Does depression predict adverse outcomes for older medical inpatients? A prospective cohort study of individuals screened for a trial

Prevalence and prognostic significance of depressive symptoms in a geriatric post-hip fracture assessment

OBJECTIVES

To investigate the prevalence and prognostic significance of post-hip fracture depressive symptoms.

METHODS

A naturalistic clinical cohort study. Data were collected on admission to hospital, geriatric assessment 4-6 months post-fracture and by telephone interview one-year post fracture. Depressive symptoms were assessed at the geriatric assessment using the 15-item Geriatric Depression Scale (GDS-15). Logistic regression analyses with multivariable models were conducted to examine the association of depressive symptoms with changes in mobility and living arrangements and Cox proportional hazards models for mortality between the geriatric assessment and one-year follow-up.

RESULTS

Of the 1070 patients, 22% (n = 238) had mild and 6% (n = 67) moderate to severe depressive symptoms. Patients with depressive symptoms had poorer nutritional status at baseline, lower scores on the cognitive and physical performance tests and poorer functional abilities in the geriatric assessment than those without. No association was observed between depressive symptoms and any of the outcomes at one-year follow-up. Poor nutritional status and physical functioning remained significant prognostic indicators.

CONCLUSION

Post-hip fracture depressive symptoms are common and deserve attention during post-hip fracture recovery and rehabilitation. Nonetheless, depressive symptoms have no impact on the change in mobility or living arrangements or mortality. These latter outcomes are mainly explained by poor nutritional status and functioning.

Lower Blood Vitamin D Levels Are Associated with Depressive Symptoms in a Population of Older Adults in Kuwait: A Cross-Sectional Study

Low serum vitamin D has been associated with an increased risk of neuropsychiatry disorders. This study aimed to examine the association between vitamin D deficiency and depression in adults aged 65 years and older. This cross-sectional study was conducted in seven primary healthcare centers across Kuwait (November 2020 to June 2021). The participants (n = 237) had their serum vitamin D 25-(OH)-D concentrations (analyzed by LC-MS) classified as sufficient, ≥75 nmol/L (30 ng/mL); insufficient, 50−75 nmol/L (20−30 ng/mL); or deficient, <50 nmol/L (20 ng/mL). Depressive symptoms were evaluated using the 15-Item Geriatric Depression Scale (15-item GDS). The mean serum 25-OH-D levels (nmol/L) in volunteers with normal, mild, moderate, and severe depression were 100.0 ± 31.7, 71.2 ± 38.6, 58.6 ± 30.1 and 49.0 ± 6.93, respectively (p < 0.001). The participants in the vitamin D sufficiency group were significantly less likely to exhibit depressive symptoms (88.2%) than patients with mild (36%) and moderate (21%) depression (p < 0.001). Ordinal logistic regression showed that vitamin D deficiency (OR = 19.7, 95% CI 5.60, 74.86, p < 0.001) and insufficiency (OR = 6.40, 95% CI 2.20, 19.91, p < 0.001) were associated with higher odds of having depressive symptoms. A low serum vitamin D level is a significant predictor of symptoms of depression among older individuals.

Anhedonia and anergia predict mortality in older Australians living in residential aged care

OBJECTIVES

Depression is common in older adults and is linked to morbidity and mortality. The aim of this study was to investigate whether specific symptoms of depression (dysphoria, anhedonia and anergia) predicted mortality in older Australian Aged Care residents.

METHODS

Eighty older adults (M = 83.16 ± 7.14) without cognitive impairment residing in 14 Residential Aged Care facilities located in Melbourne, Australia, completed the 15-item Geriatric Depression Scale-Short Form (GDS-15) and the Standardized Mini Mental State Examination. Residential Aged Care facilities provided the primary end-point of all-cause mortality at follow-up (M = 5.4 years ± 0.1).

RESULTS

Univariate Kaplan-Meier survival curves and Cox Proportional Hazards regression analyses were used to evaluate whether symptoms of depression predicted all-cause mortality, with known prognostic factors controlled. The results indicated that anhedonia (Hazard Ratio = 2.931 [95% CI 1.278-6.722], p = .011) and anergia (Hazard Ratio = 2.783 [95% CI 1.065-7.276], p = .037) were associated with almost a threefold increased risk of mortality in older adults living in RAC in adjusted analyses. Dysphoria did not predict mortality.

CONCLUSIONS

These findings advance understanding of the mortality risks of anhedonia and anergia in an understudied population. Symptoms of anhedonia and anergia should be targeted for screening in older adults living in Aged Care to increase the detection and potential for referral to treatment for depressive presentation.

