Prevalence and risk factors of depressive symptoms in a Canadian palliative home care population: a cross-sectional study

Spiritual Distress, Hopelessness, and Depression in Palliative Care: Simultaneous Concept Analysis

Spiritual distress, hopelessness, and depression are concepts that are often used in palliative care. A simultaneous concept analysis (SCA) of these concepts is needed to clarify the terminology used in palliative care. Therefore, the aim of this study is to conduct a SCA of spiritual distress, hopelessness, and depression in palliative care. A SCA was performed using the methodology of Haase's model. A literature search was conducted in March 2020 and updated in April 2022 and April 2024. The search was performed on the following online databases: CINAHL with Full-Text, MEDLINE with Full-Text, MedicLatina, LILACS, SciELO, and PubMed. The search was achieved without restrictions on the date of publication. A total of 84 articles were included in this study. The results highlight that the three concepts are different but also share some overlapping points. Spiritual distress is embedded in the rupture of their spiritual/religious belief systems, a lack of meaning in life, and existential issues. Hopelessness is a sense of giving up and an inability to control and fix the patient's situation. Finally, depression is a state of sadness with a multi-impaired situation. In conclusion, refining the three concepts in palliative care is essential since it promotes clarification and enhances knowledge development towards intervention.

Language and pain predict persistent depression among seriously ill home care clients

OBJECTIVES

This study examined potential predictors of persistent depressive symptoms in a cohort of seriously ill older adults (aged 65+ years) receiving home care services.

METHODS

This was a retrospective cohort study using secondary data collected from the Resident Assessment Instrument for Home Care for all assessments completed between 2001 and 2020. The cohort included seriously ill individuals with depressive symptoms at baseline and who continued to have depressive symptoms on reassessment within 12 months (n = 8,304). Serious illness was defined as having severe health instability, a prognosis of less than 6 months, or a goal of care related to palliative care (PC) on admission to the home care program.

RESULTS

The mean age of the sample was 80.8 years (standard deviation [SD] = 7.7), 61.1% were female, and 82.1% spoke English as their primary language. The average length of time between assessments was 4.9 months (SD = 3.3). During that time, 64% of clients had persistent symptoms of depression. A multivariate logistic regression model found that language, pain, caregiver burden, and cognitive impairment were the most significant predictors of experiencing persistent depressive symptoms.

SIGNIFICANCE OF RESULTS

Persistent depressive symptoms are highly prevalent in this population and, left untreated, could contribute to the person experiencing a "bad death." Some of the risk factors for this outcome are amenable to change, making it important to continually assess and flag these factors so interventions can be implemented to optimize the person's quality of life for as long as possible.

Subcutaneous ketamine infusion in palliative patients for major depressive disorder (SKIPMDD)-Phase II single-arm open-label feasibility study

BACKGROUND

Ketamine at subanaesthetic dosages (≤0.5mg/kg) exhibits rapid onset (over hours to days) antidepressant effects against major depressive disorder in people who are otherwise well. However, its safety, tolerability and efficacy are not known for major depressive disorder in people with advanced life-limiting illnesses.

OBJECTIVE

To determine the feasibility, safety, tolerability, acceptability and any antidepressant signal/activity to justify and inform a fully powered study of subcutaneous ketamine infusions for major depressive disorder in the palliative setting.

METHODS

This was a single arm, open-label, phase II feasibility study (Australian New Zealand Clinical Trial Registry Number-ACTRN12618001586202). We recruited adults (≥ 18-years-old) with advanced life-limiting illnesses referred to four palliative care services in Sydney, Australia, diagnosed with major depressive disorder from any care setting. Participants received weekly subcutaneous ketamine infusion (0.1-0.4mg/kg) over two hours using individual dose-titration design. Outcomes assessed were feasibility, safety, tolerability and antidepressant activity.

RESULTS

Out of ninety-nine referrals, ten participants received ketamine and were analysed for responses. Accrual rate was 0.54 participants/month across sites with 50% of treated participants achieving ≥ 50% reduction in baseline Montgomery-Åsberg Depression Rating Scale, meeting feasibility criteria set a priori. There were no clinically relevant harms encountered.

