Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale

Chemotherapy of lung cancer in the elderly

In the last few years it has become evident that the elderly lung cancer patient represents a peculiar individual with regard to both the tolerance to the tumor and its treatment. Age per se cannot be considered an adverse prognostic factor, however, the physiologic impairment of the functions of important organs like liver, kidney, bone marrow etc., may render more unpredictable the treatment-related toxicity, and moreover, the higher incidence of concomitant diseases which occurs with aging certainly translates in a worse survival outcome. As a consequence, a careful multidimensional evaluation (functional, emotional, socioeconomic status, comorbidities, etc.) should be preliminarily performed in patients eligible for chemotherapy treatment. Several approaches have been tested in elderly lung cancer patients. Different therapeutic attitudes exist, which first take into account the kind of histology (small cell lung cancer, SCLC and non-small cell lung cancer, NSCLC). Of course a more aggressive approach can be sometimes justified in an elderly SCLC patient in view of the high responsiveness of this disease, while more concerns exist about the use of aggressive chemotherapy regimen in elderly patients with NSCLC histology. In view of these considerations, more clinical trials are being planned to specifically assess the role of chemotherapy in this subset of patients.A brief review of the most important phase II and III trials conducted in elderly patients with either SCLC or NSCLC is provided here. A description of the most important still unsolved issues will be made, and an outline of the ongoing clinical trials in these patients will be provided.

Development and validation of a risk-adjustment index for older patients: the high-risk diagnoses for the elderly scale

OBJECTIVES

The purpose of this study was to develop and validate a risk-adjustment index for 1-year mortality specific to older people, based on administrative discharge diagnoses.

DESIGN

Two prospective cohort studies, in tandem. The index developed in the initial cohort was subsequently validated in a separate cohort.

SETTING

General medicine service of a university teaching hospital.

PARTICIPANTS

For the development cohort, 524 hospitalized general medical patients aged 70 and older. For the validation cohort, 852 comparable patients.

MEASUREMENTS

Administrative diagnosis data were used to construct the proposed index and several other widely used indices (Deyo-adapted Charlson; Acute Physiology, Age, Chronic Health Evaluation III conditions; total number of diagnoses; All Patient Refined Diagnosis Related Groups; and Disease Staging). We used receiver operating characteristic curve analysis and Cox proportional hazards modeling to compare our proposed index with the other indices with respect to predictive accuracy and strength of association with 1-year mortality.

RESULTS

The High-Risk Diagnoses for the Elderly Scale was developed using 10 high-risk medical diagnoses. Individual condition weights, based on the magnitude of 1-year mortality risk, ranged from 1 (pneumonia, diabetes mellitus with end-organ damage) to 6 (lymphoma/leukemia); possible index scores ranged from 0 to 27. Mortality rates for patients categorized into four risk groups based on the index were 9.5%, 31.8%, 46.4%, and 73.6% in the development cohort (C statistic = 0.76), and 9.9%, 24.3%, 33.6%, and 50.8% in the validation subjects (C statistic = 0.68). The new index was a stronger predictor of mortality than several widely used measures.

CONCLUSION

The High-Risk Diagnoses for the Elderly Scale, based on readily available administrative data,is a simple, accurate system for prediction of 1-year mortality in older hospitalized patients that demonstrated generalizability to an independent sample. Future studies are needed to test this index in other settings and populations.

Prevalence and impact of medical comorbidity in Alzheimer's disease

BACKGROUND

We examined the prevalence of comorbid medical illnesses in Alzheimer's disease (AD) patients at different severity levels. We also examined the effect of cumulative medical comorbidity on cognition and function.

METHODS

Analyses of data from 679 AD patients (Mini-Mental State Exam score range 0-30, mean +/- SD = 11.8 +/- 8) from 13 sites (four dementia centers assessing outpatients, four managed care organizations, two assisted living facilities, and three nursing homes) prospectively recruited using a stratification approach including dementia severity and care setting. Medical comorbidity was quantified using the Cumulative Illness Rating Scale-Geriatric.

RESULTS

Across patients, 61% had three or more comorbid medical illnesses. Adjusting for age, gender, race, and care setting, medical comorbidity increased with dementia severity (mild to moderate, p <.01; moderate to severe, p <.001). Adjusting for age, educational level, gender, race, and care setting, higher medical comorbidity was associated with greater impairment in cognition (p <.001) and in self-care (p <.001).

CONCLUSIONS

Despite the limitation of a cross-sectional design, our initial findings suggest that there is a strong association between medical comorbidity and cognitive status in AD. Optimal management of medical illnesses may offer potential to improve cognition in AD.

Clinical presentation of the "depression-executive dysfunction syndrome" of late life

It has been proposed that a "depression-executive dysfunction (DED) syndrome" occurs in late life. This assertion was based on clinical, neuropathological, and neuroimaging findings suggesting that frontostriatal dysfunctions contribute to the development of both depression and executive dysfunction and influence the course of depression. The authors describe the clinical presentation of DED and its relationship to disability, studying 126 elderly subjects with major depression and evaluating depressive symptoms, cognitive functioning, disability, and personality dimensions. Patients with the DED syndrome had reduced fluency, impaired visual naming, paranoia, loss of interest in activities, and psychomotor retardation, but showed a rather mild vegetative syndrome. Depressive symptomatology, and especially psychomotor retardation and loss of interest in activities, contributed to disability in DED patients, whereas paranoia was associated with disability independently of executive dysfunction. These findings may aid clinicians in identifying patients needing vigilant follow-up, because depression with executive dysfunction was found to be associated with disability, poor treatment response, relapse, and recurrence.

Validity and reliability of the FACT-G scale for use in the older person with cancer

This project was designed to evaluate the Functional Assessment of Cancer Therapy General Scale (FACT-G) for use in the older patient with cancer. Subjects were administered the MOS Short Form Health Survey (SF-36) and the FACT-G scale. Subscale and total scores were compared using the Pearson product correlation test. FACT-G total and subscores were compared with the mixed aged cancer patient normative group of Cella et al. (1993). Good correlations were found between total and subscores of the SF-36 and the FACT-G in all areas except vitality. The mean total FACT-G score was 82.2 +/- 16.2 SD for the patients with cancer, and 92.3 +/- 11.8 SD for community-dwelling elderly (CDE). The FACT-G was able to discriminate between patients that received cancer care and CDE (p < 0.002). Subjects who scored higher on the FACT-G were found to have higher Eastern Cooperative Oncology Group Performance Status (PS). Subjects with a PS of 0 had a mean total FACT-G score of 87.9 +/- 14.4 SD. Subjects with a PS of 3 had a mean score of 59.0 +/- 23.2 SD. The FACT-G is a valid and reliable instrument for use in the older patient with cancer. The FACT-G is not an age-biased instrument.