Psychometric properties and modification of the 15-item geriatric depression scale among Chinese oldest-old and centenarians: a mixed-methods study

Background

The 15-item Geriatric Depression Scale (GDS-15) shows good performance in detecting depression among older persons, but its applicability has not been well studied in non-Western oldest-old adults and centenarians. This study aimed to evaluate the psychometric property of the GDS-15 and a simplified version among a large representative longevous population in China.

Methods

A total of 1624 individuals (786 oldest-old persons aged from 80 to 99 years; 838 centenarians aged 100+ years) participated in this study. Home interviews with structured questionnaires were conducted to collect sociodemographic data. Depressive symptoms were measured using the Chinese GDS-15 version. We implemented mixed methods for the psychometric evaluation of the GDS-15. Cronbach’s α coefficient and item-total correlation coefficients were used to evaluate the internal consistency. A standard expert consultation was conducted to test the content validity of each item. Multiple factor analyses were used to explore the optimal factor structure and measurement invariance.

Results

The α coefficient of the GDS-15 was 0.745, while two items impaired the overall consistency reliability. Nineteen experts rated the applicability for each item and provided removal suggestion. Five items with less validity were removed, and a simplified 10-item GDS model with three-factor structure was proposed as an optimal solution. The GDS-10 model showed factorial equivalence across age, sex, residence, and education in multi-group confirmatory factor analyses.

Conclusions

The original GDS-15 has acceptable internal reliability, known-group validity, and concurrent validity among Chinese community-dwelling oldest-old and centenarians; however we provided preliminary evidence indicating that individual items related to somatic function or social activities may not be applicable for this population. The modified GDS-10 can be proposed as a potentially more practical and comprehensible instrument for depression screening.

Referral to geriatric rehabilitation: a scoping review of triage factors in acutely hospitalised older patients

OBJECTIVE

Old or frail acutely hospitalised patients can benefit from geriatric rehabilitation but criteria concerning referral decisions are unclear. This review presents an overview of clinical factors associated with referral to geriatric rehabilitation that may further consensus between hospital and rehabilitation professionals on triage.

DESIGN

Scoping review.

METHODS

A review was conducted following Arksey and O'Malley's framework. The search included literature concerning a broad spectrum of acutely hospitalised patients and factors associated with their referral to geriatric rehabilitation.

RESULTS

Selected abstracts were categorised into distinct geriatric rehabilitation care pathways such as stroke, hip fracture, amputation of lower limb, cardiac and oncologic rehabilitation. Abstracts on internal medical patients were further reviewed and 29 studies were included. A total of 13 studies focused on factors identifying rehabilitation needs and 16 on factors associated with outcome of geriatric rehabilitation. Triage factors were diverse and included frailty status, functional decline, cognitive symptoms and multimorbidity. Mood symptoms and living situation further specified post-acute care needs. In overview, triage factors could be characterised as demographic (n = 4), diagnosis-related (n = 8), mental (n = 6), functional (n = 10) or multi-domain (n = 12) and mapped in a transitional care pathway.

CONCLUSIONS AND IMPLICATIONS

Frailty and functional decline are characteristics frequently associated with referral to geriatric rehabilitation of acutely hospitalised internal medical patients. A comprehensive geriatric assessment or a simpler multi-domain set of tests reveals rehabilitation needs and approximates a functional prognosis. Professional consensus on factors and timing of triage in hospital is within reach.

Cognitive Impairment and Length of Stay in Acute Care Hospitals: A Scoping Review of the Literature

Older persons experiencing a longer length of stay (LOS) or delayed discharge (DD) may see a decline in their health and well-being, generating significant costs. This review aimed to identify evidence on the impact of cognitive impairment (CI) on acute care hospital LOS/DD. A scoping review of studies examining the association between CI and LOS/DD was performed. We searched six databases; two reviewers independently screened references until November 2019. A narrative synthesis was used to answer the research question; 58 studies were included of which 33 found a positive association between CI and LOS or DD, 8 studies had mixed results, 3 found an inverse relationship, and 14 showed an indirect link between CI-related syndromes and LOS/DD. Thus, cognitive impairment seemed to be frequently associated with increased LOS/DD. Future research should consider CI together with other risks for LOS/DD and also focus on explaining the association between the two.

Is preexisting mental illness associated with lower patient satisfaction for older trauma patients? A cross-sectional descriptive study

BACKGROUND

The purpose of this study was to examine if satisfaction with care differs among older trauma patients with and without preexisting mental illness (PMI+/PMI-).

