Depression in the elderly. Tailoring medical therapy to their special needs

The Association between Family Mealtime and Depression in Elderly Koreans

Background

Several studies have revealed the frequency of family mealtimes to be inversely associated with depressive symptoms in adolescents. However, there have been few studies in older populations. This cross-sectional study investigated the association between family mealtime frequency and depressive symptoms in elderly Koreans.

Methods

This study analyzed 4,959 elderly men and women (aged 65 years or older) who participated in the Korea National Health and Nutrition Examination Survey. Self-administered questionnaires were used to assess depressive status, family mealtime frequency, and covariates. Multiple logistic regression analysis was performed to evaluate the association using the eating alone group as a reference.

Results

After adjusting for all covariates, participants who had family meals 3 times a day had fewer depressive symptoms than the eating alone group; adjusted odds ratios (ORs) (95% confidence intervals [CIs]) were 0.72 (0.58– 0.89) for point depressiveness/anxiety and 0.73 (0.56–0.94) for depressiveness lasting for at least 2 weeks. In suicidal ideation, the OR (95% CI) of eating with family twice a day was significant after full adjusting for covariates at 0.67 (0.50–0.88).

Conclusion

Family mealtimes were closely associated with depressive symptoms in elderly Koreans, which suggests that maintaining intrafamilial bonding is important for mental health in an older population.

Applications of magnetic resonance imaging for treatment-resistant late-life depression

Late-life depression (LLD) is a growing public and global health concern with diverse clinical manifestations and etiology. This literature review summarizes neuroimaging findings associated with depression in older adults and treatment-response variability. LLD has been associated with cerebral atrophy, diminished myelin integrity, and cerebral lesions in frontostriatal-limbic regions. These associations help explain the depression-executive dysfunction syndrome observed in LLD, and support cerebrovascular burden as a pathogenic mechanism. Furthermore, this review suggests that neuroimaging determinants of treatment resistance also reflect cerebrovascular burden. Of the theoretical etiologies of LLD, cerebrovascular burden may mediate treatment resistance. This review proposes that neuroimaging has the potential for clinical translation. Controlled trials may identify neuroimaging biomarkers that may inform treatment by identifying depressed adults likely to remit with pharmacotherapy, identifying individualized therapeutic dose, and facilitating earlier treatment response measures. Neuroimaging also has the potential to similarly inform treatment response variability from treatment with aripiprazole (dopamine modulator) and buprenorphine (opiate modulator).

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.

Screening for geriatric depression in residential care facilities: a systematic narrative review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.

Psychiatric disorders impacting critical illness

An astounding 30% to 50% of older patients who are hospitalized for a medical condition also have a psychiatric disorder. The intent of this article is to prepare acute care nurses to meet the mental health needs of older adults with a critical illness and prevent untoward sequelae of medical events. The authors discuss the importance of baseline assessment data, issues related to informed consent, manifestations of common psychiatric disorders that may be seen in older adults in the acute care setting, as well as strategies to improve patient outcomes.

Caring for depressed elderly in the emergency department: establishing links between sub-acute, primary, and community care

Elderly patients presenting to St. Vincent's Health Emergency Department (ED) constitute approximately one third of presentations. A significant proportion of these involve preexisting conditions including depression that, within elderly patients, is associated with social isolation, physical and mental health problems, and barriers to accessing community services. It is also often overlooked as a clinical diagnosis among the elderly. This study aimed to assess the efficacy of a brief depression screening tool and examine the change over time in quality of life and social factors for elderly patients who present to ED. Patients aged 65 years and over were screened for depression using a short form of the Geriatric Depression Scale (GDS-15). Participants were randomized into control (usual care) and intervention (an assertive outreach community management program) groups and assessed in relation to depression, quality of life, and social support/functioning at recruitment and 6 weeks post discharge. Approximately one in four participants experienced mild to moderate depression that was related to medical factors and associated reduced mobility. This study suggests that an assertive outreach program, with the inclusion of community intervention and links to social supports and services, could improve the management of depression in the elderly and associated health outcomes.