CONCLUSIONS

A future definitive trial exploring the effectiveness of subcutaneous infusion of ketamine for major depressive disorder in the palliative care setting may be feasible by addressing identified study barriers. Individual dose-titration of subcutaneous ketamine infusions over two hours from 0.1mg/kg can be well-tolerated and appears to produce transient antidepressant signals over hours to days.

Prevalence and associated factors of depressive symptoms among patients with cancer receiving radiotherapy in southern Thailand: a university hospital-based cross-sectional study

BACKGROUND

Depression in patients with cancer is frequently underestimated and causes major suffering to patients and families. This study purposed to determine the prevalence of, and factors associated with, depressive symptoms among Thai patients with cancer receiving radiotherapy. The results could promote and optimize the quality of life for patients with cancer.

METHODS

A cross-sectional study explored outpatients with cancer at Songklanagarind Hospital; from May to July 2022. The questionnaires inquired about: (1) demographic and personal data, (2) The Patient Health Questionnaire-9 (PHQ-9) Thai version, (3) Verbal Numerical Rating Scale (VNRS), and (4) The meaning in life questionnaire (MLQ). Patient demographics and depressive symptoms were analyzed using the descriptive statistic method and reported as: proportion, frequency, median and interquartile range (IQR). The analysis of the association between independent variables and depressive symptoms was conducted using multiple logistic regression, and performed by R Foundation for Statistical Computing version 4.1.2. All confidence intervals (CIs) were calculated at the 2-sided, 95% level.

RESULTS

There were 113 Thai outpatients with cancer who participated in this study. The majority of them were female (61.1%), and the overall mean age was 56.2 ± 13.6 years. The participants' cancer staging was stage 2 and 3 (31.0%, and 32.7%, respectively). No participants had experienced major depression (PHQ-9 score of nine or greater), and all of them were mild (23.0%) or no/minimal depression (77.0%). Fifty-four participants (47.8%) were free of pain, with half of them (50.4%) having insomnia. Most of them had a high score in all subparts of meaning in life. The factors associated with mild depression were the history of hospitalization, the perception of one's health, the presence of physical symptoms, and pain.

CONCLUSION

In this study, all cancer participants who received radiotherapy had either no/minimal or mild depression. No participants had major depression. Most participants had meaning in their life; however, over half of them still experienced pain and insomnia. To optimize the quality of life, and prevent depression, physical symptoms, and pain should ensure they receive adequate management. Additionally, feeling meaningful in life, and satisfaction in one's health should also be promoted.

A Phase II, Open-Label Clinical Trial of Intranasal Ketamine for Depression in Patients with Cancer Receiving Palliative Care (INKeD-PC Study)

Antidepressants require several weeks for the onset of action, a lag time that may exceed life expectancy in palliative care. Ketamine has demonstrated rapid antidepressant effects, but has been minimally studied in cancer and palliative care populations. Herein, the objective was to determine the feasibility, safety, tolerability and preliminary efficacy of intranasal racemic ketamine for major depressive disorder (MDD) in patients with advanced cancer. We conducted a single-arm, open-label phase II trial at the Princess Margaret Cancer Centre in Toronto, ON, Canada. Participants with advanced cancer with moderate to severe MDD received three flexible doses of intranasal (IN) ketamine (50−150 mg) over a one-week period. The primary efficacy outcome was an antidepressant response and remission rates as determined by the Montgomery−Åsberg Depression Rating Scale (MADRS) from baseline to the Day 8 primary endpoint. Twenty participants were enrolled in the trial, receiving at least one dose of IN ketamine, with fifteen participants receiving all three doses. The Day 8 antidepressant response (MADRS decreased by >50%) and remission (MADRS < 10 on Day 8) rates were high at 70% and 45%, respectively. Mean MADRS scores decreased significantly from baseline (mean MADRS of 31, standard deviation 7.6) to Day 8 (11 +/− 7.4) with an overall decrease of 20 points (p < 0.001). Antidepressant effects were partially sustained in the second week in the absence of additional ketamine doses, with a Day 14 mean MADRS score of 14 +/− 9.9. Common adverse effects included fatigue, dissociation, nausea, dysgeusia and headaches; almost all adverse effects were mild and transient, resolving within 2 h of each ketamine dose with one dropout related to adverse effects (negative dissociative episode). Given these promising findings, larger, controlled trials are merited.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