METHODS

Data from two level I trauma centers were examined from 11/2016 through 12/2017. Trauma patients ≥55 years were included and satisfaction of those who had a diagnosis of mental illness prior to the trauma admission (PMI+) to those without a diagnosis (PMI-) (n = 299; 62 PMI+ and 237 PMI-) were compared. Enrolled patients completed the Family Satisfaction with Advanced Care Cancer Scale Patient Survey (FAMCARE-P13) prior to discharge. Associations between mental illness status and patient baseline characteristics, overall mean satisfaction, and mean satisfaction by question were compared. Generalized linear models adjusted for differences in patient satisfaction by mental illness status. Analyses were stratified by hospital to account for the interaction between hospital and mental illness status.

RESULTS

Compared to PMI- patients, PMI+ patients were more likely to be younger, female, have multiple comorbidities, and to report lower overall satisfaction with care. Among PMI+ patients, the most common diagnoses were depression and anxiety. After adjustment, PMI+ was associated with lower patient satisfaction at hospital 1; after examining individual questions lower satisfaction was associated with information provided on procedures and questions surrounding "Physical care." Conversely, PMI+ did not affect satisfaction at hospital 2 after adjustment.

CONCLUSIONS

At hospital 1, room for improvement was identified in providing information about prognosis and procedures, symptom management, and continuity of care. Reexamining practices for older PMI+ trauma patients is warranted.

Nurses' Late-Life Depression Knowledge and Attitudes Toward Depression: A Cross-Sectional Study

Depression in older population is more common now. Due to increasing numbers of older patients in hospitals, nurses have more opportunities to care for these patients. Therefore, nurses should have correct knowledge of late-life depression and more favorable attitudes about depression. The study aimed to understand hospital nurses' knowledge level of late-life depression and attitudes about depression. A cross-sectional research design was used. A convenience sample of 307 nurses from 3 hospitals in Taiwan was recruited. Nurses scored 55.15% in the Late-Life Depression Quiz. The average score of the Revised Depression Attitude Questionnaire was 71.76 (SD = 6.13). The study also found that hospital nurses had more favorable attitudes about depression when their late-life depression knowledge was higher; their interest level in providing care for older patients with depression was greater; they had ever taken care of older patients with depressive symptoms or depression; they had never received in-service training on depression in the past year; and they had ever attended lectures about depression in school. Hospital nurses' knowledge about late-life depression was limited, and they had neutral to slightly favorable attitudes about depression in Taiwan. It is suggested to carefully examine and evaluate in-service training related to depression for nurses in hospitals. In addition, developing appropriate interventions to increase hospital nurses' knowledge level of late-life depression and attitudes toward depression is recommended.

Frailty Index and functional level upon admission predict hospital outcomes: an interRAI-based cohort study of older patients in post-acute care hospitals

BACKGROUND

Geriatric assessment upon admission may reveal factors that contribute to adverse outcomes in hospitalized older patients. The purposes of this study were to derive a Frailty Index (FI-PAC) from the interRAI Post-Acute Care instrument (interRAI-PAC) and to analyse the predictive ability of the FI-PAC and interRAI scales for hospital outcomes.

METHODS

This retrospective cohort study was conducted by combining patient data from interRAI-PAC with discharge records from two post-acute care hospitals. The FI-PAC was derived from 57 variables that fulfilled the Frailty Index criteria. Associations of the FI-PAC and interRAI-PAC scales (ADLH for activities of daily living, CPS for cognition, DRS for mood, and CHESS for stability of health status) with hospital outcomes (prolonged hospital stay ≥90 days, emergency department admission during the stay, and in-hospital mortality) were analysed using logistic regression and ROC curves.

RESULTS

The cohort included 2188 patients (mean age (SD) 84.7 (6.3) years) who were hospitalized in two post-acute care hospitals. Most patients (n = 1691, 77%) were discharged and sent home. Their median length of stay was 35 days (interquartile range 18-87 days), and 409 patients (24%) had a prolonged hospital stay. During their stay, 204 patients (9%) were admitted to the emergency department and 231 patients (11%) died. The FI-PAC was normally distributed (mean (SD) 0.34 (0.15)). Each increase of 0.1 point in the FI-PAC increased the likelihood of prolonged hospital stay (odds ratio [95% CI] 1.91 [1.73─2.09]), emergency admission (1.24 [1.11─1.37]), and in-hospital death (1.82 [1.63─2.03]). The best instruments for predicting prolonged hospital stay and in-hospital mortality were the FI-PAC and the ADLH scale (AUC 0.75 vs 0.72 and 0.73 vs 0.73, respectively). There were no differences in the predictive abilities of interRAI scales and the FI-PAC for emergency department admission.

