The geriatric depression scale as a screening tool for depression and suicide ideation: a replication and extention

A narrative review: suicide and suicidal behaviour in older adults

Globally, suicide is a public health concern that claims the lives of many each year. The complex etiology and factors contributing to the risk of suicide make it hard to predict the likelihood of death by suicide. Suicide rates have been increasing over the past 25 years in patients aged 65 years and older, and with the expected increases in the size of the older adult population and the under-detection of suicide risk, these rates may continue to increase. To mitigate and attempt to limit this expected increase, it is important to understand the risk and protective factors of suicide in older adults. This narrative review focuses on individuals above the age of 65 and encompasses relevant peer-reviewed publications from the past 25 years to cover fatal and non-fatal suicidal behaviour. It summarizes several important risk factors for suicide and suicidal behaviors while considering how risk can be detected, assessed, prevented, and mitigated. Screening methods to detect suicide and depression in older adults were examined based on their effectiveness and suitability for use in this population. Lastly, the impacts of the COVID-19 pandemic on suicide rates in older adults were described.

Health Outcomes of Social Pension Expansion: A Quasi-Experiment Among Older Adults in Hong Kong

A social pension, regarded as a reliable source of income, has the potential to significantly influence the overall wellbeing of vulnerable older adults. This study aimed to extend the understanding of the effects of social pension expansion beyond its economic impacts to encompass recipients' health status. Using three-wave data from a representative sample of older adults, we employed a quasi-experimental assessment model to evaluate the impact of a recent social pension expansion in Hong Kong on health-related consumption and health outcomes among older adults. The results of the triple difference estimations revealed that an increased social pension significantly enhanced older people's engagement in entertainment activities, utilization of healthcare services, and expenditures on preventive health products. Furthermore, the increased social pension was found to have a significant positive effect on mitigating poor self-rated health and poor sleep quality. However, it did not have a significant impact on the prevalence of depression. These findings suggest that social pension expansion should be coordinated with other policy initiatives to comprehensively improve the physical and mental health of older adults.

Preferences for end-of-life care: A cross-sectional survey of Chinese frail nursing home residents

AIM AND OBJECTIVES

To assess (1) the experience, knowledge and preferences of end-of-life care among frail nursing home residents and (2) the preferences of residents' family caregivers.

BACKGROUND

Globally, nursing homes are becoming an important place where many older people will receive their end-of-life care. Thus, assessing the end-of-life care preferences among nursing home residents is crucial.

DESIGN

Cross-sectional survey.

METHODS

Residents aged ≥65 years, with frail or pre-frail status (n = 286) in 34 nursing homes were interviewed using a structured questionnaire. Descriptive statistics were used to describe the outcomes and regression analyses were used to evaluate factors related to the outcomes. Kappa statistics were used to examine the agreement between the preferences among 21 residents and their family caregivers. The manuscript was guided by the STROBE checklist.

RESULTS

5.9% and 10.5% of the participants had heard of advance care planning and advance directive respectively. After explanations of the terms by the research team, 42.3% of the participants preferred advance care planning, whereas 22.0% preferred advance directive. The top reason for not preferring advance care planning/advance directive is perceiving them as 'not necessary'. Nursing homes were the most preferred place to receive end-of-life care (41.6%). Whereas hospitals were the most preferred place for death (36.0%). The agreement among resident and family caregiver dyads ranged from none to minimal in most outcomes.

CONCLUSIONS

This study revealed the lack of awareness around advance care planning and advance directive among frail nursing home residents. Future research should focus on developing effective educational interventions to enhance the residents' awareness of these topics.

RELEVANCE TO CLINICAL PRACTICE

To increase awareness among nursing home residents, more educational programs should be implemented. Frail older residents might not see the relevance of advance care planning; interventions need to include both current and future care to increase its relevance.

Validation and Comparison of Three Short Depression Screening Tools Among Chinese Community-Dwelling Older Adults

The current study validated and compared three short Geriatric Depression Scales (GDS), including the GDS-5, D'Ath GDS-4, and van Marwijk GDS-4, among 917 Chinese community-dwelling older adults. The GDS-5, D'Ath GDS-4, and van Marwijk GDS-4 presented satisfactory accuracy against the GDS-15 (area under the curve [AUC] = 0.872 to 0.952), and the GDS-5 and D'Ath GDS-4 had better accuracy than the van Marwijk GDS-4. Satisfactory accuracy (AUC = 0.842 to 0.979) for the three scales was also observed across subgroups by age, sex, education, cognitive function, and multimorbidity. The GDS-5 but not D'Ath GDS-4 and van Marwijk GDS-4 retained a 2-point optimal cutoff for depressive symptoms across subgroups. The GDS-5 (average inter-item correlation coefficient [AIIC] = 0.233) and the D'Ath GDS-4 (AIIC = 0.171) but not van Marwijk GDS-4 (AIIC = 0.128) had acceptable internal consistency. Three scales had stable test-retest reliability within a 1- to 2-week interval (intraclass correlation coefficient = 0.670 to 0.885). The GDS-5 is an accurate and reliable depression screening tool with an invariable optimal cutoff among Chinese community-dwelling older adults. The variable optimal cutoffs for the D'Ath GDS-4 and van Marwijk GDS-4 across subgroups may limit their applicability in this population. [Research in Gerontological Nursing, xx(x), xx-xx.].

Incidence, trend and risk factors associated with suicide among patients with malignant intracranial tumors: a surveillance, epidemiology, and end results analysis

BACKGROUND

Cancer patients are associated with an elevated risk of suicide. This study aims to investigate the suicide rates and identify risk factors for suicide among patients with malignant intracranial tumors (MITs).