Rates of depression and participation in senior centre activities in community-dwelling older persons

The purpose of this study was to determine the role that senior citizen centres play in decreasing depression in community-dwelling older persons. A quantitative cross-sectional design was utilized. A questionnaire was used to determine demographic and lifestyle data. The dependent variable, depression symptoms, was measured using the 15-point Geriatric Depression Scale. Eighty-eight per cent stated that they attend for the friends and social support. Second, the study demonstrated that community-dwelling older persons can have those needs fulfilled at the senior centres. Ninety-four per cent of them have made close friends at their centres. Ninety-four per cent stated that their lives had improved since attending the senior centre. Eighty-six per cent felt they had made friends on whom they could rely when needed.

Pharmacologic management of the older woman undergoing surgery

Surgical intervention for both emergency and elective surgeries will increase as women live longer and maintain active lifestyles. Older women with operable conditions tolerate elective gynecologic and other nonvascular surgery with acceptable morbidity and mortality. However, increased medical comorbidities, with their associated increase in polypharmacy and perioperative risks as women age, make it important to a priori optimize perioperative medical conditions and medication management. Other considerations include assessing functional and cognitive status, since these may be impaired acutely with increased prevalence of drug use during surgical hospitalization. With aging and postmenopausal status, changes associated with aging appear to play a greater role than gender in pharmacologic responses. Surgical outcomes should be optimized to maintain and even improve women's quality of life.

An evidence-based review of the clinical use of sertraline in mood and anxiety disorders

Sertraline is a selective serotonin reuptake inhibitor that has been used and studied extensively throughout the world and found to be safe and well tolerated in numerous patient populations, including those with either psychiatric and/or medical comorbidities. Randomized clinical trials have shown that it is an effective treatment for depressive and anxiety disorders and its efficacy is unaffected by psychiatric comorbidity. In non-comorbid patients, sertraline is effective for the acute treatment of major depressive disorders and prevention of relapse or recurrence. It is effective for acute treatment and longer-term management of social anxiety disorder, posttraumatic stress disorder,panic disorder, and generalized anxiety disorder. In adults and in pediatric patients, it is an effective short-term and long-term treatment for obsessive compulsive disorder.Sertraline has a good tolerability profile and has low fatal toxicity. In summary, sertraline is as effective as other antidepressants over a wide range of indications but may offer tolerability benefits as well as efficacy in patients with psychiatric and/or medical comorbidities and certain subtypes of depression.

Increased plasma levels of 8-iso-PGF2alpha and IL-6 in an elderly population with depression

Oxidative damage and immune-inflammatory activation have been suggested to play a role in depression. The purpose of the study was to investigate possible associations and interactions of these pathophysiological mechanisms in geriatric depression by determining the levels of plasma 8-iso-prostaglandin F(2alpha) (8-iso-PGF(2alpha)) and interleukin-6 (IL-6) in elderly depressed individuals. Subjects over 60 years of age with depression and controls were randomly selected from a population in the community after screening with the Geriatric Depression Scale. Plasma concentrations of 8-iso-PGF2alpha and IL-6 were measured in both groups. Depressed patients had significantly higher mean (+/-S.D.) 8-iso-PGF2alpha levels compared to healthy controls (245.01+/-179.92 pg/ml vs 97.64+/-42.72 pg/ml, respectively). Similarly, the same groups demonstrated significantly elevated IL-6 levels compared with controls (58.73+/-39.90 pg/ml vs 15.41+/-9.27 pg/ml). This study indicates an association between increased levels of plasma 8-iso-PGF2alpha and IL-6 with depressive symptomatology in elderly individuals and indicates the necessity for further investigation, possibly within the framework of an integrated involvement of oxidative damage and inflammation in the pathophysiology of depression in the elderly.