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study

PURPOSE

To appraise the performance of Comprehensive Geriatric Assessment (CGA) in elderly cancer patients (> or = 65 years) and to evaluate whether it could add further information with respect to the Eastern Cooperative Oncology Group performance status (PS).

PATIENTS AND METHODS

We studied 363 elderly cancer patients (195 males, 168 females; median age, 72 years) with solid (n = 271) or hematologic (n = 92) tumors. In addition to PS, their physical function was assessed by means of the activity of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comorbidities were categorized according to Satariano's index. The association between PS, comorbidity, and the items of the CGA was assessed by means of logistic regression analysis.

RESULTS

These 363 elderly cancer patients had a good functional and mental status: 74% had a good PS (ie, lower than 2), 86% were ADL-independent, and 52% were IADL-independent. Forty-one percent of patients had one or more comorbid conditions. Of the patients with a good PS, 13.0% had two or more comorbidities; 9.3% and 37.7% had ADL or IADL limitations, respectively. By multivariate analysis, elderly cancer patients who were ADL-dependent or IADL-dependent had a nearly two-fold higher probability of having an elevated Satariano's index than independent patients. A strong association emerged between PS and CGA, with a nearly five-fold increased probability of having a poor PS (ie, > or = 2) recorded in patients dependent for ADL or IADL.

CONCLUSION

The CGA adds substantial information on the functional assessment of elderly cancer patients, including patients with a good PS. The role of PS as unique marker of functional status needs to be reappraised among elderly cancer patients.

Management of small-cell lung cancer in the elderly

More than 50% of lung cancer patients are diagnosed over the age of 65 and about 30% over 70. Small-cell lung cancer (SCLC) accounts for 20-25% of lung carcinomas. Chemotherapy is the cornerstone of treatment for SCLC. Usually in the elderly it is difficult to administer the same chemotherapy administered to younger patients because elderly patients tolerate chemotherapy poorly. The empirical reduction of drug doses may be criticized. The best approach is to design specific trials in order to develop active and well-tolerated chemotherapy regimens for SCLC elderly patients. The standard therapy in limited disease is combined chemo-radiotherapy followed by prophylactic brain irradiation for patients achieving a complete response. In the elderly, the addition of radiotherapy to chemotherapy must be accurately evaluated, considering the slight survival improvement and the potential relevant toxicity.

Subjective health measures and acute treatment outcomes in geriatric depression

BACKGROUND

Prior research suggests that elderly patients are less likely to respond to antidepressant treatment if they have low self-rated health. However, successful treatment for depression has been associated with improvement in self-rated health and other health measures.

OBJECTIVES

To examine measures of self-rated health, physical disability, and social function as predictors of treatment response in late-life depression, and to assess these same health measures as treatment outcomes. We hypothesized that greater impairment in these measures would predict poorer treatment response, and that these measures would show significant improvements with recovery from depression.

METHOD

Subjects were enrolled in a depression intervention study for people aged 60 and older with recurrent unipolar major depression; they were assessed with measures of self-rated health, physical disability, and social functioning at baseline and at the end of treatment. Baseline measures were compared between the 88 remitters, 11 non-remitters, and seven dropouts. Additionally, changes in the measures were examined in subjects who recovered from the index depressive episode.

RESULTS

Subjects with poorer self-rated health at baseline were more likely both to drop out of treatment and to not respond to adequate treatment. This relationship was independent of demographic measures, severity of depression, physical and social functioning, medical illness, personality, hopelessness, overall medication use, and side effects or non-compliance with treatment.

CONCLUSION

Although this finding is preliminary because of the small number of dropouts and non-remitters, it suggests that lower self-rated health may independently predict premature discontinuation of treatment for depression. Additionally, subjects who recovered from depression showed significant improvements in self-rated health, physical disability, and social functioning.

The measurement of health: a comparison of indices of disease severity

This study compared the utility of different health indicators in frail older people, as a component of a larger study of medical evaluations of 183 adult day care participants in five Maryland centers. Indices examined included: number of disease categories, number of active categories, number of severe categories, number of categories with worsening trajectory, and average severity score. In predicting survival, none of the medical indicators without dementia was a strong predictor of survival. When dementia was included, number of categories with worsening trajectory seemed to be the best indicator of survival, with average severity score being a close second. Among the diagnoses, dementia and its severity were the strongest predictors of survival. Prediction of continuous stay in the community (in contrast to death or entry into a nursing home) was significant for most indices and is easier to predict from medical indices than death. Different indicators provided best utility depending on the criterion applied.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

Frequency of Alzheimer's disease and other dementias in a community outreach sample of Hispanics

OBJECTIVES

To determine the proportion of Alzheimer's disease (AD) and other dementia types in a community sample of Hispanics.

DESIGN

This is a descriptive diagnostic study of a nonrandom community outreach sample utilizing established criteria for the diagnosis of dementia type. Recruitment involved direct community outreach with diagnostic evaluations conducted at a university-affiliated outpatient clinic.

SETTING

Hispanic Neuropsychiatric and Memory Research Clinic at the Olive View-UCLA Medical Center in Sylmar, California.

PARTICIPANTS

One hundred community-dwelling Hispanics age 55 and older without prior diagnosis or treatment of their cognitive symptoms.

MEASUREMENTS

Each subject underwent a complete medical diagnostic evaluation, in Spanish, including neuropsychological tests, neurological examination, laboratory tests, and brain imaging (computed tomography or magnetic resonance imaging) to establish dementia type. Presence of dementia was established according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Diagnosis for probable or possible AD and vascular dementia (VascD) was established using criteria from the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association for probable AD and by research criteria from the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences for VascD, respectively. Frontotemporal dementia was diagnosed using recommendations set forth by the Lund and Manchester groups.