METHODS

Patients diagnosed with MITs during the years of 1975-2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) program. Suicide rates and standardized mortality ratios (SMR) were calculated. Cox regression analyses were used to identified risk factors for suicide among MIT patients.

RESULTS

Among 115,668 patients with MITs collected from the SEER program, 99 committed suicide. The rate of suicide was 23.02 per 100,000 person-years, and SMR of suicide was 1.90. Diagnosis in recent era (years 2000-2015, SMR = 2.01), male gender (SMR = 1.78), older age (60-79 years, SMR = 3.54), white race (SMR = 1.86), married persons (SMR = 2.31), living in rural areas (SMR = 2.50), history of other malignancy (SMR = 3.81), diagnosis of glioblastoma (SMR = 4.05) and supratentorial location (SMR = 2.45) were associated with an increased incidence of suicide. In addition, the risk of suicide increased significantly within the first year after diagnosis (SMR = 13.04). Multivariate Cox regressions showed that older age, male sex, and supratentorial location were independent risk factors for suicide.

CONCLUSIONS

The suicide mortality among patients with MITs steadily elevated in the past decades. Male sex, older age, and supratentorial location were significantly associated with risk of suicide, especially within the first year following diagnosis. Healthcare providers should early identify and effectively intervene with MIT patients at risk.

Accuracy of 12 short versions of the Geriatric Depression Scale to detect depression in a prospective study of a high-risk population with different levels of cognition

OBJECTIVES

To determine the accuracy of 12 previously validated short versions of the Geriatric Depression Scale (GDS) to detect major depressive disorder (MDD) in a high-risk population with and without global cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Five hospitals, Western Sweden.

PARTICIPANTS

Older adults (age ≥70 years, n = 60) assessed at a home visit 1 year after hospital care in connection with suicide attempt.

MEASUREMENTS

Depression symptoms were rated using the established 15-item GDS. Eleven short GDS versions identified by a recent systematic review were derived from this administered version. Receiver operating characteristic curves and area under the curve (AUC) for the identification of MDD diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were obtained for each version. The Youden Index optimal criterion was used to determine the appropriate cutoffs. Analyses were repeated after stratification by cognitive status (Mini Mental State Examination score ≤24 and >24) for the best performing GDS short versions and the established 15-item GDS.

RESULTS

The 7-item GDS according to Broekman et al. (), with a cutoff 3, was the most accurate among the 12 short versions (AUC 0.90, 95% confidence interval 0.80-1.00), identifying MDD with sensitivity 88% and specificity 81%. The cutoff score remained consistent in the presence of global cognitive impairment, which was not the case for the standardized 15-item GDS.

CONCLUSION

The Broekman 7-item GDS had high accuracy to detect MDD in this prospective clinical cohort at high risk for MDD. Further testing of GDS short versions in diverse settings is required.

Accuracy of the Geriatric Depression Scale (GDS)-4 and GDS-5 for the screening of depression among older adults: A systematic review and meta-analysis

BACKGROUND

The Geriatric Depression Scale (GDS) is a widely used instrument to assess depression in older adults. The short GDS versions that have four (GDS-4) and five items (GDS-5) represent alternatives for depression screening in limited-resource settings. However, their accuracy remains uncertain.

OBJECTIVE

To assess the accuracy of the GDS-4 and GDS-5 versions for depression screening in older adults.

METHODS

Until May 2020, we systematically searched PubMed, PsycINFO, Scopus, and Google Scholar; for studies that have assessed the sensitivity and specificity of GDS-4 and GDS-5 for depression screening in older adults. We conducted meta-analyses of the sensitivity and specificity of those studies that used the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases-10 (ICD-10) as reference standard. Study quality was assessed with the QUADAS-2 tool. We performed bivariate random-effects meta-analyses to calculate the pooled sensitivity and specificity with their 95% confidence intervals (95% CI) at each reported common cut-off. For the overall meta-analyses, we evaluated each GDS-4 version or GDS-5 version separately by each cut-off, and for investigations of heterogeneity, we assessed altogether across similar GDS versions by each cut-off. Also, we assessed the certainty of evidence using the GRADE methodology.

RESULTS

Twenty-three studies were included and meta-analyzed, assessing eleven different GDS versions. The number of participants included was 5048. When including all versions together, at a cut-off 2, GDS-4 had a pooled sensitivity of 0.77 (95% CI: 0.70-0.82) and a pooled specificity of 0.75 (0.68-0.81); while GDS-5 had a pooled sensitivity of 0.85 (0.80-0.90) and a pooled specificity of 0.75 (0.69-0.81). We found results for more than one GDS-4 version at cut-off points 1, 2, and 3; and for more than one GDS-5 version at cut-off points 1, 2, 3, and 4. Mostly, significant subgroup differences at different test thresholds across versions were found. The accuracy of the different GDS-4 and GDS-5 versions showed a high heterogeneity. There was high risk of bias in the index test domain. Also, the certainty of the evidence was low or very low for most of the GDS versions.

CONCLUSIONS

We found several GDS-4 and GDS-5 versions that showed great heterogeneity in estimates of sensitivity and specificity, mostly with a low or very low certainty of the evidence. Altogether, our results indicate the need for more well-designed studies that compare different GDS versions.

Short versions of the Geriatric Depression Scale (GDS) among widowed older people in Taiwan: Comparing their psychometric properties

OBJECTIVE

To compare the psychometric properties of different short versions of the Geriatric Depression Scale (GDS) among community-dwelling widowed older people.

METHODS

A cross-sectional design was conducted between February 2018 and August 2019 in southern Taiwan (n = 330). The GDS short versions included Hoyl et al's 5-item version, Molloy et al's 5-item version and van Marwijk et al's 4-item version.