CONCLUSIONS

The Frailty Index derived from interRAI-PAC predicts adverse hospital outcomes. Its predictive ability was similar to that of the ADLH scale, whereas other interRAI-PAC scales had less predictive value. In clinical practice, assessment of functional ability is a simple way to assess a patient's prognosis.

Trajectories of cognitive-affective depressive symptoms in acutely hospitalized older adults: The hospital-ADL study

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.

Recognition and treatment of depression in older adults admitted to acute hospitals in England

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.

'Factors affecting services offered to older adults with psychological morbidity: an exploration of health professional attitudes'

AIM

Poor collaboration between the multiple services involved in hospital discharge planning may contribute to suboptimal patient outcomes post discharge. This study aimed to explore clinician (medical, allied health and nursing) attitudes towards the management of the older patient with psychological morbidity during and following hospitalization.

METHODS

Focus groups were held with 54 health professionals comprising of 7 from acute, 20 from subacute (geriatric assessment and rehabilitation), and 27 from community care settings. A qualitative study using focus groups of clinicians from a range of disciplines working within a large Australian health care service. Data were analysed using an inductive thematic approach with constant comparison.

RESULTS

Key themes included: (1) Clinician decision making towards psychological morbidity; (2) Supply of people with specialised skills dealing with psychological morbidity; (3) Confidence and capability; (4) Facilitating continuity of care; and (5) Perception of depression and aging.

CONCLUSIONS

Clinicians across healthcare settings are uniquely placed to identity psychological morbidity in older patients and make appropriate referrals for support. Management and referral making for older patients with psychological morbidity can be enhanced by routine education for clinicians and the introduction of clinical pathways. This has potential to improve management of psychological morbidity; however, evaluation of impact on patient outcome is required. Specifically, there is a need for greater access for counselling services.

The prevalence of depressive symptoms in Chinese longevous persons and its correlation with vitamin D status

Background

Hypovitaminosis D and depressive syndromes are common conditions in old adults. However, little is known about the relationship between vitamin D and depression in exceptional aged people. The objective of this study is to evaluate the relationship between vitamin D levels and depressive symptoms in Chinese longevous persons.

Methods

We used a dataset from a cross-sectional survey of a sample of Chinese longevous people with self-reported age 100 or older, including 175 men and 765 women, was conducted from June 2014 to December 2016 in Hainan Province, China. Data on demographics, lifestyle characteristics and health conditions were collected using a structured questionnaire. Anthropometrics and blood samples were obtained following the standard procedure. Depressive symptoms of the participants were assessed using a shortened version of the Geriatric Depression Scale (GDS-15). Serum vitamin D levels were measured using an automated radioimmunoassay.

Results

The prevalence of longevous persons with depressive symptoms among the sample was 32.2% (95% confidence interval: 29.7–34.7%). Serum vitamin D levels were lower in participants with depressive symptoms than in those without (20.8 ± 8.7 vs. 23.7 ± 9.7, ng/mL). Vitamin D deficiency was an independent risk factor for depression after controlling for the potential covariates (Odds ratio = 1.47, 95% Confidence interval = 1.08–2.00; p = 0.014). A negative relationship between serum vitamin D levels and depressive symptoms was also detected, and the relationship remained significant after adjusting for a wide range of other covariates. The multivariate adjusted odds ratio of depressive symptoms for the lowest versus highest quartiles of vitamin D levels was 1.73 (95% confidence interval: 1.10–2.72), and the adjusted odds ratio with a 5 ng/mL decrement of serum 25OHD levels was 1.10 (95% confidence interval: 1.01–1.19).

Conclusions

This study showed an inverse association between vitamin D levels and depressive symptoms among Chinese longevous persons. Depressive symptoms should be screened in longevous persons who had vitamin D deficiency. Further studies on vitamin D supplement and prevention along with treatment of depression are needed among very old population.

Depression and associated factors in hospitalized elderly: a cross-sectional study in a Saudi teaching hospital

BACKGROUND

Depression in the elderly is a serious and often underdiagnosed psychiatric disorder that has been linked to adverse outcomes in the hospital setting.

OBJECTIVES

To determine the prevalence of depression and possible associated factors among hospitalized elderly.

DESIGN

An analytical cross-sectional study.

