Severe illness in older patients: the association between depressive disorders and functional dependency during the recovery phase

Daily-Living Skills and Habits of Older Women with Depression

This study used a prospective, within-group comparison design to examine differences in the severity of disability in a community-based sample of 59 older women being treated for depression. The independent variables were three constructs: perceived skills, perceived habits, and demonstrated skills. The dependent variables were functional mobility, personal care, and instrumental activities of daily living. Results indicated that the expression of overall disability differed significantly among the three constructs. Participants' perceptions of their skill independence were greater than their ability to demonstrate independence in those skills, and their demonstrated skills of task independence were greater than their perceived ability habitually to use those skills independently. Objective, performance-based skill measures indicated greater disability than subjective, self-report skill measures, and supported the view that in older adults, depression-related disability reflects a combination of skill and habit deficits. Item analyses revealed five distinct patterns of relationships among perceived skills, perceived habits, and demonstrated skills. Practitioners need to be aware of the constructs being used to measure disability because the severity of disability may depend on the construct being used. Furthermore, the types of interventions appropriate for disability related to each construct or pattern of constructs may vary.

Predictors of survival within 2 years of inpatient rehabilitation among older adults

BACKGROUND

Restoring functional independence in elderly people with disabilities is one of the main purposes of a geriatric rehabilitation unit. However, the rehabilitation period may also represent a useful circumstance to identify predictors of long-term health outcomes. The aim of this study was to evaluate a broad spectrum of characteristics in geriatric patients admitted to a rehabilitation unit in order to identify possible predictors of long-term survival.

METHODS

This cross-sectional and prospective study was carried out in an Evaluation and Rehabilitation unit in Northern Italy. 243 persons aged 65 or older were enrolled over a period of 12 months (2007-8) and followed for 2 years. Possible predictors of survival were identified among a large spectrum of demographic, clinical (Charlson Index, lab data), nutritional (Mini-Nutritional Short-Form, bio-impedance analysis), and respiratory (spirometry) features. Logistic regression models were used to evaluate the association between patients' characteristics and survival.

RESULTS

189 (86.3%) participants were alive after 2 years of follow-up. Younger age, better functional status at discharge, a lower Charlson Index score, higher hemoglobin and albumin values at discharge, lower basal fasting glucose, creatinine, TNF-α levels, and extra-cellular water, as well as higher cholesterol, vital capacity (VC), and inspiratory capacity were significantly associated with survival. In the multivariate model, higher VC (OR=6.2; 95%CI=1.6-24.6) and albumin (OR=3.7; 95%CI=1.2-11.8) were associated with survival, whereas the Charlson Index and male gender showed an inverse correlation (OR=0.77; 95%CI=0.60-0.99 and OR=0.23; 95%CI=0.10-0.95, respectively).

CONCLUSION

VC was identified as one of the best predictors of survival along with higher albumin and lower Charlson Index score within 2 years of inpatient rehabilitation among older adults.

[Acute illness and depression in the elderly and the influence of cognitive impairment : AIDE-cog trial]

Geriatric patients with acute somatic illness have a high comorbidity of depression and dementia. The following differential diagnoses have to be discerned: pseudodementia in acute depressive states, depression as a risk factor for dementia, and a depressive episode in the early stage of dementia. For both the symptoms and the trigger factors of these differential diagnoses the overlap and the particularities were qualitatively examined in the AIDE-cog (Acute Illness and Depression in Elderly cognition) trial. A second prospective randomized controlled part of the AIDE-cog trial quantitatively evaluated the influence of cognitive impairment in geriatric patients with an acute somatic illness and comorbid depression on the therapeutic effect of cognitive behavioral therapy. A preliminary analysis shows that already in early dementia the therapeutic effects are inferior. Other psychotherapeutic methods that address the remaining cognitive and emotional functions in dementia must be evaluated.

Physical training improves motor performance in people with dementia: a randomized controlled trial

OBJECTIVES

To determine whether a specific, standardized training regimen can improve muscle strength and physical functioning in people with dementia.

DESIGN

Double-blinded, randomized, controlled trial with 3-month intervention and 3-month follow-up period in 2006 to 2009.

SETTING

Outpatient geriatric rehabilitation.

PARTICIPANTS

Individuals with confirmed mild to moderate dementia, no severe somatic or psychological disease, and ability to walk 10 m. Most participants were still living independently with or without supportive care.

INTERVENTION

Supervised, progressive resistance and functional group training for 3 months specifically developed for people with dementia (intervention, n = 62) compared with a low-intensity motor placebo activity (control, n = 60).

MEASUREMENTS

Primary outcome measures were one-repetition maximum in a leg press device for maximal strength and duration of the five-chair-stand test for functional performance. Secondary outcome measures were assessed for a number of established parameters for maximal strength, physical function, and physical activity.

RESULTS

Training significantly improved both primary outcomes (percentage change from baseline: maximal strength, intervention group (IG): +51.5 ± 41.5 kg vs control group (CG): -1.0 ± 28.9 kg, P < .001; functional performance, IG: -25.9 ± 15.1 seconds vs CG: +11.3 ± 60.4 seconds, P < .001). Secondary analysis confirmed effects for all strength and functional parameters. Training gains were partly sustained during follow-up. Low baseline performance on motor tasks but not cognitive impairment predicted positive training response. Physical activity increased significantly during the intervention (P < .001).

