Association between depression and hospital outcomes among older men

Prospective Association Between the Dispensing of Antidepressants and of Medications to Treat Osteoporosis in Older Age

BACKGROUND

Osteoporosis is a common condition associated with fragility fractures, especially in older individuals and women. Antidepressants have emerged as a potential risk factor, but their association with bone fragility remains uncertain because the results of past studies are difficult to generalize. We aimed to investigate the association between antidepressant exposure and subsequent treatment for osteoporosis in a nationally representative sample of Australians.

METHODS

Cohort study using a 10% random sample of the Pharmaceutical Benefits Scheme (PBS) data for 2012, that included 566,707 individuals aged older than or equal to 50 years not dispensed osteoporosis medications. The effect of exposure to antidepressants during 2012 (prevalent or incident) or later (up to 2022) was examined using Cox regression models adjusted for age, sex, comorbidities and other psychotropic medications.

RESULTS

Over 10 years, 73,360 (12.94%) received osteoporosis medications; 16,216 (22.10%) had been dispensed antidepressants in 2012. The hazard of osteoporosis medication dispensing was higher among those exposed to antidepressants (HR = 1.16, 99% CI = 1.14-1.18; average duration of follow up: 8.0 ± 3.1 years, range: 1-10 years). The hazard of osteoporosis medication diminished with increasing age, and the effect of antidepressants was 37%-76% more pronounced among men in the 50s and 60s. Different classes of antidepressants had a similar risk profile.

CONCLUSION

The dispensing of antidepressants in older age is associated with higher hazard of subsequent dispensing of medications for osteoporosis, and this association is more marked for young older adults, particularly men. Clinicians should monitor the bone health of older individuals treated with antidepressants in order to decrease the morbidity associated with fragility fractures.

Association between the mental domain of the comprehensive geriatric assessment and prolonged length of stay in hospitalized older adults with mild to moderate frailty

Introduction

Previous researches have shown the risk factors of prolonged length of stay (PLOS) in hospitalized older adults, but it is unclear what are the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Objective

To identify the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Methods

We recruited adults aged ≥65 years old with mild to moderate frailty admitted to a tertiary medical center in the southern Taiwan from June 2018 to September 2018. Each individual underwent a structural questionnaire interview within 72 h after admission and 72 h after discharge. The data were collected face-to-face, including demographic characteristics, comorbidities, length of stay (LOS), and multiple domains of the comprehensive geriatric assessment. The main outcome was PLOS.

Results

Individuals who had two or more drugs, were female, did not have cognitive impairment and had a Geriatric Depression Scale score ≥ 1 had a higher risk of PLOS (probability = 0.81), and these individuals accounted for 29% of the overall study population. Among male individuals younger than 87 years old, those with cognitive impairment had a higher risk of PLOS (probability = 0.76), and among male individuals without cognitive impairment, living alone was associated with a higher risk of PLOS (probability = 0.88).

Conclusion

Early detection and management of mood and cognition in older adults, together with comprehensive discharge planning and transition care, may be an important part of reducing LOS in hospitalized older adults with mild to moderate frailty.

Depressive Symptoms and Healthcare Utilization in Late Life. Longitudinal Evidence From the AgeMooDe Study

Objective

The aim of this study was to investigate the longitudinal impact of depressive symptoms on utilization of healthcare in terms of GP visits as well as specialist visits and hospital admission in late life among community-dwelling individuals.

Methods

Longitudinal data (baseline and follow-up) were derived from the German multicentre, prospective cohort study “Late-life depression in primary care: needs, health care utilization and costs” study (AgeMooDe). At baseline, n = 1,230 patients aged 75 years and older were recruited from primary care practices. Main outcomes of interest were use of health care services: the number of GP visits, the number of medical specialist visits, and hospital admission. We used the Geriatric Depression Scale (GDS-15) to measure depression. Outcomes were analyzed with multilevel random intercept negative binominal regression and logistic random-effects models.

Results

At baseline (n = 1,191), mean age was 80.7 (SD 4.6) years, 62.9% were female, and 196 individuals (16.5%) had depression (GDS-15 ≥6). Our longitudinal analyses indicated that older individuals with more depressive symptoms visited their GP more often (IRR=1.03; CI [1.01-1.04], p < 0.001), were visiting medical specialists more frequently (IRR=1.03; CI [1.01-1.04], p < 0.01), and had higher odds of being hospitalized (OR=1.08; CI [1.02-1.13], p < 0.01).

Conclusions

Based on this large longitudinal study we showed that, after adjustment for important covariates, older individuals with more depressive symptoms had higher health care utilization over time. They visited their GP and specialists more frequently and they had higher odds of being hospitalized. This may suggest that higher utilization of specialist care and increased likelihood of being hospitalized may be also attributable to unspecific symptoms or symptoms that are elevated through depressive symptoms.

Hearing loss, depression, and medical service utilization among older adults: evidence from China

OBJECTIVES

To acquire a better understanding of the mechanisms underlying the association between hearing loss and medical service utilization, this study examined the relationship between hearing loss, depression, and medical service utilization.