SETTINGS

Medical and surgical wards of King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

PATIENTS AND METHODS

The study included 200 consecutively hospitalized patients aged 60 years and older. Participants were evaluated within 48 hours of admission using an interviewer-administered question-naire to provide basic demographic and clinical information.

MAIN OUTCOME MEASURE(S)

Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) screening method and the Structured Clinical Interview for the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) mood disorder module.

RESULTS

According to PHQ-9, 17% and 10.5% of the hospitalized patients were diagnosed with a major depressive disorder and other depressive disorders, respectively. The DSM-5 criteria identified 12% of elderly with major depression. Overall, the number of comorbidities associated with depression was signifi-cantly higher in the major depressive disorder group than in the no depression group (post hoc P=.022). Depression was also associated with female gender, unmarried status, lower income, and polypharmacy. In addition, cardiovascular disease and cancer were the most prevalent medical illnesses associated with depression among hospitalized elderly.

CONCLUSION

Major depressive disorder was prevalent among hospitalized elderly, especially among those with comorbid conditions. Hospital physicians must, therefore, maintain a high index of suspicion to identify early and manage depressive symptoms in these patients.

LIMITATION

The small size of certain subgroups limits the statistical power to examine for associations of depression with particular conditions.

Screening for depression in hospitalized medical patients

Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer-reviewed articles in English (1990-2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full-text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self-administered by patients or when abbreviated versions were administered by individuals without formal training. With regard to outcomes, studies from several individual hospitals found depression to be associated with poorer functional outcomes, worse physical health, and returns to the hospital after discharge. These findings suggest that depression screening may be feasible in the inpatient setting, and that more research is warranted to determine whether screening for and treating depression during hospitalization can improve patient outcomes. Journal of Hospital Medicine 2017;12:118-125.

The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review

OBJECTIVES

This paper aims to systematically review observational studies that have analysed whether depressive symptoms in the community are associated with higher general hospital admissions, longer hospital stays and increased risk of re-admission.

METHODS

We identified prospective studies that looked at depressive symptoms in the community as a risk factor for non-psychiatric general hospital admissions, length of stay or risk of re-admission. The search was carried out on MEDLINE, PsycINFO, Cochrane Library Database, and followed up with contact with authors and scanning of reference lists.

RESULTS

Eleven studies fulfilled our inclusion and exclusion criteria, and all were deemed to be of moderate to high quality. Meta-analysis of seven studies with relevant data suggested that depressive symptoms may be a predictor of subsequent admission to a general hospital in unadjusted analyses (RR=1.36, 95% CI: 1.28-1.44), but findings after adjustment for confounding variables were inconsistent. The narrative synthesis also reported depressive symptoms to be independently associated with longer length of stay, and higher re-admission risk.

CONCLUSIONS

Depressive symptoms are associated with a higher risk of hospitalisation, longer length of stay and a higher re-admission risk. Some of these associations may be mediated by other factors, and should be explored in more details.

Hospital outcomes in major depression among older adults: differences by alcohol comorbidity

OBJECTIVE

The prevalence of depression in older adults has been increasing over the last 20 years and is associated with economic costs in the form of treatment utilization and caregiving, including inpatient hospitalization. Comorbid alcohol diagnoses may serve as a complicating factor in inpatient admissions and may lead to overutilization of care and greater economic cost. This study sought to isolate the comorbidity effect of alcohol among older adult hospital admissions for depression.

METHODS

We analyzed a subsample (N = 8,480) of older adults (65+) from the 2010 Nationwide Inpatient Sample who were hospitalized with primary depression diagnoses, 7,741 of whom had depression only and 739 of whom also had a comorbid alcohol disorder. To address potential selection bias based on drinking and health status, propensity score matching was used to compare length of stay, total costs, and disposition between the two groups.

RESULTS

Bivariate analyses showed that older persons with depression and alcohol comorbidities were more often male (59.9% versus 34.0%, p <.001) and younger (70.9 versus 75.9 years, p <.001) than those with depression only. In terms of medical comorbidities, those with depression and alcohol disorders experienced more medical issues related to substance use (e.g., drug use diagnoses, liver disease, and suicidality; all p <.001), while those with depression only experienced more general medical problems (e.g., diabetes, renal failure, hypothyroid, and dementia; all p <.001). Propensity score matched models found that alcohol comorbidity was associated with shorter lengths of stay (on average 1.08 days, p <.02) and lower likelihood of post-hospitalization placement in a nursing home or other care facility (OR = 0.64, p <.001). No significant differences were found in overall costs or likelihood of discharge to a psychiatric hospital.