Depression and cancer: an unexplored and unresolved emergent issue in elderly patients

Despite the high prevalence of depressive disorders in cancer patients and elderly people, the topic of depression in elderly cancer patients still remains unexplored. This emerges from a systematic review of the literature conducted to investigate issues of depression, diagnosis, pathogenesis, treatment and their complex neuroimmunobiological interactions. Indeed, it becomes apparent that depression in elderly patients with cancer may have a peculiar phenomenology. In addition, the moderate rate of major depressive disorder and the high rate of minor depressive disorder are accompanied by subthreshold forms of depression that are at risk to be underrecognized and untreated. Immune dysfunction may represent a common pathogenic ground of depression, cancer and aging. This may have important implications for treatment. In the near future, we need to develop validated mood disorder diagnoses and verify antidepressant treatment efficacy for elderly cancer patients with depression in order to improve their clinical outcome and quality of life.

Depressive symptomatology, medication persistence, and associated healthcare costs in older adults with glaucoma

PURPOSE

Depressive symptoms may impact patients' medication use behavior and utilization of healthcare services. This study examined association between depressive symptoms and Glaucoma medication-related persistence and predictors of associated healthcare charges in older adults with primary open angle Glaucoma.

METHODS

This study used a retrospective cohort of older adults with primary open angle Glaucoma who completed health status assessment, used Glaucoma medications, and were enrolled in a Medicare Health Maintenance Organization. Baseline assessment surveyed patients on demographics, healthcare service utilization in year before enrollment, lifestyle, and quality of life. Demographic, clinical, and utilization-related economic variables were retrieved from administrative claims database of patients' Health Maintenance Organization. Survival techniques were used to measure time to discontinuation (persistence) and Center for Epidemiologic Studies Depression Scale a 20-item self-reporting scale assessed depressive symptomatology on a range of 0 to 60. Associations were examined using mixed-model regression approach. Sensitivity analysis that considered log-transformed and untransformed specifications of cost variable tested model appropriateness.

RESULTS

In total 268 patients were followed for 2 years (N=536). After controlling for potential confounders and temporal effects, depressive symptomatology was associated with decreased Glaucoma medication-related persistence (P<0.005). Patients who lived alone and had cardiovascular disease showed higher odds of experiencing depressive symptoms (P<0.005). Healthcare charges increased with number of comorbidities and prescriptions (P<0.005).

CONCLUSIONS

Presence of depressive symptoms in patients lead to poor Glaucoma medication use behavior. Healthcare expenditures increased for patients with increase in comorbidities. Plan enrollees' risk assessment offers advantage of improving health outcomes and reduces healthcare utilization.

Gender-specific and gender-sensitive associations with psychological health and morbidity in older age. Baseline findings from a British population survey of ageing

OBJECTIVE

To examine gender-specific and gender-sensitive factors associated with psychological health and morbidity.

DESIGN

Face-to-face home interview survey of random sample of 999 people aged 65 and over living in Britain.

RESULTS

A fifth of respondents had symptoms of psychological morbidity. Men with high self-efficacy had over six times the odds of men with lower levels, of scoring as a non-case with the 12-item General Health Questionnaire (GHQ-12). Women with excellent to good health status had over five times the odds of those in worse health of scoring as a non-case. Self-efficacy and mobility were the strongest independent predictive variables of GHQ score among men; health status and subjective QoL were the strongest, independent predictors among women.

DISCUSSION

This paper is unique in examining in detail the independent, gender-specific and gender-sensitive predictors of psychological morbidity in a national random sample of older adults. Optimism, self-efficacy, quality of life and mobility were gender-specific predictors, and health status was a gender-sensitive predictor of psychological morbidity. These differences suggest that interventions aiming to improve the mental health outcomes of older people need to be guided by evidence on risk factors by gender.

