On the Inseparability of Mental and Physical Health in Aged Persons: Lessons From Depression and Medical Comorbidity

Using digital assessment technology to detect neuropsychological problems in primary care settings

Introduction

Screening for neurocognitive impairment and psychological distress in ambulatory primary and specialty care medical settings is an increasing necessity. The Core Cognitive Evaluation™ (CCE) is administered/scored using an iPad, requires approximately 8 min, assesses 3- word free recall and clock drawing to command and copy, asks questions about lifestyle and health, and queries for psychological distress. This information is linked with patients' self- reported concerns about memory and their cardiovascular risks.

Methods

A total of 199 ambulatory patients were screened with the CCE as part of their routine medical care. The CCE provides several summary indices, and scores on 44 individual digital clock variables across command and copy tests conditions.

Results

Subjective memory concerns were endorsed by 41% of participants. Approximately 31% of participants reported psychological distress involving loneliness, anxiety, or depression. Patients with self-reported memory concerns scored lower on a combined delay 3- word/ clock drawing index (p < 0.016), the total summary clock drawing command/ copy score (p < 0.050), and clock drawing to command Drawing Efficiency (p < 0.036) and Simple and Complex Motor (p < 0.029) indices. Patients treated for diabetes and atherosclerotic cardiovascular disease (ASCVD) scored lower on selected CCE outcome measures (p < 0.035). Factor analyses suggest that approximately 10 underlying variables can explain digital clock drawing performance.

Discussion

The CCE is a powerful neurocognitive assessment tool that is sensitive to patient's subjective concerns about possible decline in memory, mood symptoms, possible cognitive impairment, and cardiovascular risk. iPad administration ensures total reliability for test administration and scoring. The CCE is easily deployable in outpatient ambulatory primary care settings.

Characteristics and correlates of poststroke depression: An Indian study

BACKGROUND

Post stroke depression adversely affects long term outcome of stroke and increases mortality risk. Few studies have looked into the comprehensive picture of post stroke depression in past.

AIM

The current study aimed to look into the phenomenology, characteristic features and various correlates of post stroke depression.

METHOD

142 consecutive stroke patients aged 60 years or above, fulfilling the inclusion criteria were assessed. Sociodemographic and clinical data were gathered using a specially designed pro-forma. Depression, apathy and psychosis were assessed by Post stroke depression rating scale, Apathy Evaluation Scale, and Brief Psychiatric Rating Scale respectively. Groups (with or without major depression) were compared using Mann-Whitney U, chi square or Fisher's exact test. One way ANOVA was conducted to see the relations of lesion location and laterality with various clinical parameters. Kaplan-Meier survival analysis was done to see the time to develop depression. The effect sizes were reported as r and partial eta squared.

RESULTS

Guilt was significantly higher (p<.05) with lesions in parietal lobe and remaining of middle cerebral artery territory. Catastrophic reaction (p<.05) and emotional dyscontrol (p<.05) were higher for diffuse lesions, periventricular lesions and lesions in frontal/occipital lobe. BPRS score, but not apathy, had a significant positive correlation with depression (Pearson's r=.692). Mean time to develop depression after stroke was 28.34 (95% CI 22.37 to 34.31) months.

CONCLUSIONS

Post stroke depression consists of various clinically important sub-components whose occurrence varies with different lesion locations. Post stroke depression is discriminable from apathy but is related to psychosis.

Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness

INTRODUCTION

Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).

METHODS AND ANALYSIS

In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.

ETHICS AND DISSEMINATION

The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.

TRIAL REGISTRATION NUMBER

NCT03021902; Pre-results.

Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011-2014

OBJECTIVES

Sarcopenia is a gradual loss of muscle mass and strength that occurs with aging. This muscle deterioration is linked to increased morbidity, disability, and other adverse outcomes. Although reduced handgrip strength can be considered a marker of sarcopenia and other aging-related decline in the elderly, there is limited research on this physical health problem in at-risk groups with common biopsychosocial conditions such as depression. Our primary objective was to ascertain level of combined handgrip strength and its relationship with depression among adults aged 60 years and older.

DESIGN

Unadjusted and adjusted linear regression models were conducted with a cross-sectional survey dataset.

