A new version of the geriatric depression scale for nursing and residential home populations: the geriatric depression scale (residential) (GDS-12R)

Effectiveness of Psychotherapy for Community-Dwelling Vulnerable Older Adults with Depression and Care Needs: Findings from the PSY-CARE Trial

BACKGROUND

For older adults with care needs, evidence for the effectiveness of psychotherapy on depression is scarce.

METHODS

In PSY-CARE, a pragmatic randomized controlled trial, N = 197 home-living older adults with depression and care needs were randomized into outpatient psychotherapy or an active control condition. Residential psychotherapists offered age-sensitive cognitive-behavioral psychotherapy (at-home if needed). Control group participants received telephone counseling and a self-help guide. Outcomes were assessed at baseline (T1), after (T2), 3 months after (T3), and 12 months after the intervention (T4).

RESULTS

There was a significant decrease in depressive symptoms across both arms with Cohen's d T4-T1 = .52 in the psychotherapy and .55 in the control group. Mixed models revealed no statistically significant difference in primary and secondary outcomes between interventions. Posthoc, we found control group participants with greater ADL limitations experienced significantly increased depressive symptoms compared to those reporting lower limitations.

CONCLUSIONS

Interventions were successful in reducing depressive symptoms, even though treatment fidelity was decreased due to the COVID-19 pandemic. We could not demonstrate superior effectiveness of psychotherapy for older adults with care needs.

CLINICAL IMPLICATIONS

Findings suggest that psychotherapy may be an important and superior treatment to circumvent aggravation of depression in older patients with high functional limitations.

TRIAL REGISTRATION

The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN55646265, February 15, 2019).

Psychological therapies for depression in older adults residing in long-term care settings

BACKGROUND

Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

OBJECTIVES

To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Life-space mobility among home-living older adults with care needs and clinical depression-A cross-sectional analysis

OBJECTIVES

While life-space mobility is key for wellbeing, social participation and access to health care, vulnerable older adults face physical and mental barriers that may restrict mobility. The present exploratory study examined associations between physical functional limitations, depressive symptoms, life-space mobility and outpatient health care utilization.

METHODS

Cross-sectional data from 197 community-dwelling older adults with care needs and clinical depression was collected. Life-space assessment composite score (LS-C), instrumental activities of daily living scale (iADL), Geriatric Depression Scale (GDS-12) and outpatient health care utilization have been assessed. Multiple regression analyses were conducted.

RESULTS

Mean LS-C score was 31.8 (SD = 17.7, range: 0-92), indicating low mobility levels. Depressive symptoms (β = -0.21, p = 0.001) and iADL (β = 0.54, p < 0.001) were significantly related with life-space mobility, over and above age and living alone. An interaction effect between depressive symptoms and iADL was not significant (β = -0.07, 0.17, p = 0.26). Moreover, life-space mobility was positively associated with primary care (β = 0.19, p = 0.02) and mental health care utilization (β = 0.33, p < 0.001).

CONCLUSIONS

Life-space mobility appears to be largely restricted in home-living vulnerable older adults with clinically significant depression; and factors associated with these restrictions appear to be physical and mental. The interplay of depression, mobility and health care utilization and its potential for interventional approaches need further investigations. Present findings underline an urgent need for new health care services that allow mobility-impaired older patients to receive mental health outpatient treatment in their own home.

CLINICAL TRIAL REGISTRATION

The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN55646265, registered February 15, 2019).

Experiences of Home-living Vulnerable Older Adults with Clinical Depression during the COVID-19 Pandemic: A Qualitative Study

OBJECTIVES

Little is known about the diversity of older adults' experiences during the COVID-19 pandemic. We therefore investigated the pandemic experiences of home-living vulnerable older adults with depression, an understudied subpopulation.

METHODS

We conducted unstructured interviews with N= 20 older (60+ years) adults with clinical depression receiving care in their homes in June and again in December 2020. Interviews were coded according to the grounded theory approach.

RESULTS

We identified eight themes. Participants described feeling disconnected before and during the pandemic, which they attributed to their physical impairments and old age. Their social relations with family, medical providers, and caregivers helped them feel connected. Participants did not feel significantly impacted by the COVID-19 pandemic, but they missed social and physical contact. During the pandemic, isolation was normalized. Participants therefore experienced loneliness due to their isolation, but also a sense of togetherness with the rest of society. Isolation within the home was re-framed as cocooning, which provided a sense of autonomy. Participants nevertheless expressed resignation.

CONCLUSIONS

Home-living vulnerable older adults with depression experienced loneliness but also a degree of relief during the pandemic.

CLINICAL IMPLICATIONS

Positively re-framing isolation and the stability of formal caregiving helped participants endure feeling disconnected during the pandemic.

Motivation and Psychotherapy in Older Adults with Care Needs and Depression

Abstract. The utilization of psychotherapy for home-living, vulnerable older adults with depression is limited. Understanding patients’ motivation is essential to tailoring psychotherapy to their needs and improving therapeutical efficacy. Based on cross-sectional data obtained from a pragmatic, randomized controlled trial (PSY-CARE study), this study investigated general intake concerns (ICs) and patients’ treatment goals (PTG) of home-living older adults with depression. Data on ICs ( N = 251 older adults interested in participation) were analyzed using qualitative content analysis. Data on PTGs ( N = 86 participants receiving psychotherapy) were analyzed quantitatively. Main ICs included reducing depressive symptoms and coping with new (health) situations. PTGs focused on coping with health problems and age-related losses. The results provide clinicians with valuable insights into motivational factors in this vulnerable and hard-to-reach population.

A Scoping Review of the Measurement of Depression in Older Adults with Cognitive Impairment

OBJECTIVES

Depression and cognitive impairment are disabling conditions that commonly occur together in older adults. The interaction is challenging when choosing appropriate measurement scales. This review aimed to summarize the scales to measure depression symptoms in older people with cognitive impairment, investigating how cognitive impairment is related to the choice of measurement, and how the setting may affect the choice of measurement.

METHODS

A scoping review of literature published between 2015 and 2021.

RESULTS

After screening 1580 articles, 26 were included in the review with 11 different measures of depression symptoms identified. The measures mostly commonly used were the Geriatric Depression Scale (GDS), Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory (NPI-Q). Most studies did not report on the usability of depression scales used with people with cognitive impairment and only two scales (CSDD and NPI-Q, not GDS) have been validated for use with this population.

CONCLUSIONS

Severe cognitive impairment was under-represented in the identified studies, and no association was detected between study setting, cognitive impairment and type of measure used.

CLINICAL IMPLICATIONS

Clinicians and researchers should consider both the cognitive status of participants and the setting they live in when choosing a measure of depression symptoms.

