The structure of depression among elderly institution residents: affective and somatic correlates of physical frailty

Frailty, Disability, and Mortality in a Rural Community-Dwelling Elderly Cohort from Northern India

INTRODUCTION

With increasing proportion of the elderly in the world, detecting and preventing frailty assumes importance to improve the quality of life and health. The study aimed to estimate the prevalence of frailty, disability and its determinants and their relation with mortality among community dwelling elderly cohort.

MATERIALS AND METHODS

The study was conducted in a cohort in rural Haryana, India, and was followed till October 2018. Frailty was assessed using the Edmonton Frailty Scale and disability was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) scale by trained physicians.

RESULTS

The prevalence of frailty was found to be 47.3% (95% confidence interval [CI]: 44.0-50.8). The median WHODAS-2 score was found to be 10.4 (2.1-29.2). Those who were older (odds ratio [OR] - 2.5; 95% CI: 1.8-3.4), women (OR - 3.3; 95% CI: 2.2-4.9) and those with chronic disease (OR 2.3; 95% CI: 1.7-3.1) had higher rates of frailty. The adjusted hazard ratio of death among frail people was 4.7 (2.3-9.7).

CONCLUSION

In this study we found the frailty is associated with the mortality among community dwelling elderly. Thus early identification of the frailty and its determinants may help us to reduce the mortality related to this.

The impact of relocation stress on cognitively impaired and cognitively unimpaired long-term care residents

Objectives: The current aims were to explore the effects of relocation stress on depression and anxiety in long-term care residents and to investigate the moderating effect of cognitive status.Methods: The study used existing data from nursing home and congregate apartment residents. Self-reported measures of relocation stress, cognitive status, depression, and anxiety were examined. Exploratory analyses examined group differences in depression and anxiety within the full sample (n = 568) and the sample of first-year residents (n = 347). Main analyses were conducted in a subsample of 107 first-year residents who completed the measure of relocation stress.Results: Residents who had moved in the past year reported more anxiety but not depression than longer-term residents. Relocation stress significantly predicted depression but not anxiety in the subsample of first-year residents. There was no significant effect of cognitive status or the interaction of cognitive status and relocation stress on depression and anxiety.Conclusion: Findings suggest that cognitively impaired older adults are no more vulnerable to the negative effects of relocation stress than cognitively unimpaired older adults. Relocation stress should be regarded as a risk factor for depression in long-term care residents, regardless of cognitive status, in the first year after relocation.

Efficacy of brief behavioral treatment for insomnia in older adults: examination of sleep, mood, and cognitive outcomes

OBJECTIVE

The aim of the present study was to examine the effects of a brief behavioral intervention for insomnia (BBTi) on sleep parameters, mood, and cognitive functioning in older adults.

METHODS

Older adults (aged 65 years or more) underwent four weekly sessions of BBTi or self-monitoring control (SMC). Participants completed 14 days of sleep diaries and actigraphy measuring sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), sleep efficiency (SE), and sleep quality ratings at baseline, post-treatment, and three month follow-up. Participants also completed mood scales (Geriatric Depression Scale [GDS]; Beck Depression Inventory-II; and State Trait Anxiety Inventory) and neuropsychological testing (measuring global cognition, language, memory, attention and processing speed, and executive function) at the three timepoints.

RESULTS

Significant condition (BBTi vs. SMC) x time (baseline vs. post-treatment vs. follow-up) interactions revealed that BBTi improved relative to baseline in sleep diary-reported SOL, WASO, SE, and sleep quality, and these improvements were maintained at follow-up. SMC showed no change in these measures. A main effect of time showed that actigraphy-measured WASO improved from baseline for both BBTi and SMC at post-treatment. A main effect of time revealed that both BBTi and SMC patients endorsed fewer GDS symptoms relative to baseline at post-treatment and follow-up. We observed no change in performance on neuropsychological measures.

CONCLUSIONS

A four-week BBTi is an efficacious intervention for reducing insomnia symptoms in older adults. BBTi does not selectively improve mood or cognitive functioning. Future work should examine effects of BBTi on physiological measures of sleep architecture and day-to-day cognition.

CLINICAL TRIAL IDENTIFER

NCT02967185.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

What factors mediate the inter-relationship between frailty and pain in cognitively and functionally sound older adults? A prospective longitudinal ageing cohort study in Taiwan

OBJECTIVES

The main aim was to investigate the complex inter-relationship between frailty and pain, and the mediating roles of cognitive function, morbidity and mood in this nexus.

DESIGN

A cross-sectional analysis.

