Social isolation in the oldest-old: determinants and the differential role of family and friends

PURPOSE

To examine the association of sociodemographic and health-related determinants with social isolation in relation to family and friends in the oldest-old.

METHODS

Database was the multi-center prospective AgeCoDe/AgeQualiDe cohort study assessed at follow-up wave 5 (N = 1148; mean age 86.6 years (SD 3.0); 67% female). Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6). The LSNS-6 contains two sets of items establishing psychometrically separable subscales for isolation from family and friends (ranges 0-15 points), with lower scores indicating higher isolation. Cross-sectional linear (OLS) regression analyses were used to examine multivariate associations of sociodemographic and health-related determinants with social isolation from family and friends.

RESULTS

Overall, n = 395 participants (34.6%) were considered socially isolated. On average, isolation was higher from friends (mean 6.0, SD 3.8) than from family (mean 8.0, SD 3.5). Regression results revealed that in relation to family, males were more socially isolated than females (β = - 0.68, 95% CI - 1.08, - 0.28). Concerning friends, increased age led to more isolation (β = - 0.12, 95% CI - 0.19, - 0.05) and functional activities of daily living to less isolation (β = 0.36, 95% CI 0.09, 0.64). Independent of the social context, depression severity was associated with more social isolation, whereas cognitive functioning was associated with less social isolation.

CONCLUSIONS

Different determinants unequally affect social isolation in relation to family and friends. The context of the social network should be incorporated more strongly regarding the detection and prevention of social isolation to sustain mental and physical health.

Perceived Physical Health and Cognitive Behavioral Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression: A Secondary Analysis of a Randomized Clinical Trial

Importance

Physical diseases co-occur with late-life depression (LLD). The influence of physical diseases and the subjective perception of physical health (PPH) on treatment outcome in LLD, however, is not well understood.

Objective

To assess the association of physical diseases and PPH with the outcomes of 2 different types of psychotherapy in LLD.

Design, Setting, and Participants

This post hoc secondary analysis of a multicenter, observer-blinded, controlled, parallel-group randomized clinical trial assessed participants 60 years or older with moderate to severe depression recruited at 7 psychiatric-psychotherapeutic outpatient trial sites in Germany from October 1, 2018, to November 11, 2020. Data analysis was performed from April 1 to October 31, 2023.

Interventions

Patients received LLD-specific cognitive behavioral therapy (LLD-CBT) or supportive unspecific intervention (SUI).

Main Outcomes and Measures

Depression severity, response, and remission were measured during treatment and at 6-month follow-up by the change in the 30-item Geriatric Depression Scale (GDS) score. Physical health and PPH were assessed by the number of physical diseases, Charlson Comorbidity Index (CCI), and the World Health Organization Quality of Life Brief Version physical health subscale.

Results

A total of 251 patients were randomized to LLD-CBT (n = 126) or SUI (n = 125), of whom 229 (mean [SD] age, 70.2 [7.1] years; 151 [66%] female) were included in the intention-to-treat analysis. Patients with low and moderate PPH at baseline had significantly less reduction in the GDS score across both treatment groups than patients with high PPH (estimated marginal mean difference [EMMD], 2.67; 95% CI, 0.37-4.97; P = .02 for low PPH and EMMD, 1.82; 95% CI, 0.22-3.42; P = .03 for moderate vs high PPH). Higher PPH at baseline was associated with higher likelihood of response (odds ratio [OR], 1.04; 95% CI, 1.00-1.06; P = .009) and remission at the end of treatment (OR, 1.04; 95% CI, 1.02-1.08; P = .002) and response (OR, 1.05; 95% CI, 1.02-1.08; P < .001) and remission at follow-up (OR, 1.06; 95% CI, 1.03-1.10; P < .001) across both treatment groups. However, a significant interaction of PPH with treatment group was observed with low PPH at baseline being associated with significantly larger reduction in GDS scores in SUI compared with LLD-CBT at the end of treatment (EMMD, -6.48; 95% CI, -11.31 to -1.64; P = .009) and follow-up (EMMD, -6.49; 95% CI, -11.51 to -1.47; P = .01). In contrast, patients with high PPH at baseline had a significantly greater reduction in GDS scores in LLD-CBT compared with SUI at all time points (week 5: EMMD, -4.08; 95% CI, -6.49 to -1.67; P = .001; end-of-treatment: EMMD, -3.67; 95% CI, -6.72 to -0.61; P = .02; and follow-up: EMMD, -3.57; 95% CI, -6.63 to -0.51; P = .02). The number of physical diseases or CCI at baseline did not have an effect on the change in GDS score, response, or remission, neither across both groups nor within either group.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, subjective PPH was associated with treatment outcome, response, and remission in psychotherapy of LLD. Patients with LLD responded differently to LLD-CBT and SUI, depending on their baseline PPH score. Treatment approaches for patients with LLD should address PPH in personalized interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT03735576; Deutsches Register Klinischer Studien Identifier: DRKS00013769.

Behind the times? Associations of working-time autonomy with health-related and occupational outcomes in health care personnel- a latent profile analysis

BACKGROUND

In the light of personnel shortage, the health care sector is facing the challenge to combine increasing employees' as well as patients' needs. The aim of this study was to investigate the association between working-time autonomy and health-related (fatigue, psychosomatic complaints and work ability), as well as occupational outcomes (job satisfaction and turnover intention) in a large sample of health care employees.