RESULTS

All GDS short versions had satisfactory internal consistency (α = 0.83-0.90), with strong item loading embedded in the same construct of depression (0.43-0.72). The activity of daily living (ADL) scores had strong associations with van Marwijk et al's 4-item version (absolute standardised coefficient [|β|] = 0.15-0.59), Hoyl et al's 5-item version (|β| = 0.16-0.45) and Molloy et al's 4-item version (|β| = 0.09-0.40).

CONCLUSIONS

Hoyl et al's 5-item version was found to be more suitable than the other two versions of the GDS to assess the precise construct of depression. Meanwhile, van Marwijk et al's 4-item version can be used when the focus is on ADL performance. However, the conclusion should be interpreted with caution since the results were derived only from a widowed population in Taiwan. More research on this topic among other populations is thus needed to corroborate our conclusion.

Clinical Usefulness of the Geriatric Depression Scale to Identify the Elderly at Risk of Suicide

OBJECTIVE

Population-based suicidal screening can be an important intervention method to reduce suicidal attempt rate in community. However, directly asking about suicidal behavior may be burdensome to non-mental health workers. This study aimed to evaluate the clinical usefulness of the Geriatric Depression Scale-15 (GDS-15) in identifying the elderly at risk of suicide in community.

METHODS

Nine hundred forty-eight over 60 years of age participated in this study. All participants completed the GDS-15. A trained interviewer interviewed each participant for suicidality including suicidal ideation, plan, and prior attempt using the Structured Clinical Interview for DSM-IV.

RESULTS

When the cut-off score of 10 in the GDS-15 was applied to identify the elderly at risk of suicide, the proportion of directly asking about suicidal behavior by non-mental health workers was reduced by 33.1%; however, 19.5% at risk of suicide were missed. When the cut-off was changed to 6, 100% at risk of suicide were covered by the GDS-15.

CONCLUSION

Screening for suicidality using GDS-15 is a promising way to reduce the proportion of directly asking about suicidal behavior by non-mental health workers among the high-risk suicidal elderly in a community setting.

Preferences for end-of-life care: a study protocol for a cross-sectional survey of Chinese frail elderly home residents in Hong Kong

INTRODUCTION

Existing literature on attitudes toward end-of-life care (EoLC) covers the general public but has little information on the frail elderly population. The aim of the current study is to investigate the preferences of Chinese frail elderly home residents with respect to EoLC by conducting cross-sectional surveys.

METHODS AND ANALYSIS

Surveys, including resident and family versions, were developed based on the existing literature and our pilot interviews. The targeted participants were 400 frail elderly home residents (aged ≥65 years old) and 200 family caregivers. Purposive sampling will be used as each elderly home will help to recruit five to 15 elderly participants for the study. Descriptive analysis and modelling will be used to examine preferences on EoLC and related factors, as well as to compare the responses of elderly home residents with those of their family caregivers.

ETHICS AND DISSEMINATION

The cross-sectional survey has obtained approval from the Institutional Review Board. Confidentiality and safety issues will be carefully observed. The results of the study will be disseminated through international conferences, peer-reviewed academic journal publications, and a report in plain language to be shared with elderly residential homes.

Assessing the relative contribution of social exclusion, income-poverty, and financial strain on depressive symptoms among older people in Hong Kong

Objectives: The role of social exclusion in depressive symptoms in older people has not been examined systematically. This study examines the associations of social exclusion, income poverty, and financial strain with depressive symptoms and evaluates the moderating effect of social support in the link between social exclusion and depressive symptoms. Method: Our sample consisted of 850 older people (65 years old or above) in Hong Kong randomly selected through a household survey. We used a logistic regression to evaluate the associations of social exclusion, income poverty, and financial strain with depressive symptoms, controlling for social support and social network variables, health indicators, and socio-demographic variables. Results: We found that social exclusion, income poverty, and financial strain are positively associated with depressive symptoms, but only social exclusion (OR: 2.13, 95% CI: 1.51-2.99, p < 0.001) and financial strain (OR: 1.54, 95% CI: 1.16-2.03, p < 0.01) maintain their significance after all other covariates are adjusted. Moreover, perceived social support negatively moderates the relationship between social exclusion and depressive symptoms. Conclusion: Social exclusion is significantly associated with depressive symptoms in older people, but this association can be moderated by social support.

Determining Risk for Depression among Older People Residing in Vietnamese Rural Settings

(1) Background: Major causes of the burden of disease in older persons include mental disorders and neurological diseases, such as depression. This study aims to explore the prevalence of older people at risk for depression and identify the factors associated with this risk in rural Vietnam. (2) Methods: A cross-sectional study was conducted in Soc Son, Hanoi with 523 community dwelling elders aged 60 and over. Face-to-face interviews were performed to collect data about socioeconomic status, risk for depression, health status, and health utilization. The Geriatric Depression Scale-4 items (GDS-4) was used to assess the risk for depression occurrence. Multivariable logistic regression was employed for determining the factors associated with the risk for depression. (3) Results: Among 523 participants, there were 26.4% of participants at risk for depression. The proportion of females at risk for depression (29.0%) was significantly higher than males (20.4%). Differences were found in economic status (near poor group had higher risk for depression compared to the poor group) (p < 0.01). Older adults living with spouse/partner, living in near-poor household, and suffering pain/discomfort were all more likely to be at risk for depression. (4) Conclusions: Being female, living in a near poor household, being in pain or experiencing discomfort are all factors strongly correlated to high risk for depression. These findings highlight the urgent need for additional research among Vietnamese community-dwelling older people.