SETTING

A prospective community-dwelling population-based cohort.

PARTICIPANTS

1682 adults age ≥50 years without evident cognitive or functional impairment, or history of cancer.

PRIMARY AND SECONDARY OUTCOME MEASURES

The mediating effect of depression, cognitive function and comorbidity on the nexus between pain and frailty among older and middle-aged adults.

RESULTS

The pain score among older subjects (≥65 years), increased with the degree of frailty (robust=0.96±0.82; pre-frail=1.13±0.86; frail=1.63±1.02; P<0.001); multivariate analysis gave the same result, while moderate pain was associated with frailty in older subjects (OR=3.00, 95% CI 1.30 to 6.60). Conversely, pain and frailty among middle-aged subjects (aged 50-64 years) did not appear to be significantly related; in mediation analysis, pain exerted an indirect effect on frailty via depression (indirect effect=0.03, 95% CI 0.01 to 0.07), while neither cognitive function nor comorbidity had any significant effect in mediating the relationship between pain and frailty.

CONCLUSION

In cognitively and functionally sound community-dwelling adults aged ≥50 years, moderate pain was related to frailty in those older than 65 years, but not younger ones. Besides the direct influence of pain on frailty, depression partially mediated the pain-frailty nexus. The mechanism by which depression influences pain and frailty requires further investigation.

The structure of affective symptomatology in older adults with osteoarthritis

OBJECTIVE

To examine the structure of symptoms of affective disorder among older adults with a chronic health problem (osteoarthritis) and to explore cross-sectional and longitudinal associations of obtained affective symptom clusters with key health outcomes (pain, functional disability, perceived health).

METHODS

One-year longitudinal study of older adults with diagnosed osteoarthritis of the knee. Symptoms of DSM depression and anxiety were assessed in a research diagnostic interview by using a DSM-IV symptom checklist; self-reports captured demographic characteristics, objective health, pain, disability, and perceived health. Confirmatory factor analysis tested comparability of affective symptom structure in this sample to findings of previous research; ordinary least squares regression examined cross-sectional and longitudinal associations of affective symptoms with health outcomes, controlling for demographics and objective health.

RESULTS

The current sample displayed an affective symptom structure comparable with that observed in previous research, with symptoms clustering into depressed mood (DM), somatic symptoms (SS), and psychic anxiety (PA) factors. DM was cross-sectionally associated with pain and disability and marginally with perceived health; SS predicted current pain and perceived health. Only DM predicted 1 year change in disability and perceived health (but not pain).

CONCLUSIONS

This research confirms the role of SS of distress in fueling disability and perceived ill health among older adults who are chronically ill. However, it is DM that drives changes in perceived health and functional ability.

Gender differences in aging: cognition, emotions, and neuroimaging studies

Gender and aging moderate brain-behavior relationships. Advances in neuroscience enable integration of neurobehavioral, neuroanatomic, and neurophysiology measures. Here we present neurobehavioral studies thai examine cognitive and emotion processing in healthy men and women and highlight the effects of sex differences and aqinq. Neuroanatomic studies with maqnetic resonance imaging (MRI) indicate that the progressive decrease in brain volume affects froniotemporal brain regions in men more than in Vi/omen, Functional imaging methods suggest sex differences in rate of blood flow, pattern of glucose metabolism, and receptor activity. The role of ovarian hormones is important in elucidating the observed relationships. A life span perspective on gender differences through the integration of available methodologies will advance understanding healthy people and the effects of brain disorders.

Depression and frailty in later life: a synthetic review

BACKGROUND

Many of the symptoms, consequences, and risk factors for frailty are shared with late-life depression. However, thus far, few studies have addressed the conceptual and empirical interrelationships between these conditions. This review synthesizes existing studies that examined depression and frailty among older adults and provides suggestions for future research.

METHODS

A search was conducted using PubMed for publications through 2010. Reviewers assessed the eligibility of each report and abstracted information on study design, sample characteristics, and key findings, including how depression and frailty were conceptualized and treated in the analysis.

RESULTS

Of 133 abstracted articles, 39 full-text publications met inclusion criteria. Overall, both cross-sectional (n = 16) and cohort studies (n = 23) indicate that frailty, its components, and functional impairment are risk factors for depression. Although cross-sectional studies indicate a positive association between depression and frailty, findings from cohort studies are less consistent. The majority of studies included only women and non-Hispanic Whites. None used diagnostic measures of depression or considered antidepressant use in the design or analysis of the studies.