CONCLUSIONS

In older adults, depression with alcohol comorbidity does not lead to increased costs or higher levels of care after discharge. Comorbidity may lead to inpatient hospitalization at lower levels of severity, and depression with alcohol comorbidity may be qualitatively different than non-comorbid depression. Additionally, increased costs and negative outcomes in this population may occur at other levels of care such as outpatient services or emergency department visits.

Do depressive symptoms on hospital admission impact early functional outcome in elderly patients with hip fracture?

BACKGROUND

Depression is the most common mood disorder in elderly people and one of the most prevalent comorbidities in older people with hip fracture. While several authors have confirmed that depressive symptoms assessed at a later stage after hip fracture impact functional outcome and mortality, the role of depressive symptoms identified at an earlier stage after hip fracture remains understudied. The aim of the present study was to determine if depressive symptoms assessed on hospital admission impact early functional outcome after hip fracture surgery.

METHODS

We studied 112 patients who underwent surgery for hip fracture during a 6-month period. Depressive symptoms were assessed using the 30-item Geriatric Depression Scale on admission to the acute setting. Multidimensional assessment included sociodemographic characteristics, general health status, cognitive status, functional status prior to injury, and perioperative variables. The primary outcome measure was motor Functional Independence Measure at discharge.

RESULTS

Adjusted multivariate regression analysis revealed that the presence of moderate to severe depressive symptoms (Geriatric Depression Scale ≥ 20), older age, and female gender were independently related to motor Functional Independence Measure at discharge.

CONCLUSION

Increasing levels of depressive symptoms in elderly hip fracture patients influence short-term functional outcome. We strongly support the introduction of routine assessment of this baseline comorbidity, especially in female patients. Failure to identify such patients is a missed opportunity for possible improvement of early functional outcome after hip fracture in elderly.

Geriatric multidimensional assessment for elderly patients with acute respiratory diseases

The case of an 87-year-old woman who falls at home and is admitted to the Emergency Department of an acute hospital with delirium exemplify a common situation that physicians face in their everyday clinical practice. We describe the typical context of frailty in which acute illnesses frequently present in frail elderly patients and, in particular, the relationship between comorbidity, disability and frailty. We also report the current knowledge about frailty theories and we focus on the "atypical" presentation of many acute illnesses. Major attention is devoted on delirium and on mobility impairment, two of the most common atypical symptoms of elderly frail subjects. Finally we describe the evidence on the comprehensive geriatric assessment, i.e., the method that is required to identify and understand the ultimate needs of elderly complex subjects.

Associação entre sintomatologia depressiva e óbito hospitalar em idosos

OBJETIVO: Avaliar se a presença de sintomas depressivos associa-se a uma evolução hospitalar desfavorável (aumento da permanência e mortalidade hospitalar), independente da capacidade funcional. MÉTODO: Coorte prospectivo em pacientes idosos internados nas enfermarias de Clínica Médica do Hospital Universitário Lauro Wanderley (HULW), avaliados em dois momentos (segundo dia de internação e na alta). Os instrumentos utilizados foram a Escala de Depressão Geriátrica, versão breve (EDG-15) e Índice de Barthel para Incapacidade em Atividades da Vida Diária (IBAIVD). RESULTADOS: A idade dos 100 pacientes variou entre 60 e 96 anos (69,47 ± 7,45). A mortalidade hospitalar relacionou-se com os escores da EDG-15 da internação (p = 0,001). Observou-se correlação entre os escores da EDG-15 e IBAIVD no início (p = 0,008) e final da internação (p = 0,01), verificando-se correlações lineares inversas (p = -0,30), porém de magnitudes fracas (p = -0,30 e p = -0,28, respectivamente). CONCLUSÃO: Sintomatologia depressiva associou-se à maior mortalidade, independente da capacidade funcional. Ressalta-se a importância da avaliação da sintomatologia depressiva nos idosos internados. Novos estudos e análises prospectivas poderão oferecer mais indicadores sobre esse problema de pesquisa.

Six-month outcomes following an emergency hospital admission for older adults with co-morbid mental health problems indicate complexity of care needs

Background: two-thirds of older patients admitted as an emergency to a general hospital have co-existing mental health problems including delirium, dementia and depression. This study describes the outcomes of older adults with co-morbid mental health problems after an acute hospital admission.

Methods: a follow-up study of 250 patients aged over 70 admitted to 1 of 12 wards (geriatric, medical or orthopaedic) of an English acute general hospital with a co-morbid mental health problem and followed up at 180 days.