Profiling obesity phenotypes and trajectories in older adults of the Quebec NuAge cohort on nutrition and successful aging: A cluster analysis

Obesity in older adults results from several interacting factors. Consequently, interventions have shown mitigated effects. We determined (a) the different subgroups of older adults with obesity based on clusters of associated comorbidities and (b) the trajectory of these clusters to assess their stability over 3 years and factors contributing to transitions. Obese men (n = 193; body mass index [BMI] = 33.15 ± 2.69 kg/m² ) and women (n = 220; BMI = 33.71 ± 3.71 kg/m² ) aged between 68 and 82 years were studied. Outcome variables were body composition, strength, physical capacity (PC), nutrition, psychological and physical health and social participation. Cluster analyses, stratified by sex, were used to identify obesity profiles at baseline and follow-up. Three profiles were identified, based on general health (GH), psychological health (PH) and PC: Cluster 1: healthy obese (GH+, PH+, PC+); Cluster 2: obese with low PC (GH+/-, PH+/-, PC-); Cluster 3: unhealthy obese (GH-, PH-, PC-). After 3 years, 61.2% and 70.2% of men and women remained in their initial cluster, compared to 20.4% and 13.7% who transitioned towards a worse health cluster and 18.3% and 16.0% who transitioned towards a more favourable cluster, partly explained by changes in physical health for men and physical health and PH for women. The results of this study show that targeting physical function in men and physical health and PH functions in women could prevent further health decline in older adults with obesity. Further studies are needed to investigate the role of these clusters in the prediction of cardiometabolic complications and mortality.

Poverty, deprivation, and depressive symptoms among older adults in Hong Kong

OBJECTIVES

Examine the association of income poverty and material deprivation with depression in old age.

METHODS

Our data contains a survey of 1,959 older Chinese adults in Hong Kong. We used the Geriatric Depression Scale - Short Form to assess their depressive symptoms. Income poverty was defined as having household income below half the median household income (adjusted by household size); material deprivation was measured by a validated 28-item material deprivation. In addition to income poverty and material deprivation, we also assessed the effect of socio-demographic variables, financial strain, health indicators, and social and community resources on depressive symptoms.

RESULTS

Those who experienced material deprivation reported a significantly more severe depressive symptoms, even after income poverty and all other covariates were controlled for; the bivariate association between income poverty and depressive symptoms disappeared once material deprivation was controlled for. Further, we found a significant interaction effect between income poverty and material deprivation on depressive symptoms; and both engagement in cultural activities and neighborhood collective efficacy moderated the impact of being materially deprived on depressive symptoms.

CONCLUSION

Our results have important policy implications for the measurement of poverty and for the development of anti-poverty measures for materially deprived older adults.

Physical, mental, and social functioning in women age 65 and above with and without a falls history: An observational case-control study

Objectives:

There is a lack of knowledge about how falls are associated with the older person’s physical, mental, and social functioning which would help find effective methods for identifying rehabilitation needs in the older population to ensure appropriate follow-up. The aim was to investigate and compare functioning in women with and without a falls history.

Methods:

This was an observational case-control study. Study participants were fallers aged ≥65 years recruited consecutively from a hospital; age matched randomly selected community controls (fallers without contact with the healthcare system due to falls and non-fallers). Fallers were classified as once only fallers and recurrent fallers.

Results:

The sample constituted a group of older women with and without a falls history; 117 fallers from the Falls Clinic, and 99 fallers and 106 non-fallers community controls, median age 80 years. Both fallers from the clinic and the community had significantly lower functioning compared to non-fallers in all three domains. Recurrent fallers had poorer functioning compared to once only fallers.

Conclusion:

This study contributes to knowledge about older people’s functioning and disability in conjunction with a high fall-risk and highlights the importance of rehabilitation and prevention strategies that focus on early identification of disability in the older population regardless of falls history.

Sociodemographic and clinical characteristics of old-old suicide attempters compared with young-old and middle-aged attempters

OBJECTIVES

The purpose of this study was to identify distinctive characteristics of old-old suicide attempters (75 years and older) from young-old (60-74 years old) and middle-aged suicide attempters (45-59 years old).

METHODS

We included consecutive series of 920 patients aged 45 years and older who had visited the emergency room from 2009 to 2015 because of suicide attempts. They were divided into 3 groups according to age. Information about the suicide attempt and sociodemographic status was gathered through interviews with attempters or caregivers. Chi-square test and logistic regression analysis were performed to evaluate the differences among the 3 groups.

RESULTS

We found that old-old suicide attempters had high intent to die and high medical lethality as a result of the attempt, and illness-related problems exerted a strong motivational effect on this group. Psychiatric drugs, pesticides, and herbicides were frequently used to attempt suicide. These attempts were less likely to be associated with alcohol consumption compared to other age groups.

CONCLUSION

Old-old suicide attempters have different characteristics, compared with young-old and middle-aged counterparts. It is necessary to assess suicide risk and depression when examining patients with physical illness or when prescribing psychotropic drugs. High-risk groups should be given immediate intervention including psychiatric treatment before they act on high suicide intent.