CONCLUSIONS

A number of empirical studies support for a bidirectional association between depression and frailty in later life. Extant studies have not adequately examined this relationship among men or racial/ethnic minorities, nor has the potential role of antidepressant medications been explored. An interdisciplinary approach to the study of geriatric syndromes such as late-life depression and frailty may promote cross-fertilization of ideas leading to novel conceptualization of intervention strategies to promote health and functioning in later life.

Évaluation de l’usage à risque des benzodiazépines chez les personnes âgées : facteurs de risque et impacts

L’usage à risque de la benzodiazépine (BZD), fréquent chez les aînés, est un problème souvent sous-estimé. Cet article présente une recension des écrits qui explore ce profil de consommation problématique sur les plans biologique, psychologique et environnemental. Les auteurs constatent qu’il y un manque de consensus et de validité quant à la description du phénomène. Ils discutent de certains facteurs qui contribuent à l’usage à risque des BZD chez les aînés : des habitudes de prescriptions et des attitudes parfois laxistes des médecins ; les attitudes des aînés envers la maladie mentale et la façon dont se manifestent leurs symptômes ; les difficultés dans l’évaluation de l’anxiété et de la dépression des aînés. En conclusion, les auteurs proposent que la recherche s’intéresse à des méthodes intégratives pour l’évaluation de l’usage à risque de la BZD chez les aînés.

Correlates of Functional Capacity Among Centenarians

This study investigated correlates of functional capacity among participants of the Georgia Centenarian Study. Six domains (demographics and health, positive and negative affect, personality, social and economic support, life events and coping, distal influences) were related to functional capacity for 234 centenarians and near centenarians (i.e., 98 years and older). Data were provided by proxy informants. Domain-specific multiple regression analyses suggested that younger centenarians, those living in the community and rated to be in better health were more likely to have higher functional capacity scores. Higher scores in positive affect, conscientiousness, social provisions, religious coping, and engaged lifestyle were also associated with higher levels of functional capacity. The results suggest that functional capacity levels continue to be associated with age after 100 years of life and that positive affect levels and past lifestyle activities as reported by proxies are salient factors of adaptation in very late life.

Psychiatric illness in relation to frailty in community-dwelling elderly people without dementia: a report from the Canadian Study of Health and Aging

We investigated whether frailty, defined as the accumulation of multiple, interacting illnesses, impairments and disabilities, is associated with psychiatric illness in older adults. Five-thousand-six-hundred-and-seventy-six community dwellers without dementia were identified within the Canadian Study of Health and Aging, and self-reported psychiatric illness was compared by levels of frailty (defined by an index of deficits that excluded mental illnesses). People with psychiatric illness (12.6% of those surveyed, who chiefly reported depression) had a higher mean frailty index value than those who did not. Older age was not associated with higher odds of psychiatric illness. Taking sex, frailty, and education into account, the odds of psychiatric illness decreased with each increasing year of age (OR 0.95; 95% CI, 0.94-0.97). Frailty was associated with psychiatric illness; for each additional deficit-defining frailty, odds of psychiatric illness increased (OR 1.23; 95% CI, 1.19-1.26). Similarly, psychiatric illness was associated with much higher odds of being among the most frail. These findings lend support to a multidimensional conceptualization of frailty. Our data also suggest that health care professionals who work with older adults with psychiatric illness should expect frailty to be common, and that those working with frail seniors should consider the possible co-existence of depression and psychiatric illness.

The prevalence of anxiety in older adults: methodological issues and a review of the literature

BACKGROUND

Despite the relative neglect of anxiety in older adults, the growing literature on its prevalence suggests that anxiety is highly prevalent and associated with considerable distress and morbidity in this age group. This review provides a comprehensive overview of this literature and discusses some unresolved controversies in the field.

METHODS

A systematic search of articles published from 1980-2007 was performed. Articles were included for review if they reported the prevalence of anxiety symptoms, anxiety disorder or specified anxiety disorders in adults aged >60 in either community or clinical settings.

RESULTS

The prevalence of anxiety in community samples ranges from 1.2% to 15%, and in clinical settings from 1% to 28%. The prevalence of anxiety symptoms is much higher, ranging from 15% to 52.3% in community samples, and 15% to 56% in clinical samples. These discrepancies are partly attributable to the conceptual and methodological inconsistencies that characterise this literature. Generalised Anxiety Disorder is the commonest anxiety disorder in older adults.

LIMITATIONS

The methodologies used in the studies are so variable as to make comparisons difficult.

CONCLUSIONS

Although anxiety disorder, particularly Generalised Anxiety Disorder is common, issues in relation to comorbidity and the nature of anxiety in old age remain unresolved. This hampers the design of intervention programmes, and highlights the need for further research with a primary focus on anxiety.