STUDY DESIGN

Using the methods of probability proportional to size, a survey conducted in 28 provinces, 150 countries/districts, 450 villages/urban communities, 11,628 households, and 19,816 individuals of China in 2018.

METHODS

The data for this article were derived from the 2018 China Health and Retirement Longitudinal Study, which enrolled 14,455 people aged 50-80 years. Hearing loss was determined using self-reported hearing status. Self-reported outpatient visits in the last month and hospitalization within the last year were used to determine medical service utilization. Depression was obtained from the CES-D-10 scale. Logistic regression and stepwise regression methods were used.

RESULTS

Older adults with hearing loss problems used significantly more outpatient care services (odds ratio [OR] = 1.292, 95% confidence interval [CI] 1.152, 1.449; P < 0.001) and inpatient care services (OR = 1.238, 95% CI 1.021, 1.501; P < 0.05) than those without hearing loss problems. Following that, individuals with hearing loss problems were more likely to experience depressive symptoms (OR = 1.467, 95% CI 1.345, 1.599; P < 0.001) than those without. Moreover, respondents with depressive symptoms used outpatient care services at a significantly higher rate (OR = 1.292, 95% CI 1.152, 1.449; P < 0.001) and inpatient care service at a significantly higher rate (OR = 1.238, 95% CI 1.021, 1.501; P < 0.05) compared with those without depressive symptom.

CONCLUSION

This article discovered that depression acted as a mediation variable in the relationship between hearing loss and medical service utilization. This research provided possible interventions for reducing the burden of the healthcare system and society that older adults with hearing loss imposed.

Relationship between the Kihon Checklist and all-cause hospitalization among community-dwelling older adults

AIM

To examine the relationship between the Kihon Checklist (KCL) and incidence of hospitalization among community-dwelling older adults.

METHOD

We analyzed the cohort data of 2920 community-dwelling adults aged ≥65 years, who were living independently in a city in Shiga prefecture. We investigated the frailty status, instrumental activities of daily living, physical function, nutritional status, oral function, homebound status, cognitive function and mood using the KCL in the baseline survey. The outcome was incident all-cause hospitalization in the 2-year period. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships between the frailty status and each domain of the KCL as well as all-cause hospitalization.

RESULTS

The prevalence of frailty, pre-frailty and robustness were 29.7%, 34.5% and 35.8%, respectively. During the 2-year follow-up period, 417 participants (14.3%) underwent an incident of all-cause hospitalization. The participants with frailty (adjusted OR 1.38, 95% CI 1.05-1.81) had a significantly elevated incidence of hospitalization according to the multivariate analysis compared with patients with robustness, but not in participants with pre-frailty (adjusted OR 1.07, 95% CI 0.82-1.40). Participants with low physical function (adjusted OR 1.45, 95% CI 1.12-1.87) and depressed mood (adjusted OR 1.35, 95% CI 1.08-1.70) had a significantly elevated incidence of hospitalization according to multivariate analysis compared with non-risk.

CONCLUSION

These results suggest that older adults with frailty are more likely to be hospitalized and that the KCL may be the screening tool to estimate the hospitalization risk. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.

Impact of depressive disorders on primary total shoulder arthroplasties: a matched control analysis of 113,648 Medicare patients

INTRODUCTION

The purpose of this study was to investigate whether patients with depressive disorders undergoing primary total shoulder arthroplasty have higher rates of (1) in-hospital lengths of stay, (2) readmission rates, (3) medical complications, and (4) implant-related complications.

METHODS

A retrospective query was performed using a national claims database. Study group patients were matched to controls in a 1:5 ratio according to age, sex, and medical comorbidities. The query yielded 113,648 patients who were with (n = 18,953) and without (n = 94,695) depressive disorders. Pearson's χ² analyses were used to compare patient demographics. Logistic regression analyses were used to calculate odds-ratios of complications and readmission rates. Welch's t-tests were used to test for significance for in-hospital lengths of stay. A p-value less than 0.003 was considered statistically significant.

RESULTS

Study group patients had significantly longer in-hospital lengths of stay (2.7 days versus 2.3 days; p < 0.0001). Patients who have depressive disorders had higher incidences and odds of readmissions (9.4 versus 6.15%; odds-ratio: 1.6, p < 0.0001), medical complications (2.7 versus 0.9%; odds-ratio: 3.0, p < 0.0001), and implant-related complications (6.1 versus 2.4%; odds-ratio: 2.59, p < 0.0001) compared to controls.

CONCLUSION

Depressive disorder patients have longer in-hospital lengths of stay and increased odds of readmissions and complications following primary total shoulder arthroplasty.

Could Frailty be an Explanatory Factor of the Association between Depression and Other Geriatric Syndromes in Later Life?

OBJECTIVES

This study aimed to investigate whether frailty could be an explanatory factor of the association between depression and the number of geriatric syndromes.

METHODS

Cross-sectional baseline data from a cohort study (MiMiCS-FRAIL) were analyzed in a sample of 315 older adults. Depression was measured according to DSM-5 criteria and a self-report questionnaire (PHQ-9). Frailty was assessed according to the FRAIL questionnaire and a 30-item Frailty Index (FI). We considered six geriatric syndromes. Multiple linear regression analyses were performed and adjusted for potential confounders.