METHOD

Based on data of the BauA-Working Time survey, a sample of n = 1,093 employees working in the health care sector was analysed. Outcomes were assessed by the German Fatigue Scale, the Work Ability-Index and single-item measurements. Besides descriptive analyses, latent profile analysis (LPA) was used to determine clusters of employees based on working-time autonomy. Subsequently, regression analyses have been conducted to examine the association between autonomy clusters with health-related and occupational outcomes, controlling for sociodemographic characteristics and employment status.

RESULTS

LPA revealed that a three-cluster model was most suitable: high autonomy (cluster 1), medium autonomy (cluster 2) and low autonomy (cluster 3). The extracted profiles of working-time autonomy differed significantly in terms of sociodemographic and occupational characteristics, but not in terms of average working hours per week or monthly household income. The multivariate regression analysis revealed that being in the low-autonomy cluster was associated with more psychosomatic health complaints (IRR: 1.427, p = 0.008), lower work ability (OR 0.339, p < 0.001), as well as less job satisfaction (OR 0.216, p < 0.001).

DISCUSSION

Overall, the analyses indicate that it is crucial to prospectively consider working-time autonomy as an important factor of satisfaction, well-being and turnover intention in health care employees.

[How Successful is the Participation of People with Mental Illness and Family Members in the Development of Evidence- and Consensus-Based Clinical Practice Guidelines? Results of a Survey in Psychiatry]

OBJECTIVE

The study examines how successful the participation of people with mental illness and family members is currently in the development of psychiatric guidelines.

METHODS

Survey results of N=561 (Response 37%) guideline developers are analyzed.

RESULTS

Involvement of affected individuals succeeds more often than that of family members (61% vs. 55%). 68% felt that this participation was central to successful guideline development. 51% perceived discrepancies between empirical evidence and experience perspective. 33-36% perceived a lack of appreciation of experience expertise, 37% an insufficient representation and 46% an inequality in consensus building. 45% did not see barriers effectively removed.

CONCLUSION

There remain challenges in the participation of people with mental illness and family members. There is an increasing awareness that their participation is central.

The different areas of chronic stress and food addiction: Results from the LIFE-Adult-Study

There is an empirical association between stress and symptoms of food addiction (FA), but it is still not clear which domains of stress are the most relevant when it comes to FA, limiting the ability of researchers and practitioners to address problematic eating-related health outcomes. In order to address this gap in the literature, we analysed how different domains of chronic stress are related to FA. We used data from a subsample of the LIFE-Adult-Study (N = 1172), a German cohort study. We conducted a linear regression analysis with stress domains (Trier Inventory for Chronic Stress, TICS) as predictors of FA (Yale Food Addiction Scale, YFAS). In the second regression analysis we included sociodemographic variables, personality, and smoking as control variables. There was a significant and positive association between Social Overload, Work Discontent, Excessive Demands from Work, and Chronic Worrying and FA. After adding control variables, only Social Overload, Excessive Demands from Work, and Chronic Worrying remained significant predictors. Connections between stress domains and FA can serve as starting points for the development of meaningful interventions that support individuals self-care strategies (Social Overload), complexity management (Excessive Demands from Work), and coping with negative emotions (Chronic Worrying).

Experiencing (Shared) Decision Making: Results from a Qualitative Study of People with Mental Illness and Their Family Members

(1) Background: There is a fundamental shift in healthcare toward shared decision making (SDM). This study explores SDM from the perspective of individuals affected by mental illness and their family members and investigates factors which promote and hinder the process. (2) Methods: We conducted N = 15 telephone interviews (n = 4 adults affected by mental illness, n = 5 family members, n = 6 both applicable, the majority reporting experiences with affective and anxiety disorders). Data were recorded, transcribed, and analyzed according to procedures established by Mayring. (3) Results: Individuals affected by mental illness and their family members have a strong desire to be involved in treatment decisions and to participate in finding a diagnosis. Often these stakeholders are denied the opportunity to participate; sometimes enabling behaviors impede participation. The stigmatization of mental illnesses is a major barrier. There are also structural barriers to SDM within the healthcare system. Peer support, self-help associations, and psychosocial counseling services are important to empowering individuals and promoting SDM. (4) Conclusions: SDM has the potential to improve the quality of mental healthcare. Barriers can be mitigated and new approaches for interventions in the psychiatric sector have been identified. This study has also shown the importance of understanding SDM as a process that should begin at the diagnostic phase.

E-mental health in Germany - what is the current use and what are experiences of different types of health care providers for patients with mental illnesses?

BACKGROUND

As a new and effective support option, e-mental health interventions can be useful in complementing treatment in mental health care. To date, little is known about how health care providers use these programs to treat patients with mental illnesses in Germany. The present study aims to examine the use of and experiences with e-mental health interventions from the point of view of different types of health care providers for patients with mental illnesses.

METHODS

Data from a cross-sectional survey of routine care health care providers in Germany in 2021 were analysed. In this survey, data were collected from n = 107 general practitioners (GPs), n = 114 specialist doctors, n = 102 psychotherapists, and n = 102 inpatient clinicians. Assessments included professional use of digital media, as well as knowledge, use and experiences regarding e-mental health interventions in care of people with mental illness.