The relationship between BDNF Val66Met polymorphism and functional mobility in chronic stroke survivors

Background A single nucleotide polymorphism, Val66Met, in the Brain Derived Neurotrophic Factor (BDNF) gene has been studied for its role in recovery following stroke. Despite this work, the role of BDNF genotype on long-term recovery is unclear. Additionally, no study has examined its impact on functional mobility. As a result, the purpose of this study was to examine the relationship between BDNF genotype and functional mobility in chronic stroke survivors by first accounting for factors related to the Val66Met polymorphism and post-stroke recovery. Methods Participants 6 months post-stroke completed the Fugl-Meyer Lower Extremity Assessment (FMLE), Yesavage Geriatric Depression Scale (YGDS), 10 meter walk test (SSWS), and BDNF genotype testing. A regression model was used to determine if including genotype (Val or Met) and the genotype's interactions with age, gender, and depression increased the model's fit in predicting functional mobility, as measured by SSWS, after accounting for physical impairment (FMLE) and personal information (age, gender, and YGDS). Results Sixty-three subjects, twenty-two percent of whom had at least one Met allele, were included. Impairment and personal information significantly predicted SSWS (R² = 0.268, p < 0.001 and ΔR² = 0.158, p = 0.002, respectively). The addition of genotype and genotype's interactions did not significantly increase the variance accounted for in SSWS (ΔR² = 0.012, p = 0.27, and ΔR² = 0.006, p = 0.723, respectively). Conclusions Our results suggest that the Val66Met polymorphism does not predict long-term, functional mobility following stroke. This difference may be due to differences in model variables or a reduced impact of the polymorphism as recovery progresses.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVES

Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D.

SETTING AND PARTICIPANTS

Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire.

MAIN OUTCOME MEASURES

Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA_1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented.

RESULTS

Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35-6.00, P = 0.006) of reporting prior history of co-morbidities.

CONCLUSION

In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

Relationship Between Walking Capacity, Biopsychosocial Factors, Self-efficacy, and Walking Activity in Persons Poststroke

BACKGROUND/PURPOSE

Many factors appear to be related to physical activity after stroke, yet it is unclear how these factors interact and which ones might be the best predictors. Therefore, the purpose of this study was twofold: (1) to examine the relationship between walking capacity and walking activity, and (2) to investigate how biopsychosocial factors and self-efficacy relate to walking activity, above and beyond walking capacity impairment poststroke.

METHODS

Individuals greater than 3 months poststroke (n = 55) completed the Yesavage Geriatric Depression Scale (GDS), Fatigue Severity Scale (FSS), Modified Cumulative Illness Rating (MCIR) Scale, Walk 12, Activities-Specific Balance Confidence (ABC) Scale, Functional Gait Assessment (FGA), and oxygen consumption testing. Walking activity data were collected via a StepWatch Activity Monitor. Predictors were grouped into 3 constructs: (1) walking capacity: oxygen consumption and FGA; (2) biopsychosocial: GDS, FSS, and MCIR; (3) self-efficacy: Walk 12 and ABC. Moderated sequential regression models were used to examine what factors best predicted walking activity.

RESULTS

Walking capacity explained 35.9% (P < 0.001) of the variance in walking activity. Self-efficacy (ΔR = 0.15, P < 0.001) and the interaction between the FGA×ABC (ΔR = 0.047, P < 0.001) significantly increased the variability explained. The FGA (β = 0.37, P = 0.01), MCIR (β = -0.26, P = 0.01), and Walk 12 (β = -0.45, P = 0.00) were each individually significantly associated with walking activity.

DISCUSSION AND CONCLUSION

Although measures of walking capacity and self-efficacy significantly contributed to "real-world" walking activity, balance self-efficacy moderated the relationship between walking capacity and walking activity. Improving balance self-efficacy may augment walking capacity and translate to improved walking activity poststroke.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A139).

Assessing suicide risk in older adults

Suicide in older adults is continuing to rise and, as the older population increases, so will the rate of suicide. By learning more about the risk factors, assessment areas to explore, and ways to improve treatment, primary care providers can help decrease the incidence of suicidal behaviors in this population.

Depressive Symptoms on the Geriatric Depression Scale and Suicide Deaths in Older Middle-aged Men: A Prospective Cohort Study

Objectives:

Prospective evaluations of the associations between depressive symptoms and suicide deaths have been mainly performed in high-risk populations, such as individuals with psychiatric disorders or histories of self-harm. The purpose of this study was to prospectively examine whether more severe depressive symptoms assessed using the Geriatric Depression Scale (GDS) were associated with a greater risk of death from suicide in a general-risk population.

Methods:

A total of 113 478 men from the Korean Veterans Health Study (mean age, 58.9 years) who participated in a postal survey in 2004 were followed up for suicide mortality until 2010.

Results:

Over 6.4 years of follow-up, 400 men died by suicide (56.7 deaths per 100 000 person-years). More severe depressive symptoms were associated with greater risk of suicide death (p for trend <0.001). The unadjusted hazard ratios (HRs) in comparison to the absence of depression were 2.18 for mild depression, 2.13 for moderate depression, 3.33 for severe depression, and 3.67 for extreme depression. After adjusting for potential confounders, men with a potential depressive disorder had an approximate 90% higher mortality from suicide (adjusted HR, 1.92; 95% confidence interval [CI], 1.38 to 2.68; p<0.001) than men without depression. Each five-point increase in the GDS score was associated with a higher risk of death by suicide (adjusted HR, 1.22; p<0.001). The value of the area under the receiver operating characteristics curve of GDS scores for suicide deaths was 0.61 (95% CI, 0.58 to 0.64).

Conclusions:

Depressive symptoms assessed using the GDS were found to be a strong independent predictor of future suicide. However, the estimate of relative risk was weaker than would be expected based on retrospective psychological autopsy studies.

Suicidality-based prediction of suicide attempts in a community-dwelling elderly population: Results from the Osan Mental Health Survey

BACKGROUND

Data on outcomes of suicidality in the community-dwelling elderly are scarce. We investigated the association of suicidality with the suicide attempts in a community-dwelling elderly cohort.