Effects of the use of autobiographical photographs on emotional induction in older adults: a systematic review

There is evidence to support the positive contribution of autobiographical recall based techniques on individuals' quality of life, mood and cognitive functioning. In this review, we analyzed the effects of the use of personal photographs in interventions based on autobiographical memory in older people with and without cognitive impairment. The PRISMA guidelines for systematic reviews were followed. The search was carried out in the electronic databases Web of Sciences (WOS), Medline (PubMed), SCIELO and PsycInfo (American Psychological Association). The articles based on clinical trials selected were evaluated using the PEDRo scale, which is specific to this type of article. Of the 1098 articles initially found, 6 met the inclusion criteria. The final articles focused their intervention on the use of autobiographical photographs as a means of stimulation. The results show that the use of photographs in different autobiographical recall stimulation techniques is associated with higher scores on well-being and quality of life, as well as with improvements in personal identity and cognitive functioning. This suggests that using personal photographs shows promise in enhancing the effect of these types of interventions in healthy or cognitively impaired older adults.

Types of exercise and training duration on depressive symptoms among older adults in long-term care facilities

BACKGROUND

Depression is associated with a greater risk of disability, cognitive impairment, and suicide. Older adults in long-term care facilities (LTCFs) are more likely to develop depression due to changes in family roles and separation from family members. The aim of this study was to synthesize and analyze the effects of different types of exercise and training duration on depressive symptoms of older adults in LTCFs.

METHODS

Relevant peer-reviewed journal articles published in English were identified through a search of six electronic databases up to June 2021.

RESULTS

A total of 25 studies were included in the systematic review and 22 in the meta-analysis. The results of meta-analysis showed that exercise interventions reduced depression in cognitively intact older adults and in cognitively impaired older adults. Both exercising less than 150 min per week or more than 150 min per week, reduced depressive symptoms of older adults. In terms of exercise types, mind-body exercises, exergames, and strength training reduced depressive symptoms.

CONCLUSION

Exercise has a positive effect on reducing depressive symptoms with mind-body exercises, exergames, and strength training producing the best effect. Regardless of cognitive impairment, older adults in LTCFs benefited from exercise in reducing depressive symptoms.

Accuracy of 12 short versions of the Geriatric Depression Scale to detect depression in a prospective study of a high-risk population with different levels of cognition

OBJECTIVES

To determine the accuracy of 12 previously validated short versions of the Geriatric Depression Scale (GDS) to detect major depressive disorder (MDD) in a high-risk population with and without global cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Five hospitals, Western Sweden.

PARTICIPANTS

Older adults (age ≥70 years, n = 60) assessed at a home visit 1 year after hospital care in connection with suicide attempt.

MEASUREMENTS

Depression symptoms were rated using the established 15-item GDS. Eleven short GDS versions identified by a recent systematic review were derived from this administered version. Receiver operating characteristic curves and area under the curve (AUC) for the identification of MDD diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were obtained for each version. The Youden Index optimal criterion was used to determine the appropriate cutoffs. Analyses were repeated after stratification by cognitive status (Mini Mental State Examination score ≤24 and >24) for the best performing GDS short versions and the established 15-item GDS.

RESULTS

The 7-item GDS according to Broekman et al. (), with a cutoff 3, was the most accurate among the 12 short versions (AUC 0.90, 95% confidence interval 0.80-1.00), identifying MDD with sensitivity 88% and specificity 81%. The cutoff score remained consistent in the presence of global cognitive impairment, which was not the case for the standardized 15-item GDS.

CONCLUSION

The Broekman 7-item GDS had high accuracy to detect MDD in this prospective clinical cohort at high risk for MDD. Further testing of GDS short versions in diverse settings is required.

Evaluation of Recruitment Strategies for Home-Living Vulnerable Older Adults With Depression: Findings From a Randomized Controlled Psychotherapy Trial

OBJECTIVE

Vulnerable older adults, such as physically impaired or care-dependent individuals, are vastly underrepresented in psychotherapy research. Improving their inclusion in randomized controlled trials is necessary to determine the effectiveness of psychotherapy in this population. This study is the first to systematically evaluate strategies to recruit home-living vulnerable older adults with clinically significant depression into a large randomized controlled psychotherapy trial. Potential participants were approached directly (self-referral) or via cooperation with gatekeepers (gatekeeper-referral).

METHODS

Successful recruitment strategies and the person initiating the first contact with the study team were recorded. Recruitment strategies were compared with respect to the number of inquiries and inclusion rates, study personnel's time investment, and participant characteristics (sociodemographics, functional and cognitive status, depression and anxiety scores).

RESULTS

Most of the N = 197 participants were included via gatekeeper-referral (80.5%, 95% confidence interval = [74.9, 86.1]), but time investment for gatekeeper-referrals was five times higher than for self-referral by media reports. Clinical psychologists and medical practitioners referred the largest proportion of participants (32.3% each) and referral by medical practitioners led to highest inclusion rates (55.6%; χ²(3) = 8.964, p <0.05). Most participants were referred from a hospital setting (50.3%), whereas referral numbers by medical practices were low (15.9%). Participants who initiated the first contact themselves had higher inclusion rates and were less functionally impaired.

CONCLUSION

Including home-living vulnerable older adults into psychotherapy trials requires simultaneous implementation of diverse recruitment strategies. Medical practitioners and psychologists, especially in hospitals, are the most effective recruitment strategy, but self-referral via media is most cost-efficient in terms of time investment.

Detecting depression in persons living in long-term care: a systematic review and meta-analysis of diagnostic test accuracy studies

OBJECTIVE

Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings.

METHODS

We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias.

RESULTS

We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%-76.5%), specificity was 76.5% (95% CI 62.9%-86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%-90.0%) for persons in LTC living with dementia.

CONCLUSIONS

There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses.

Mobility enhancement among older adults 75 + in rural areas: Study protocol of the MOBILE randomized controlled trial

BACKGROUND

Maintaining mobility in old age is crucial for healthy ageing including delaying the onset and progress of frailty. However, the extent of an individuals´ mobility relies largely on their personal, social, and environmental resources as outlined in the Life-Space Constriction Model. Recent studies mainly focus on facilitating habitual out-of-home mobility by fostering one type of resources only. The MOBILE trial aims at testing whether tablet-assisted motivational counselling enhances the mobility of community-dwelling older adults by addressing personal, social, and environmental resources.

METHODS

In the MOBILE randomized controlled trial, we plan to enrol 254 community-dwelling older adults aged 75 and older from Havelland, a rural area in Germany. The intervention group will receive a tablet-assisted motivational counselling at the participant´s home and two follow-up telephone sessions. Main focus of the counselling sessions lays on setting and adapting individual mobility goals and applying action planning and habit formation strategies by incorporating the personal social network and regional opportunities for engaging in mobility related activities. The control group will receive postal general health information. The primary mobility outcome is time out-of-home assessed by GPS (GPS.Rec2.0-App) at three points in time (baseline, after one month, and after three months for seven consecutive days each). Secondary outcomes are the size of the GPS-derived life-space convex hull, self-reported life-space mobility (LSA-D), physical activity (IPAQ), depressive symptoms (GDS), frailty phenotype, and health status (SF-12).

DISCUSSION

The MOBILE trial will test the effect of a motivational counselling intervention on out-of-home mobility in community-dwelling older adults. Novel aspects of the MOBILE trial include the preventive multi-level intervention approach in combination with easy-to-use technology. The ecological approach ensures low-threshold implementation, which increases the benefit for the people in the region.

TRIAL REGISTRATION

The MOBILE trial is prospectively registered at DRKS (Deutsches Register Klinischer Studien, German Registry of Clinical Trials) DRKS00025230 . Registered 5 May 2021.