Elevation of plasma concentration of adhesion molecules in late-life depression

OBJECTIVES

Late-life depression may be associated with vascular disease. The purpose of the study was to investigate this association by determining the levels of soluble adhesion molecules (sICAM-1 and sVCAM-1) which represent markers of ischemia-induced inflammation in elderly individuals with depression.

METHODS

Blood samples were obtained from 33 subjects with depression selected from a community-dwelling population after screening with the Geriatric Depression Scale, and 33 matched controls. Serum concentrations of sICAM-1 (ng/mL) and sVCAM-1 (ng/mL) were measured in both groups.

RESULTS

Depressed patients (Group A) possessed significantly higher sICAM-1 levels compared to healthy controls (Group B) (674.94 +/- 166.90 ng/ml vs 467.05 +/- 231.26 ng/ml, respectively, p < 0.01). Similarly the same groups demonstrated elevated sVCAM-1 levels compared to controls (572.14 +/- 182.20 ng/ml vs 449.04 +/- 285.27 ng/ml, p < 0.05); a difference that in both cases remained significant after adjustment for potential confounders (gender, smoking, presence of metabolic syndrome).

CONCLUSION

These findings indicate an association between high serum levels of VCAM-1, and ICAM-1 and depression in the elderly and further support the vascular depression hypothesis, which has important implications for the understanding and management of late-life depression.

Mood disorders in the elderly

Mood disorders in the elderly are a growing source of morbidity and mortality. Unfortunately, mood disorders in later life frequently are not diagnosed and treated. Appropriate, prompt diagnosis and treatment of late-life mood disorders can significantly improve the quality of life of patients and families and may prove life saving. Current treatments can help most older adults with mood disorders. Future treatments are promising, particularly for those with treatment-resistant depression.

Effect of a qigong exercise programme on elderly with depression

OBJECTIVES

This report released findings of a randomized controlled trial conducted in Hong Kong to further our understanding of the psychosocial effects of qigong on elderly persons with depression.

DESIGN

Eighty-two participants with a diagnosis of depression or obvious features of depression were recruited and randomly assigned into the intervention and comparison group. The intervention group was given a 16-week period of Qigong practice while the comparison group participated in a newspaper reading group with same duration and frequency.

RESULTS

After eight weeks of qigong practice, the intervention group participants outstripped themselves in improvement in mood, self-efficacy and personal well being, and physical and social domains of self-concept when compared with comparison subjects. After 16 weeks of practice, the improvement generalized to the daily task domain of the self-concept.

CONCLUSIONS

This report shows that regular qigong practice could relieve depression, improve self-efficacy and personal well being among elderly persons with chronic physical illness and depression.

Rehabilitation of the Older Adult with Stroke

Stroke is an increasing public health concern throughout the world as the leading cause of long-term disability. It is well known that there exist differences related to epidemiology, pathophysiology, comorbidity, and functional outcome of stroke patients with advanced age compared with the young. Factors that have been suggested to influence this disparity include age-related complications, availability of resources, lack of aggressive management, and possible diminished capacity for neuroplasticity. This article reviews the current medical and rehabilitative aspects of stroke and the possible disparities related to advanced age.

Risk of the "androgen deprivation syndrome" in men receiving androgen deprivation for prostate cancer

BACKGROUND

Androgen deprivation therapy for prostate cancer has been associated with a spectrum of adverse effects, such as depression, memory difficulties, and fatigue, termed the androgen deprivation syndrome. Primary care physicians providing follow-up care for men with prostate cancer will be faced with managing these effects. We therefore sought to estimate the incidence of these effects and, by using a control group, ascertain whether these effects were related to androgen deprivation itself.

METHODS

We assessed the risk of physician diagnoses of depression, cognitive impairment, or constitutional symptoms in Medicare data following androgen deprivation using a sample of 50 613 men with incident prostate cancer and 50 476 men without cancer, from 1992 through 1997, in the linked Surveillance, Epidemiology, and End Results-Medicare database. Cox proportional hazards regression was used to adjust for confounding variables.