Associations Between Prognostic Awareness, Acceptance of Illness, and Psychological and Spiritual Well-being Among Patients With Heart Failure

BACKGROUND

This study aimed to (1) investigate the association of prognostic awareness with psychological (distress level and emotional well-being) and spiritual well-being among patients with heart failure, and (2) assess the main and moderating effects of illness acceptance on the relationship between prognostic awareness and psychological and spiritual well-being.

METHODS AND RESULTS

This study used baseline data of a Singapore cohort of patients with heart failure (N = 245) who had New York Heart Association class 3 or 4 symptoms. Patients reported their awareness of prognosis and extent of illness acceptance. Multivariable linear regressions were used to investigate the associations. Prognostic awareness was not significantly associated with psychological and spiritual well-being. Illness acceptance was associated with lower levels of distress (β [SE] = -0.9 [0.2], P < .001), higher emotional well-being (β [SE] = 2.2 [0.4], P < .001), and higher spiritual well-being (β [SE] = 5.4 [0.7], P < .001). Illness acceptance did not moderate the associations of prognostic awareness with psychological and spiritual well-being.

CONCLUSIONS

This study suggests that illness acceptance could be a key factor in improving patient well-being. Illness acceptance should be regularly assessed and interventions to enhance illness acceptance should be considered for those with poor acceptance.

Compromised end-of-life syndrome: Concept development from the condition of adults and older adults in palliative care

PURPOSE

This study aimed to develop the nursing diagnosis concept "compromised end-of-life syndrome" in palliative care.

METHODS

The authors used the integrative strategy by Meleis to develop the concept in this study and identifying clinical indicators from a literature review. For data organization, we applied the Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA).

FINDINGS

Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety, were identified. Through conceptualization, the authors propose a new nursing diagnosis, "compromised end-of-life syndrome." The manuscript includes a model case of a patient with nursing diagnosis syndrome as a clinical example.

CONCLUSIONS

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as a nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes. Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety were identified. Conceptualization was used to propose a new nursing diagnosis, "compromised end-of-life syndrome." A model case of a patient with nursing diagnosis syndrome is described as a clinical example.

CONCLUSION

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes.

Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses-A Systematic Review

CONTEXT

Currently, systematic evidence of the prevalence of clinically significant depressive symptoms in people with extremely short prognoses is not available to inform its global burden, assessment, and management.

OBJECTIVES

To determine the prevalence of clinically significant depressive symptoms in people with advanced life-limiting illnesses and extremely short prognoses (range of days to weeks).

METHODS

A systematic review and meta-analysis (random-effects model) were performed (PROSPERO: CRD42019125119). MEDLINE, Embase, PsycINFO, CINAHL, and CareSearch were searched for studies (1994-2019). Data were screened for the prevalence of clinically significant depressive symptoms (assessed using validated depression-specific screening tools or diagnostic criteria) of adults with advanced life-limiting illnesses and extremely short prognoses (defined by survival or functional status). Quality assessment was performed using the Joanna Briggs Institute Systematic Reviews Checklist for Prevalence Studies for individual studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) across studies.

RESULTS

Thirteen studies were included. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n = 10 studies; extremely short prognoses: N = 905) using depression-specific screening tools was 50% (95% CI: 29%-70%; I² = 97.6%). Prevalence of major and minor depression was 10% (95% CI: 4%-16%) and 5% (95% CI: 2%-8%), respectively. Major limitations included high heterogeneity, selection bias, and small sample sizes in individual studies.

CONCLUSIONS

Clinically, significant depressive symptoms were prevalent in people with advanced life-limiting illnesses and extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms to allow for timely intervention.