SETTING

Secondary dataset from the 2011-2014 National Health and Nutrition Examination Survey (NHANES).

PARTICIPANTS

Community-dwelling, non-institutionalized adults ≥60 years old (n=3,421).

MEASUREMENTS

The predictor variables included a positive screen for clinically relevant depression (referent=PHQ-9 score <10). The criterion variable of combined handgrip strength (kg) was determined using a dynamometer.

RESULTS

Mean age and BMI were 69.9 years (51.5% female) and 28.8 kg/m2, respectively. Mean combined handgrip strength in the overall cohort was 73.5 and 46.6 kg in males and females, respectively. Three hundred thirty-six (9.8%) reported symptoms of depression. In unadjusted and fully adjusted models, depression was significantly associated with reduced handgrip strength (B = -0.26±0.79 and B = -0.19±0.08, respectively; p<0.001).

CONCLUSION

Our findings demonstrate handgrip strength has a significant inverse association with depression. Future longitudinal studies should investigate the causal processes and potential moderators and mediators of the relationships between depression and reduced handgrip strength. This information may further encourage the use of depression and handgrip strength assessments and aid in the monitoring and implementation of health care services that address both physical and mental health limitations among older adult populations.

Discrimination and psychiatric disorders among older African Americans

OBJECTIVES

This study examined the impact of everyday discrimination (both racial and non-racial) on the mental health of older African Americans.

METHODS

This analysis is based on the older African American subsample of the National Survey of American Life (NSAL) (n = 773). We examined the associations between everyday discrimination and both general distress and psychiatric disorders as measured by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Six dependent variables were examined: lifetime mood disorders, lifetime anxiety disorders, any lifetime disorder, number of lifetime disorders, depressive symptoms as measured by the 12-item Center for Epidemiological Scale of Depression (CES-D), and serious psychological distress as measured by the Kessler 6 (K6).

RESULTS

Overall, racial and non-racial everyday discrimination were consistently associated with worse mental health for older African Americans. Older African Americans who experienced higher levels of overall everyday discrimination had higher odds of any psychiatric disorder, any lifetime mood disorder, any lifetime anxiety disorder, and more lifetime DSM-IV disorders, in addition to elevated levels of depressive symptoms and serious psychological distress. These findings were similar for both racial discrimination and non-racial discrimination.

CONCLUSIONS

This study documents the harmful association of not only racial discrimination, but also non-racial (and overall) discrimination with the mental health of older African Americans. Specifically, discrimination is negatively associated with mood and anxiety disorders as well as depressive symptoms and psychological distress. Copyright © 2016 John Wiley & Sons, Ltd.

Well-Being and Institutional Care in Older Adults: Cross-Sectional and Time Effects of Provided and Received Support

BACKGROUND

The aim of the study was to examine the cross-sectional and longitudinal effects of provided and received support on older adults' subjective well-being (positive affect and depression) and to examine whether being a recipient of institutional care moderates these effects.

METHODS

Social support (provided and received), positive affect, and depressive symptoms were assessed twice (at baseline and 1 month later) for 277 older adults (age 77.39 ± 9.20 years, 67.50% women, 65% residents of an institutional care facility).

FINDINGS

Two structural equation models were analyzed: cross-sectional (at baseline) and longitudinal (after 1 month). The first model revealed a significant positive relationship between providing and receiving support and positive affect, and a negative relationship between receiving support and depression. However, being a recipient of institutional care appeared to be a significant moderator in the longitudinal model. Specifically, the findings indicated effects of both providing and receiving support on positive affect but only for noninstitutionalized older adults.

DISCUSSION

Although both types of support may be beneficial for older adults, their effects depend on the nature of social exchange and the dimensions of well-being. This suggests that such factors should be systematically investigated in future research.

Depression and Frailty in Late Life: Evidence for a Common Vulnerability

OBJECTIVES

The study purpose is to estimate the correlation between depression and competing models of frailty, and to determine to what degree the comorbidity of these syndromes is determined by shared symptomology.