RESULTS

Multiple linear regression analyses yielded significant associations between depression and geriatric syndromes. These associations decreased substantially in strength when frailty was added to the models. Findings were consistent for different definitions of depression and frailty.

CONCLUSIONS

Among depressed patients, frailty may be hypothesized as a causal pathway toward adverse health outcomes associated with depression. Longitudinal studies should explore the causality of this association.

CLINICAL IMPLICATIONS

Frailty should be treated or prevented in order to minimize the impact of other geriatric syndromes among depressed older adults. Screening for frailty would be of utmost importance in mental health care, as frailty is neglected especially in this field. Integrated care models are crucial for clinical practice in mental illness care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of technology for mental healthcare delivery among older adults with depressive symptoms: A systematic literature review

Depression has been identified as the single largest contributor to poor health and functioning worldwide. Global estimates indicate that 4.4% of the world's population lives with depression, equating to about 322 million individuals. Research demonstrates that telehealth interventions (i.e. delivering therapy by phone or videoconferencing) have potential for improving mental health care among community-based older adults. This review analyses scholarly literature on telehealth interventions among older adults with depressive symptoms. Following PRISMA guidelines, a systematic search of peer-reviewed papers was conducted using the following key terms: telemedicine, telepsychogeriatrics, telepsychiatry, eHealth, mental health, depression, and geriatric. The review included nine articles examining telehealth for mental health care, published in English between 1946 and 26 September 2017. Telehealth for mental health care among older adults demonstrates a significant impact on health outcomes, including reduced emergency visits, hospital admissions, and depressive symptoms, as well as improved cognitive functioning. Positive or negative influences on the use of telehealth among older adults are identified. This review highlights keys aspects to consider in using telehealth interventions, including levels of education, cognitive function, and prior technology experience. The review highlights vital factors for designing interventions which aim to capitalize on the benefits of the use of telehealth for mental healthcare service delivery, especially in older adults with depressive symptoms.

Depression is associated with self-rated frailty in older adults from an outpatient clinic: a prospective study

ABSTRACTObjectives:The aim of the present study was to evaluate the association between depression and SSRI monotherapy and frailty both baseline and prospectively in older adults.

DESIGN

Prospective cohort study, 12-month follow-up.

SETTING

Geriatric outpatient clinic in São Paulo, Brazil.

PARTICIPANTS

A total of 811 elderly adults aged 60 or older.

MEASUREMENTS

Depression was diagnosed as follows: (1) a diagnosis of major depression disorder (MDD) according to DSM-5; or (2) an incomplete diagnosis of MDD, referred to as minor or subsyndromic depression, plus Geriatric Depression Scale 15-itens ≥ 6 points, and social or functional impairment secondary to depressive symptoms and observed by relatives. Frailty evaluation was performed through the FRAIL questionnaire, which is a self-rated scale. Trained investigators blinded to the baseline assessment conducted telephone calls to evaluate frailty after 12-month follow-up. The association between depression and the use of SSRI with frailty was estimated through a generalized estimating equation adjusted for age, gender, total drugs, and number of comorbidities.

RESULTS

Depression with SSRI use was associated with frailty at baseline (OR 2.82, 95% CI = 1.69-4.69) and after 12 months (OR 2.75, 95% CI = 1.84-4.11). Additionally, depression with SSRI monotherapy was also associated with FRAIL subdomains Physical Performance (OR 1.99, 95% CI = 1.29-3.07) and Health Status (OR 4.64, 95% CI = 2.11-10.21). SSRI use, without significant depressive symptoms, was associated with subdomain Health Status (OR 1.52, 95% CI = 1.04-2.23).

CONCLUSION

It appears that depression with SSRI is associated to frailty, and this association cannot be explained only by antidepressant use.

Changes in healthcare resource use and costs associated with early versus delayed initiation of atypical antipsychotic adjunctive treatment in major depressive disorder

AIMS

The study compared all-cause and major depressive disorder (MDD)-related healthcare resource use (HRU) and costs in patients with MDD treated with atypical antipsychotic (AAP) adjunctive therapy early or later in treatment.

MATERIALS AND METHODS

Adults with MDD and antidepressant treatment (ADT) who newly initiated adjunctive aripiprazole, brexpiprazole, lurasidone, or quetiapine between October 1, 2014 and September 30, 2015 were identified in the IQVIA Real-World Data Adjudicated Claims database; the index date was the date of the first AAP claim. Patients were stratified into three cohorts: AAP initiated in the first year (Y1); in the second year (Y2); and more than 2 years (Y3) of first ADT use. Within each cohort, HRU and costs were compared between the 12 months before and after the index date. Pre-post changes in HRU and costs were then compared between cohorts.

RESULTS

Five hundred and six (36.7%) patients were categorized as Y1; 252 (18.3%) as Y2; and 622 (45.1%) as Y3. AAP use was associated with significantly decreased rates of all-cause and MDD-related hospitalization and emergency department visits, and increased rates of pharmacy fills and physician office visits; and the magnitude of changes was largest in cohort Y1. Cohort Y1 had the largest reductions in mean (±SD) all-cause medical costs per patient (-$10,496 ± $85,022, p = .015) compared to Y2 (-$2,474 ± $85,022, p = .572) and Y3 (-$472 ± $31,334, p = .823), mainly due to the reduction in hospitalization. After adjusting for differences in baseline characteristics, the largest reductions in hospitalization and medical costs were observed in cohort Y1. Similar increases in all-cause pharmacy costs were seen in all cohorts. A similar trend in costs was observed in MDD-related healthcare services.