Validity and reliability of a shorter version of the Geriatric Depression Scale in institutionalized older Portuguese adults

OBJECTIVES

Depressive symptoms are common in older adults in institutional contexts; however, there is a lack of validated measures for these settings. Identifying depressive symptoms can help clinicians to manage them and to prevent or delay their complications. This study aimed to validate the Geriatric Depression Scale (GDS) in an institutionalized sample of older adults.

METHOD

493 institutionalized older people (73% women) aged 60 or over were evaluated through the GDS, the Mini International Neuropsychiatric Interview (MINI) (depression vs. no depression = 11% vs. 89%), the Geriatric Anxiety Inventory (GAI), the Positive Affect (PA) and Negative Affect (NA) Schedule, and the Satisfaction with Life Scale (SWLS). Test-retest reliability was assessed with 57 older adults.

RESULTS

An 8-item version presented a Cronbach's alpha value of .87 with a single factor explaining its variance. The correlations (p < .01) attested the concurrent validity (GAI: r = .76; PA: r = -.22; AN: r = .62; SWLS: r = -.32). Test-retest reliability (6.51 months) was adequate (r = .52). ROC analysis (AUC = .82; sensitivity = 80%; specificity = 77%) and Youden index revealed a cutoff of 5/6 for the diagnosis of depression.

CONCLUSION

Results support the validity and the screening capacity of a short version of GDS in institutional contexts. Short screening instruments for depressive symptoms may facilitate their identification, allowing for timely clinical interventions in institutional settings.

Performance of the Geriatric Depression Scale-15 with Older Adults Aged over 65 Years: An Updated Review 2000-2019

OBJECTIVES

This up-to-date systematic review and meta-analysis aimed to examine the predictive validity of the Geriatric Depression Scale-15 (GDS-15) for screening depression in older adults aged over 65 years.

METHODS

Electronic searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycINFO database using the following keywords: depression, depressive disorder, major, geriatric depression scale, and geriatric depression scale short. The Quality Assessment of Diagnostic Accuracy Studies-2 was applied to assess the risk of bias in diagnostic studies.

RESULTS

Thirty-one studies that included 8,897 older adults were analyzed. The pooled sensitivity of the GDS-15 was 0.80 (95% CI:0.78 to 0.82), its pooled specificity was 0.79 (95% CI:0.78 to 0.80), the area under the curve (AUC) was 0.89 (SE = 0.01) and the Q* value was 0.82 (SE = 0.01). The subgroup analysis revealed that the pooled sensitivity and specificity of the GDS-15 were higher in older adults with normal cognitive function than in those with cognitive impairment.

CONCLUSIONS

These finding suggest that the GDS-15 may be more accurate for screening depression in older adults with normal cognitive function.

CLINICAL IMPLICATIONS

The utility the GDS-15 may be restricted because its diagnostic accuracy is slightly lower among older adults with cognitive impairment.

Outpatient psychotherapy for home-living vulnerable older adults with depression: study protocol of the PSY-CARE trial

BACKGROUND

There is a need to improve psychotherapeutic approaches to treatment for vulnerable older adults with depression in terms of both clinical practice and health care supply. Against this background, PSY-CARE is testing the feasibility and effectiveness of outpatient psychotherapy for home-living older adults in need of care with depression in Berlin, Germany, and neighboring suburban areas.

METHODS

In a two-arm single-center pragmatic randomized controlled trial (RCT), manual-guided outpatient psychotherapy will be compared to brief psychosocial counseling. The study population will be compromised of older adults with clinically significant depressive symptoms who have a long-term care grade, as assessed by the German compulsory state nursing care insurance. In the intervention group, individual cognitive-behavioral psychotherapy tailored to the specific needs of this population will be offered by residential psychotherapists as part of the regular healthcare service. In the active control group, participants will receive individual psychosocial telephone counselling and a self-help guide. The planned sample size is N = 130 (n = 65 participants per group). The reduction of depressive symptoms (primary outcome) as well as the maintaining of activities of daily living, quality of life, and functioning will be assessed with questionnaires provided at baseline, after the end of the intervention and after three months. Feasibility and process evaluation will be conducted qualitatively based on documentation and interviews with psychotherapists, gatekeepers and the participants.

DISCUSSION

PSY-CARE investigates the potentials and limitations of providing outpatient psychotherapeutic treatment meeting the demands of vulnerable home-living older adults with depression under the real conditions of the health care system. The study will provide practical implications to improve access to and quality of outpatient psychotherapy for this poorly supplied population.

TRIAL REGISTRATION

The trial is registered at ISRCTN55646265 ; February 15, 2019.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Pushing the Boundaries: A Physical Activity Intervention Extends Sensor-Assessed Life-Space in Nursing Home Residents

Background and Objectives

To determine whether a multicomponent, individually tailored intervention to promote physical activity (PA) enhances life-space (LS) utilization in nursing home (NH) residents and whether intervention effects can be sustained at follow-up after continuation of the program as part of institutional daily routines.

Research Design and Methods

Pre-post-assessed controlled trial in two highly similar NHs with a 3month follow-up in 143 NH residents (intervention group: n = 78; control group: n = 65) and LS as primary outcome. The PA promoting intervention consisted of several components (group sessions; individual exercise; serious games training; competence training for staff) tailored to residents' individual functional capacity. LS was innovatively assessed via an indoor wireless sensor network including three assessment-specific LS parameters: overall LS score (LSSc), time spent away from the private room (TAFR), and the maximally distal zone from private room visited (MaxZ). To exploit the available intervention-control comparative data in the best way possible, a generalized linear mixed model approach was applied.

Results

At post-test, intervention participants had a significantly higher overall LSSc, spent more TAFR, and had extended their MaxZ as compared to controls. At follow-up, a significant group difference remained for MaxZ.

Discussion and Implications

A PA intervention in the NH setting impacts on LS utilization as measured using sensor-based assessment. The program has proven its practical sustainability when being handed over to NH personnel for continuation in daily practice. Further research is needed to determine whether an increase in LS utilization also impacts on social participation and quality of life.

Does a physical activity program in the nursing home impact on depressive symptoms? A generalized linear mixed-model approach

OBJECTIVES

Physical activity (PA) may counteract depressive symptoms in nursing home (NH) residents considering biological, psychological, and person-environment transactional pathways. Empirical results, however, have remained inconsistent. Addressing potential shortcomings of previous research, we examined the effect of a whole-ecology PA intervention program on NH residents' depressive symptoms using generalized linear mixed-models (GLMMs).

METHOD

We used longitudinal data from residents of two German NHs who were included without any pre-selection regarding physical and mental functioning (n = 163, M_age = 83.1, 53-100 years; 72% female) and assessed on four occasions each three months apart. Residents willing to participate received a 12-week PA training program. Afterwards, the training was implemented in weekly activity schedules by NH staff. We ran GLMMs to account for the highly skewed depressive symptoms outcome measure (12-item Geriatric Depression Scale-Residential) by using gamma distribution.