RESULTS

In the total sample of n = 425, 65.6% (n = 279) were female. The study participants had an average age of 47.7 years (SD = 11.0) and their average work experience was 20.0 years (SD = 11.1). Overall, the majority (83.8%, n = 353) had heard of e-mental health interventions, but few felt well informed. Only 28.5% (n = 121) had already used e-mental health interventions for treatment support. The most commonly recommended e-mental health interventions in the sample were deprexis (39.7%, n = 48), moodgym (24.8%, n = 30), and iFightDepression (22.3%, n = 27). The use was predominantly considered to be helpful and satisfactory. Insufficient knowledge about e-mental health interventions and lack of informational materials for patients were reported as relevant barriers to the use of e-mental health interventions.

CONCLUSIONS

E-mental health interventions can be a useful support option, but they are rarely used in the treatment of patients with mental illnesses. There is a need to disseminate information specific to the various types of health care providers. Tailored implementation strategies need to be developed in order to capitalize on the potential of effective e-mental health interventions and to improve health care for patients with mental illnesses.

[Expectations of guideline developers on living guidelines]

BACKGROUND

Guidelines are central pillars of high-quality care and care planning. The quality requirements for the development of guidelines and the associated effort are very high. Therefore, more efficient approaches are being forced.

OBJECTIVE

The opportunities and challenges in the introduction of a dynamic updating concept within the framework of the digitalization of guidelines were explored from the perspective of guideline developers in the field of psychiatry. This perspective should be included in the implementation.

MATERIAL AND METHODS

Between January and May 2022 a cross-sectional survey was conducted among guideline developers (N = 561, response 39%) based on a questionnaire developed and tested in advance. Data were analyzed descriptively.

RESULTS

A total of 60% were familiar with the concept of living guidelines. A large proportion endorsed a dynamic updating (83%) and digitalization (88%) of guidelines; however, various challenges are associated with the concept of living guidelines: the risk of inflationary changes (34%), the need for continuity of all actors (53%), involvement of patient and family representatives (37%) and definition of criteria regarding the decision what to change (38%). The vast majority (85%) thought it necessary that guideline development should be followed by implementation projects.

CONCLUSION

German guideline developers are very receptive regarding the implementation of living guidelines; however, they named numerous challenges, which need to be addressed in this approach.

Cognitive Behavioral Therapy for Late-Life Depression (CBTlate): Results of a Multicenter, Randomized, Observer-Blinded, Controlled Trial

INTRODUCTION

Different psychotherapeutic interventions for late-life depression (LLD) have been proposed, but their evaluation in large, multicenter trials is rare.

OBJECTIVE

The present study evaluated the efficacy of a specific cognitive behavioral therapy (CBT) for LLD (LLD-CBT) in comparison with a supportive unspecific intervention (SUI), both administered in a specialist psychiatric outpatient setting.

METHODS

In this randomized, controlled, parallel group trial, we recruited participants (≥60 years) with moderate to severe depression at 7 trial sites in Germany. Participants were randomly assigned to the LLD-CBT or SUI group. The primary outcome was depression severity at the end of treatment measured by change on the Geriatric Depression Scale (GDS). Secondary outcomes included change in observer-rated depression, anxiety, sleep ratings, and quality of life throughout the treatment phase and at 6-month follow-up.

RESULTS

Between October 1, 2018, and November 11, 2020, we randomly assigned 251 patients to either LLD-CBT (n = 126) or SUI (n = 125), of whom 229 provided primary-outcome data. There was no significant between-group difference in the change in GDS scores at the end of treatment (estimated marginal mean difference: -1.01 [95% CI: -2.88 to 0.86]; p = 0.287). Secondary analyses showed significant improvements in several outcomes after 8 weeks and at follow-up in both treatment arms.

CONCLUSIONS

Our data suggest that LLD-specific CBT and a supportive unspecific treatment both provide clinical benefit in patients with moderate to severe LLD without evidence for superiority of LLD-CBT.

Comparison of the accuracy of the 7-item HADS Depression subscale and 14-item total HADS for screening for major depression: A systematic review and individual participant data meta-analysis

The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of ≥7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and ≥15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from -0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02-0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The impact of BMI on psychological health in oldest old individuals-Are there differences between women and men?

OBJECTIVE

The aim of this study was to determine the association of mental health issues associated with BMI and gender in the oldest old population (secondary data analyses).

METHOD

The data were taken from the second follow-up of a long-term study investigating the impact of the COVID-19 pandemic on health in oldest old individuals (range: 77-96 years). The response rate was 80.0%. Apart from sociodemographic characteristics (age, gender, weight and height); anxiety, depression, somatic complaints and social support were assessed in this survey.

RESULTS

Analyses revealed gender-specific differences, indicating that male participants with excess weight show more complaints compared to their counterparts without excess weight. According to regression results, BMI was associated with somatization, but not depression or anxiety.

CONCLUSION

High BMI contributed to more somatic complaints and men may be affected differently by BMI regarding their mental well-being. Longitudinal results are needed in order to confirm these findings and develop suitable interventions based on individual needs of the oldest old.