RESULTS

Subjects were poor, with low acculturation levels despite long years of U.S. residence. Forty percent of subjects had had undiagnosed cognitive symptoms for 3 or more years. Of those demented, 38.5% had AD and 38.5% met criteria for VascD. The best predictors of VascD were hypertension and cerebrovascular disease, whereas apolipoprotein E4 allele best predicted AD. Other forms of dementia were also present. Twenty percent of the sample was clinically depressed but not demented.

CONCLUSIONS

In comparison with data from predominantly white populations, our proportion of AD cases was lower and that of VascD cases was considerably higher than anticipated. The percentage of clinically depressed older individuals was also high. These findings could have implications for differential cultural and genetic risk factors for dementia among diverse ethnic/racial groups. Further studies are needed to obtain accurate prevalence estimates of dementing disorders among the different U.S. Hispanic populations.

Influence of age and comorbidities on the chemotherapeutic management of lung cancer

More than 60% of all patients with cancer are currently older than 65 years. Correspondingly, the peak of lung cancer incidence is reached in the age group between 75 and 80 years. As a consequence to this ageing patient population, three factors become of major importance for the chemotherapeutic management of lung cancer, namely functional status, age-specific phenomenon and the presence of comorbidities. While the functional status is dependent on physiological changes in organ function, ageing-specific phenomena include depression, alterations of mental status, reduced nutritional status and missing social support. Comorbidities frequently have a risk profile comparable to that of lung cancer. Clinical studies with a special focus on elderly patients are still rare. In small-cell lung cancer retrospective analyses have demonstrated that age alone is not a major prognostic factor compared to performance status, tumor stage or gender. Nevertheless elderly patients with lung cancer are still frequently excluded from clinical trials, and receive less optimal or even no chemotherapeutic treatment at all. Studies evaluating less aggressive treatment figured out that single agent therapy with etoposide is inferior compared to combination chemotherapy in patients with small cell lung cancer (SCLC). In elderly patients with non-small cell lung cancer (NSCLC), single agent treatment with vinorelbine plus 'Best Supportive Care' was significantly superior to 'Best Supportive Care (BSC)' alone; with respect to survival and symptom palliation.

A short-term inpatient program for agitated demented nursing home residents

OBJECTIVE

This case series describes the various contributors of disruptive behavior in demented nursing home residents and outlines the necessary steps to identify and treat them.

DESIGN

Evaluation of overall clinical improvement and agitation at discharge from the hospital and at follow-up.

SETTING

Nursing home residents consecutively admitted to the geriatric psychiatry service of a psychiatric university hospital in the New York metropolitan area.

PATIENTS

15 elderly demented nursing home residents with agitation.

MEASURES

Overall clinical improvement was assessed with the 'global assessment of functioning scale'. Agitation was evaluated with the 'brief agitation rating scale' and the 'nursing home scale for agitation'. Medication side-effects were measured with the 'Simpson-Angus scale' and the 'abnormal involuntary movement scale'.

RESULTS

The patients showed significantly more overall clinical improvement at discharge compared with admission. Additionally, agitation scores were significantly lower at discharge and at follow-up compared with admission.

CONCLUSION

A comprehensive medical and neurological assessment, an accurate identification of comorbid psychopathology, evaluation of drug toxicity, and a thorough history of psychotropic medication trials are essential steps for a successful treatment.

Initial recovery patterns may predict which maintenance therapies for depression will keep older adults well

BACKGROUND

Although active maintenance treatments appear superior to placebo in preventing depression recurrence in older adults, few data are available to guide maintenance modality selection to maximize the probability of continued wellness for a given patient. Patients' temporal patterns of acute treatment response may predict who requires which maintenance therapy to remain well.

METHODS

Depression levels were observed over 16 weeks of combined nortriptyline (NT) and interpersonal psychotherapy (IPT) in 140 persons aged >or=60 years with recurrent major depression. Subjects were empirically classified into four groups: rapid, sustained responders; delayed, sustained responders; mixed responders without sustained improvement; prolonged nonresponders. Groups were compared on subsequent recovery rates and on time to depression recurrence after randomization to 3 years of combined maintenance therapy (monthly IPT with NT), monotherapy (either IPT or NT alone), or medication clinic with placebo. Pretreatment psychosocial and clinical variables were controlled.

RESULTS

Initial response profile predicted ultimate recovery rates, as well as who remained well, given the maintenance treatment received. Rapid initial responders showed lower recurrence risk with either combined or monotherapy, relative to placebo. Specific types of monotherapy appeared equally effective in rapid responders. In initially mixed responders, only combined therapy was superior to placebo. It was marginally superior to monotherapy. For delayed responders, combined therapy was superior to placebo; monotherapy did not differ from the other maintenance conditions. Prolonged nonresponders did not benefit from maintenance treatment.

LIMITATIONS

Subjects had only recurrent, unipolar depression. Initial response profile groups were established empirically and require replication. Sample sizes in initial response profile by maintenance treatment cells were small.

CONCLUSION

The ability to match patients to maintenance treatments more likely to prevent recurrence may be enhanced by considering the temporal profile of initial response to acute treatment.

Neuropsychiatric assessment of Alzheimer's disease and related dementias

Alzheimer's disease (AD) patients exhibit a variety of behavioral alterations including agitation, apathy, depression, anxiety, delusions, irritability and disinhibition. Most patients with AD exhibit neuropsychiatric symptoms, and behavioral changes become more frequent with advancing disease severity. The NPI is a valid and reliable means of assessing neuropsychiatric symptoms in patients with dementia. The NPI correlates with increasing disability in activities of daily living and increasing cognitive impairment. Physical illness contributes little to behavioral symptoms measured by the NPI. Reduced frontal lobe metabolism and perfusion have been identified in patients with apathy, agitation, psychosis and depression. Patients with elevated agitation scores on the NPI have a higher burden of frontal lobe neurofibrillary tangles than patients without agitation. The NPI is sensitive to behavioral improvements following treatment with cholinesterase inhibitors and psychotropic agents. Neuropsychiatric symptom profiles differ among dementia syndromes, and the NPI provides a means of assessing neuropsychiatric symptoms that may aid in differential diagnosis. Evaluation of neuropsychiatric symptoms is a critical aspect of dementia diagnosis and management.

The systematic assessment of depressed elderly primary care patients

Studies of the primary care treatment of depressed elderly patients are constrained by limited time and space and by subject burden. Research assessments must balance these constraints with the need for obtaining clinically meaningful information. Due to the wide-ranging impact of depression, assessments should also focus on suicidality, hopelessness, substance abuse, anxiety, cognitive functioning, medical comorbidity, functional disability, social support, personality, service use and satisfaction with services. This paper describes considerations concerning the assessment selection process for primary care studies, using the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study as an example. Strategies are discussed for ensuring that data are complete, valid and reliable.