RESULTS

Exercising (n = 78) and non-exercising residents (n = 85) showed a comparable level of depressive symptoms at pretest. For exercising residents, depressive symptoms stabilized between pre-, posttest, and at follow-up, whereas an increase was observed for non-exercising residents. The intervention group's stabilization in depressive symptoms was maintained at follow-up, but increased further for non-exercising residents.

CONCLUSION

Implementing an innovative PA intervention appears to be a promising approach to prevent the increase of NH residents' depressive symptoms. At the data-analytical level, GLMMs seem to be a promising tool for intervention research at large, because all longitudinally available data points and non-normality of outcome data can be considered.

Understanding depressive symptoms in nursing home residents: the role of frequency and enjoyability of different expanded everyday activities relevant to the nursing home setting

Depressive symptoms are highly prevalent in nursing home (NH) residents. We assume that enjoyability, besides frequency of activities, is an important facet of expanded everyday activities (EEAs; Baltes et al., in: Baltes and Mayer (eds) The Berlin aging study, University of California Press, Berkeley, 2001) and affects residents' depressive symptoms. Furthermore, we assume that associations with depressive symptoms vary for different EEAs, namely contact with co-residents and staff and participation in organized in-home activities. To investigate these associations, longitudinal data from 160 residents (M _age = 83.1 years, SD = 9.8 years, 73% female) of two German NHs, assessed across four measurement occasions each 3 months apart, were analyzed. Depressive symptoms were assessed by the Geriatric Depression Scale-Residential (GDS-12R); the frequency of EEAs and their enjoyabilities were assessed via proxy ratings and interviews, respectively. As data from the completed Long-Term Care in Motion intervention study were used, 49% of the sample also received a physical activity intervention. Generalized linear mixed models were run to test the hypothesized effects as flexibly as possible, accounting for non-normality of the GDS-12R and controlling for residents' intervention status. The results showed that the interaction effect of the enjoyability of contact with co-residents and contact frequency was relevant for residents' depressive symptoms rather than the effect of contact frequency alone. The frequency of staff contact was only marginally associated with fewer depressive symptoms. Further, enjoying participating in organized in-home activities was associated with fewer depressive symptoms. In conclusion, findings support our conceptually driven expectation of differential effects in terms of different EEAs on depressive symptoms.

[Self- and informant-rating mood scales applied in elderly persons with Alzheimer's dementia, with or without a language disorder]

INTRODUCTION

Alzheimer's Dementia (AD) may be associated with symptoms of depression. In AD, problems of language expression or understanding will arise sooner or later. The aim of this study was to determine whether elderly persons with AD, with or without a language disorder, experience difficulties understanding and answering mood related questions. In addition to this, it was our object to test the validity of the answers of nurses as informants, on the mood of an elderly client.

METHODS

53 elderly persons, living in care homes, and their nurses, took part in the study. 25 participants had been diagnosed with Alzheimer's disease, 28 participants had no cognitive impairment. Language skills were tested using the SAN-test (Stichting Afasie Nederland) and subtests of the Aachen Aphasia Test (AAT). Mood was assessed with the Beck Depression Inventory-second edition (BDI-II-NL) and the Geriatric Depression Scale (GDS-30).

RESULTS

There were no significant differences in scores on the mood related questionnaires between participants without cognitive impairment and participants with Alzheimer's disease, with or without a language disorder. The correlation between self- and informant-rating was very limited. In general, nurses reported more depressive symptoms than the elderly persons did themselves. Disparities between self- and informant-ratings varied from informant scores overestimating low self-ratings of depression to informant scores underestimating high self-ratings.

CONCLUSION

Alzheimer's disease, whether or not it is complicated by a language disorder, does not disturb the normal score distribution on either test (BDI or GDS). This means that elderly persons with Alzheimer's disease are capable of adequately answering questions related to their own mood. However, considerable discrepancies were found between observer- and self-ratings of emotional wellbeing. Therefore it is important to not only take into account the information of an informant when testing for depression, but also the elderly person's own assessment of their mood.

Can mindfulness-based interventions influence cognitive functioning in older adults? A review and considerations for future research

OBJECTIVES

An increased need exists to examine factors that protect against age-related cognitive decline. There is preliminary evidence that meditation can improve cognitive function. However, most studies are cross-sectional and examine a wide variety of meditation techniques. This review focuses on the standard eight-week mindfulness-based interventions (MBIs) such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).

METHOD

We searched the PsychINFO, CINAHL, Web of Science, COCHRANE, and PubMed databases to identify original studies investigating the effects of MBI on cognition in older adults.

RESULTS

Six reports were included in the review of which three were randomized controlled trials. Studies reported preliminary positive effects on memory, executive function and processing speed. However, most reports had a high risk of bias and sample sizes were small. The only study with low risk of bias, large sample size and active control group reported no significant findings.

CONCLUSION

We conclude that eight-week MBI for older adults are feasible, but results on cognitive improvement are inconclusive due a limited number of studies, small sample sizes, and a high risk of bias. Rather than a narrow focus on cognitive training per se, future research may productively shift to investigate MBI as a tool to alleviate suffering in older adults, and to prevent cognitive problems in later life already in younger target populations.

Cognitive interventions in patients with dementia living in long-term care facilities: Systematic review and meta-analysis

BACKGROUND

Previous reviews and meta-analyses demonstrated effects of cognitive interventions in dementia, but none specifically considered residents with dementia in long-term care (LTC) facilities.

OBJECTIVE

To analyse the efficacy of cognitive interventions in institutionalised individuals with dementia.

METHODS

After identifying 27 articles, a systematic review was performed. A meta-analysis was calculated for 15 studies of the randomized controlled trials regarding effects on relevant outcomes. Fixed-effects meta-analyses were conducted using standardized mean differences (SMD) of changes from baseline pooled using the inverse variance method.

RESULTS

When comparing cognitive interventions to passive control groups, the meta-analysis revealed significant moderate effects on global cognition (SMD=0.47, 95% CI 0.27-0.67), autobiographical memory (0.67, 0.02-1.31), and behavioral and psychological symptoms in dementia (BPSD; 0.71, 0.06-1.36). Significant small effects were detected for quality of life (QoL; 0.37, 0.05-0.70). Moderate effects on activities of daily living (0.28; -0.02 to 0.58) failed to reach significance; no effects were found on depression (0.22; -0.08 to 0.51). Significant moderate effects of global cognition (0.55; 0.22-0.89) and depression (0.64; 0.21-1.07) were also found for cognitive interventions contrasting active control groups. No harmful events related to the participation in the interventions were observed.

CONCLUSION

Cognitive interventions are safe and effective for residents with dementia in LTC. However, while it seems clear that cognitive benefits can specifially be assigned to these forms of intervention, further research is necessary to clarify whether the effects on BPSD and QoL reflect unspecific changes due to additional attention. Furthermore, future studies will have to determine which intervention type yields the largest benefits.

Life-space and movement behavior in nursing home residents: results of a new sensor-based assessment and associated factors

Background

Studies on life-space (LS) and its determinants have previously been limited to community-dwelling subjects but are lacking in institutionalized older persons. The purpose of this study was to provide an advanced descriptive analysis of LS in nursing home residents and to identify associated factors based on an established theoretical framework, using an objective, sensor-based assessment with a high spatiotemporal resolution.

