Depressive symptoms in the frail elderly: physical and psycho-social correlates

Hospitalisation and surgery: Is exposure associated with increased subsequent depressive symptoms? Evidence from The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

The dramatic shift in the global population demographic has led to increasing numbers of older people undergoing hospitalisation and surgical procedures. While necessary, these exposures may lead to an increase in depressive symptoms.

OBJECTIVES

To determine whether hospitalisation or hospitalisation with surgery under general anaesthesia is associated with an increase in depressive symptoms in adults over the age of 50.

METHODS

Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale in 8036 individuals at waves 1 and 2 of The Irish Longitudinal Study on Ageing (TILDA), 2 years apart. Mixed-effects models were used to investigate the hypothesis after adjustment for risk factors for depression and potential confounders.

RESULTS

During the 12 months preceding wave 1, a total of 459 participants were hospitalised (mean age, 67.0; 55.3% female), and a further 548 participants (mean age, 64.6; 51.8% female) were hospitalised and underwent surgery with general anaesthesia; 6891 (mean age, 63.5; 54.3% female) were not hospitalised. Analysis of waves 1 and 2 data using mixed-effects models demonstrated that there was a 7% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.07 [1.02-1.11]) in the Center for Epidemiologic Studies Depression Scale in the hospitalisation group and a 4% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.04 [1.00-1.08]) in the surgery group compared with those with no hospitalisation.

CONCLUSION

Hospitalisation and hospitalisation with surgery and general anaesthesia are associated with increased depressive symptoms. This is the first time a longitudinal population-representative study has demonstrated this relationship for both exposures simultaneously.

Providing Care in the End of Life

As modern technology advances, people live longer and are more likely to face death later in life from chronic or degenerative diseases. The location of death has also changed, resulting in more people dying in impersonal settings. The final months in the life of George, a terminally ill 89-year-old Caucasian male are discussed from four perspectives: existential approach, the stage model of death and dying, the reinforcement model, and an integrated model. Therapeutic interventions, aimed toward assisting George in dealing with his medical condition and existential issues, consisted of the following three major components: family therapy, religiosity, and preparation for death. Ethical and therapeutic considerations related to issues of death and dying are addressed.

Depressive symptoms and frailty

BACKGROUND

Frailty and depressive symptoms are common issues facing older adults and may be associated.

OBJECTIVES

To determine if: (i) depressive symptoms are associated with frailty; (ii) there is a gradient in this effect across the range of depressive symptoms; and (iii) the association between depressive symptoms and frailty is specific to particular types of depressive symptoms (positive affect, negative affect, somatic complaints, and interpersonal relations).

METHOD

Secondary analysis of an existing population-based study was conducted.

POPULATION

In 1991, 1751 community-living adults aged 65+ years were interviewed.

MEASURES

Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Frailty was graded from 0 (no frailty) to 3 (moderate/severe frailty). Age, gender, education, marital status, self-rated health, and the number of comorbid conditions were self-reported.

ANALYSES

Logistic regression models were constructed with the outcome of no frailty/urinary incontinence only versus frailty.

RESULTS

Depressive symptoms were strongly associated with frailty, and there was a gradient effect across the entire range of the CES-D scale. The odds ratio and 95% confidence interval was 1.08 (1.06, 1.09) per point of the CES-D in unadjusted models. After potential confounding factors were adjusted, the adjusted odds ratio (95% confidence interval) was 1.03 (1.01, 1.05). Positive affect, negative affect, and somatic complaints were all associated with frailty, whereas interpersonal relations were not associated with frailty.

CONCLUSIONS

Depressive symptoms are associated with frailty. Clinicians should consider assessing frail older adults for the presence of depression.

Depression and frailty in later life: a synthetic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of acculturation on depression among older Muslim immigrants in the United States

Using a cross-sectional design, this study utilized a self-administered survey to examine the relationship between acculturation, physical and emotional health, health locus of control (LOC), life events and depression among a convenient sample of 70 immigrant Muslim elderly in United States of America. In addition to demographic variables, 5 standardized measures including the Vancouver Index of Acculturation, Center for Epidemiologic Studies Depression Scale (CESD), Iowa Self-Assessment Inventory, Multidimensional Health Locus of Control Scale, and the Geriatric Scale of Recent Life Events were utilized in this study. The results showed that about 50% of participants reported a score of 16 and above on the CESD scale, indicating a presence of depressive symptoms. In addition, most participants identified with their heritage culture compared to the American culture. The results of multiple regression analysis revealed 4 significant predictors of depression: cognitive status (β = -.34, p < .01), heritage culture (β = .35, p < .01), physical health (β = -.27, p < .05), and internal health locus of control (β = -.25, p < .05). These factors explain about 37% of the total variance in levels depression (R = .61).