Personality profiles among normal aged individuals as measured by the NEO-PI-R

The revised Neuroticism (N), Extraversion (E), Openness (O) to experience Personality Inventory (NEO-PI-R) is a multidimensional measure of normal personality traits that is intended to assess five major personality dimensions or domains-N, E, O, Agreeableness (A), and Conscientiousness (C). Although several studies have been conducted examining N, E, and O factors in people 65 through to 85 years old, there has been little research examining all five-core domains of personality in individuals 85 and older. We compared the NEO-PI-R domains and facet traits in the middle-aged/young-old versus old-old normal subjects. Thirty-eight community-dwelling subjects (22 women, 16 men) free from major neuropsychiatric disorders were given the NEO-PI-R, a self-administered 240-item personality inventory, assessing 30 facet traits within the five domains. We compared the scores of 21 middle-aged and young-old (age 50-84) individuals, to those of 17 old-old (age 85-100) subjects. The personality profiles of the two groups were similar except that the old-old group had lower scores on Extraversion, and four of the 30 facet traits (warmth, positive emotions, impulsiveness, and order) compared to the middle-aged/young-old group. These results were limited by the cross-sectional design and small sample size. Nonetheless, the findings suggest that the middle-aged/young-old and the old-old normal subjects have fairly similar personality traits.

Control-relevant intervention in the treatment of minor and major depression in a long-term care facility

The authors assessed the effect of a control-relevant psychosocial intervention in 31 nursing home residents with either major depressive episode or minor depression. An initial group of 22 residents were randomized to either active treatment or waiting list. Four of 11 residents randomized to active treatment were deemed Responders, compared with 0 of 11 on the waiting list (P < 0.05). Of the total of 31 residents who participated in the intervention, 14 (45%) were deemed Responders during the intervention period. For these Responders, the Hamilton Rating Scale for Depression (Ham-D) and Geriatric Depression Scale scores improved significantly during the intervention. The improvement in the Ham-D was not sustained 2 months after intervention was terminated. These findings suggest that a psychosocial intervention enhancing socialization according to each resident's choice had a positive therapeutic impact on almost half of the nursing home residents with major or minor depression. However this effect could not be sustained by the residents without the support of the structured program.

Predictors of improvement in health-related quality of life among elderly patients with depression

BACKGROUND

Depression is the most prevalent disabling psychiatric syndrome of aging and may lead to important decrements in the elderly depressed patient's health-related quality of life (HRQL). The goal of this study was to determine whether severity of chronic illness at admission, severity of depressive symptoms at admission, or living alone before admission was associated with lack of improvement in HRQL at 3 months postdischarge among elderly depressed inpatients.

METHODS

Subjects were 100 consecutive patients admitted to a 26-bed inpatient geriatric psychiatry unit from 1994 through 1997, who were residing in the community and were not demented. At admission, severity of depressive symptoms was assessed using the Geriatric Depression Scale and severity of chronic physical illness was measured using the Cumulative Illness Rating Scale (Geriatrics). HRQL was assessed at admission and again at 3 months postdischarge using the Medical Outcomes Study (MOS) 6-Item General Health Survey.

RESULTS

This study found large improvements in all MOS items between admission and 3 months postdischarge. Severity of chronic physical disease was negatively associated with the probability of improvement in three MOS items (role functioning, psychological functioning, and general health perceptions) whereas the severity of depressive symptoms on admission was negatively associated with the probability of improvement in role functioning, social functioning, and bodily pain. Living alone was negatively associated with social functioning but not with any of the other MOS items.

CONCLUSION

The results of this study suggest that the inpatient treatment of depression in the elderly brings about improvements in quality of life that persist for at least 3 months following discharge. The patient's initial level of depression and initial level of physical health may be important factors to be considered when evaluating a patient's prognosis.

Fluvoxamine pharmacotherapy of anxiety disorders in later life: preliminary open-trial data

The authors present data from an open trial of fluvoxamine (median daily dosage: 200 mg) in the treatment of generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder in 19 older outpatients (mean age = 66.8). Of the 12 subjects completing the 21-week trial, 8 achieved a good response (50% reduction in symptom measures) and 7 were rated as much or very much improved. Fluvoxamine pharmacotherapy also had a significant effect in reducing comorbid depressive symptoms and in increasing levels of functioning. These data support the effectiveness of fluvoxamine in older subjects with anxiety disorders (particularly generalized anxiety disorder) and warrant further double-blind, placebo-controlled evaluation.

Life-sustaining treatment and assisted death choices in depressed older patients

OBJECTIVES

The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life-sustaining treatments, physician-assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices.

DESIGN

Cross-sectional study.

SETTING

General medical hospital.

PARTICIPANTS

One hundred fifty-eight medically hospitalized, nondemented patients age 60 or older, mean age 74.1 (range 60-94). The sample was divided, based on Center for Epidemiologic Studies-Depression (CES-D) scores, into a depressed group (n = 71) and a nondepressed control group.

MEASUREMENTS

Subjects underwent a structured interview evaluating their life-sustaining treatment choices and whether they would accept or refuse PAS or euthanasia under a variety of hypothetical conditions. These choices were reevaluated with the introduction of financial impact. In addition, assessment included measures of depression, suicide, cognition, social support, functioning, and religiosity.

RESULTS

Depression was found to be highly associated with acceptance of PAS and euthanasia in most hypothetical clinical scenarios in addition to patients' current condition. Compared with nondepressed people, depressed respondents were 13 times as likely to accept PAS when considering their current condition (95% confidence interval [CI] 1.68-110.98), and over twice as likely to accept PAS when facing a hypothetical terminal illness or coma. Depression alone was weakly associated with life-sustaining treatment choices but, when financial impact was introduced, significantly more depressed subjects refused treatment options they had previously desired than did nondepressed subjects. The presence of suicidal ideation, even passive ideation, was strongly predictive of life-sustaining treatment refusals and increased interest in PAS and euthanasia. Depression's effect on acceptance of PAS was confirmed by logistic regression, which also showed that religious coping was significantly correlated with less interest in PAS in two hypothetical scenarios. CONCLUSION. Depressed subjects and even subjects with subtle, passive suicidal ideation were markedly more interested in PAS and euthanasia than nondepressed subjects in hypothetical situations. Depressed subjects were also particularly vulnerable to rejecting treatments if financial consequences might have resulted.