Family History of Dementia in Old-Age Participants with Subjective Memory Complaints Predicts Own Risk for Dementia in a Longitudinal Multi-Center Cohort Study

BACKGROUND

Subjective memory complaints and family history of dementia are possibly intertwined risk factors for the own subsequent dementia risk and Alzheimer's disease. However, their interaction has rarely been studied.

OBJECTIVE

To study the association between subjective memory complaints and family history of dementia with regard to the own subsequent risk of dementia.

METHODS

Cross-sectional and longitudinal analyses over a follow-up period of up to 13 years were conducted in a population sample of participants without dementia at baseline (n = 3,256, mean age = 79.62 years), using group comparisons and Cox proportional hazards models.

RESULTS

Cross-sectionally, participants with subjective memory complaints were significantly more likely to report family history of dementia. Longitudinally, family history of dementia (FH) was significantly associated with subsequent dementia in the subjective memory complaints (SMC) group, but not in those without SMC. A relative excess risk due to interaction analysis confirmed a significant FHxSMC-interaction.

CONCLUSIONS

Family history of dementia was a predictor of incident dementia in those with SMC, which can serve as an additional, clinically relevant criterion to gauge the risk of dementia in older-aged subjects with SMC with and without objective cognitive impairment.

The Association of Resilience with Mental Health in a Large Population-Based Sample (LIFE-Adult-Study)

Resilience describes a good adaptation to adversity. Strengthening resilience is a promising approach in the prevention of mental health problems. Yet, research on the association of resilience with mental health symptoms in the general population is scarce. The aim of our study is to examine comprehensively the association of resilience with depressive symptoms, anxiety, and perceived stress in a large population-based sample. We analyzed data of n = 3762 participants from the follow-up assessment of the LIFE-Adult-Study, a population-based cohort study in Leipzig. Assessments included resilience (RS-11), depressive symptoms (CES-D), anxiety (GAD-7), and perceived stress (PSQ). The association of resilience with mental health symptoms was examined via multiple linear regression analyses. In our analyses, higher resilience predicted less mental health problems and contributed significantly to the explained variance in mental health outcomes. Women, individuals with previous mental disorders, and those without employment had higher mental health symptoms. Resilience is closely associated with mental health problems in the general population. Vulnerable groups should be targeted with public health measures. Strengthening resilience is a promising approach in the large-scale prevention of mental disorders.

Demands on Health Information and Clinical Practice Guidelines for Patients from the Perspective of Adults with Mental Illness and Family Members: A Qualitative Study with In-Depth Interviews

(1) Background: "Patient health information" promote health literacy. "Patient guidelines" as a sub group reflect the current evidence about illnesses and treatment options adapted to the needs of laypersons. Little is known about factors promoting and hindering their use by people affected by mental illness and their relatives. (2) Methods: Telephone interviews (N = 15; n = 4 adults affected by mental illness, n = 5 relatives, n = 6 both applicable) were conducted according to the Sørensen model of health literacy. Data were recorded, transcribed and content-analyzed following Mayring. (3) Results: Health information is used regularly by individuals affected by mental illness and their relatives, but "patient guidelines" are largely unknown. Yet, there is a great willingness to use them. Main barriers are a lack of statistical knowledge, the complexity of health-related topics and cognitive impairment sometimes accompanying mental illnesses. Target group-oriented adaptation as well as transparent and even-handed presentation of (dis-)advantages of treatment options can increase trust. (4) Conclusions: Health information and guidelines can help affected persons and relatives to make treatment decisions by conveying unbiased, up-to-date knowledge. Target group-specific adaptations should be made for psychiatric illnesses and features specific to mental illnesses compared to physical illnesses should be included. Clinical practice guidelines must be distributed more widely to increase their impact.

Understanding eating-related health outcomes: connections between anxiety and eating behavior

Background

Research shows that anxiety is connected to a variety of mental health outcomes, and that it is widespread among the population. In the light of the great personal and societal costs of obesity and eating disorders, we want to understand the connection between anxiety and different dimensions of eating behaviors that have a strong empirical link with negative eating-related health outcomes.

Methods

We used data from the population- based LIFE-Adult-Study (n = 5019) to analyze the connection between anxiety (GAD-7) and the three dimensions of eating behaviors: Cognitive Restraint, Disinhibition, and Hunger (FEV, German version of the Three-Factor-Eating-Questionnaire). We controlled for sociodemographic variables, smoking, physical activity, personality, and social support.

Results

Multivariate regression analyses showed significant positive associations between anxiety and Disinhibition (β = 0.23, p ≤ 0.001), Hunger (β = 0.21, p ≤ 0.001) and Cognitive Restraint (β = 0.04, p ≤ 0.01). After adding control variables, analyses revealed significant positive associations between anxiety and Disinhibition (β = 0.15, p ≤ 0.001) as well as Hunger (β = 0.14, p ≤ 0.001), but not between anxiety and Cognitive Restraint (β = 0.03, p = 0.076).

Conclusions

There is an empirical connection between anxiety and two factors of eating behavior, i.e., Disinhibition and Hunger. If future research strengthens the assumption of a causal direction from anxiety to those factors, interventions that help individuals to better regulate and cope with anxiety, could be one potential pathway to reducing eating disorders and obesity in the population.