LIMITATIONS AND CONCLUSIONS

AAP treatment was associated with reductions in all-cause and MDD-related medical costs, primarily in decreased hospitalization. The reductions were largest among patients who initiated treatment in the first year.

Health, Social, and Functional Characteristics of Older Adults With Continuing Care Needs: Implications for Integrated Care

Objective: To identify older adults who could benefit from integrated care, we examined (a) health, social, and functional characteristics of older, hospitalized adults who required continuing care on discharge and (b) associations between these characteristics and potentially unnecessary health care use. Method: Personal characteristics were extracted from patient charts (N = 214) and examined in relation to three outcomes: discharge to institutional care, unnecessary hospital stay (alternative level of care), and long hospital stay. Results: Twenty-nine percent of the sample was discharged to an institution, 32.7% was coded as alternate level of care, and 27.6% had a long length of stay. Independent predictors of potentially avoidable health care use were mental and behavioral issues, living alone, functional status, and preadmission concerns about the patient managing in the community. Discussion: High users of health care services were identifiable prior to hospital admission, supporting the use of community-based integrated care approaches.

Depression as a modifiable factor to decrease the risk of dementia

Depression is an accepted risk factor for dementia, but it is unclear if this relationship is causal. This study investigated whether dementia associated with depression decreases with antidepressant use and is independent of the time between exposure to depression and the onset of dementia. We completed a 14-year longitudinal study of 4922 cognitively healthy men aged 71-89 years, and collected information about history of past depression, current depression and severity of depressive symptoms. Other measures included use of antidepressants, age, education, smoking and history of diabetes, hypertension, coronary heart disease, and stroke. The onset of dementia and death during follow-up was ascertained via the Western Australian Data Linkage System. A total of 682 men had past (n=388) or current (n=294) depression. During 8.9 years follow-up, 903 (18.3%) developed dementia and 1884 (38.3%) died free of dementia. The sub-hazard ratios (SHRs) of dementia for men with past and current depression were 1.3 (95% confidence interval (CI)=1.0, 1.6) and 1.5 (95% CI=1.2, 2.0). The use of antidepressants did not decrease this risk. Compared to men with no symptoms, the SHRs of dementia associated with questionable, mild-to-moderate and severe depressive symptoms were 1.2 (95% CI=1.0, 1.4), 1.7 (95% CI=1.4, 2.2) and 2.1 (95% CI=1.4, 3.2), respectively. The association between depression and dementia was only apparent during the initial 5 years of follow-up. Older men with history of depression are at increased risk of developing dementia, but depression is more likely to be a marker of incipient dementia than a truly modifiable risk factor.

Higher morale is associated with lower risk of depressive disorders five years later among very old people

OBJECTIVE

The aim of this study was to investigate whether higher morale, i.e. future-oriented optimism, at baseline was associated with lower risk of depressive disorders five years later among very old people.Methods The Umeå85+/GErontological Regional Database, a population-based study with a longitudinal design, recruited participants in Sweden and Finland aged 85, 90 and ≥95 years. The sample in the present study included 647 individuals (89.1±4.4 years (Mean±SD), range 85-103). After five years, 216 were alive and agreed to a follow-up (92.6±3.4 years, range 90-104). The Philadelphia Geriatric Center Morale Scale (PGCMS) was used to assess morale. The depressive disorder diagnosis was determined according to DSM-IV based on medical records and interview data including assessment scales for depressive disorders. A number of sociodemographic, functional and health-related variables were analysed as possible confounders.Results For those with no depressive disorders at baseline, the only baseline variable significantly associated with depressive disorders five years later was the PGCMS score. A logistic regression model showed lower risk of depressive disorders five years later with higher baseline PGCMS scores (odds ratio 0.779 for one point increase in PGCMS, p<0.001). The association remained after adjusting for social isolation (p<0.1 association with depressive disorders five years later).Conclusion Our results indicate that the higher the morale, the lower the risk of depressive disorders five years later among very old people. The PGCMS seems to identify those very old individuals at increased risk of depressive disorders five years later. Preventive measures could befocused on this group.

The Impact of Depression on Discharge to Hospitals and Other Outcomes in Medicare Home Health Care Patients

The aim of this study was to determine the association of active depressive symptoms in older home health care (home care) patients and discharge to the hospital. This study was based on a cross-sectional secondary data analysis. The data were from the Montefiore Home Healthcare Agency, Bronx, New York. Patients 65 years and older who were admitted to home care in 2010 ( N = 3,761) with a valid depression screen in the medical record were included. Disposition at discharge and the Patient Health Questionnaire–2 depression screen were collected from the home care nursing assessment. Demographic and clinical factors were collected from the medical record. The adjusted odds ratio (AOR) was greater for discharge resulting in hospitalization (AOR = 1.70, 95% confidence interval = [1.29, 2.25]) among those with positive depression screens compared with those with a negative screen at the time of admission. Conclusion: Active depressive symptoms at the time of admission to home care were associated with increased odds of hospitalization at discharge. Interventions to reduce depression during the home care admission may have implications for readmission rates and overall health care utilization.