METHODS

Data come from the 2010 Health and Retirement Study. Analysis was limited to community-dwelling participants 65 and older (N = 3,453). Depressive symptoms were indexed by the 8-item Centers for Epidemiologic Studies Depression (CESD) scale. Frailty was indexed by 3 alternative conceptual models: (a) biological syndrome, (b) frailty index, and (c) functional domains. Confirmatory factor analysis (CFA) was used to estimate the correlation between depression and each model of frailty.

RESULTS

Each of the 3 frailty latent factors was significantly correlated with depression: biological syndrome (ρ = .68, p < .01), functional domains (ρ = .70, p < .01), and frailty index (ρ = .61, p < .01). Substantial correlation remained when accounting for shared symptoms between depression and the biological syndrome (ρ = .45) and frailty index (ρ = .56) models.

DISCUSSION

Results indicate that the correlation of frailty and depression in late life is substantial. The association between the two constructs cannot be fully explained by symptom overlap, suggesting that psychological vulnerability may be an important component of frailty.

An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms

Background

Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services.

Methods

A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation.

Results

Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period.

Conclusions

Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms.

Trial registration

Clinicaltrials.gov identifier: NCT01407926.

Depression, neighborhood deprivation and risk of type 2 diabetes

Neighborhood characteristics have been associated with both depression and diabetes, but to date little attention has been paid to whether the association between depression and diabetes varies across different types of neighborhoods. This prospective study examined the relationship between depression, neighborhood deprivation, and risk of type 2 diabetes among 336,340 adults from a national-representative sample of primary care centers in Sweden (2001-2007). Multi-level logistic regression models were used to assess associations between depression and risk of type 2 diabetes across affluent and deprived neighborhoods. After accounting for demographic, individual-level socioeconomic, and health characteristics, depression was significantly associated with risk of diabetes (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.06-1.14), as was neighborhood deprivation (OR for high vs. low deprivation: 1.66, 95% CI: 1.22-1.34). The interaction term between depression and neighborhood deprivation was non-significant, indicating that the relationship between depression and diabetes risk is similar across levels of neighborhood socioeconomic deprivation.

Depression in late life

Despite its prevalence and seriousness, depression in late life remains underappreciated as a source of disability and suffering for older people and their families. Despite a solid and substantial body of research, recognition of depression remains problematic and is often attributed to normal developmental changes in aging. Treatment efficacy data notwithstanding, the adequacy and appropriateness of treatment is highly variable. This paper contains a broad overview of new research developments in depression in late life and the disabilities associated with it Serving as an introduction to the specific papers that follow in this issue of Dialogues in Clinical Neuroscience, this article scans the knowledge base in basic, clinical, and health services research, identifying the highlights of current work in the area and proposing areas of needed expansion of research efforts.

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.

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention

BACKGROUND

Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services.

METHODS/DESIGN

This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation.

DISCUSSION

Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01407926.

A review of treating depression in diabetes: emerging findings

BACKGROUND

Depression in patients with diabetes is associated with poorer adherence and worse health outcomes, however treating depression may help improve these outcomes.

OBJECTIVE

The present systematic review identified published papers to evaluate treatments for depression in patients with diabetes.

RESULTS

Seventeen studies that met criteria were identified, indicating that psychosocial interventions, particularly cognitive-behavior therapy, anti-depressant medications, and collaborative care are effective in the treatment of depression in patients with diabetes.

CONCLUSION

Evidence for the efficacy of these interventions in improving glycemic control was mixed. No study targeted adherence to treatment or health behaviors in addition to depression, which may be necessary to maximize improvement in diabetes outcomes such as glycemic control.

Epidemiology and treatment of depression in patients with chronic medical illness

There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.

Use of the late-life function and disability instrument to assess disability in major depression

OBJECTIVES

To determine whether there was greater disability in subjects with depression than in those without, the correlation between disability and depression severity and quality of life, and whether improvement in disability after antidepressant pharmacotherapy was greater in those who responded to antidepressant treatment.

DESIGN

Disability in subjects with and without depression from two different studies was compared for 22 weeks. Correlations were performed for the subjects with depression between disability and depression, anxiety, health-related quality of life (HRQOL), and medical comorbidity. T-tests were used to compare disability between subjects who did and did not respond to antidepressant treatment and change in disability after pharmacotherapy.