Key messages

• There is a significant connection between anxiety and eating behavior.

• Interventions that address anxiety could reduce problematic eating-related health outcomes like eating disorders and obesity.

Social Network and Participation in Elderly Primary Care Patients in Germany and Associations with Depressive Symptoms-A Cross-Sectional Analysis from the AgeWell.de Study

This study aims to describe social network and social participation and to assess associations with depressive symptoms in older persons with increased risk for dementia in Germany. We conducted a cross-sectional observational study in primary care patients (aged 60−77) as part of a multicenter cluster-randomized controlled trial (AgeWell.de). We present descriptive and multivariate analyses for social networks (Lubben Social Network Scale and subscales) and social participation (item list of social activities) and analyze associations of these variables with depressive symptoms (Geriatric Depression Scale). Of 1030 included patients, 17.2% were at risk for social isolation (Lubben Social Network Scale < 12). Looking at the subscales, a reduced non-family network was found almost twice as often as a reduced family network. Patients with depressive symptoms had significantly smaller social networks than patients without depression (p < 0.001). They rather engaged in social activities of low involvement level or no weekly social activity at all (p < 0.001). The study shows associations of depressive symptoms with a decreased social network and less social participation in elderly participants. Sufficient non-family contacts and weekly social activities seem to play an important role in mental health and should be encouraged in elderly primary care patients.

Do oldest old individuals perceive receipt of informal care as a restriction or support of their autonomy?

OBJECTIVES

Autonomy (defined as self-governance; not equivalent to independence) is relevant to well-being and psychological functioning. However, there is a lack of research on individuals aged >85 years and their perception of autonomy when receiving informal care. This study aims to answer the question if and how the receipt of informal care is associated with perceived autonomy of individuals aged over 85 years.

METHOD

A cross-sectional study was conducted with data from follow-up 9 of the AgeQualiDe study (2015/2016), which is a multi-centric prospective cohort study in Germany. The analytical sample included 570 participants aged >85 years and with a score of ≥ 19 on the Mini-Mental-State-Examination. Perceived autonomy was assessed with the Perceived Autonomy in Old Age Scale. Receipt of care was assessed as performance of at least one care task (help with basic and instrumental activities of daily living, and supervision) by relatives or friends. Sociodemographic information, mental health, functional level and receipt of professional ambulatory care were controlled for.

RESULTS

Unadjusted and adjusted linear regression analyses indicated a significant negative association between receipt of informal care and perceived autonomy. The results remained stable in sensitivity analyses; no significant interaction effect was found for gender or education.

CONCLUSION

Findings indicate that informal care recipients aged >85 years perceive lower autonomy compared to those not receiving care. Additional or other forms of support, and improving the care relationship and communication might be considered to support autonomy of care recipients aged >85 years.

What Builds Resilience? Sociodemographic and Social Correlates in the Population-Based LIFE-Adult-Study

Resilience is closely related to mental health and well-being. Identifying risk groups with lower resilience and the variables associated with resilience informs preventive approaches. Previous research on resilience patterns in the general population is heterogeneous, and comprehensive large-scale studies are needed. The aim of our study is to examine sociodemographic and social correlates of resilience in a large population-based sample. We examined 4795 participants from the LIFE-Adult-Study. Assessments included resilience (RS-11), social support (ESSI), and social network (LSNS), as well as the sociodemographic variables age, gender, marital status, education, and occupation. The association of resilience with sociodemographic and social correlates was examined using linear regression analyses. Higher resilience was associated with female gender, married marital status, high education, and full-time occupation. Social support and social network were positively associated with resilience. Our results implicate that resilience is related to various sociodemographic variables. Social variables seem to be particularly important for resilience. We identified risk groups with lower resilience, which should be given special attention by public health policies, especially in times of crisis. Reducing loneliness and promoting social connectedness may be promising ways to build resilience in the general population.

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 &lt; 0.001), were visiting medical specialists more frequently (IRR=1.03; CI [1.01-1.04], p &lt; 0.01), and had higher odds of being hospitalized (OR=1.08; CI [1.02-1.13], p &lt; 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.

Are self-managed online interventions for depression effective in improving behavioral activation? A secondary analysis of a cluster-randomized controlled trial

BACKGROUND

Online interventions can effectively improve depressive symptoms. They often include behavioral activation (BA) techniques, but research on the effects on behavioral activation is scarce. This study aims to examine short- and long-term effects of online interventions on behavioral activation in routine care.

METHODS

This study is a secondary analysis of a pragmatic cluster-randomized controlled trial (@ktiv) with a sample of N = 647 GP patients with mild to moderate depression. The intervention group (IG) received treatment-as-usual (TAU) and adjunct access to an online intervention; the control group (CG) received TAU. BA was assessed in terms of the frequency and enjoyment of pleasant activities at baseline, after six weeks and after six months. Intention-to-treat analyses were performed via multilevel mixed linear regression.

RESULTS

The frequency of pleasant activities was significantly higher in the IG than in the CG six months after baseline (t(1406) = 2.25, p = .024). The enjoyment of pleasant activities was significantly higher in the IG than in the CG both six weeks (t(1405) = 2.11, p = .035) and six months after baseline (t(1405) = 3.44, p = .001). Initial depressive symptoms significantly moderated the treatment effect on the enjoyment but not the frequency of pleasant activities.