METHODS

In the Osan Mental Health Survey, 848 randomly sampled elderly Koreans participated in the baseline evaluation, 623 completed 2-year follow-up evaluation and 32 died during the follow-up period. The survey was conducted between February 2010 and January 2013. We evaluated suicidality using the Mini-International Neuropsychiatric Interview suicidality module that includes both suicidal ideation and attempts.

RESULTS

The incidences of suicidality and suicide attempts were 70.7 and 13.1 per 1000 persons per year, respectively. Suicidality was associated with increased risk of suicide attempts (odds ratio (OR) = 3.84, 95% CI = 1.06-13.87). Two men with suicidality committed suicide by self-poisoning. Moderate to high intensity daily exercise decreased the risk of suicidality to become persistent or recurrent (OR = 0.32, 95% CI = 0.12-0.81). Low education level (OR = 2.41, 95% CI = 1.21-4.77) and depression (OR = 3.02, 95% CI = 1.65-5.53) were associated with risk of incident suicidality.

LIMITATIONS

Study sample was enrolled from a single city of Korea, and the size of the study sample was small.

CONCLUSIONS

We may reduce suicide attempts by screening for suicidality and implementing exercise programs in community-dwelling elderly people.

Suicide in the old elderly: results from one Italian county

OBJECTIVES

To investigate factors differentiating old-old elderly (those aged 75 years and older) who died by suicide from middle-aged (those aged 50-64 years) and young-old (aged 65-74 years) adults who took their own lives, and from living psychiatric outpatients 75 years and older who had no suicidal behaviors in the last 12 months before assessment.

METHODS

Cases for psychological autopsy interviews were 117 old-old elderly who died by suicide between 1994 and 2009. Comparisons were 97 young-old adult and 98 middle-aged suicide victims and 117 psychiatric outpatients admitted to the Department of Psychiatry of the University of Parma (Parma, Italy) between 1994 and 2009. Information for suicide decedents was gathered through proxy-based interviews, and data regarding living comparison subjects were extracted from medical records.

RESULTS

A high number of old-old elderly were widowed and lived alone before death; widowhood was more prevalent in the old-old elderly than in the younger suicide groups and the psychiatric outpatients. In addition, old-old elderly were more frequently characterized by the presence of life stressors in the few months before death compared with the psychiatric outpatients.

CONCLUSIONS

Clinicians involved in the prevention of suicide in older adults should pay particular attention to loneliness and lack of social support, two conditions that may push the individual to feel hopeless, especially in those individuals who are facing stressful life events.

Pontine microbleeds and depression in stroke

OBJECTIVES

Depression is the most common affective disorder following stroke yet the neuroanatomical model of poststroke depression (PSD) remains unclear. This study examined the association between PSD and cerebral microbleeds (CMBs) and hypothesized that CMBs in specific regions would be associated with PSD.

METHODS

Of the 4766 patients with first ever or recurrent acute ischemic stroke admitted to the Acute Stroke Unit of the Prince of Wales Hospital between June 2004 and October 2010, 229 met the entry criteria and formed the study sample. Patients with a Geriatric Depression Scale score of 7 or above were classified as having PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

Compared to the non-PSD group, patients with PSD were more likely to have pontine CMBs (32.0% vs 18.2%; P = .019). The presence of pontine CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.2 (P = .016).

CONCLUSION

The results suggest that pontine CMBs are associated with a higher risk of developing PSD.

Psychological need satisfaction and well-being in adults aged 80 years and older living in residential homes: using a self-determination theory perspective

Based on the self-determination theory (SDT), this study aims to examine the psychological needs satisfaction of the elderly living in residential homes and their relationship with indicators of well-being, and then to test the contribution of each need on these indicators. Participants (N=100; Mage=86.7 years, SD=3.78) completed the measures of psychological needs satisfaction, purpose in life, personal growth and geriatric depression. Cluster analyses showed two distinct profiles: one profile with a high satisfaction of the three basic psychological needs and another profile with a low satisfaction of the three basic psychological needs. These profiles did not differ in terms of residents' characteristics, health problems and functional limitations. Multivariate analysis of variance (MANOVA) results revealed that the participants with the profile of a high satisfaction of psychological needs have significantly higher levels of purpose in life and personal growth than participants with the profile of a low satisfaction of psychological needs, and no effect of cluster membership on depressive feelings was reported. Moreover, for all participants, relatedness need satisfaction was significantly and positively related to personal growth, and autonomy and relatedness needs satisfaction was related to purpose of life. In conclusion, our results offer evidence that old age can be fruitful and, in consistent with SDT, show that autonomy and relatedness need satisfaction is positively associated with indicators of well-being such as purpose in life and personal growth, considered as essential components of optimal functioning.

Cerebral microbleeds and fatigue in stroke

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is a frequent and persistent problem in stroke survivors. The neuroanatomical model of PSF remains unclear. This study examined the association between PSF and cerebral microbleeds (CMBs).

METHODS

The sample comprised 199 patients with acute ischemic stroke. A psychiatrist who was blind to the subjects' radiological data administered the Chinese version of the Fatigue Severity Scale. PSF was defined as a Fatigue Severity Scale score of 4.0 or more. The locations of CMBs were evaluated with magnetic resonance imaging within 7 days of admission.

RESULTS

Of the 199 patients screened, 47 (23.6%) had PSF. The PSF group had a higher Geriatric Depression Scale score (p < 0.001) and a trend for a higher age (p = 0.074). The proportion of patients with deep CMBs was significantly higher in the PSF group (66.0 vs. 48.7%; p = 0.038). The presence of deep CMBs was a significant independent predictor of PSF with an odds ratio of 2.68 (p = 0.016).

CONCLUSION

The results suggest that deep CMBs are associated with a higher risk of PSF. Further studies are needed to clarify whether CMBs affect the clinical presentation, treatment response and outcome of PSF.