Cross-sectional Study of Prevalence and Correlates of Urinary Incontinence in Older Home-Care Clients With Type 2 Diabetes in Ontario, Canada

OBJECTIVES

Urinary incontinence (UI) is a burdensome condition for older adults with diabetes receiving home-care services, yet little is known about the prevalence and correlates of UI in this population. The objective of this cross-sectional study, informed by a complexity model, was to determine the prevalence and correlates of UI in older adults with diabetes receiving home care in Ontario, Canada.

METHODS

In this study, we analyzed population-level data of the most recently completed Resident Assessment Instrument for Home Care from 2011 to 2016 for older (≥65 years) home-care clients with diabetes. Older adults with daily or multiple daily episodes of UI were compared with adults who were continent or had less than daily UI on sociodemographic, functional, psychosocial and clinical variables. Multiple logistic regression was used to determine correlates of UI in this population.

RESULTS

Of 118,519 older adults with diabetes, 39,945 (33.7%) had daily or multiple daily episodes of UI. Correlates of UI included: impaired function in activities of daily living (odds ratio [OR], 5.31; 95% confidence interval [CI], 5.14‒5.50), cognitive impairment (OR, 2.37; 95% CI, 2.28‒2.47), female sex (OR, 1.87; 95% CI, 1.82‒1.93), multiple (≥2) chronic conditions (OR, 1.83; 95% CI, 1.74‒1.93), presence of a distressed caregiver (OR, 1.31; 95% CI, 1.27‒1.35), making economic trade-offs (OR, 1.23; 95% CI, 1.11‒1.34) and falls (OR, 1.22; 95% CI, 1.19‒1.26).

CONCLUSIONS

Urinary incontinence is common among older adults with diabetes using home-care services. Targeted interventions are required to address the social, functional and clinical factors associated with UI in this population.

What influences intentions to request physician-assisted euthanasia or continuous deep sedation?

The increasing prevalence of euthanasia in Belgium has been linked to changing attitudes. Using National health survey data (N = 9651), we investigated Belgian adults' intention to ask a physician for euthanasia or continuous deep sedation in the hypothetical scenario of a terminal illness and examined its connection to sociodemographic and health characteristics. Respectively, 38.3 and 25.8% could envisage asking for euthanasia and continuous deep sedation. Those with very bad to fair subjective health and with depression more likely had an intention to ask for euthanasia, which suggests need for attention in the evaluation of requests from specific patient groups.

The incidence of depression among residents of assisted living: prevalence and related risk factors

AIM

This study aims to recognize and estimate the prevalence of depression and its risk factors among residents of assisted living facilities (ALs) in Jordan.

BACKGROUND

Depression is commonly experienced by residents of ALs. The condition is, however, often misunderstood as a part of normal aging and may be overlooked by health care professionals. Little is known about the extent of depression and its risk factors among AL residents in Jordan.

SUBJECTS AND METHODS

A national representative sample of 221 residents selected from all AL units across Jordan was recruited to the study. Data on expected risk factors for depression were collected, including sociodemographics; smoking status; number of roommates; number of family members; assessments for cognitive functioning, for lower limb functioning, for hand, shoulder, and arm impairments; and oral health status. Levels of depression among the sample respondents were also assessed.

RESULTS

The study found that around 60% of the participants reported depressive manifestations, with 48.0% of AL residents exhibiting impaired cognitive functions, one-third (33.2%) having >50% upper limb disability, two-thirds (63.2%) being at moderate risk of falls, and 69.7% having fair to poor oral health status. Being female, and having a higher level of education, disability of the upper limbs, and impairment of cognitive functions were found to be independent risk factors for depression in participants.

CONCLUSION

Depression is relatively common among residents of AL units in Jordan. Health care professionals, nurses, physiotherapists, and dentists working in these facilities need to work cooperatively to identify the manifestations of depression in residents and collaboratively implement the best practice in the treatment of depression and circumvent its long-term impacts on the health of residents.