SETTING

Late-life depression research clinic.

PARTICIPANTS

The 313 subjects were recruited from primary care and the community and were aged 60 and older; 244 subjects were participants in a depression treatment protocol, and 69 subjects without depression participated in a separate longitudinal observational study of the mental and cognitive health of depression-free older adults.

MEASUREMENTS

The Late-Life Function and Disability Instrument (LL-FDI), a measure of instrumental activity of daily living, personal role, and social role functioning.

RESULTS

Subjects with depression scored lower than controls for domains measuring limitation (can do) and frequency (does do) of activities. Both disability domains correlated with depression severity, anxiety, HRQOL, and cognition. Disability improved with antidepressant treatment; for partial responders who continued to receive higher-dose antidepressant treatment out to 22 weeks, there was continued improvement, although not to the level of comparison subjects without depression.

CONCLUSION

The LL-FDI appears to discriminate subjects with depression from those without, correlates with depression severity, and demonstrates sensitivity to antidepressant treatment response. We recommend further investigation of the LL-FDI and similar disability instruments for assessing depression-related disability.

Mental health status of home care elders in Michigan

PURPOSE

This study describes the mental health status of community-living frail elders in Michigan and identifies subgroups of individuals who are vulnerable to mental health problems.

DESIGN AND METHODS

We analyzed the baseline assessment data collected from older adults who were admitted to two community-based long-term-care programs in Michigan (N = 18,939).

RESULTS

Results show that 40.5% of the individuals in the sample have recognized mental disorders, 39.6% use psychotropic medications, 24.5% have probable depression, and 1.4% have self-injury thoughts or attempts. Frail elders who are White, younger, and female - as well as those who experience more pain, disease burden, cognitive impairment, and limitations in instrumental activities of daily living - are more prone to psychological distress.

IMPLICATIONS

Mental health care is greatly needed by community-living frail elders.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

Effectiveness and cost-effectiveness of a minimal psychological intervention to reduce non-severe depression in chronically ill elderly patients: the design of a randomised controlled trial [ISRCTN92331982]

Background

Depression is a prevalent disorder in chronically ill elderly persons. It may decrease quality of life, and increase functional disability, medical costs, and healthcare utilisation. Because patients may slip into a downward spiral, early recognition and treatment of depression is important. Depression can be treated with antidepressants or psychological interventions; the latter can also be applied by trained paraprofessionals.

In this paper, we describe the design of the DELTA study (Depression in Elderly with Long-Term Afflictions). The first objective of the DELTA study is to evaluate the effectiveness and cost-effectiveness of a minimal psychological intervention (MPI) to reduce depression in chronically ill elderly patients. The second objective is to evaluate whether a potential effect of the MPI may differ between types of chronic illnesses. The tailor-made intervention is administered by nurses, who are trained in the principles of cognitive behavioural therapy and self-management.

Methods/Design

DELTA is a two-armed randomised controlled trial, comparing MPI to usual care. A total number of 180 patients with diabetes mellitus type II (DM) and 180 patients with chronic obstructive pulmonary disease (COPD), who in addition suffer from non-severe depression, will be included in the study. In our study, non-severe depression is defined as having minor depression, mild major depression or moderate major depression. The primary outcome measure is depression using the Beck Depression Inventory. Secondary outcome measures include quality of life, daily functioning, self-efficacy, autonomy, and participation. In the economic evaluation, cost-effectiveness and cost-utility ratios will be calculated. Furthermore, a process evaluation will be carried out.

Analyses will include both univariate and multivariate techniques and according to the intention to treat principle. The economic evaluation will be done from a societal perspective and data of the process evaluation will be analysed using descriptive techniques.

Discussion

A total number of 361 patients has been included in the study. All interventions have been administered and follow-up data will be complete in September 2006.

Preliminary results from the process evaluation indicate that patients' satisfaction with the intervention is high. If this intervention proves to be effective, implementation of the DELTA intervention is considered and anticipated.

Late-life depression among black and white elderly homecare patients

OBJECTIVE

The authors compared the prevalence of major depressive disorder (MDD) and the prescription rates of antidepressant medication, by race, among frail, older homecare patients.