RESULTS

Of men surviving at least 5 years after diagnosis, 31.3% of those receiving androgen deprivation developed at least 1 depressive, cognitive, or constitutional diagnosis compared with 23.7% in those who did not (P<.001). After adjustment for variables such as comorbidity, tumor characteristics, and age, the risks associated with androgen deprivation were substantially reduced or abolished: relative risk (RR) for depression diagnosis, 1.08 (95% confidence interval [CI], 1.02-1.15); RR for cognitive impairment, 0.99 (95% CI, 0.94-1.04); and RR for constitutional symptoms, 1.17 (95% CI, 1.13-1.22).

CONCLUSION

Depressive, cognitive, and constitutional disorders occur more commonly in patients receiving androgen deprivation, but this appears to be primarily because patients receiving androgen deprivation are older and have more comorbid conditions and more advanced cancers.

Risk of the "androgen deprivation syndrome" in men receiving androgen deprivation for prostate cancer

BACKGROUND

Androgen deprivation therapy for prostate cancer has been associated with a spectrum of adverse effects, such as depression, memory difficulties, and fatigue, termed the androgen deprivation syndrome. Primary care physicians providing follow-up care for men with prostate cancer will be faced with managing these effects. We therefore sought to estimate the incidence of these effects and, by using a control group, ascertain whether these effects were related to androgen deprivation itself.

METHODS

We assessed the risk of physician diagnoses of depression, cognitive impairment, or constitutional symptoms in Medicare data following androgen deprivation using a sample of 50 613 men with incident prostate cancer and 50 476 men without cancer, from 1992 through 1997, in the linked Surveillance, Epidemiology, and End Results-Medicare database. Cox proportional hazards regression was used to adjust for confounding variables.

RESULTS

Of men surviving at least 5 years after diagnosis, 31.3% of those receiving androgen deprivation developed at least 1 depressive, cognitive, or constitutional diagnosis compared with 23.7% in those who did not (P<.001). After adjustment for variables such as comorbidity, tumor characteristics, and age, the risks associated with androgen deprivation were substantially reduced or abolished: relative risk (RR) for depression diagnosis, 1.08 (95% confidence interval [CI], 1.02-1.15); RR for cognitive impairment, 0.99 (95% CI, 0.94-1.04); and RR for constitutional symptoms, 1.17 (95% CI, 1.13-1.22).

CONCLUSION

Depressive, cognitive, and constitutional disorders occur more commonly in patients receiving androgen deprivation, but this appears to be primarily because patients receiving androgen deprivation are older and have more comorbid conditions and more advanced cancers.

Pharmacotherapy of depression in old age

This review addresses the pharmacotherapy of antidepressants in the elderly. We performed a search based on Medline and the Cochrane Library. In addition to a meta-analysis of 17 randomised controlled studies, 36 randomised controlled trials of patients over the age of 60 published between 1980 and 2005 in English met the selection criteria and were included. Existing evidence suggests that no one class of antidepressant drugs has been found to be more effective than another in the treatment of depression in the elderly. Although newer antidepressants are not more effective than older ones, they are better tolerated and are safe especially in overdose. The adverse effect data suggest modest superiority of selective serotonin reuptake inhibitors over tricyclic antidepressants. The evidence available indicates that antidepressant treatment of four weeks has a beneficial effect compared to placebo. As to prevention of relapse and recurrence, antidepressants should be continued for at least six months after good initial response. In patients with high risk of relapse, treatment should be continued for at least two years. Long-term efficacy has been shown for dosulepin, nortriptyline and citalopram. In patients with dementia with persistent and significant symptoms antidepressant treatment may be indicated. At present, clomipramine, citalopram and sertraline have been reported as being superior to placebo. There is a paucity of data on the use of antidepressants in very elderly individuals, patients with significant comorbidity and patients with dementia. More data on the effect of antidepressants in the elderly, especially in the over 80-age group are needed.