LIMITATIONS

BA measures have not been validated in a clinical context.

CONCLUSIONS

GP patients with mild to moderate depressive symptoms profited from access to an online adjunct intervention in terms of improved behavioral activation. The findings emphasize the usefulness of online interventions as supportive options in mental health care.

Incidence and risk factors of depressive symptoms in the highest age groups and competing mortality risk. Evidence from the AgeCoDe-AqeQualiDe prospective cohort study

INTRODUCTION

Only a few studies have investigated incidence and risk factors of depression in the highest age groups. This study aims to determine incidence rates as well as risk factors of incident depressive symptoms in latest life, adjusting for the competing event of mortality.

METHODS

Data of a prospective, longitudinal, multi-centered cohort study conducted in primary care - the AgeCoDe-/AgeQualiDe study. 2436 GP patients aged 75+ years were assessed from baseline to sixth follow-up every 18 months and from seventh to ninth follow-up every 10 months. Depressive symptoms were assessed using the 15-item version of the Geriatric Depression Scale (cut-off ≥6). Competing risk regression models were used to assess determinants of incident depressive symptoms, taking care of accumulated mortality.

RESULTS

The incidence of depressive symptoms was 39 per 1000 person-years (95% CI 36-42; last observed exit 13.26 person-years at risk). In a competing risk regression model, female sex, unmarried family status, subjective cognitive decline as well as vision and mobility impairment were significant risk factors of incident depression.

LIMITATIONS

Excluding individuals with a lack of ability to provide informed consent at baseline may have influenced the incidence of depression. Depressive symptoms were not assessed by DSM criteria. Furthermore, in studies with voluntary participation, participation bias can never be completely avoided.

CONCLUSION

Findings provide a better understanding of risk and protective factors of depressive symptoms in the oldest age taking mortality as a competing event into account. Addressing this aspect in future research may yield new insights in that research field.

What Comes after the Trial? An Observational Study of the Real-World Uptake of an E-Mental Health Intervention by General Practitioners to Reduce Depressive Symptoms in Their Patients

Unguided and free e-mental health platforms can offer a viable treatment and self-help option for depression. This study aims to investigate, from a public health perspective, the real-world uptake, benefits, barriers, and implementation support needed by general practitioners (GPs). The study presents data from a spin-off GP survey conducted 2.5 years subsequent to a cluster-randomized trial. A total of N = 68 GPs (intervention group (IG) GPs = 38, control group (CG) GPs = 30) participated in the survey (response rate 62.4%). Data were collected via postal questionnaires. Overall, 66.2% of the GPs were female. The average age was 51.6 years (SD = 9.4), and 48.5% of the GPs indicated that they continued (IG) or started recommending (CG) the e-mental health intervention under real-world conditions beyond the trial. A number of benefits could be identified, such as ease of integration and strengthening patient activation in disease management. Future implementation support should include providing appealing informational materials and including explainer videos. Workshops, conferences, and professional journals were identified as suitable for dissemination. Social media approaches were less appealing. Measures should be taken to make it easier for health care professionals to use an intervention after the trial and to integrate it into everyday practice.

Gender Specifics of Healthy Ageing in Older Age as Seen by Women and Men (70+): A Focus Group Study

(1) The rising proportion of older adults in the population represents a challenge for the healthcare system. Women and men age differently. This study aims to examine gender-specific characteristics of health in old age from male and female perspectives. (2) Two focus groups were formed in this qualitative study of older (70+) women (n = 10) and men (n = 8) in accordance with the theoretical framework of the World Health Organization (WHO) on healthy ageing determinants. The data were audio recorded and fully transcribed. Qualitative content analysis was performed using MAXQDA. (3) In both focus groups (average age: women 77.1 years, men 74.9 years), gender-specific characteristics regarding healthy ageing were discussed. Women focused on healthy eating, while men focused on an active lifestyle and meaningful activities. Physical and social activities were considered as important for healthy ageing in both groups. (4) Important gender-specific characteristics of health in old age were identified and recommendations for gender-unspecific and gender-specific recommendations were derived. The results provide important information for promoting and maintaining health in old age. Women and men show both similarities and differences in terms of health-related needs and individual experiences. We suggest gender-specific features in nutrition and health programs for older adults.

Anxiety and Food Addiction in Men and Women: Results From the Longitudinal LIFE-Adult-Study

BACKGROUND

Anxiety is a widespread phenomenon, and it is connected to disordered eating and obesity. We want to analyze the connection between anxiety and food addiction (FA) over two points in time to better understand the directionality of the association. Since there are gender differences with regard to anxiety and eating, we are also interested in differences between men and women.

METHODS

We used data from the population-based LIFE-Adult-Study (N = 1,474) at time 1 (baseline) and time 2 (first follow-up) to analyze the connections between anxiety (GAD-7) and FA (YFAS) using a multiple group latent cross-lagged panel model with female and male participants as groups. We controlled for age, marital status, socioeconomic status and social support.