Comorbidity and rehabilitation

Screening patients admitted to a rehabilitation center has become important. Actually, co-existing diseases are not very often evaluated and their importance is underestimated. At our department 166 consecutive patients were enrolled. The Cumulative Illness Rating Scale (CIRS) appeared to be the most suitable for these cases. In this series, stroke patients presented with higher severity and higher comorbidity than the hip fracture patients. The hip fracture cases were older but the stroke cases had higher severity and comorbidity. Comorbidity, also, showed a significant negative correlation with FIM in the stroke patients. These data show that severe comorbid conditions influence the functional autonomy. Severity and comorbidity were correlated both in the hip fracture and stroke cases. A review of geriatric literature demonstrates lower values in patients in rehabilitation. The difference is due to our accurate selection of patients at admission, where general health conditions are considered. In conclusion, the CIRS should be used as a method for selecting patients at admission and as a prognostic index for improvement at discharge. The CIRS, however, has some inconveniences and amelioration is necessary, such as the inclusion of a double testing (admission-discharge), psychiatric disturbances and a new item for skin alone. The Severity Index was higher in women, who were older than men, whereas, comorbidity was the same. In the patients suffering from hip fracture, the age was higher in women, but dependence, severity and comorbidity did not statistically differ between the groups.

Day-clinic treatment of late-life depression

BACKGROUND

There are few studies evaluating treatment in gerontopsychiatric day-clinics. In this paper, data are presented on the outcome of day-clinic treatment in late-life depression.

METHOD

Forty-four depressed elderly patients (mean Hamilton Depression Score: 17.6) were examined at admission and discharge for psychopathology, functioning in daily living, social situation, burden with medical disease and quality of life.

RESULTS

At discharge, the patients showed a significant reduction in depressive symptoms, improvements in cognitive performance, social activities and contacts. However, a more detailed analysis revealed that only patients responding to treatment (n=20) improved in the respective parameters. Patients, who did not recover fully from depression (n=24), did not improve in any of these parameters. At admission, responders and nonresponders did not differ concerning quality of life. At discharge, responders were significantly more satisfied in 11 of 20 domains of life quality. A shorter life time duration of depressive disease and male sex were predictive for a remission of depression. Thus, it could be shown that a considerable number of patients suffering from late-life depression may be successfully treated in a gerontopsychiatric day-clinic and 45.5% fully recover from depression.

CONCLUSIONS

The day-clinic setting meets the specific needs of patients suffering from late-life depression by maintaining them in the community, supporting their abilities for self-care and promoting social contacts. Treatment in a day-clinic may be recommended for many elderly depressed patients.

Panic disorder in primary care: biopsychosocial differences between recognized and unrecognized patients

Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in more symptomatic and impaired patients. As part of a randomized effectiveness study in primary care patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a significantly higher frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with more prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However, the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care.

Symptoms of striatofrontal dysfunction contribute to disability in geriatric depression

OBJECTIVE

To examine whether symptoms of striatofrontal dysfunction contribute to disability in geriatric depression.

DESIGN

Cross-sectional evaluation of the relationship of specific cognitive impairments, psychomotor retardation, severity of depression, and medical burden to impairment of instrumental activities of daily living.

SETTING

Inpatient and outpatient services of a psychiatric university hospital located in a suburban metropolitan area.Patients. One hundred and fifty elderly psychiatric inpatients and outpatients with major depression and cognitive function ranging from normal to moderate dementia.

MEASURES

Psychomotor retardation was evaluated with the Hamilton retardation item and executive dysfunction was assessed with the initiation/perseveration (IP) domain of the Dementia Rating Scale. Disability, severity of depression and medical burden were assessed with the Instrumental Activities of Daily Living Index of the Multilevel Assessment Instrument, the Hamilton Depression Rating Scale and the Cumulative Illness Rating Scale-Geriatric, respectively.

RESULTS

In the entire sample (N = 150) and in the non-demented subjects (N = 101), stepwise regression analyses revealed that IP and psychomotor retardation were associated with IADL impairment. Additionally, a 'striatofrontal component', which consisted of IP and psychomotor retardation was also significantly associated with IADL impairment in the whole sample, as well as in the non-demented patients.

CONCLUSION

Clinical symptoms and neuropsychological findings associated with striatofrontal dysfunction contribute to disability in depressed elderly patients.

Measurement and impact of comorbidity in older cancer patients

As the world population ages, oncologists are increasingly confronted with the problem of comorbidity in cancer patients. This has stemmed an increasing interest into approaching comorbidity in a systematic way, in order to integrate it in treatment decisions. So far, data on the subject have been widely scattered through the medical literature. This article is aimed at reviewing the available data on the interaction of comorbidity and prognosis. This overview should provide an accessible source of references for oncological investigators developing research in the field. Various methods have been used to sum comorbidity. However, a major effort remains to be done to analyze how various diseases combine in influencing prognosis. The main end-point explored so far is mortality, with which comorbidity globally is reliably correlated. A largely open challenge remains to correlate comorbidity with treatment tolerance, and functional and quality of life outcomes, as well as to integrate it in clinical decision-making.

Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health-related quality of life among older adults receiving PEG.

DESIGN

A prospective cohort study.

SETTING

A small community of approximately 60,000 residents served by two hospital systems.

PARTICIPANTS

One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community.

MEASUREMENTS

Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics, process of care data, physical and cognitive function, subjective health status, nutritional status, complications, and mortality.

RESULTS

Over a 14-month period, 150 patients received PEG tubes in the targeted community; the mean age was 78.9. The most frequent indications for the PEG were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%). All measures of functional status, cognitive status, severity of illness, comorbidity, and quality of life demonstrated profound and life-threatening impairment; 30-day mortality was 22% and 1-year mortality was 50%. Among patients surviving 60 days or more, at least 70% had no significant improvement in functional, nutritional, or subjective health status. Serious complications were rare, but most patients experienced symptomatic problems that they attributed to the enteral tube feeding.

CONCLUSIONS

PEG tube feeding in severely and chronically ill older adults can be accomplished safely. However, there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional, nutritional, or subjective health status in this cohort of older adults. The issues raised in this descriptive study provide impetus for a randomized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating.