Functional status and depressive symptoms among older adults from residential care facilities in the Czech Republic

BACKGROUND

Depressive symptoms are common among older adults, particularly those living in long-term care facilities. However, little is known about factors associated with depressive symptoms among long-term care residents in the Czech Republic and in other Eastern European countries. Moreover, the role of mobility and pain in depressive symptoms among long-term care residents is relatively understudied.

OBJECTIVE

We examined the relationship between functional status and depressive symptoms in 308 older adults from residential care facilities (RCFs) in the Czech Republic.

METHOD

We used baseline data from two randomized controlled trials testing the effects of dance and reminiscence therapies on quality of life in older RCF residents. Functional status was measured as cognitive function, general ability to perform basic Activities of Daily Living (ADLs), mobility, and functional limitation by pain. Depressive symptoms were measured using the 15-item Geriatric Depression Scale.

RESULTS

In multiple regression analyses adjusted for sociodemographic factors and taking antidepressants, we found that cognitive function and functional limitation by pain were most strongly associated with depressive symptoms. The ability to perform basic ADLs and mobility were also related to depressive symptoms.

CONCLUSION

Our findings suggest factors that may be important in efforts to improve psychological well-being in this population.

The phenomenology of non-clinical panic in older adults in comparison to younger adults

The prevalence and nature of panic symptoms in the elderly are poorly understood. In a replication and extension of Deer and Calamari [J. Behav. Ther. Exp. Psychiatry 29 (1998) 303], the current study sought to determine which symptoms of anxiety best differentiated elderly endorsers of panic from elderly who do not panic, and to compare these results to a reference younger sample. Based on a sample of 302 community-dwelling older adults and a comparison group of 275 younger adults, non-clinical panic (NCP) was endorsed in 26.2% of older adults, which is less frequent than the younger adults (42.7%). Although older and younger adults were similar in terms of clinical features of panic, health factors interacted significantly with panic symptoms in the elderly. When controlling for health, cognitive symptoms of anxiety were stronger predictors of panic in older adults than were physiological symptoms. Clinical implications for the assessment of panic in older adults are discussed.

Health-related quality of life and health utility for the institutional elderly in Taiwan

OBJECTIVE

To explore the health-related quality of life (HRQOL) and health utility in an institutional elderly population.

METHODS

Four hundred sixty-five elderly persons living in long-term care institutions in Taiwan were interviewed using Taiwan's abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF), rating scale (RS) and the Time-Trade-Off (TTO) utility measurement.

RESULTS

The WHOQOL-BREF showed acceptable internal consistency (alpha range: 0.75-0.80 across domains) and validity. The sexual activity facet had the lowest response rate. Educational level, number of chronic diseases, physical performance, and number of caregivers had significant (p < 0.05) impacts on the domain scores of the WHOQOL-BREF. Physical performance had the strongest impact on the physical domain (R2 = 0.40) and accounted for significant percentages of the variance on the other three domains (R2 = 0.06-0.13). The mean RS score (score 0-100) was 61.3 +/- 16.2 (mean +/- SD). The mean TTO utility (score 0-1) was 0.92 +/- 0.22.

CONCLUSIONS

Results indicate that the WHOQOL-BREF, excepting the sexual activity item, is useful for evaluating HRQOL of conscious elderly in institutions. The validity of TTO utility for studying the institutionalized elderly needs further evaluation.

Nurse staffing patterns and quality of care in nursing homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

Does quality of care lead to better financial performance?: the case of the nursing home industry

The study describes the relationship between quality of care and financial performance (operating profit margin) as it pertains to the nursing home industry. We found that nursing homes that produce better outcomes and process of care were able to achieve lower patient care costs and report better financial performance.

Evaluation of the diagnosis and management of cognitive impairment in long-term care