Testing of a Statewide Initiative to Enhance Depression Care in Older Home Care Patients

Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.

Depression and healthcare service utilization in patients with cancer

OBJECTIVE

It is estimated that as many as 38% of cancer patients suffer from depression, which may have distal impacts on cancer care, including clinical outcomes, health care utilization, and cost of care. The purpose of this study was to determine the impact of depression on overall healthcare utilization among patients with cancer.

METHODS

A retrospective analysis of administrative data was conducted on 5055 patients with an ICD-9 diagnosis of cancer from a single large healthcare system. Of these, 561 (11.1%) had ICD-9 diagnoses consistent with a depressive disorder. Negative binomial regression modeling was used to test the association between depression status and total annual healthcare visits for the year 2011. Logistic regression was used to examine the association between depression and secondary outcomes of emergency department visit, overnight hospitalization, and 30-day hospital readmission.

RESULTS

After adjusting for age, gender, race/ethnicity, insurance type, medical comorbidities, length of time with cancer, and metastatic status, depressed patients had significantly more annual non-mental health provider healthcare visits (aRR = 1.76, 95% CI = 1.61-1.93), and were significantly more likely to have an ED visit (OR = 2.45; 95% CI = 1.97-3.04), overnight hospitalization (OR = 1.81; 95% CI = 1.49-2.20), and 30-day hospital readmission (OR = 2.03; 95% CI = 1.48-2.79) than non-depressed patients with cancer.

CONCLUSIONS

Among patients with cancer, the presence of depression was associated with greater healthcare utilization. Effective screening for, and management of, depression may help reduce overall healthcare utilization and cost while improving care quality. Copyright © 2016 John Wiley & Sons, Ltd.

Depression as a risk factor for cognitive impairment in later life: the Health In Men cohort study

BACKGROUND

Depression is an established risk factor for dementia in later life, but it is unclear if this relationship is causal. This study aimed to determine if clinically significant depressive symptoms are likely to be causally related to cognitive impairment in later life.

METHODS

Observational cohort study of 4568 men aged 70-89 years living in Perth, Western Australia, who were free of cognitive impairment at the beginning of follow-up. Current clinically significant depressive symptoms were defined by a score of 7 or more on the Geriatric Depression Scale 15 items. Past depression was ascertained via electronic medical records, by self-report or use of antidepressants. A score of 27 or less on the Telephone Interview for Cognitive Status modified or a recorded diagnosis of dementia in electronic medical records established the presence of cognitive impairment.

RESULTS

During the 5-year follow-up, 534 men developed cognitive impairment, 811 died and 1455 were lost. The presence of clinically significant depressive symptoms at study entry was associated with increased risk rate (RR) of cognitive impairment (RR = 2.59, 95% confidence interval: 95%CI = 1.57-4.27), death (RR = 5.07, 95%CI = 3.32-7.75) and loss to follow-up (RR = 2.03, 95%CI = 1.32-3.13). These associations remained statistically significant after adjustment for age, country of birth, education, smoking history, and prevalence hypertension, diabetes, coronary heart disease and stroke. History of past clinically significant depressive symptoms was not associated with incident cognitive impairment (RR = 1.09, 95%CI = 0.78-1.52).

CONCLUSIONS

The lack of association between past depression and cognitive impairment suggests that the link between depression and cognitive impairment is not causal and that the presence of clinically significant depressive symptoms in later life may herald the onset of cognitive impairment in at least some people.

New medical diagnoses and length of stay of acutely unwell older patients: Implications for funding models

AIM

To examine the relationship between newly made medical diagnoses and length of stay (LOS) of acutely unwell older patients.

METHODS

Consecutive patients admitted under the care of four geriatricians were randomly allocated to a model development sample (n = 937) or a model validation sample (n = 855). Cox regression was used to model LOS. Variables considered for inclusion in the development model were established risk factors for LOS and univariate predictors from our dataset. Variables selected in the development sample were tested in the validation sample.

RESULTS

A median of five new medical diagnoses were made during a median LOS of 10 days. New diagnoses predicted an increased LOS (hazard ratio 0.90, 95% confidence interval 0.88-0.92). Other significant predictors of increased LOS in both samples were malnutrition and frailty.

CONCLUSIONS

Identification of new medical diagnoses may have implications for Diagnosis Related Groups-based funding models and may improve the care of older people.

Health care expenditures associated with depression in adults with cancer

BACKGROUND

The rates of depression in adults with cancer have been reported as high as 38%-58%. How depression affects overall health care expenditures in individuals with cancer is an under-researched area.

OBJECTIVE

To estimate excess average total health care expenditures associated with depression in adults with cancer by comparing those with and without depression after controlling for demographic, socioeconomic, access to care, and other health status variables.