Methods

Cross-sectional study in two nursing homes in Heidelberg, Germany (n = 65; mean age: 82.9 years; 2/3 female). Changes of location in the nursing home (Transits) as well as time spent away from the private room (TAFR) were assessed using a wireless sensor network. Measures of physical, psychosocial, cognitive, socio-demographic, and environmental factors were assessed via established motor performance tests, interviews, and proxy-reports.

Results

LS of residents was largely restricted to the private room and the surrounding living unit (90%); 10% of daytime was spent outside the living unit and/or the facility. On average, TAFR was 5.1 h per day (±2.3; Range: 0–8); seven Transits (6.9 ± 3.2; Range: 0–18) were performed per day. Linear regression analyses revealed being male, lower gait speed, higher cognitive status, and lower apathy to be associated with more Transits; higher gait speed, lower cognitive status, and less depressive symptoms were associated with more TAFR. LS was significantly increased during institutional routines (mealtimes) as compared to the rest of the day.

Conclusions

The sensor-based LS assessment provided new, objective insights into LS of institutionalized persons living in nursing homes. It revealed that residents’ LS was severely limited to private rooms and adjacent living units, and that in institutional settings, daily routines such as meal times seem to be the major determinant of LS utilization. Gait speed, apathy, and depressive symptoms as well as institutional meal routines were the only modifiable predictors of Transits and/or TAFR, and thus have greatest potential to lead to an enhancement of LS when targeted with interventions.

Trial registration

Current Controlled Trials ISRCTN96090441 (retrospectively registered).

A new look at nursing home residents' depressive symptoms: the role of basic versus expanded everyday competence

BACKGROUND

Depressive symptoms are highly prevalent in nursing home (NH) residents. The relationship between depressive symptoms and everyday competence in terms of basic (BaCo) and expanded everyday competence (ExCo; see Baltes et al., 2001) in the NH setting is, however, not clear. Applying Lewinsohn's depression model, we examined how residents' BaCo and ExCo relate to their depressive symptoms. Furthermore, we investigated the mediating role of perceived control.

METHODS

Cross-sectional data from 196 residents (M age = 83.7 years, SD = 9.4 years) of two German NHs were analyzed. Study variables were assessed by the Geriatric Depression Scale-Residential (GDS-12R), maximal gait speed (BaCo), proxy ratings of residents' in-home activity participation, and self-initiated social contact done by staff (ExCo). Structural equation modeling (SEM) was used and a simulation study was included to determine power and potential estimation bias.

RESULTS

At the descriptive level, one quarter of the residents showed symptoms of depression according to the GDS-12R cut-off criterion. Residents' BaCo and ExCo were independently and equally strongly associated with their depressive symptoms in the SEM analysis. These findings were affected neither by cognitive impairment, sex, nor age. Perceived control mediated between BaCo but not ExCo and depressive symptoms.

CONCLUSION

Future research needs to follow the connection between residents' everyday competence and their depressive symptoms longitudinally to better understand the underlying mechanisms.

[Instruments developed for the management and care of the elderly in long-stay care institutions: a systematic review]

The demand for long-stay care institutions for the elderly (ILPIs) is increasing and it is relevant for public health systems to discuss the process of assessing the health status of its residents. The study aimed to identify measurement tools built specifically for the management and care of elderly residents in long-stay care facilities. A systematic review was conducted following PRISMA recommendations in Medline and CINAHL databases since their creation to May 2013 using the Medical Subject Headings terms suitable for the search. A total of 1858 articles were located, of which 30 were selected and 28 instruments were identified in the studies. The United States was the country that created most instruments geared to this population and the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) was the one most used in the studies of this review. The variables most frequently evaluated by the instruments were depression, cognition and functional capacity. The reformulation of public policies that ensure a standardized assessment system for residents in ILPIs in Brazil is urgently needed and the challenge is to ensure that the instruments developed are disseminated and effectively implemented in the daily tasks of the professionals working in these institutions.

[Reliability and validity of the Japanese version of the Apathy Evaluation Scale]

AIM

Clinicians need an objective scale to measure apathy in patients with dementia. However, different cutoff scores for the Apathy Evaluation Scale Informant version (AES-I), an international apathy scale, have been used in previous studies. The purpose of this study was to investigate the cutoff score, reliability and validity of the Japanese version of the AES-I (AES-I-J).

METHODS

We acquired the author's permission to translate the AES from English to Japanese. The subjects of this study included 50 patients with dementia living in institutions or the community. The mean (standard deviation; SD) age of the subjects was 82.7 (5.7) years, the mean (SD) educational level was 8.9 (2.7) years and the mean (SD) Mini-Mental State Examination score was 14.8 (8.1). We provided the caregivers with two apathy scales to assess each patient: the AES-I-J (re-test: four weeks later) and the Neuropsychiatric Inventory in Nursing Home version apathy score.

RESULTS

The mean (SD) score for the AES-I-J was 45.8 (16.2). For this test, Cronbach's α was 0.97, and the intraclass correlation coefficient of test-retest was 0.88 (95%CI: 0.72-0.95) (p<0.0001). In addition, the area under the receiver operating characteristic curve was 0.90 (95%CI: 0.78-1.00) (p<0.0001) and the cut-off score was 45/46, with a sensitivity of 89.5% and specificity of 81.0%.

CONCLUSIONS

Our findings suggest that the cutoff score for the AES-I-J is higher than that used in previous reports.

Digital life storybooks for people with dementia living in care homes: an evaluation

Background and aim

There is increasing interest in using information and communication technology to help older adults with dementia to engage in reminiscence work. Now, the feasibility of such approaches is beginning to be established. The purpose of this study was to establish an evidence-base for the acceptability and efficacy of using multimedia digital life storybooks with people with dementia in care homes, in comparison with conventional life storybooks, taking into account the perspectives of people with dementia, their relatives, and care staff.

Methods

Participatory design was used to create a life story movie based on a previously completed conventional life storybook with six older adults with dementia (four females; mean age 82 years). Relatives were involved in helping the participant to provide additional information and materials for the digital life storybook. In this multiple case study design, both quantitative and qualitative approaches were used. For quantitative purposes, a set of questionnaires that had been completed three times before and after the conventional life storybook was developed were repeated 4 weeks after the life story movie was completed. Semistructured interview questions were designed to collect feedback from participants, relatives, and care staff.

Results

The result indicated that five of the six participants showed additional improvement in measures of quality of life and autobiographical memory. All participants showed improvement or stability in depression scores. Thematic analysis showed that, participants, relatives, and care home staff viewed digital life storybooks as a very useful tool triggering memories and (largely) positive emotions. Participants’ case vignettes were presented to document the impact of digital life storybook.

Behavioural activation written self-help to improve mood, wellbeing and quality of life in people with dementia supported by informal carers (PROMOTE): a study protocol for a single-arm feasibility study

BACKGROUND

Increases in life expectancy have resulted in a global rise in dementia prevalence. Dementia is associated with poor wellbeing, low quality of life and increased incidence of mental health difficulties such as low mood or depression. However, currently, there is limited access to evidence-based psychological interventions for people with dementia experiencing low mood and poor wellbeing. Behavioural activation-based self-help, supported by informal carers and guided by mental health professionals, may represent an effective and acceptable solution.