Barriers to healthcare access for cognitively impaired older Hispanics

This study describes the development of the Barriers to Healthcare Access Survey (BHAS) used to evaluate seven barrier factors believed to influence healthcare access for elderly Hispanics with memory or cognitive problems. This study further reports the results of the BHAS applied to a community sample of cognitively impaired older Hispanics and their caregivers. The study includes (1) The BHAS's development and procedures to establish instrument validity and reliability; (2) Interviews with the BHAS on 65 cognitively impaired Hispanics who were undergoing full diagnostic assessment for dementia and their caregivers. The most frequently perceived healthcare barriers reported in our study were related to (1) personal beliefs (38%), (2) language proficiency (33%), and (3) economic status (13%). The BHAS possesses the requisite psychometric properties to be an effective instrument for an initial survey of perceived barriers to access health care for low-education, cognitively impaired, elderly Hispanic patients. The findings suggest that perceptions regarding illness, health consequences of aging, and beliefs about the utility of medicine do, in fact, influence healthcare use by older Hispanic patients with dementia. Language proficiency and economic status remain common barriers among elderly Hispanic subgroups, but when these barriers are experienced by the cognitively impaired, serious healthcare implications ensue, especially delay in early diagnosis and treatment.

Determinants of seizure threshold in ECT: benzodiazepine use, anesthetic dosage, and other factors

The electrical dosage of the ECT stimulus impacts on efficacy and cognitive side effects, yet seizure threshold (ST) may vary as much as 50-fold across patients. It would be desirable to predict ST on the basis of patient and treatment characteristics. In particular, concerns have been raised that benzodiazepine use and higher dosage of barbiturate anesthetics elevate ST. In a three-site study, ST was quantified at the first ECT session using an identical empirical titration procedure in 294 patients who met RDC and DSM-IIIR criteria for a major depressive episode. ST varied over a 35-fold range across patients treated with right unilateral (RUL) (n = 267) and bilateral (BL) (n = 27) ECT. Higher ST was associated with BL electrode placement (p = 0.001). Among patients treated with RUL ECT, univariate analyses indicated that higher ST was associated with advanced age (p < 0.001), male gender (p < 0.001), greater burden of medical illness (p < 0.001), weight (p < 0.01), duration of mood disorder (p < 0.01), and history of previous ECT (p < 0.05). Average lorazepam dose in the 48 hours prior to ECT was not associated with ST, but was associated with decreased seizure duration (p < 0.01). Absolute, but not weight-adjusted, methohexital dose was associated with ST (p < 0.01). Multivariate analyses in patients treated with unilateral ECT showed that only 27.6% of the variance in ST (p < 0.0001) could be predicted. In the multivariate analyses, only age (p = 0.0001), gender (p = 0.01), and methohexital dose (p = 0.0001) were independently related to ST. Low dosage of lorazepam and methohexital dosage below 1 mg/kg are unlikely to impact on ST. Given the limited capacity to predict ST, empirical titration remains the only accurate method to determine electrical dosage in RUL ECT.

Measuring comorbidity in older cancer patients

The aim of this article was to provide oncology researchers with adequate tools and practical advice to integrate comorbidity into clinical studies. Open research questions are also discussed. Commonly used comorbidity indexes were identified and a detailed literature search was done by MEDLINE and cross-referencing. Expert opinion was sought on each index. A common scheme exploring the description of the index, clinical experience, metrological performance, easiness of use, cross-compatibility and preservation of data was followed. The actual indexes are included in the Appendix. Four commonly used indexes were identified: the Charlson Comorbidity Index (Charlson), the Cumulative Illness Rating Scale (CIRS), the Index of Coexistent Disease (ICED), and the Kaplan-Feinstein index. The Charlson is the most commonly used whereas the performance of the first two indexes is best characterised. Most studies are retrospective and focus on mortality as an outcome and a base of grading. All indexes are easy to use and require a maximum of 10 min to be filled. Inter-rater and test-retest reliability is generally good. Little is known about other outcomes and the way various diseases cumulate in influencing prognosis. Thus, several reliable indexes are available to measure comorbidity in cancer patients. They show that globally comorbidity is a strong predictor of outcome. Since little is still known about the importance of individual comorbidities for various outcomes and the way comorbidity cumulates in influencing cancer treatment, a wide integration of comorbidity in prospective studies is essential.

Assessment of the older cancer patient

The correct assessment of a cancer patient is a key step in the treatment process. In older people, this assessment entails not only the patient's basic medical history and the standard cancer staging, but also much more comprehensive evaluation of the various facets of the patient's health and environment that may interfere with his or her therapy. Patient fitness for elective surgery, radiation therapy, and chemotherapy must be considered. Geriatricians have defined the relevant aspects of the general evaluation of the older person, and now this work is being adapted to cancer patients. This article reviews the various aspects of a comprehensive assessment applicable to the cancer patient in settings such as academic oncology programs, cooperative group studies, and private oncology practice.

Relationship between depression and cerebrovascular disease: conceptual issues

OBJECTIVES

The association between cerebrovascular disease (CVD) and depression has been well described, but our understanding of various aspects of the relationship between these two disorders remains limited.

METHOD

Based on a selective literature review, this paper examines empirical evidence and discusses conceptual issues concerning hierarchical, interactive, and co-morbid relationships between CVD and depression.

RESULTS

The concept of vascular depression minimizes the importance of the contribution of psychosocial factors. The interactive and co-morbid relationships have been largely neglected in psychiatric research. There is evidence that depression may increase the risk of CVD morbidity in patients with vascular disease and delay recovery in stroke patients, implying an interactive relationship. The concurrent existence of these two disorders based on common etiological factors such as genetic vulnerability, alcoholism and personality traits seems plausible.

CONCLUSIONS

A modified comorbidity model may guide investigation into the hierarchical, interactive and common etiological relationships between CVD and depression.