METHODS

Cross-sectional data on 4,766 adult survivors of cancer from 2006-2009 of the nationally representative household survey, Medical Expenditure Panel Survey (MEPS), were used. The patients were older than 21 years. Cancer and depression were identified from the patients' medical conditions files. Dependent variables consisted of total, inpatient, outpatient, emergency department, prescription drugs, and other expenditures. Ordinary least square (OLS) on logged dollars and generalized linear models with log-link function were performed. All analyses (SAS 9.3 and STATA12) accounted for the complex survey design of the MEPS.

RESULTS

Overall, 14% of individuals with cancer reported having depression. In those with cancer and depression, the average annual health care expenditures were $18,401 compared with $12,091 in those without depression. After adjusting for demographic, socioeconomic, access to care, and other health status variables, those with depression had about 31.7% greater total expenditures compared with those without depression. Total, outpatient, and prescription expenditures were higher in individuals with depression than in those without depression. Individuals with cancer and depression were significantly more likely to use emergency departments (adjusted odds ratio, 1.46) compared with their counterparts without depression.

LIMITATIONS

Cancer patients who died during the reporting year were excluded. The financial burden of depression may have been underestimated because the costs of end-of-life care are high. The burden for each cancer type was not analyzed because of the small sample size.

CONCLUSION

In adults with cancer, those with depression had higher health care utilization and expenditures compared with those without depression.

FUNDING/SPONSORSHIP

One author was partially supported by the National Institute of General Medical Sciences, U54GM104942.

Does life satisfaction predict five-year mortality in community-living older adults?

OBJECTIVES

Depression and depressive symptoms predict death, but it is less clear if more general measures of life satisfaction (LS) predict death. Our objectives were to determine: (1) if LS predicts mortality over a five-year period in community-living older adults; and (2) which aspects of LS predict death.

METHOD

1751 adults over the age of 65 who were living in the community were sampled from a representative population sampling frame in 1991/1992 and followed five years later. Age, gender, and education were self-reported. An index of multimorbidity and the Older American Resource Survey measured health and functional status, and the Terrible-Delightful Scale assessed overall LS as well as satisfaction with: health, finances, family, friends, housing, recreation, self-esteem, religion, and transportation. Cox proportional hazards models examined the influence of LS on time to death.

RESULTS

417 participants died during the five-year study period. Overall LS and all aspects of LS except finances, religion, and self-esteem predicted death in unadjusted analyses. In fully adjusted analyses, LS with health, housing, and recreation predicted death. Other aspects of LS did not predict death after accounting for functional status and multimorbidity.

CONCLUSION

LS predicted death, but certain aspects of LS are more strongly associated with death. The effect of LS is complex and may be mediated or confounded by health and functional status. It is important to consider different domains of LS when considering the impact of this important emotional indicator on mortality among older adults.

Prevalência de sintomas depressivos entre idosos em um serviço de emergência

OBJETIVOS: Estimar a prevalência de sintomas depressivos entre idosos internados no Serviço de Emergência do Hospital de Clínicas de Porto Alegre-RS e verificar a associação entre sintomas depressivos e características sociodemográficas e de utilização de serviços de saúde pelos idosos. MÉTODOS: Estudo transversal com 96 idosos internados em um serviço de emergência. A presença de sintomas depressivos foi avaliada por meio da aplicação da Escala de Depressão Geriátrica - versão reduzida (EDG-15), e foi aplicado instrumento sobre variáveis sociodemográficas e de utilização dos serviços de saúde. Foram realizadas análises descritivas e bivariáveis, e o nível de significância estatística adotado foi de 5% (p≤0,05). RESULTADOS: Encontrou-se a prevalência de 36,5% de sintomas depressivos na amostra, sendo que destes, 6,3% dos idosos apresentavam pontuação sugestiva de depressão grave. Identificou-se associação significativa entre sintomas depressivos e viuvez, observando-se que os sintomas depressivos foram mais frequentes entre as mulheres, os de baixa escolaridade e os que não utilizaram serviços de saúde. CONCLUSÃO: O estudo encontrou alta prevalência de sintomas depressivos entre idosos internados no serviço de emergência. Ressalta-se a importância do reconhecimento e realização do diagnóstico de depressão em idosos nesses serviços com objetivo de se trabalhar com uma visão ampliada do processo de saúde-doença, oferecer tratamento e melhores intervenções na rede.

Cross-sectional associations of depressive symptom severity and functioning with health service use by older people in low-and-middle income countries

Background: Comprehensive understanding of the determinants of health service use (HSU) by older people with depression is essential for health service planning for an ageing global population. This study aimed to determine the extent to which depressive symptom severity and functioning are associated with HSU by older people with depression in low and middle income countries (LMICs). Methods: A cross-sectional analysis of the 10/66 Dementia Research Group population-based surveys dataset. Participants (n = 4590) were those aged 65 or older, in the clinical range for depressive symptoms (defined as scoring four or more on the EURO-D), living in 13 urban and/or rural catchment areas in nine LMICs. Associations were calculated using Poisson regression and random-effects meta-analysis. Results: After adjustment for confounding variables, (EURO-D) depressive symptom severity was significantly associated with “any community HSU” (Pooled Prevalence Ratios = 1.02; 95% CI = 1.01–1.03) but not hospital admission. Conversely, after adjustment, (WHODAS-II) functioning was significantly associated with hospital admission (Pooled PR = 1.14; 95% CI = 1.02–1.26) but not “any community HSU”. Conclusions: Depressive symptom severity does not explain a large proportion of the variance in HSU by older people with depression in LMICs. The association of functioning with this HSU is worthy of further investigation. In LMICs, variables related to accessibility may be more important correlates of HSU than variables directly related to health problems.