Cerebral microbleeds as a predictor of 1-year outcome of poststroke depression

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) are common in stroke survivors and community-dwelling elderly. The clinical significance of CMBs in the outcome of poststroke depression (PSD) is unknown. This study examined the association between the 1-year outcome of PSD and CMBs.

METHODS

The study population comprised 774 Chinese patients with acute ischemic stroke who were admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong. Three and 15 months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Geriatric Depression Scale score of ≥7. Of the 213 patients with PSD at the 3-month follow-up, 135 (63.4%) attended the 15-month follow-up, at which time 89 (65.9%) patients remained depressed (nonremitters), and 46 (34.1%) had recovered (remitters). The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

In comparison with the remitters, nonremitters were more likely to have lobar CMBs (18.4% versus 4.3%; P=0.024). Lobar CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 4.96 (P=0.039).

CONCLUSIONS

The results suggest that lobar CMBs may influence the outcome of PSD. The importance of CMBs in the clinical course of depression in stroke survivors warrants further investigation.

Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium

BACKGROUND

Most previous studies on the efficacy of antipsychotic medication for the treatment of delirium have reported that there is no significant difference between typical and atypical antipsychotic medications. It is known, however, that older age might be a predictor of poor response to antipsychotics in the treatment of delirium. The objective of this study was to compare the efficacy and safety of haloperidol versus three atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) for the treatment of delirium with consideration of patient age.

METHODS

This study was a 6-day, prospective, comparative clinical observational study of haloperidol versus atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) in patients with delirium at a tertiary level hospital. The subjects were referred to the consultation-liaison psychiatric service for management of delirium and were screened before enrollment in this study. A total of 80 subjects were assigned to receive either haloperidol (N = 23), risperidone (N = 21), olanzapine (N = 18), or quetiapine (N = 18). The efficacy was evaluated using the Korean version of the Delirium Rating Scale-Revised-98 (DRS-K) and the Korean version of the Mini Mental Status Examination (K-MMSE). The safety was evaluated by the Udvalg Kliniske Undersogelser side effect rating scale.

RESULTS

There were no significant differences in mean DRS-K severity or K-MMSE scores among the four groups at baseline. In all groups, the DRS-K severity score decreased and the K-MMSE score increased significantly over the study period. However, there were no significant differences in the improvement of DRS-K or K-MMSE scores among the four groups. Similarly, cognitive and non-cognitive subscale DRS-K scores decreased regardless of the treatment group. The treatment response rate was lower in patients over 75 years old than in patients under 75 years old. Particularly, the response rate to olanzapine was poorer in the older age group. Fifteen subjects experienced a few adverse events, but there were no significant differences in adverse event profiles among the four groups.

CONCLUSIONS

Haloperidol, risperidone, olanzapine, and quetiapine were equally efficacious and safe in the treatment of delirium. However, age is a factor that needs to be considered when making a choice of antipsychotic medication for the treatment of delirium.

TRIAL REGISTRATION

Clinical Research Information Service, Republic of Korea, (http://cris.nih.go.kr/cris/en/search/basic_search.jsp, Registered Trial No. KCT0000632).

The assessment of changes in cognitive functioning: age-, education-, and gender-specific reliable change indices for older adults tested on the CERAD-NP battery: results of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe)

OBJECTIVES

The Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological (CERAD-NP) battery represents a commonly used neuropsychological instrument to measure cognitive functioning in the elderly. This study provides normative data for changes in cognitive function that normally occur in cognitively healthy individuals to interpret changes in CERAD-NP test scores over longer time periods.

DESIGN

Longitudinal cohort study with three assessments at 1.5-year intervals over a period of 3 years.

SETTING

: Primary care medical record registry sample.

PARTICIPANTS

As part of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients, a sample of 1,450 cognitively healthy general practitioner patients, age 75 years and older, was assessed.

MEASUREMENTS

Age-, education-, and gender-specific Reliable Change Indices (RCIs) were computed for a 90% confidence interval for selected subtests of the CERAD-NP battery.

RESULTS

Across different age, education, and gender subgroups, changes from at least six to nine points in Verbal Fluency, four to eight points in Word List Memory, two to four points in Word List Recall, and one to four points in Word List Recognition indicated significant (i.e. reliable) changes in CERAD-NP test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated.

CONCLUSIONS

Smaller changes in CERAD-NP test scores can be interpreted with only high uncertainty because of probable measurement error, practice effects, and normal age-related cognitive decline. This study, for the first time, provides age-, education-, and gender-specific CERAD-NP reference values on the basis of RCI methods for the interpretation of cognitive changes in older-age groups.

Depressive symptoms and suicide in 56,000 older Chinese: a Hong Kong cohort study

OBJECTIVE

To examine dose-response associations between depressive symptoms and suicide and modification effects of sex, age and health status in older Chinese.

METHODS

We used the Chinese version of the 15-item Geriatric Depression Scale (GDS) to measure depressive symptoms (GDS score ≥ 8) and Cox regression to examine association with suicide mortality in a population-based cohort of 55,946 individuals, aged 65 years or above, enrolled from July 1998 to December 2000 at one of 18 Elderly Health Centres of Hong Kong Department of Health. The cohort was followed up for suicide mortality till 31 March 2009 (mean follow-up 8.7 years).

RESULTS

Depressive symptoms were associated with suicide in men [hazard ratio (HR) 2.03, 95% confidence interval (CI) 0.96-4.29] and women (HR = 2.36, 95% CI 1.31-4.24) after adjusting for age, education, monthly expenditure, smoking, alcohol drinking, physical activity, body mass index, health status, and self-rated health. There was no threshold for GDS score and suicide in either sex. Age, sex and health status did not modify the association.