Results: twenty-seven per cent did not return to their original place of residence after the hospital admission. After 180 days 31% had died, 42% had been readmitted and 24% of community residents had moved to a care home. Only 31% survived without being readmitted or moving to a care home. However, 16% spent >170 of the 180 days at home. Significant predictors for poor outcomes were co-morbidity, nutrition, cognitive function, reduction in activities of daily living ability prior to admission, behavioural and psychiatric problems and depression. Only 42% of survivors recovered to their pre-acute illness level of function. Clinically significant behavioural and psychiatric symptoms were present at follow-up in 71% of survivors with baseline cognitive impairment, and new symptoms developed frequently in this group.

Conclusions: the variable, but often adverse, outcomes in this group implies a wide range of health and social care needs. Community and acute services to meet these needs should be anticipated and provided for.

Depression in the elderly with visual impairment and its association with quality of life

Background

Visual impairment is more prevalent in the elderly and depression is common in this population. Although many studies have investigated depression or quality of life (QOL) in older adults with visual impairment, few have looked at the association between these two concepts for this population. The aim of this systematized review was to describe the association between depression and QOL in older adults with visual impairment.

Methods

A search was done using multiple electronic databases for studies addressing the relationship between QOL and depression in elders with visual impairment. The concept of QOL was divided into two different approaches, ie, QOL as achievement and QOL as subjective well-being. Comparison of QOL scores between participants with and without depression (Cohen’s d) and correlations between depression and QOL (Pearson’s r) were examined.

Results

Thirteen studies reported in 18 articles were included in the review. Nearly all of the studies revealed that better QOL was moderately to strongly correlated with less severe depressive symptoms (r = 0.22–0.68 for QOL as achievement; r = 0.68 and 0.72 for QOL as subjective well-being). Effect sizes for the QOL differences between the groups with and without depression ranged from small to large (d = 0.17 to 0.95 for QOL as achievement; no data for QOL as subjective well-being).

Conclusion

Additional studies are necessary to pinpoint further the determinants and mediators of this relationship. Considering the high prevalence rate of depression in this community and its disabling effects on QOL, interventions to prevent and treat depression are essential. More efforts are needed in clinical settings to train health care practitioners to identify depressed elders with visual impairment and provide appropriate treatment.

Moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture

OBJECTIVE

To evaluate if depressive symptoms affect recovery of walking ability and 1-year institutionalization or mortality in older adults who underwent post-hip fracture (HF) surgery rehabilitation.

METHODS

Depressive symptoms were assessed on admission using the 15-item Geriatric Depression Scale (GDS), with scores ≥10/15 indicating moderate to severe depressive symptoms. Multidimensional assessment included Mini Mental State Examination, Charlson Comorbidity Index, Body Mass Index, albumin serum levels, number of drugs, antidepressants and Barthel Index (BI) on admission and at discharge. Walking ability was evaluated using the BI walking sub-item referred to 1 month before HF, on admission, and at discharge. Patients scoring ≤3/15 BI walking sub-item on admission (i.e. those fully dependent or requiring major supervision in walking) were included. Walking independence at discharge was defined as a score ≥12/15 at the BI walking sub-item.

RESULTS

In multivariate analyses, after adjustment for covariates and potential confounders, patients with moderate to severe depressive symptoms were more likely to fail walking independence at discharge (odds ratio, OR = 3.2; 95% CI = 1.3 to 7.8; p = 0.010) and to be institutionalized or died at 1 year (OR = 3.6, 95% CI = 1.4 to 9.1, p = 0.007). In further analyses, the failure to recover walking independence at discharge partly mediates the relationship between moderate to severe depressive symptoms and 1-year adverse events.

CONCLUSIONS

Moderate to severe depressive symptoms affect the recovery of walking independence after HF rehabilitation and are associated with severe adverse outcomes at 1 year.

Prevalence and influence of psychiatric comorbidity on rehabilitation outcome for older hospital inpatients

BACKGROUND

The objectives of this study were to characterize the psychiatric comorbidity of a group of older subacute inpatients and then determine whether their psychiatric comorbidity affected measures of rehabilitation outcomes.

METHODS

Eighty-eight older subacute inpatients were recruited for this prospective study. Psychiatric comorbidity was defined according to a participants' performance on four inventory scales: the Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), Brief Psychiatric Rating Scale and Health of the Nation Outcome Scale 65+. Rehabilitation outcome referred to the participants' length of stay and their performance at discharge on the EuroQol-5D health-related quality of life questionnaire and Barthel index.