Prevalence and predictors of depression in populations of elderly: a review

OBJECTIVE

To offer an update on prevalence and predictors of old age depression in populations of elderly Caucasians.

METHOD

The databases MEDLINE and Psychinfo were searched and relevant literature from 1993 onwards was reviewed.

RESULTS

The prevalence of major depression ranges from 0.9% to 9.4% in private households, from 14% to 42% in institutional living, and from 1% to 16% among elderly living in private households or in institutions; and clinically relevant depressive symptom 'cases' in similar settings vary between 7.2% and 49%. The main predictors of depressive disorders and depressive symptom cases are: female gender, somatic illness, cognitive impairment, functional impairment, lack or loss of close social contacts, and a history of depression.

CONCLUSION

Depression is frequent in populations of elderly. Methodological differences between the studies hinder consistent conclusions about geographical and cross-cultural variations in prevalence and predictors of depression. Improved comparability will provide a basis for consistent conclusions.

Psychosocial correlates of nutritional risk in older adults

The psychosocial correlates of nutritional risk among older adults were examined in a study involving 54 people over age 65 (range, 65 to 98; average, 81), who were selected through a convenience sampling strategy. Measures included a background questionnaire, Mini Nutritional Assessment, Life Satisfaction Index Form Z, Geriatric Depression Scale, and Lubben's Social Network Scale. Seventeen percent of participants were found to be at risk of malnutrition. Compared with those who had adequate nutrition, at-risk participants had lower levels of social support (approaching statistical significance, p=0.08) and life satisfaction (not significant), and significantly higher levels of depression (p=0.04). Hierarchical multiple regression analysis showed that depression and social support were significant correlates of nutritional risk (p=0.01). Nutrition professionals should have a multidisciplinary perspective when they assess older adults' nutritional status.

Diseño y validación de un cuestionario para la detección de depresión mayor en pacientes ancianos

BACKGROUND AND OBJECTIVE

The aim of this study was to design and validate a scale to detect major depressive disorders in elderly individuals in primary care (Detection of Depression in the Elderly Scale [DDES]).

METHODS

We performed an observational and cross-sectional study for the validation of a scale, administered by means of a personal interview, in 259 patients aged 65 years old or older. Available instruments were reviewed and the questions were designed. Subsequently, a first pilot study was performed. In a second pilot study the reproducibility of the instrument was analyzed. The gold standard was the result of a standardized psychiatric interview performed by psychiatrists (DSM-IV criteria and SCAN interviews).

RESULTS

The intraclass correlation coefficients corresponding to the test-retest and inter-rater reliability were 0.858 (95% confidence interval [CI], 0.634-0.946) and 0.908 (95% CI, 0.726-0.969) respectively. Two hundred sixteen subjects underwent an assessment, in which primary care and psychiatric evaluations were blinded. Major depression was diagnosed in 81 patients (37.5%; 95% CI, 31.1-44.4). The internal consistency of the DDES was good (Cronbach's alpha = 0.79). Exploratory factorial analysis revealed an 8-component structure (55.8% of explained variance). A cutoff score of 15 or more for the DDES showed sensitivity of 90.1% (95% CI, 80.95-95.33), specificity of 74.8% (95% CI, 66.48-81.71) and a likelihood ratio (+) of 3.58 (95% CI, 2.65-4.83).

CONCLUSIONS

The DDES is a clinically useful instrument for the detection of major depression in elderly patients in primary care.

Detection of depression and anxiety disorders by home care nurses

Several studies have reported that psychiatric disorders, mainly depression and anxiety disorders, were masked and undiagnosed among older adults, particularly frail elderly. This phenomenon could have a significant impact on elderly quality of life. In this study, we assessed the utility of three measures for detecting mental health disorders among frail elderly receiving home care services: (1) the PRIME-MD; (2) a standard psychological distress measure (PDI-29), and (3) the health care case manager'sa priori judgment on the subject's mental health status. Results obtained by home care nurses were compared to those obtained by clinical psychologists using a structured diagnostic interview (SCID for DSM-IV). The study was conducted in two community health service centres. During the study's period, all patients in the health care workers' caseload without cognitive impairment and not reporting significant stressful life events during the six-week period preceding the interview (n = 315) were asked to participate in the study. Results showed that 42.9% of the volunteers that agreed to meet a psychologist at home (n = 177) had a current SCID-IV diagnosis. The specificity of the PRIME-MD test performed by nurses was 83.8% and its sensitivity was 41.7%. The correct classification rate was 66.7%. Results indicated that the PDI-29 items showed better performance characteristics than the PRIME-MD in identifying current cases. The specificity of the PDI-29 was 59.0% and its sensitivity was 73.6%. These results lead us to the conclusion that the PRIME-MD, previously proposed by Spitzer, R.L., Williams, J.B., Kroenke, K., Linzer, M., DeGruy, F.V. 3rd, Hahn, S.R., et al. (1994, Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. Journal of the American Medical Association, 272 (22), 1749-1756.) to help physicians in primary care clinics, could be less appropriate than the PDI-29 when used by home care nurses in identifying undiagnosed mental health disorders in frail older adults living at home. Moreover, this study showed that the health care case manager'sa priori judgment on the care receiver's mental health status is not sufficient in identifying frail elderly mental health services needs. A two-stage screening procedure is proposed to help home care nurses.