CONCLUSIONS

Depressive symptoms predict higher suicide risk in older Chinese in a dose-response pattern. These associations were not attenuated by adjustment for health status, suggesting that depressive symptoms in older people are likely to be an independent causal factor for suicide. The GDS score showed no threshold in predicting suicide risk, suggesting that older people with low GDS scores deserve further attention and those with very high scores need urgent intervention.

Cerebral microbleeds and depression in lacunar stroke

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMB) are common in stroke survivors and the community-dwelling elderly. The clinical significance of CMB in the development of depression after a stroke is unknown. This study examined the association between poststroke depression (PSD) and CMB.

METHODS

A cohort of 235 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Genetic Depression Scale score of ≥7. The presence and location of CMB were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, PSD patients were more likely to have lobar CMB (33.3% versus 19.9%; P=0.022). Lobar CMB remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.08 (P=0.032).

CONCLUSIONS

The results suggest that lobar CMB may play a role in the development of PSD. The importance of CMB in the pathogenesis of depression in stroke survivors and the general elderly population warrants further investigation.

Social exchanges and subjective well-being: do sources of positive and negative exchanges matter?

OBJECTIVES

To decompose the effects of positive and negative social exchanges on well-being in terms of relationship type (vertically extended family, horizontally extended family, or nonfamily) and subjective closeness (close vs. peripheral).

METHODS

One thousand and five Chinese older adults rated each network member on positive and negative exchanges, which were aggregated for each relationship type and closeness category. Regression analyses estimated the influences of positive and negative exchanges on well-being, controlling for network size, health, and demographic factors.

RESULTS

Social exchanges with close and peripheral vertical family members as well as close horizontal family members were associated with well-being, whereas exchanges with nonkin did not contribute independent effects. These results were similar for both positive and negative exchanges.

DISCUSSION

Well-being is determined not just by social exchanges but also by where they come from. In this regard, the vertical family, the horizontal family, and the nonfamily represent a hierarchy of preference for Chinese older adults, which, to some extent, reflects the influence of familism.

Suicides in late life

Suicide in late life is an enormous public health problem that will likely increase in severity as adults of the baby boom generation age. Data from psychological autopsy studies supplemented with recent studies of suicidal ideation and attempts point to a consistent set of risk factors for the spectrum of suicidal behaviors in late life (suicide ideation, attempts, and deaths). Clinicians should be vigilant for psychiatric illness (especially depression), physical illness, pain, functional impairment, and social disconnectedness. Recent advances in late-life suicide prevention have in common collaborative, multifaceted intervention designs. We suggest that one mechanism shared by all preventive interventions shown to reduce the incidence of late-life suicide is the promotion of connectedness. For the clinician working with older adults, our recommendation is to not only consider risk factors, such as depression, and implement appropriate treatments but to enhance social connectedness as well.

The relationships between quality of life, psychiatric illness, and suicidal ideation in geriatric veterans living in a veterans' home: a structural equation modeling approach

OBJECTIVE

This study tested a structural model and examined the relationships between age, suicidal ideation, and scores on the 5-item Brief Symptom Rating Scale (BSRS-5), the 15-item Geriatric Depression Scale (GDS-15), and the Medical Outcome Study Short Form-12 (MOS SF-12) in a sample of veterans' home residents.

METHODS

Of the 266 individuals recruited, 226 completed the questionnaires, resulting in a response rate of 84.9%. Participants completed the BSRS-5, GDS-15, MOS SF-12, and a demographic survey. Analysis of Moment Structures, Version 7.0, was used to test the structural relationships of the model with a structural equation modeling analysis and a maximum likelihood ratio estimation. Patient subitem scores, which ranked their feelings of depression, hostility, and inferiority, were summed to determine their 3-BSRS-subitem sum scores.

RESULTS

The measures of model fitness were as follows: goodness-of-fit (χ = 12.03, df = 7, p = 0.1), goodness-of-fit index (0.98), adjusted goodness-of-fit index (0.95), comparative fit index (0.99), parsimony ratio (0.47), and root mean square error of approximation (0.06). All indices suggested that the final model fit the data well. Age was inversely related to physical component summary, which was inversely related to the 3-BSRS-subitem sum score. Mental component summary was inversely related to the 3-BSRS-subitem sum score and the GDS-15. Physical component summary was inversely related to the GDS-15. The 3-BSRS-subitem sum score correlated with suicidal ideation.

CONCLUSIONS

The data reveal a significant relationship between quality of life and suicidal ideation, which may be affected more by the 3-BSRS-subitem sum score than by the GDS-15. The proposed model has the potential to help healthcare professionals effectively design and implement their suicide prevention programs.

Social support and psychological well-being of nursing home residents in Hong Kong

BACKGROUND

This study sought to investigate the extent to which structural and functional social support promotes psychological well-being among nursing home residents in a Chinese society.

METHODS

71 nursing home residents (57 women, 14 men) provided ratings on contact frequency and emotional and instrumental support exchanges with network members. Psychological well-being was measured using depression, loneliness, positive affect, and life satisfaction.

RESULTS

Network size was associated with well-being, but was largely nonsignificant after controlling for frequency of contact or functional support. Contact and support from staff and fellow residents were consistently related to all well-being variables, whereas interactions with family were associated with life satisfaction and positive affect only. Being able to reciprocate support was also related to well-being in this sample of frail elderly, controlling for other factors.

CONCLUSION

Interactions with staff and residents in the institution are more protective of well-being than interactions with family members. Even in a society where familism is strongly valued, assimilation into the institution facilitates support exchange when needed.