Effect of Bupropion SR on the Quality of Life of Elderly Depressed Patients With Comorbid Medical Disorders

BACKGROUND: There is a need for additional studies of the quality of life (QOL) of elderly depressed subjects with medical comorbidity. METHOD: We conducted an 8-week, open trial of bupropion sustained release (SR) in 18 elderly (60-81 years) subjects with DSM-IV major depressive disorder and one or more serious medical illnesses (e.g., congestive heart failure, type 1 diabetes mellitus, irritable bowel syndrome) with a week-12 follow-up interview. The intent-to-treat method with the last observation carried forward was used to analyze depression and QOL measures. Dosing was initiated at 100 mg once daily and increased at weekly intervals to a maximum of 150 mg twice daily as clinically indicated. RESULTS: Bupropion SR treatment was associated with reductions in Clinical Global Impressions-Severity of Illness scale (p <.0001) score and in the 17-item Hamilton Rating Scale for Depression (HAM-D) total score (p <.0001). QOL as measured by the Medical Outcomes Study Short Form-36 (SF-36) also tended to improve with treatment. The SF-36 "mental health" (p <.01) and "social functioning" (p <.0006) domains improved significantly by week 4. "Vitality" (p <.03) improved significantly by week 12. On the HAM-D, statistically significant improvement was noted on "depressed mood" (p <.0001), "feelings of guilt" (p <.01), "work and activities" (p <.001), "hypochondriasis" (p <.02), and "insomnia" (p <.01) at week 8. The mean dose of bupropion SR at endpoint was 222 mg/day, and the drug was relatively well tolerated. Two subjects dropped out owing to adverse events and 2 owing to other reasons. No drug-drug interactions occurred. CONCLUSION: These data suggest that bupropion SR is well tolerated and may improve depression, insomnia, somatic symptoms, work functioning, and certain quality-of-life measures in elderly depressed subjects with medical disorders. A randomized, placebo-controlled study is warranted to confirm these promising findings.

Acute efficacy of ECT in the treatment of major depression in the old-old

OBJECTIVE

There are few data addressing the outcome of ECT for persons over 75 years of age. In a prospective, multisite study, the authors compared characteristics and treatment outcomes of adult (59 and younger), young-old (60 to 74 years), and old-old (75 and older) patients treated with ECT for major depression.

METHOD

At four hospitals, 268 patients with primary unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner. Demographic variables, clinical characteristics, and short-term outcomes of the three groups were compared.

RESULTS

The demographic and clinical characteristics of the old-old patients were similar to those of the young-old patients, whereas both groups differed from the adult patients on these variables. Both older groups had significantly greater burdens from physical illness and global cognitive impairment at baseline than the adult subjects. Both older groups had shorter index depressive episodes and were less likely to have had inadequate responses to adequate medication trials before ECT. The older groups had higher seizure thresholds, but the three groups received similar courses of treatment. The adult patients experienced a significantly lower rate of ECT response (54%) than the young-old patients (73%), while the old-old patients had an intermediate rate of response (67%).

CONCLUSIONS

Despite a higher level of physical illness and cognitive impairment, even the oldest patients with severe major depression tolerate ECT in a manner similar to that for younger patients and demonstrate similar or better acute response.

Clinical and neuroradiologic features associated with chronicity in late-life depression

The authors conducted a 6-year follow-up of 16 patients with late-life depression to evaluate the relationships between clinical and neuroradiologic variables and disease outcome. Patients had a comprehensive neuropsychiatric evaluation and magnetic resonance imaging (MRI) at baseline and follow-up. Eight of the 16 developed a chronic course of unremitting major depression sufficient to cause significant psychosocial impairment. Six patients with a chronic course and four patients with a non-chronic course of depression had white matter hyperintensities (WMH) on MRI at baseline. Four patients whose WMH increased in size over time developed a chronic unremitting course of depression. No patients with non-chronic depression had large areas of WMH at baseline or exhibited increased WMH size over time. Chronic depression was associated with severity of cerebrovascular risk factors, apathy, and poor quality of life. Treatment and prevention of cerebrovascular disease may improve the outcome of late-life depression.

Depressive symptoms in schizophrenia

OBJECTIVE

The authors assessed the presence and severity of depressive symptoms, as well as their associations with other clinical measures, in a group of mid- to late-life patients with schizophrenia who were not in a major depressive episode or diagnosed with schizoaffective disorder.

METHOD

Sixty outpatients with schizophrenia between the ages of 45 and 79 years and 60 normal comparison subjects without major neuropsychiatric disorders, proportionally matched for age and gender, were studied. Depressive symptoms were rated primarily with the Hamilton Depression Rating Scale. Standardized instruments were also used to measure global psychopathology, positive and negative symptoms, abnormalities of movement, and global cognitive status.

RESULTS

Depressive symptoms were more frequent and more severe in schizophrenic patients than in normal comparison subjects; 20% of the women with schizophrenia had a Hamilton depression scale score of 17 or more. Severity of depressive symptoms correlated with that of positive symptoms but not with age, gender, negative symptoms, extrapyramidal symptoms, or neuroleptic dose.

CONCLUSIONS

Depressive symptoms are common in older patients with schizophrenia. They may be an independent, core component of the disorder or, alternatively, may be a by-product of severe psychotic symptoms.

Suicidal feelings in the last year of life in elderly people who commit suicide

We examined suicidal feelings noted by doctors and by relatives of 85 elderly (> or = 65 years) people who died by suicide. When depression is suspected in an elderly patient, suicidal feelings should be assessed even during follow-up treatment.

Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery

OBJECTIVE

To determine whether patients with knee or hip osteoarthritis (OA) who have worse physical function preoperatively achieve a postoperative status that is similar to that of patients with better preoperative function.

METHODS

This study surveyed an observational cohort of 379 consecutive patients with definite OA who were without other inflammatory joint diseases and were undergoing either total hip or knee replacement in a US (Boston) and a Canadian (Montreal) referral center. Questionnaires on health status (the Short Form 36 and Western Ontario and McMaster Universities Osteoarthritis Index) were administered preoperatively and at 3 and 6 months postoperatively. Physical function and pain due to OA were deemed the most significant outcomes to study.

RESULTS

Two hundred twenty-two patients returned their questionnaires. Patients in the 2 centers were comparable in age, sex, time to surgery, and proportion of hip/knee surgery. The Boston group had more education, lower comorbidity, and more cemented knee prostheses. Patients undergoing hip or knee replacement in Montreal had lower preoperative physical function and more pain than their Boston counterparts. In patients with lower preoperative physical function, function and pain were not improved postoperatively to the level achieved by those with higher preoperative function. This was most striking in patients undergoing total knee replacement.

CONCLUSION

Surgery performed later in the natural history of functional decline due to OA of the knee, and possibly of the hip, results in worse postoperative functional status.

