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management.

CONCLUSIONS

Depressive symptoms are common in LTC residents -particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.