The objective was to determine the prevalence of screening for cognitive impairment and its effect on diagnosis and management of cognitive impairment in a long-term care setting, especially in comparison to depressive and behavioral symptoms. The study was a prospective cohort study of medical records of 60 patients admitted to the 120 bed Veterans Administration Nursing Home in San Francisco. Screening was determined by documented results on the Mini-Mental Status Examination, Geriatric Depression Scale, and Minimum Data Set. Diagnosis and management were determined by review of medical records for provider documentation. Strategies for management were broad, including interventions such as pharmacological therapy, education, behavioral strategies, or caregiver interventions. Screening was conducted routinely for cognitive impairment (95%), depressive symptoms (95%), and behavioral symptoms (85%). Cognitive status was uncertain in 8 patients; 23 (44%) met criteria for cognitive impairment. Twelve (52%) had a differential diagnosis of cognitive impairment and 11 (48%) had evidence of strategies for management. Depressive and behavioral symptoms were equally or almost as common as cognitive impairment (44% and 25%, respectively), but evidence of a management plan was more frequently present (80% and 100%; p = 0.002 vs. with cognitive impairment). Although depressive and behavioral symptoms were frequently diagnosed and interventions initiated, the diagnosis and management of cognitive impairment were often imprecise or absent. Further research is needed to identify barriers to diagnosis and management so that greater numbers of patients can benefit from recommended strategies.

Correlates of subjective health in older adults: a meta-analysis

Age-associated changes of subjective health and associations of subjective health with physical health, functional health, and mental health were meta-analyzed in older adults (M age > 60 years). An age-associated decline of subjective health, which was stronger in old-old samples than in young-old samples, was found. Subjective health was correlated with the indicators of objective health, but the association with physical health was stronger than with functional health. Correlations of subjective health with physical health and functional health were lower in the old-old than in the young-old samples, whereas associations of subjective health with mental health were stronger in older samples. Furthermore, the size of the association between subjective and objective health varied by the method of assessment of objective health, showing highest associations with symptom checklists and results of medical examinations due to strict protocols.

The protective effect of emotional vitality on adverse health outcomes in disabled older women

OBJECTIVE

Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women.

DESIGN

A community-based study, The Women's Health and Aging Study.

PARTICIPANTS

A total of 1002 moderately to severely disabled women aged 65 years and older living in the community.

MEASUREMENTS

Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. The onset of new disability was determined by semiannual assessments of disability in performing activities of daily living (ADLs), walking across a room, walking 1/4 mile, and lifting/carrying 10 pounds. Mortality status was determined by proxy interviews and linkage with death certificates. Survival analyses with time to onset of specific disabilities (among those not disabled at baseline) and time to mortality were performed and adjusted for age, baseline level of difficulty, physical performance, and chronic conditions.

RESULTS

Three hundred fifty-one of the 1002 older disabled women studied were emotionally vital. Among women without the specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking one-quarter mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression since protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed.

CONCLUSIONS

Emotional vitality in older disabled women reduces the risk for subsequent new disability and mortality. Our findings suggest that positive emotions can protect older persons against adverse health outcomes.

Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts

BACKGROUND

Few studies have addressed depression among Puerto Rican and Dominican elders. This study examined the prevalence of depressive symptomatology and associated situational factors, among a representative sample of Hispanic elders in the state of Massachusetts and a neighborhood comparison group of non-Hispanic whites (NHWs).

METHODS

Participants included 715 Hispanic elders (429 Puerto Rican, 128 Dominican, and 149 other Hispanic) in Massachusetts and 238 NHW elders living in the same neighborhoods. Depressive symptomatology was measured with the Center for Epidemiologic Studies Depression Scale (CES-D). The associations between socioeconomic status, household arrangements, acculturation, health problems, and depression score were examined with multiple linear and logistic regression.

RESULTS

Puerto Rican and Dominican elders had significantly greater prevalences of high depression scores when compared with neighborhood NHWs. After controlling for various social, demographic, and health characteristics, the scores of Puerto Ricans remained significantly greater than those of the NHWs, but not "Other Hispanic" groups. Higher CES-D scores were significantly associated with being female, living alone, and having a higher number of health problems, but not with income. Effects of acculturation were only found among Dominican elders.

CONCLUSIONS

Puerto Rican elders experience high rates of depressive symptomatology that are associated with, but not fully explained by, high numbers of chronic health conditions. Further investigation is needed to both understand and treat this prevalent problem.

Measuring depression in hospitalized, medically ill, older adults

Studies have consistently shown high prevalence rates of depression associated with negative medical, functional, and psychosocial outcomes in hospitalized, medically ill, older adults. Several issues pose challenges to measurement of depression in this population. In particular, symptoms simultaneously attributable to both medical illness and psychiatric problems may confound measurement of depression, and there is no distinct boundary between normal and abnormal symptoms. This article critiques prevalence research methods used to measure depression in hospitalized, medically ill, older adults and makes recommendations regarding future measurement approaches in both research and clinical practice. Through the identification of appropriate methods for measurement of depression in this population, psychiatric nurses can make a valuable contribution in this area of research as well as enhance effective case-finding and evaluation of depression in older, hospitalized, medically ill patients in the clinical setting.