METHODS

A random sample of 56 black and 458 white newly admitted homecare patients age 65 and over was assessed for MDD with structured interviews and medical records, and antidepressant prescription rates were tallied.

RESULTS

The prevalence of MDD did not differ significantly across racial groups. Only 16.7% of black patients and 32.0% of white patients were prescribed antidepressant medication.

CONCLUSIONS

Prevalence of MDD was similar among black and white elderly homecare patients. In both groups, depression is undertreated and contributes to the burden of this frail, older patient group.

Validation of a telephone-administered geriatric depression scale in a hispanic elderly population

OBJECTIVE

To develop and validate a Spanish version of the Geriatric Depression Scale (GDS) for telephone administration.

DESIGN, SETTING, AND PATIENTS

The original version of the GDS was translated into Spanish. A random sample of 282 ambulatory elderly individuals was contacted by phone. Those completing the phone GDS (GDS-T) were asked to schedule an appointment within two weeks in which we collected data on demographics, physical exam, functional and mental status, and a face-to-face version of the GDS (GDS-P). We estimated question-to-question kappa statistics and the Pearson correlation coefficient between the GDS-T and GDS-P scores. We evaluated reliability of the GDS-T and GDS-P using the Cronbach's alpha coefficient. We estimated the sensitivity, specificity, and criterion validity of the GDS using the DSM IV criteria for depression as our gold standard.

RESULTS

Thirty patients (11%) refused to participate. Of the remaining 252 patients, 169 (67%) attended the personal interview. The Cronbach's alpha coefficient was 0.85 for GSD-P and 0.88 for GDS-T. Sensitivity and specificity were 88% and 82% for GDS-P and 84% and 79% for GDS-T. The prevalence of depression in the group completing both scales was 12.8% using the GDS-P and 14.9% using the GDS-T (P >.05). Among those who only completed the GDS-T, the prevalence was 22.7% (P <.05) suggesting that depressed patients kept their appointments less frequently.

CONCLUSIONS

The telephone GDS had high internal consistency and was highly correlated with the validated personal administration of the scale, suggesting that it could be a valid instrument for screening of depression among elderly ambulatory Spanish-speaking patients. Because the depression rate was significantly higher among those not presenting to the personal evaluation, the adoption of GDS-T may help detect and plan early interventions in patients who otherwise would not be identified.

Mortality, symptoms, and functional impairment in late-life depression

OBJECTIVE

To determine whether depressive symptoms measured at baseline are associated with mortality and to describe the course of depressive symptoms and their relation to physical decline in patients over a 6-year period.

DESIGN

Prospective cohort study conducted from 1990 through 1996.

SETTING

Urban academic primary care group practice.

PATIENTS

A cohort of 3,767 patients aged 60 years and older screened for depressive symptoms during routine office visits using the Centers for Epidemiologic Studies Depression Scale (CES-D) participated in the mortality study. A subsample of 300 patients with CES-D scores 16 or above and a subsample of 100 patients with CES-D scores less than 16 participated in the study of the course of depressive symptoms and physical decline.

MEASUREMENTS AND MAIN RESULTS

Mortality by December 1995 was measured for all screened patients; reinterviewed patients completed the CES-D and the Sickness Impact Profile (SIP). The mean follow-up period was 45 months (+/- SD 12.2 months); 561 (14.9%) of the patients died by December 1995. In proportional hazards models, age, gender, race, history of smoking, serum albumin value, and an ideal body weight in the lowest 10% were significant correlates of time to death, but the baseline CES-D was not. Patients with depressive symptoms had significantly worse physical and psychosocial functioning scores on the SIP than did patients without depressive symptoms. Using the generalized estimating equation method, the strongest predictor of the current CES-D score was the patient's prior CES-D score. However, worsening physical functioning score on the SIP was also independently correlated with worse CES-D scores p < or = .001).

CONCLUSIONS

Symptoms of depression were not associated with mortality in this cohort of older adults. However, patients with depressive symptoms reported greater functional impairment than did those without depressive symptoms. Moreover, decline in physical functioning was independently correlated with a concurrent increase in depressive symptoms.