Long-term mortality and quality of life after prolonged mechanical ventilation

OBJECTIVE

To describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation.

DESIGN

Prospective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr.

SETTING

Intensive care units at a tertiary care university hospital.

PATIENTS

Adult patients receiving prolonged mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27).

CONCLUSIONS

Mortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.

Association between medical comorbidity and treatment outcomes in late-life depression

OBJECTIVES

Previous studies have demonstrated an association between major depression and physical disability in late life. The objectives of this study were to examine the relationship between specific medical illnesses and the outcomes of treatment for late-life depression.

DESIGN

The study was a longitudinal assessment of medical illness, depression, and disability. Patients were assessed during an initial inpatient psychiatric hospitalization and 3 months postdischarge.

SETTING

All patients were initially evaluated after admission to one of 71 inpatient psychiatric treatment facilities.

PARTICIPANTS

A sample of 671 older patients who received inpatient treatment for depression was evaluated at entry into the hospital and 3 months after discharge.

MEASUREMENTS

Depressive symptoms were measured using the Geriatric Depression Scale. Disability was measured using the instrumental activities of daily living scale and the Medical Outcomes Study 36-item short form. Medical illness was assessed using the medical illness checklist.

RESULTS

As previously reported, physical disability and the total number of medical illnesses were significantly related to change in depressive symptoms. In this study, we find that arthritis, circulatory problems, a speech disorder, or a skin problem, but not other general medical conditions, were related to a worse outcome with respect to depression symptoms. The effect of these problems was statistically and clinically significant. After controlling for pretreatment disability, arthritis and skin problems continued to predict a worse outcome. However, the apparent effect of each of these conditions was mediated by the residual disability after treatment.

CONCLUSION

The results of this study support the hypothesis that certain somatic disorders play a role in the treatment response of late-life depression and suggest that the effect of specific illnesses on depression may be mediated by the presence of functional disability.

The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes

The prevalence of osteoporosis is rising as the population of the United States and other developed countries ages. These increasing numbers of people have motivated pharmaceutical companies to develop and market several antiresorptive medications that can slow down the bone loss associated with osteoporosis. Although these are not cures for this disease, they are an important first step in a vital ongoing public health effort to prevent osteoporosis in the future and to manage osteoporosis now. We cannot expect to remediate the problems caused by this disease if we attend only to its skeletal implications. Like any other chronic disease, osteoporosis has significant psychologic and social consequences. From anxiety and depression to social withdrawal and isolation, if these problems are left unresolved, they can have a significant negative impact not only on health issues but also on overall quality of life. No quick fixes exist for the numerous ways in which osteoporosis can transform an autonomous person into a dependent and hopeless patient. In part, responsibility for helping this patient rests with the medical community. Referrals to appropriate providers can improve a patient's physical and emotional well-being. Physician specialists can help the patient manage comorbid conditions. Physical and occupational therapists can teach exercises, home safety, and safe movement. Social workers can provide a framework for coping that enables individuals to improve their interpersonal interactions and minimize stress in their lives. Nutritionists, pharmacists, nurses, and other health care professionals can make major contributions to the quality of life of people with osteoporosis and should be encouraged to do so. Unfortunately, managed care has set policies that deprive patients with osteoporosis of the kinds of care that would be most useful to them. As we have advocated for the last 15 years, a multidisciplinary approach offers patients the most positive overall way to manage osteoporosis. Therefore, new alternatives need to be examined, alternatives that provide both low-cost and high-quality care. In the long run, patients who practice self-management, that is, those who take responsibility for their own calcium and vitamin D intake, are compliant with medications, exercise, and practice home safety, and who have a healthy outlook, can control their osteoporosis. The most effective intervention for the future may be to teach individuals how to use self-management strategies so that they can take charge of their osteoporosis and positively influence their quality of life.