Depressive symptomatology in severe dementia in a European sample: prevalence, associated factors and prescription rate of antidepressants

BACKGROUND

Depression is a common comorbid disorder of dementia. This study explores the prevalence of and factors associated with depressive symptomatology, and antidepressant prescription rates in severe dementia across eight European countries.

METHODS

In total, 414 people with severe dementia completed measures of cognition and quality of life (QoL), whilst carers completed proxy measures of activities of daily living (ADLs), depression, neuropsychiatric symptoms, QoL and comorbidity.

RESULTS

Findings indicated that 30% of the sample had depression, whilst the highest and lowest prevalence of depression was reported in Germany and Finland, respectively. Lower QoL, the presence of pain and more frequent neuropsychiatric symptoms were associated with depressive symptomatology, whilst no significant relationship between impairment of ADLs, comorbidity, and depression emerged. Spain and Estonia had the highest and lowest rates of antidepressant prescribing, respectively, whilst Germany had the highest discrepancy between depressive symptomatology and prescription.

CONCLUSIONS

The study highlights variations across countries in the prevalence of depressive symptomatology in severe dementia and prescription of antidepressants. Information about factors associated with depressive symptomatology may help to better identify and manage depression.

Association of antidepressant treatment with emergency admission to medical units for patients 65 years or older

INTRODUCTION

There is increasing evidence relating the presence of depression in seniors and the risk of hospital admission in medical departments from the Emergency Services.

OBJECTIVE

To determine the impact of antidepressant treatment (ATD) as a protective factor for emergency hospitalization in older people.

METHOD

All patients aged 65 and over who required urgent attention for medical reasons at the Emergency Department of the Corporació Sanitària i Universitària Parc Taulí (Sabadell, Barcelona, Spain) for the period between January and October 2012 were included in the study. Sociodemographic variables, alcohol and tobacco use, medical history and psychopharmacological treatment were obtained. The necessary sample size was calculated and a simple randomization was performed. Subsequently, a descriptive statistical analysis and parametric tests were conducted.

RESULTS

A total of 674 patients (53% women) were evaluated, with a mean age of 78.45 years, and 27.6% of the cases (71% women) were receiving ATD. Among the 333 admitted patients (50%), 83 individuals (24.6%) had previously received ATD; this contrasts with the 103 cases (30.6%) of prior ATD treatment among the patients who were not admitted. After comparative analysis, the relationship between previous use of ATD and being admitted to hospital was not statistically significant in our global sample. This relationship was only statistically significant among the group aged 75 and over (neg. sig. 0.012).

CONCLUSIONS

In our study, ATD was associated with a decreased risk of hospital admission for urgent medical conditions in people aged 75 and over. Treating depression may protect the elderly against admission to the Emergency department and may potentially be a quality criterion in preventing complications in this population.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Psychotherapeutic work with older patients]

Despite the high prevalence of mental illness in Germany, elderly people are significantly under-represented in psychotherapeutic treatment. This is not only due to their own reservations about psychotherapy but also to a greater extent a reflection of the models of old age in our society. Deficit-oriented theories dating back to the origins of psychotherapy in the last century are still widespread leading to fear of contact with consultants and therapists.The specific methods of psychotherapeutic work with older patients are presented. Methodologically, the treatment of elderly patients with depressive disorders has been elaborately worked out. In addition, detailed psychotherapeutic programs have also been developed for anxiety disorders, trauma-related diseases and dementia. Overall, relatively little research has been done in the field of geriatric psychotherapy despite the fact that from the scientific and clinical perspectives, different approaches or methods, such as cognitive-behavioral therapy, interpersonal therapy, psychodynamic therapy, as well as systemic therapy, can be considered effective and may be applied to the entire spectrum of mental disorders in old age.

The Kimberley assessment of depression of older Indigenous Australians: prevalence of depressive disorders, risk factors and validation of the KICA-dep scale

Objective

This study aimed to develop a culturally acceptable and valid scale to assess depressive symptoms in older Indigenous Australians, to determine the prevalence of depressive disorders in the older Kimberley community, and to investigate the sociodemographic, lifestyle and clinical factors associated with depression in this population.

Methods

Cross-sectional survey of adults aged 45 years or over from six remote Indigenous communities in the Kimberley and 30% of those living in Derby, Western Australia. The 11 linguistic and culturally sensitive items of the Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep) scale were derived from the signs and symptoms required to establish the diagnosis of a depressive episode according to the DSM-IV-TR and ICD-10 criteria, and their frequency was rated on a 4-point scale ranging from ‘never’ to ‘all the time’ (range of scores: 0 to 33). The diagnosis of depressive disorder was established after a face-to-face assessment with a consultant psychiatrist. Other measures included sociodemographic and lifestyle factors, and clinical history.