METHODS/DESIGN

The present study is a phase II (feasibility) single-arm trial informed by the Medical Research Council complex interventions research methods framework. Up to 50 dementia participant/informal carer dyads will be recruited from a variety of settings including primary care, dementia-specific health settings and community outreach. People living with dementia will receive behavioural activation-based self-help and be supported by their informal carer who has received training in the skills required to support the self-help approach. In turn, during the use of the intervention, the informal carer will be guided by mental health professionals to help them work through the materials and problem solve any difficulties. Consistent with the objectives of feasibility studies, outcomes relating to recruitment from different settings, employment of different recruitment methods, attrition, data collection procedures, clinical delivery and acceptability of the intervention will be examined. Clinical outcomes for people with dementia (symptoms of depression and quality of life) and informal carers (symptoms of depression and anxiety, carer burden and quality of life) will be measured pre-treatment and at 3 months post-treatment allocation.

DISCUSSION

This study will examine the feasibility and acceptability of a novel behavioural activation-based self-help intervention designed to promote wellbeing and improve low mood in people living with dementia, alongside methodological and procedural uncertainties associated with research-related procedures. As determined by pre-specified progression criteria, if research procedures and the new intervention demonstrate feasibility and acceptability, results will then be used to inform the design of a pilot randomised controlled trial (RCT) to specifically examine remaining methodological uncertainties associated with recruitment into a randomised controlled design.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42017211.

Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study

This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component.

[Caregiver intervention studies : Recommendations on endpoints and outcome measures for cognitively impaired care recipients]

BACKGROUND

Even though the intervention effects on cognitively impaired care recipients are of interest, the evaluation in dementia caregiver studies on caregiver outcomes is often limited. Furthermore, the comparison of studies and interventions is difficult because of the large variance of endpoints and assessments used in this field.

OBJECTIVE

The aim of this study was to give an overview on the most prevalent outcomes for cognitively impaired care recipients and expert based recommendations for assessment.

MATERIAL AND METHODS

A written Delphi survey was carried out on 16 assessments from 5 dimensions with 14 experts working in different disciplines in German healthcare and research institutes.

RESULTS

The most important outcomes and best rated assessments were 1) for problem behavior: revised memory and behavior problem checklist and neuropsychiatric inventory Q, 2) for depressive symptoms: geriatric depression scale, 3) for quality of life: quality of life in Alzheimer's disease, 4) for cognition: mini mental state examination and 5) for ADL/IADL: Katz activities of daily living and Lawton instrumental activities of daily living.

CONCLUSION

Due to the varying experiences of the experts with particular assessments, the ratings were in some cases relatively heterogeneous. Overall previous international recommendations could be confirmed. There is particular need of German validation studies on internationally used instruments within the dimensions of problem behavior and quality of life.

Neuroepidemiologic and Neurobehavioral Characteristics of Motoric Cognitive Risk Syndrome in an Old-Old Population: The Kurihara Project

Background

Recently, the concept of motoric cognitive risk (MCR) syndrome was proposed, where slow gait is considered a risk factor for conversion to dementia.

Aim

To retrospectively investigate the characteristics of MCR among a population aged 75+ years, focusing on the aspects of epidemiology and neurobehavioral characteristics.

Method

The participants were 590 residents aged 75+ years living in Kurihara who underwent MRI and neurobehavioral assessments including walking velocity. The prevalence of MCR and conversion to dementia (AD8 Dementia Screening Interview cutoff 2/8), together with the neurobehavioral characteristics of the MCR group, were analyzed.

Results

The prevalence was 11.1%, and the conversion ratio in the MCR group was higher than that in the non-MCR group (OR = 1.38). The MCR group had lower scores on the executive function test as well as gait velocity.

Conclusions

The MCR syndrome increases the rate of conversion to dementia, and both slow gait and lower scores in executive tests, which are ‘frontal-based’ functions, are predictive of higher rates of conversion to dementia.

Mindfulness-Based Interventions for Older Adults: A Review of the Effects on Physical and Emotional Well-being

This comprehensive review examined the effects of mindfulness-based interventions on the physical and emotional wellbeing of older adults, a rapidly growing segment of the general population. Search procedures yielded 15 treatment outcome studies meeting inclusion criteria. Support was found for the feasibility and acceptability of mindfulness-based interventions with older adults. Physical and emotional wellbeing outcome variables offered mixed support for the use of mindfulness-based interventions with older adults. Potential explanations of mixed findings may include methodological flaws, study limitations, and inconsistent modifications of protocols. These are discussed in detail and future avenues of research are discussed, emphasizing the need to incorporate geriatric populations into future mindfulness-based empirical research.

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

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

Life concerns of elderly people living at home determined as by Community General Support Center staff: implications for organizing a more effective integrated community care system. The Kurihara Project

BACKGROUND

In Japan, the integrated community care system aims to enable people to continue to live in their homes. Based on the concept, one of the activities of a Community General Support Center (CGSC) is to provide preventive intervention based on a Community Support Program. Currently, a Basic Checklist (BC) is sent to elderly people to identify persons appropriate for a Secondary Prevention Program.

METHODS

To find people who had not responded to the BC, CGSC staff evaluated the files of 592 subjects who had participated in the Kurihara Project to identify activities they cannot do that they did in the past, decreased activity levels at home, loss of interaction with people other than their family, and the need for medical interventions. This information was classified, when applicable, into the following categories: (A) 'no life concerns'; (B) 'undecided'; and (C) 'life concerns'. The relationships between these classifications and clinical information, certified need for long-term care, and items on the BC were examined.

RESULTS

The numbers of subjects in categories A, B, and C were 291, 42, and 186, respectively. Life concerns were related to scores on the Clinical Dementia Rating, global cognitive function, depressive state, and apathy. Most items on the BC were not associated with classification into category C, but ≥25% of the subjects had life concerns related to these items.

DISCUSSION

Assessment of life concerns by the CGSC staff has clinical validity. The results suggest that there are people who do not respond to the checklist or apply for Long-Term Care Insurance, meaning that they 'hide' in the community, probably due to apathy or depressive state. To organize a more effective integrated community care system, the CGSC staff should focus mainly on preventive care.

The potential effects of meditation on age-related cognitive decline: a systematic review

With a rapidly aging society it becomes increasingly important to counter normal age-related decline in cognitive functioning. Growing evidence suggests that cognitive training programs may have the potential to counteract this decline. On the basis of a growing body of research that shows that meditation has positive effects on cognition in younger and middle-aged adults, meditation may be able to offset normal age-related cognitive decline or even enhance cognitive function in older adults. In this paper, we review studies investigating the effects of meditation on age-related cognitive decline. We searched the Web of Science (1900 to present), PsycINFO (1597 to present), MEDLINE (1950 to present), and CABI (1910 to present) to identify original studies investigating the effects of meditation on cognition and cognitive decline in the context of aging. Twelve studies were included in the review, six of which were randomized controlled trials. Studies involved a wide variety of meditation techniques and reported preliminary positive effects on attention, memory, executive function, processing speed, and general cognition. However, most studies had a high risk of bias and small sample sizes. Reported dropout rates were low and compliance rates high. We conclude that meditation interventions for older adults are feasible, and preliminary evidence suggests that meditation can offset age-related cognitive decline.