RESULTS

68% of the participants scored in the clinical range on at least one of the four scales assessing psychiatric comorbidity at admission, with 51% in the clinical range for GDS and 32% for the GAI. The decrease in scores by the time of discharge was significant for all four scales. Linear regression analyses pointed to a trend for depressive symptoms at admission to be an influential but nonsignificant predictor of rehabilitation outcome. An interesting association was found between the length of the previous acute admission and the GDS score on admission to the subacute unit.

CONCLUSION

A high prevalence of psychological symptoms was identified upon admission, with a significant decrease by the time of discharge. These factors did not significantly predict the selected measures of rehabilitation outcome. Opportunities for future longitudinal research on the prevalence and impact of psychiatric comorbidities on patient outcomes are considered.

Patterns and correlates of depression in hospitalized older adults

Depression is often associated with illness or injury requiring acute hospitalization, particularly in older adults. We sought to determine patterns of change in depressive symptoms in older adults from hospitalization to 3 months post discharge and to examine factors associated with depressive symptoms 3 months after discharge. The study included 197 patients aged 65 years or older hospitalized with an acute medical illness. Sociodemographic and clinical measures, including depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) scale, were collected during the inpatient stay and at 3 months post discharge. Mean age was 75.3 ± 7.5 (± S.D.) years, 59% of the participants were female, 61% unmarried, and 72% had a high school education or more. High depressive symptoms (i.e., CES-D ≥ 16) were reported in 37% at admission. Of the 8% depressed at follow-up, 81% were also depressed at admission; 19% were new cases of depression. Depressive symptoms 3 months post-hospitalization were significantly associated with follow-up daily living skills (p=0.001) and social support (p<0.0001). Patients with persistent depressive symptoms make up the majority of post-hospitalization depression cases. Post-hospitalization social support and daily living skills appear to be important in the management of follow-up depressive symptoms.

Determining the association of medical co-morbidity with subjective and objective cognitive performance in an inner city memory disorders clinic: a retrospective chart review

BACKGROUND

Medical co-morbidity may be associated with impaired cognitive function based on prior studies. However, no studies to date have determined to what extent this association is linked to medical illness or other factors that may be linked to medical illness (such as education, income levels, depression or subjective memory loss). The present study examined how medical co-morbidity, socioeconomic status (defined as residential SES), education and depression are associated with subjective and objective memory function in a sample of patients recruited from a university affiliated Memory Disorders Clinic located in a large Canadian inner city teaching hospital.

METHODS

Data was collected from 85 consecutive referrals to an Inner City Memory Disorders Clinic including socio-demographic characteristics, cognitive status and medical co-morbidity. Descriptive and correlational analyses were conducted.

RESULTS

Impaired objective cognitive function correlated significantly with increased medical co-morbidity and partially with education but not with residential SES or depression. Elevated memory complaints correlated significantly with depression, inversely with residential SES and not at all with medical co-morbidity or education.

CONCLUSIONS

Increased medical co-morbidity is significantly associated with impaired cognitive performance but not with subjective memory complaints in an Inner City Memory Clinic sample.

Telomere length and psychological well-being in patients with chronic heart failure

BACKGROUND

psychological stress and depressive symptoms have been implicated with accelerated ageing and increased progression of diseases. Shorter telomere length indicates a more advanced biological age. It is unknown whether psychological well-being is associated with telomere length in patients with the somatic condition of chronic heart failure (CHF).

DESIGN

a cross-sectional analysis was used.

SETTING

patients were admitted to the hospital with signs and symptoms of CHF.

OBJECTIVE

the study aimed to assess the association between telomere length and psychological well-being in patients with CHF.

METHODS

telomere length was determined by quantitative polymerase chain reaction in 890 patients with New York Heart Association functional class II to IV CHF. We evaluated the perceived mental health by the validated RAND-36 questionnaire. Depressive symptoms were assessed by the Centre for Epidemiologic Studies Depression scale (CES-D), and the presence of type D personality was evaluated by the DS14.

RESULTS

a lower perceived mental health on the RAND-36 score was associated with shorter telomere length. Adjustment for age and gender did not change our findings (standardised beta, 0.11; P-value, 0.002). Telomere length was not associated with the CES-D or DS14 score.

CONCLUSION

decreased perceived mental health is associated with shorter leukocyte telomere length in patients with CHF. Future work should determine whether psychological stress accelerates biological ageing.