Communication in palliative care: the applicability of the SAGE and THYME model in Singapore

BACKGROUND

Majority of the progress and development in palliative care in the last decade has been improvements in physical aspects of treatment, namely pain and symptom management. Psychosocial aspects of care have improved, although not enough to meet the needs of many patients and family members. This is evident in many parts of the world and notably in Singapore, where palliative care is seen as an emerging medical and nursing specialty.

AIM

To discuss the implementation of the SAGE and THYME communication model in a palliative care context. The article examines the use of the model and how its implementation can improve communication between patients and nurses. The model works by reviewing contemporary developments made in relation to improving communication in palliative care. These include, highlighting the importance of meeting individual needs, therapeutic relationship building, and advanced communication training within a Singaporean context.

RESULTS

The implementation of the SAGE and THYME model can be a useful way of enabling nurses to improve and maintain effective communication in a medically dominated health care system. The challenges and constraints in educating and training nurses with limited skills in palliative care, forms part of the review, including the cultural and attitude constraints specific to Singaporean palliative care.

Changes in social engagement and depression predict incident loneliness among seriously ill home care clients

Objective:

This study identified the predictors of incident loneliness in a group of seriously ill older adults (aged 65+) receiving home care.

Method:

Existing data collected with the Resident Assessment Instrument for Home Care (RAI–HC) were utilized. A cohort of clients (N = 2,499) with two RAI–HC assessments and no self-reported loneliness at time 1 were included. Self-reported loneliness, upon reassessment, was the outcome of interest. Clients with a prognosis of less than six months or severe health instability were included.

Results:

The average length of time between assessments was 5.9 months (standard deviation = 4.10). During that time, 7.8% (n = 181) of the sample developed loneliness. In a multivariate regression model, worsening symptoms of depression, a decline in social activities, and not living with a primary caregiver all increased the risk of loneliness.

Significance of results:

These results highlight how changes in psychosocial factors over time can contribute to loneliness, which can inform clinicians as they seek to identify those who may be at risk for loneliness.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale

AIMS

Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS.

METHODS

The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment.

RESULTS

The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( r_s = 0.30, 95% CI = 0.09-0.48, P = .006).

CONCLUSION

This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

The wish to die among palliative home care clients in Ontario, Canada: A cross-sectional study

Background

In the pursuit to provide the highest quality of person centered palliative care, client preferences, needs, and wishes surrounding end of life should be used to inform the plan of care. During a clinical assessment for care services, clients may voluntarily express a ‘wish to die’ either directly to the clinician or it may be indirectly reported second-hand to the clinician through an informal caregiver or family member. This is the first study using data gathered from the interRAI Palliative Care Assessment instrument (interRAI PC) to examine socio-demographic, clinical, and psycho-social factors of palliative home care clients with the voluntary expression of a ‘wish to die now’. Factors associated with the risk for depression within this group were also identified. Awareness and understanding of clients who express the ‘wish to die’ is needed to better tailor a person-centered approach to end-of-life care.

Methods

This cross-sectional study included assessment records gathered from 4,840 palliative home care clients collected as part of pilot implementation of the interRAI PC assessment instrument in Ontario, Canada from 2006 through 2011.

Results

During the clinical assessment, 308 palliative home care clients (6.7 %) had voluntarily expressed a ‘wish to die now’. Independent factors emerging from multivariate logistic regression analyses predicting the expression of a ‘wish to die’ included not being married/widowed, a shorter estimated prognosis, depressive symptoms, functional impairment, too much sleep (excessive amount), feeling completion regarding financial/legal matters, and struggling with the meaning of life. Among persons who expressed a ‘wish to die now’, those who exhibited depressive symptoms (23.8 %, n = 64) were also more likely to exhibit cognitive impairment, have decline in cognition in the last 90 days, exhibit weight loss, have informal caregivers exhibiting distress, ‘not have a consistent positive outlook on life’ and report ‘struggling with the meaning of life’.

Conclusion

When clients voluntary express a wish to die clinicians should take notice and initiate follow-up to better understand the context of this meaning for the individual. Clients who expressed a ‘wish to die’ did not all experience pain, depression, and psychological distress suggesting an individualized approach to care management be taken.