RESULTS

Anxiety (women: β = 0.50, p ≤ 0.001; men: β = 0.59, p ≤ 0.001) as well as FA (women: β = 0.37, p ≤ 0.001; men: β = 0.58, p ≤ 0.001) exhibited stability over time for both genders. We found a significant association between anxiety at time 1 and FA at time 2 for women (β = 0.25, p ≤ 0.001) but not for men (β = 0.04, p = 0.10), and significant associations between FA at time 1 and anxiety at time 2 for women (β = 0.23, p ≤ 0.001) as well as men (β = 0.21, p ≤ 0.001).

CONCLUSION

Food addiction longitudinally affects anxiety, independent of gender and other sociodemographic variables. In addition, anxiety affects subsequent FA as well, but only in women. Interventions that address FA could reduce anxiety in men and women, while interventions that mitigate anxiety could help prevent FA in women.

Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis

BACKGROUND

Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking.

OBJECTIVE

We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement.

METHODS

We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes.

RESULTS

In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95% CI 0.32-0.77), depression (g=0.44, 95% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75% and 55.19%, respectively) and low for posttraumatic stress symptoms (I2=0%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria.

CONCLUSIONS

Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131428.

Loss and bereavement in late life (60+): Study protocol for a randomized controlled trial regarding an internet-based self-help intervention

BACKGROUND

The death of a close person is a highly stressful, yet common life event in later life. While most individuals seem to cope well with bereavement, a substantial proportion of older individuals suffer from prolonged grief symptoms. E-mental health interventions have been shown to be efficient for a variety of psychological illnesses. Yet, there is a large research gap of studies with a special focus on older adults. This study protocol describes a randomized controlled trial for an internet-based self-help intervention addressing bereavement and loss in adults aged 60 years and over. The self-management intervention is based on techniques of cognitive behavioral therapy and consists of 8 modules. The objective of the AgE-health study is to evaluate the effectiveness and acceptability of this intervention in comparison to a bibliotherapy control group.

METHODS

The AgE-health study aims at implementing a randomized controlled trial. Eligible participants aged 60+ years will be randomly allocated to an intervention group (access to the intervention) or to an active control group (access to bibliotherapy). Primary outcome is the reduction in grief symptoms (13-item Prolonged Grief Inventory); secondary outcomes are depression, social activity and network, quality of life, self-efficacy, satisfaction with the intervention/bibliotherapy, loneliness, acceptability, up-take and adherence. Assessments will take place before the intervention (baseline) as well as 4 months (follow-up 1) after the intervention.

DISCUSSION

This study addresses an under-recognized and understudied mental health burden in later life and may add valuable insight into our knowledge about the effectiveness of eHealth interventions for loss and bereavement in late life. To our knowledge, the AgE-health study will be the first randomized controlled trial to evaluate the effectiveness of an internet-based intervention targeting prolonged grief in adults aged 60 years and over.

TRIAL REGISTRATION

The study has been registered at the German Clinical Trials Register (Identifier: DRKS00020595, Registered 30th July 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020595).

Unmet needs of the oldest old primary care patients with common somatic and psychiatric disorders-A psychometric evaluation

OBJECTIVES

Unmet needs are common in older patients and should be assessed via suitable instruments. The adapted German version of the Camberwell Assessment of Need for the Elderly (CANE) represents an often used tool to determine the needs in older individuals. Evidence on the psychometric properties of the CANE is still pending.

METHODS

A sample of 231 patients with common somatic and psychiatric diseases were interviewed about their needs including their caring relatives and general practitioners (GPs). Frequencies of unmet needs were evaluated across the different perspectives. Interrater agreement, convergent and discriminant validity were evaluated.

RESULTS

On average, psychiatric patients reported more unmet needs than somatic patients, particularly regarding to psychological distress and behavior. The interrater agreement was higher in the somatic subgroup than in the psychiatric subgroup, and higher between patients and relatives compared to patients and GPs. Evidence for construct validity was reported.

CONCLUSIONS

Patients with common somatic and psychiatric disorders report specific unmet needs that should be considered in healthcare. Moderate to good psychometric characteristics were found for the CANE. The use of valid instruments to record needs in health and nursing care can be useful and represents an important starting point for targeted interventions and effective treatment.

Prevalence of High Resilience in Old Age and Association with Perceived Threat of COVID-19-Results from a Representative Survey

Little is known about resilience in old age and its manifestation during the COVID-19 pandemic. This study aims to estimate the prevalence of high resilience in the German old age population. We further examine the socio-demographic correlates and whether high resilience reflects on older adults’ perception of the threat posed by COVID-19. The data were derived from a representative telephone survey of n = 1005 older adults (≥65 years) during the first COVID-19 lockdown. Assessments included socio-demographic variables, the perceived threat of COVID-19, and high resilience (Brief Resilience Scale; cutoff: ≥4.31). The association between high resilience and threat from COVID-19 was analyzed using ordinal logistic regression. The study sample had a mean age (SD) of 75.5 (7.1) years, and n = 566 (56.3%) were female. The estimated prevalence of high resilience was 18.7% (95% CI = [16.3; 21.2]). High resilience was more prevalent in the younger age group and participants with higher education levels. High resilience was significantly associated with a lower perception of threat from COVID-19. The results of the representative survey in the German old age population showed that one out of five adults aged 65 years and older had high resilience. Older adults with high resilience tended to feel less threatened by COVID-19. Further research on resilience in old age is needed to support vulnerable groups in the context of care.