Screening for Depression with the Depression in Old Age Scale (DIA-S) and the Geriatric Depression Scale (GDS15)

Purpose of the study. The Depression in Old Age Scale (DIA-S), a new screening tool for geriatric depression, was designed to be both practical and appropriate for use with medically ill geriatric patients. The diagnostic accuracy of the DIA-S and the short form of the Geriatric Depression Scale (GDS15) were tested and compared. Methods. Using the Montgomery and Asberg Depression Rating Scale (MADRS) as gold standard, the scales were validated with a sample of N = 331 geriatric inpatients. Results. ROC curves, AUC outcomes, sensitivity and specificity, and logistic regression models for impact factors on misclassification rates indicate good psychometrical qualities of the DIA-S, whereas the validity of the GDS15 was lower.

Life review and life story books for people with mild to moderate dementia: a randomised controlled trial

OBJECTIVES

To evaluate the effect of different pathways for developing a life story book (LSB) for people with dementia.

METHOD

Preliminary randomised control trial; 23 people with dementia in care homes (mean age 86) randomly assigned to receive either 12 individual life review sessions and co-creating a LSB or a personal LSB created by their relatives as a 'gift'

RESULTS

No difference in quality of life (quality of life-Alzheimer's disease (QOL-AD)) was observed between the two groups, six weeks after having received the LSB (F(1,20) = 0.08, p = 0.77). At this point, QOL-AD had improved for both groups, but there was a significant between-group difference at an intermediate assessment immediately after the life review sessions had been completed, before the LSBs were received (F(1, 20) = 5.11, p = 0.035), in favour of life review. A similar pattern was observed on autobiographical memory (extended autobiographical memory interview), with the life review group improving significantly more than the gift group during the life review sessions, but no difference was observed once all participants had had their LSB for six weeks. After the LSBs were produced - by either pathway - quality of relationship as rated by relatives improved significantly (F(2, 39) = 19.37, p < 0.001) and staff knowledge regarding the resident and attitudes to dementia improved.

CONCLUSION

The creation of LSBs - either through a life review process or by relatives without involving the person with dementia - has benefits for people with dementia, relatives and staff in care homes. However, undertaking a life review requires training and supervision.

Vascular dementia with left thalamic infarction: neuropsychological and behavioral implications suggested by involvement of the thalamic nucleus and the remote effect on cerebral cortex. The Osaki-Tajiri project

Vascular dementia (VaD) is a condition whereby decreased cerebral perfusion causes cognitive deterioration. We hypothesized that lesions of the anterior nucleus (AN) including the mammillo-thalamic tract cause a decline in the recollection of past episodes/events, and that the left thalamic infarction can cause frontal dysfunction through the "diaschisis." We investigated 18 VaD cases with only left thalamic infarction. (99m)Tc-ECD single photon emission computed tomography (SPECT) was used to assess regional cerebral blood flow (CBF). To test the first hypothesis, the scores on the Cognitive Abilities Screening Instrument (CASI) domain Recent memory or the rating on the Clinical Dementia Rating (CDR) domain Memory were analyzed. To test the second hypothesis, we selected the six regions of interest that correlated with the two measures, i.e., word fluency and/or depressive state, as assessed with the Geriatric Depression Scale (GDS). We found that all patients had amnesia, especially in the AN group, six of the eight patients had scores of 1+ on the CDR Memory scale, and all but one disclosed the CASI domain Recent memory impairment. There were significant correlations between the left anterior cingulate CBF and word fluency scores, and between the right rectal gyrus CBF and GDS scores. We suggest that these observations are due to a remote effect of the thalamic lesion.

Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial

BACKGROUND

Depression is common and is associated with poor outcomes among elderly care-home residents. Exercise is a promising low-risk intervention for depression in this population. We tested the hypothesis that a moderate intensity exercise programme would reduce the burden of depressive symptoms in residents of care homes.

METHODS

We did a cluster-randomised controlled trial in care homes in two regions in England; northeast London, and Coventry and Warwickshire. Residents aged 65 years or older were eligible for inclusion. A statistician independent of the study randomised each home (1 to 1·5 ratio, stratified by location, minimised by type of home provider [local authority, voluntary, private and care home, private and nursing home] and size of home [<32 or ≥32 residents]) into intervention and control groups. The intervention package included depression awareness training for care-home staff, 45 min physiotherapist-led group exercise sessions for residents (delivered twice weekly), and a whole home component designed to encourage more physical activity in daily life. The control consisted of only the depression awareness training. Researchers collecting follow-up data from individual participants and the participants themselves were inevitably aware of home randomisation because of the physiotherapists' activities within the home. A researcher masked to study allocation coded NHS routine data. The primary outcome was number of depressive symptoms on the geriatric depression scale-15 (GDS-15). Follow-up was for 12 months. This trial is registered with ISRCTN Register, number ISRCTN43769277.

FINDINGS

Care homes were randomised between Dec 15, 2008, and April 9, 2010. At randomisation, 891 individuals in 78 care homes (35 intervention, 43 control) had provided baseline data. We delivered 3191 group exercise sessions attended on average by five study participants and five non-study residents. Of residents with a GDS-15 score, 374 of 765 (49%) were depressed at baseline; 484 of 765 (63%) provided 12 month follow-up scores. Overall the GDS-15 score was 0·13 (95% CI -0·33 to 0·60) points higher (worse) at 12 months for the intervention group compared with the control group. Among residents depressed at baseline, GDS-15 score was 0·22 (95% CI -0·52 to 0·95) points higher at 6 months in the intervention group than in the control group. In an end of study cross-sectional analysis, including 132 additional residents joining after randomisation, the odds of being depressed were 0·76 (95% CI 0·53 to 1·09) for the intervention group compared with the control group.

INTERPRETATION

This moderately intense exercise programme did not reduce depressive symptoms in residents of care homes. In this frail population, alternative strategies to manage psychological symptoms are required.

FUNDING

National Institute for Health Research Health Technology Assessment.

Effect of Talbinah food consumption on depressive symptoms among elderly individuals in long term care facilities, randomized clinical trial

Talbinah is a barley syrup cooked with milk and sweetened by honey. In his famous Hadith on Talbinah, the Prophet Mohammad (SAW) recommended it when sad events happen for its effect on soothing hearts and relieving sadness. This 3-week crossover designed, randomized clinical trial was conducted to determine the effect of Talbinah on mood and depression among institutionalized elderly people in Seremban. A sample of 30 depressed elderly subjects (21 men and 9 women) was selected from the long term care facility. Three different interview-based validated scales (Geriatric Depression Scale, Depression Anxiety Stress Scales, and Profile of Mood States) were used to determine mood, depression, stress, and anxiety at week 0, 3, 4, and 7. The nutritional value of Talbinah was examined using proximate food analysis, minerals content analysis, and differential amino acid analysis. The results indicated that Talbinah is a high carbohydrate food (86.4%) and has a high tryptophan: branch chain amino acids ratio (1:2). A Wilcoxon nonparametric test showed that there was a statistically significant decrease on depression, stress, and mood disturbances scores among the intervention group (P < 0.05) for all parameters. In conclusion, Talbinah has the potential to reduce depression and enhance mood among the subjects. Ingestion of functional foods such as Talbinah may provide a mental health benefit to elderly people.

Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment

OBJECTIVES

The aim of this population-based study was to investigate the usefulness of the Geriatric Depression Scale 15-item version (GDS-15) to assess depressive symptoms among very old people with differing levels of cognitive function.

METHODS

The 834 participants were aged 85 and over. Feasibility of GDS-15 was evaluated as the proportion of people who completed the scale. Concurrent criterion validity was evaluated by calculating correlations between GDS-15 and Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS measures psychological wellbeing which is closely related with depressive symptoms. Correlations were calculated within groups according to cognitive function assessed with Mini-Mental State Examination (MMSE); 0-4, 5-9, 10-14, 15-19, 20-24, 25-27, and 28-30, using Pearson's two-sided correlation and compared using Fisher r-to-z transformation. Internal consistency of the GDS-15 was evaluated by calculating Cronbach's α in each group.

RESULTS

In total, 651 (78%) of the 834 participants completed the GDS-15. For the two MMSE-groups with scores of <10, the proportion who completed GDS-15 were 1% and 42%, respectively, compared to 65-95% in the MMSE-groups with scores of ≥10. Cronbach's α in each MMSE-group ranged from 0.636 (MMSE 28-30) to 0.821 (MMSE 5-9). The level of correlation between GDS-15 and PGCMS did not significantly differ between MMSE-groups with scores of 5-27 compared to the MMSE-group with scores of 28-30.

CONCLUSIONS

The GDS-15 seems to have an overall usefulness to assess depressive symptoms among very old people with an MMSE score of 10 or more. More studies are needed to strengthen the validity of GDS-15 among older people with MMSE scores of 10-14. For older people with MMSE scores lower than 10, there is a need to develop and validate other measurements.

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

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

Improved social interaction and increased anterior cingulate metabolism after group reminiscence with reality orientation approach for vascular dementia

A group reminiscence approach (GRA) with reality orientation (RO) is widely used as a psychosocial intervention for dementia. Since clinical effectiveness was reported for the intervention, interest has been directed toward areas of the neuronal network that might be being stimulated. We hypothesized that the frontal lobe associated with social interaction was being stimulated. To test this hypothesis, we studied 24 patients with vascular dementia. In addition to conventional care, a 1-h session of GRA with RO was provided once a week for 3 months in the GRA-RO arm (n=12). Only supportive care was provided in the control arm (n=12). Before and after the interventions, cognitive function, depressive state, and social activities were assessed. Since glucose metabolism is associated with brain function, cerebral glucose metabolism was measured by positron emission tomography (PET). Regarding behavioral improvement, 10 patients in the GRA-RO arm showed improvement compared with only two patients in the control arm, a significant difference. PET demonstrated that metabolism in the anterior cingulate was increased in the GRA-RO arm, whereas no significant changes were observed in the control arm. These results suggest that GRA-RO stimulates the anterior cingulate and has a positive effect on social interaction.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture trial

Background

Hip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.

Methods/design

The intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.

Discussion

We believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.

Trials registration

ClinicalTrials.gov, NCT00667914

Comprehensive assessment of depression and behavioral problems in long-term care

BACKGROUND

The IPA Taskforce on Mental Health Issues in Long-Term Care Homes seeks to improve mental health care in long-term care (LTC) homes. The aim of this paper is to provide recommendations on comprehensive assessment of depression and behavioral problems in order to further stimulate countries and professionals to enhance their quality of care.

METHODS

Existing guidelines on comprehensive assessment of depression or behavioral problems in nursing home (NH) patients or patients residing in LTC homes were collected and a literature review was carried out to search for recent evidence.

RESULTS

Five guidelines from several countries all over the world and two additional papers were included in this paper as a starting point for the recommendations. Comprehensive assessment of depression in LTC homes consists of a two-step screening procedure: an investigation to identify factors that influence the symptoms, followed by a formal diagnosis of depression according to DSM-IV-TR or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease in cases of dementia. Comprehensive assessment of behavioral problems encompasses three steps: description and clarification of the behavior, additional investigation, and assessment of probable causes of the behavior. The procedure starts in the case of moderate behavioral problems.

CONCLUSION

The recommendations given in this paper provide a useful guide to professional workers in the LTC sector, but clinical judgment and the consideration of the unique aspects of individual residents and their situations is necessary for an optimal assessment of depression and behavioral problems. The recommendations should not be rigidly applied and implementation will differ from country to country.

Approach to major depression in old people

BACKGROUND

The difficulty in identifying and distinguishing Major Depressive Disorder (MDD) in primary care is well known. The main objective of this study is to determine the frequency of MDD in persons aged 65 years and older using the Detection of Depression in the Elderly Scale (DDES). A second objective is to determine the convergent validity of the DDES with the Geriatric Depression Scale (GDS).

METHODS

A cross-sectional, observational study was carried out of 1,387 subjects aged 65 years and older. The variables considered were: affective state (GDS and DDES), physical and cognitive functional state, health problems and sociodemographic characteristics.

RESULTS

Using the DDES we identified MDD in 50 subjects (4.3%). There was a moderate correlation (r = 0.570; p < 0.001) between the DDES and the GDS scores (p < 0.001). According to logistic regression analysis, the variables associated with a probable MDD (DDES +) were: dependence in activities of daily living (OR: 3.3), female gender (OR: 2.3), marital status single/widowed/divorced (OR: 2.0), and the presence of four of more health problems (OR: 2.1).

CONCLUSIONS

Using the DDES scale we found a 4.3% prevalence of MDD in a representative sample of older adults. Compared to the GDS, the most commonly used scale, the DDES may be considered a more sensitive screening tool for the identification of MDD in primary care.

The geriatric depression scale in palliative care

OBJECTIVE

This research examined the psychometric properties of previously published short forms of the Geriatric Depression Scale (GDS) in patients receiving palliative care. It also uses the full form of the GDS to examine the prevalence of nonsomatic symptoms of depression in palliative patients.

METHOD

Participants were 84 patients with advanced cancer attending palliative care outpatient clinics. Scores for short forms of the GDS were derived from administering the original 30-item scale. Patients also completed the single item numerical analogue scale for depression from the Edmonton Symptom Assessment System and parallel numerical analogue scales for will-to-live and hope. A subset of the sample completed the measures twice. Short forms were judged on the extent to which they captured information gained from the full scale and their internal consistency, test-retest reliability, convergent and concurrent validity, and their distribution of scores.

RESULTS

Overall, five short forms showed good psychometric properties at both visits. Two of these forms were very brief. Some nonsomatic symptoms assessed on the full GDS were reported with high frequency. However, few individuals reported a large number of symptoms. At both visits, patients identified as likely to have severe depression gave different responses from other patients on most items on the GDS-30.

SIGNIFICANCE OF RESULTS

Several short forms of the GDS may be appropriate for use in palliative care. Patients identified as likely to have severe depression showed many of the same symptoms that characterise depression in other geriatric populations.