The effect of major depression on functional status in patients with coronary artery disease

OBJECTIVE

To examine the effect of major depression on reported functional status in a group of patients with coronary artery disease (CAD).

SETTING

An inpatient cardiology service.

PARTICIPANTS

Three hundred thirty-five inpatients with coronary artery disease who were free of dementia, Parkinson's disease, and other primary neurological illnesses.

MEASUREMENTS

Duke Depression Evaluation Schedule, a structured psychiatric interview which included the Diagnostic Interview Schedule depression subscale, the Cumulative Illness Rating Scale, and two scales for measuring instrumental and self-maintenance activities of daily living.

RESULTS

Twenty-seven subjects met DSM-IV criteria for major depression. Compared with subjects without major depression, depressed subjects were more than twice as likely to report a self-maintenance ADL deficit and were significantly more likely to report an IADL deficit than were nondepressed subjects (93 vs 71%). In regression models, female gender, older age, greater medical illness severity, and presence of major depression were significant predictors of self-maintenance ADL disability; and female gender, older age, greater medical severity, and presence of major depression significantly predicted greater IADL impairment.

CONCLUSION

The presence of major depression was associated with functional disability in patients with CAD. Further research is needed to clarify whether antidepressant treatment significantly impacts both affective symptoms and functional status in patients with coronary heart disease.

High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide

OBJECTIVE

To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people.

DESIGN

Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression.

SETTING

An outpatient research clinic providing two treatment protocols of late-life mood disorders.

PARTICIPANTS

A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment.

MEASUREMENTS

Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission.

RESULTS

After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients.

CONCLUSIONS

Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late-life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.

Assessing life expectancies of older nursing home residents

OBJECTIVE

Care of nursing home (NH) residents is often based on the usual survival of the home's residents. In order to improve our understanding of this population, and, thus, ultimately facilitate individualization of their care, we developed a mathematical model that predicts their survival.

SETTING

The Jewish Home and Hospital (JHH), a nursing home.

PARTICIPANTS

1145 older residents who were at the JHH from January 1, 1986, through July 1, 1986.

MEASUREMENTS

Information abstracted from medical records and JHH computerized data: clinical, demographic, and dependencies in activities of daily living (ADLs).

MAIN OUTCOME MEASURE

survival from July 1, 1986.

DESIGN

Retrospective cohort study via medical chart review. The study period covered admission to JHH through January 17, 1996. Accelerated failure time (AFT) models generated the life expectancy model derived from 50% of the study group and were validated on the remaining sample. We computed predicted AFT and proportional hazards (PH) life expectancies.

RESULTS

Significant, independent predictors of decreased survival were male gender, increased age, increase in summary ADL index, and impairment of cardiac, respiratory, neurological, and endocrine/metabolic systems. The interaction between gender and respiratory system impairment was significant. The Spearman correlation coefficients between the observed survivals and those predicted by the Phase I model are 0.49 for Phase I residents and 0.42 for Phase II residents. Our sample life table includes NH residents with different risk profiles and their associated survival estimates as well as interquartile ranges. AFT and PH survivals were similar.

CONCLUSION

This first comprehensive model that predicts survival of NH residents can help formulate public health policies and identify appropriate NH residents for clinical trials. The model is a promising step toward improving the health care of NH residents.

Correlates of functional status in older patients with schizophrenia

There is a growing recognition of the importance of quantifying the impact of illness on functional abilities. Measures of function frequently rely on a self-report. Few studies have directly assessed functional capacity in psychiatric patients, especially older ones who may be at an increased risk for disability. Subjects were 102 middle-aged and elderly outpatients with DSM-III-R or DSM-IV diagnosis of schizophrenia or schizoaffective disorder, and 66 normal comparison subjects, ranging in age from 45 to 86. The Direct Assessment of Functional Status (DAFS), a standardized measure of behavior during simulated daily activity tasks (i.e. time orientation, communication, transportation, finance, shopping, grooming and eating) was used to quantify levels of disability. Schizophrenic patients demonstrated significantly greater disability than normal subjects. An evaluation of specific behaviors indicated that the patients were significantly more limited than comparison subjects across all subscales of the DAFS except for grooming and eating. A lower level of formal education, greater severity of extrapyramidal symptoms, and greater cognitive deficits, but not severity of symptoms of schizophrenia, were related to lower DAFS scores. Relative to published findings, schizophrenic patients appeared more disabled than outpatients with major depression, but less disabled than those with Alzheimer's disease. The DAFS is a useful instrument for characterizing functional abilities in older patients with schizophrenia. Our findings of significant functional disability in older schizophrenic patients have implications for treatment as well as allocation of health-care resources.

Medical comorbidity in elderly psychiatric inpatients

A multidisciplinary diagnostic evaluation was performed for 868 older psychiatric inpatients during a 46-month interval. A total of 402 (46%) met DSM-III-R criteria for organic mental disorders, 329 (38%) had mood disorders, 90 (10%) had psychotic disorders, and 47 (5%) had other mental disorders or conditions. Concurrent medical problems were systematically assessed and classified according to ICD-9-CM criteria. The patients suffered from a mean of 5.6 +/- 3.1 (SD) active medical problems (range 0-18). This level of medical comorbidity was significantly greater than that of older psychiatric outpatients and comparable to that of elderly inpatients in general medical hospitals. When the effects of age and education were controlled for, there were no significant differences in mean numbers of medical problems among the four groups of psychiatric inpatients. An association of major depression with diseases of the digestive system was observed and may be related to peripheral autonomic dysregulation.

Sleep in the wake of complicated grief symptoms: an exploratory study

Our aim was to explore the concept that the symptoms of complicated grief may be a form of posttraumatic distress, rather than depression, and thus may have different effects on sleep. Sixty-five recently bereaved elders with varying levels of symptoms of complicated grief and depression were stratified by high versus low levels of symptoms; a two-way analysis of variance examined main effects of level of complicated grief symptoms and depressive symptoms on selected sleep measures, as well as interactions. Complicated grief symptoms were independently associated with mild subjective sleep impairment but showed no main effects on electroencephalographic (EEG) sleep measures. In a multiple regression analysis, complicated grief symptoms interacted with depressive symptoms to increase REM sleep percent. Thus, it appears that complicated grief symptoms do not entail the changes of EEG sleep physiology seen in depression, with the possible exception of an interaction with coexisting depression to enhance REM sleep percent.