Correlates of institutionalization among the oldest old-Evidence from the multicenter AgeCoDe-AgeQualiDe study

OBJECTIVES

There is a lack of studies identifying the correlates of institutionalization specifically among the oldest old. Therefore, our aim was to fill this gap in knowledge.

METHODS

Cross-sectional data (Follow up wave 9; n = 633 observations in the analytical sample) were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" Correlates of institutionalization among the oldest old-Evidence from a multicenter cohort study. The sample consists of primary care patients aged 86 years and over (mean 90.5 years, SD: 2.9 years). Sociodemographic and health-related independent variables were included in our regression model. Institutionalization was defined as living in a nursing home or an old-age home (not including assisted living facilities).

RESULTS

Out of the 633 participants, 502 individuals (79.3%) did not live in an institutionalized setting, whereas 73 individuals (20.7%) lived in an institutionalized setting. Multiple logistic regressions showed that the likelihood of institutionalization increased with being divorced/widowed/single (compared to being married; OR: 5.35 [95% CI: 1.75-16.36]), the presence of social isolation (OR: 2.07 [1.20-3.59]), more depressive symptoms (OR: 1.11 [1.01-1.23]), increased cognitive impairment (OR: 1.67 [1.31-2.15]) and higher levels of frailty (OR: 1.48 [1.07-2.06]).

CONCLUSION

The study findings identified various sociodemographic and health-related factors associated with institutionalization among the oldest old. Longitudinal studies are required to gain further insights into these associations.

Sex-Specific Associations Between Depressive Symptoms and Risk for Subsequent Dementia

BACKGROUND

An association between depression and an increased risk for subsequent dementia is well-established. Sexspecific associations are understudied yet.

OBJECTIVE

We aimed to investigate sex-specific associations between depressive symptoms and dementia risk.

METHODS

Longitudinal analyses were conducted in a pooled data set (n = 4,255, mean age = 80 years) of two prospective cohort studies (LEILA 75+, AgeCoDe). Depressive symptoms were harmonized by dichotomized scores of two different depression screening scales using established cutoffs. Transition to dementia was used as outcome in Cox proportional hazards models.

RESULTS

Depressive symptoms at baseline were associated with an increased risk for subsequent dementia, and this association was more pronounced in males (interaction of depressive symptoms × sex: HR = 1.64, 95% CI: 1.02-2.64, p = 0.042) in a model adjusted for study, age, and education. After additional adjustment for subjective and objective cognition, depressive symptoms and their interaction with sex (HR = 1.38, 95% CI: 0.85-2.23, p = 0.188) were no longer significantly associated with the risk for subsequent dementia. Sex-stratified analyses showed stronger and significant associations between depressive symptoms and subsequent dementia in men (e.g., HR= 2.10, 95% CI: 1.36-3.23, p = 0.001, compared to HR= 1.28, 95% CI: 1.04-1.58, p = 0.020, in women).

CONCLUSIONS

Overall, we provide evidence for a stronger association between depression and dementia in men compared to women. Depressive symptoms should be diagnosed, monitored, and treated, not only due to depression, but also with respect to the risk for subsequent dementia, especially in elderly men.

Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress

Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.

Using a brief web-based 5A intervention to improve weight management in primary care: results of a cluster-randomized controlled trial

BACKGROUND

The primary health care setting is considered a major starting point in successful obesity management. However, research indicates insufficient quality of weight counseling in primary care. Aim of the present study was to implement and evaluate a 5A online tutorial aimed at improving weight management and provider-patient-interaction in primary health care. The online tutorial is a stand-alone low-threshold minimal e-health intervention for general practitioners based on the 5As guidance for obesity management by the Canadian Obesity Network.

METHODS

In a cluster-randomized controlled trial, 50 primary care practices included 160 patients aged 18 to 60 years with obesity (BMI ≥ 30). The intervention practices had continuous access to the 5A online tutorial for the general practitioner. Patients of control practices were treated as usual. Primary outcome was the patients' perspective of the doctor-patient-interaction regarding obesity management, assessed with the Patient Assessment of Chronic Illness Care before and after (6/12 months) the training. Treatment effects over time (intention-to-treat) were evaluated using mixed-effects linear regression models.

RESULTS

More than half of the physicians (57%) wished for more training offers on obesity counseling. The 5A online tutorial was completed by 76% of the physicians in the intervention practices. Results of the mixed-effects regression analysis showed no treatment effect at 6 months and 12 months' follow-up for the PACIC 5A sum score. Patients with obesity in the intervention group scored lower on self-stigma and readiness for weight management compared to participants in the control group at 6 months' follow-up. However, there were no significant group differences for weight, quality of life, readiness to engage in weight management, self-stigma and depression at 12 months' follow-up.

CONCLUSION

To our knowledge, the present study provides the first long-term results for a 5A-based intervention in the context of the German primary care setting. The results suggest that a stand-alone low-threshold minimal e-health intervention for general practitioners does not improve weight management in the long term. To improve weight management in primary care, more comprehensive strategies are needed. However, due to recruitment difficulties the final sample was smaller than intended. This may have contributed to the null results.

TRIAL REGISTRATION

The study has been registered at the German Clinical Trials Register (Identifier: DRKS00009241 , Registered 3 February 2016).