Results

The study included 250 participants aged 46 to 89 years (mean±SD = 60.9±10.7), of whom 143 (57.2%) were women. The internal reliability of the KICA-dep was 0.88 and the cut-point 7/8 (non-case/case) was associated with 78% sensitivity and 82% specificity for the diagnosis of a depressive disorder. The point-prevalence of a depressive disorder in this population was 7.7%; 4.0% for men and 10.4% for women. Heart problems were associated with increased odds of depression (odds ratio = 3.3, 95% confidence interval = 1.2,8.8).

Conclusions

The KICA-dep has robust psychometric properties and can be used with confidence as a screening tool for depression among older Indigenous Australians. Depressive disorders are common in this population, possibly because of increased stressors and health morbidities.

Prevention of depression in older age

Depression is a common disorder in later life that is associated with increased disability and costs, and negative health outcomes over time. Antidepressant treatments in the form of medications or psychotherapy are available, but a large proportion of those treated fail to respond fully, and relapse or recurrence of symptoms is frequent among those who recover. Hence, successful prevention would avoid these negative outcomes. This paper selectively reviews currently available observational and trial data on the prevention of depression. It initially reviews risk factors associated with depression, and then discusses strategies for primary (including universal, selective and indicated), secondary and tertiary prevention. Currently available evidence suggests that selective and indicated preventive interventions are feasible and initial results look promising. Existing trial data indicate that ongoing antidepressant treatments reduce the risk of relapse and recurrence of symptoms, but benefits may not extend beyond two or three years. At this point in time, no interventions have been shown to reduce the long term complications associated with depression. Mental health professionals will need to work collaboratively to develop primary, secondary and tertiary preventive interventions that are effective at targeting relevant risk factors systematically and that can be easily adopted into clinical practice.

Depression and anxiety among high-risk obstetric inpatients

OBJECTIVE

To assess the following among women hospitalized antenatally due to high-risk pregnancies: (1) rates of depression symptoms and anxiety symptoms, (2) changes in depression symptoms and anxiety symptoms and, (3) rates of mental health treatment.

METHODS

Sixty-two participants hospitalized for high-risk obstetrical complications completed the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder 7-item scale (GAD-7) and Short-Form 12 weekly until delivery or discharge, and once postpartum.

RESULTS

Average length of total hospital stay was 8.3 ± 7.6 days for women who completed an initial admission survey (n = 62) and 16.3 ± 8.9 (n = 34), 25.4 ± 10.2 (n = 17) and 35 ± 10.9 days (n = 9) for those who completed 2, 3 and 4 surveys, respectively. EPDS was ≥ 10 in 27% (n=17) and GAD-7 was ≥ 10 in 13% (n = 8) of participants at initial survey. Mean anxiety (4.2 ± 6.5 vs. 5.2 ± 5.1, p = .011) and depression (4.4 ± 5.6 vs. 6.9 ± 4.8, p = .011) scores were lower postpartum compared to initial survey. Past mental health diagnosis predicted depression symptoms [odds ratio (OR) = 4.54; 95% confidence interval (CI) 1.91-7.17] and anxiety symptoms (OR = 5.95; 95% CI 3.04-8.86) at initial survey; however, 21% (n = 10) with no diagnostic history had EPDS ≥ 10. Five percent (n = 3) received mental health treatment during pregnancy.

CONCLUSION

Hospitalized high-risk obstetrical patients may commonly experience depression symptoms and/or anxiety symptoms and not receive treatment. A history of mental health treatment or diagnosis was associated with depression symptoms or anxiety symptoms in pregnancy. Of women with an EPDS ≥ 10, > 50% did not report a past mental health diagnosis.

Depression and anxiety in Singaporean high-risk pregnancies - prevalence and screening

OBJECTIVE

Data on psychiatric morbidity in high-risk pregnant Singaporean women are limited. This study aimed to establish the prevalence of antenatal depression and anxiety in high-risk pregnancies, compare the prevalence of antenatal depression in high-risk pregnancies vs. pregnancies of unspecified obstetric risk and examine the Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Inventory (STAI) as screening tools for these disorders.

METHOD

Two hundred high-risk pregnant inpatients at a national public maternity hospital were included. Three psychometric assessment tools were used to evaluate all participants: the diagnostic Mini International Neuropsychiatric Interview and the screening EPDS and STAI.

RESULTS

Rates of major depression, minor depression, anxiety disorder (agoraphobia, generalized anxiety disorder, panic disorder), and comorbid depression and anxiety were 11%, 7%, 12.5% and 5%, respectively. Major depression was more prevalent in high-risk pregnancies than in the historical cohort of unspecified obstetric risk (11% versus 4.3%). EPDS (cutoff 8/9) screens well for depression and anxiety in high-risk pregnancies (area under the receiver operating characteristic curve=0.82-0.87).

CONCLUSION

Antenatal depression and anxiety are highly prevalent in a sample of high-risk pregnant Singaporean women. EPDS performs well in screening for depression and anxiety in high-risk pregnant women, with further psychiatric assessment recommended for women with score ≥ 9.