CONCLUSION

The intensive, dementia-adjusted training was feasible and substantially improved motor performance in frail, older people with dementia and may represent a model for structured rehabilitation or outpatient training.

Prevalence and correlates of geriatric frailty in a northern Taiwan community

BACKGROUND/PURPOSE

Frailty is the core of geriatric syndromes in the elderly. However, there is no solid prevalence data in Taiwan even with the rapid growth of the elderly population. The aim of this study was to explore the prevalence of frailty defined by different instruments and to identify the factors associated with frailty in a northern Taiwan community.

METHODS

The 65-79-year old community-dwelling residents randomly selected from Toufen were first screened with a telephone version of the Chinese Canadian Study of Health and Aging Clinical Frailty Scale (CCSHA-CFS; level 1-7). Those who scored 3-6 with this instrument were evaluated at a local hospital with the Fried Frailty Index (FFI) and the Edmonton Frail Scale (EFS). Other baseline characteristics including health and functional performance were also evaluated.

RESULTS

Among the 2900 population representative samples, 845 (29.1%) completed the CCSHA-CFS telephone interview with the prevalence of frailty approximately 11.0% [95% confidence interval (CI) 8.9-13.1]. Among the 275 who completed assessments with FFI and EFS, prevalence of frailty was 11.3% (95% CI = 7.6-15.0) by FFI and 14.9% (95% CI = 10.7-19.1) by EFS. About 57.5% of respondents had memory impairment, 29.8% experienced pain, 25.1% experienced falls, 16.7% had depression, 14.5% had urinary incontinence, and 5.8% had polypharmacy. Being older, having more complaints with falls, pain, dysphagia, polypharmacy, depression, comorbidity, longer time for the Timed Up and Go test, less education, lower Mini-Mental State Examination score, and lower Barthel Index were associated with frailer status. In multinomial logistic regression analysis, increasing age, less education status, lower Barthel Index score and depression were positively associated with physical frailty.

CONCLUSION

In this study, the prevalence of frailty was from 11.0% to 14.9% by different criteria and methodology. Various correlates were independently associated with frailty status. It is suggested that intervention for frailty requires an interdisciplinary approach.

Depression and anxiety symptoms after lower limb amputation: the rise and fall

OBJECTIVE

To examine the time course of anxiety and depressive symptoms over a three year period after amputation.

DESIGN AND SETTINGS

A prospective study in inpatients admitted to a rehabilitation ward after lower limb amputation.

SUBJECTS

Successive admissions over a one-year period of whom 68 were alive at follow-up, 2-3 years later.

INTERVENTIONS

Nil.

MAIN MEASURES

Hospital Anxiety and Depression Scale (HADS) on admission and discharge from inpatient rehabilitation and at a 2.7(SD=0.4) year mean follow-up period with correlation to demographic and patient features.

RESULTS

Of the 68 responding patients, 12 (17.6%) and 13 (19.1%) had symptoms of depression and anxiety respectively. This compared to an original incidence of 16 (23.5%) for both on admission and 2 (2.9%) on discharge. This rise in incidence from time of discharge was highly significant for both depression (P<0.001) and anxiety (P<0.001). Depression at follow-up was correlated to depressive symptoms at admission (P=0.03) and to having other significant comorbidities (P=0.02). Anxiety symptoms were commoner in younger patients (P=0.03). There was no association with age, gender, living in isolation, vascular cause for amputation, wearing a limb prosthesis or length of original inpatient stay.

CONCLUSIONS

Depression and anxiety are common after lower limb amputation but resolve during inpatient rehabilitation. The incidence then rises again after discharge.

Predictors of successful rehabilitation in geriatric patients: subgroup analysis of patients with cognitive impairment

BACKGROUND AND AIMS

Understanding which patients benefit from rehabilitation programs may be useful in balancing resources and needs. The aim of this study was to evaluate whether cognitive and nutritional status are associated with functional improvement after rehabilitation in old persons.

METHODS

2650 patients (aged > or =60 years) consecutively admitted to a geriatric rehabilitation unit in Italy between August 2001 and December 2005, were included. Functional status was evaluated with the Tinetti scale, cognitive status with the Mini-Mental State Examination (MMSE), and nutritional status with the Mini-Nutritional Assessment Short Form (MNA-SF). To identify predictors of functional recovery, multiple logistic regression models were run, with improvement on the Tinetti scale score as dependent variable.

RESULTS

Eighty per cent of old persons functionally improved after rehabilitation, ranges being 84% of those with MMSE> or =24 to 58% of those with MMSE<10. Persons with both good cognition and good nutritional status were most likely to improve [odds ratio (OR)=2.5; 95% confidence interval (95% CI)=1.9-3.2]. Stratifying the sample according to cognitive status, we found that in patients with MMSE> or =18 better nutritional status emerged as a factor associated with functional improvement, whereas in patients with severe cognitive impairment (MMSE<18), the only associated factor was a higher MMSE score.

CONCLUSIONS

The results of the present study suggest that both good cognition and good nutritional status are associated with functional improvement in older persons. However, patients with poor cognition can also improve, depending on their degree of cognitive impairment, and they should not be routinely excluded from rehabilitation.

Cognitive Dysfunction and Depression May Decrease Activities in Daily Life More Strongly Than Pain in Community-Dwelling Elderly Adults Living With Persistent Pain

BACKGROUND AND OBJECTIVES

Chronic pain, dementia, and depression may reduce activities of daily life in elderly people. We evaluated the correlation between pain intensity and daily activities, cognitive state, and depression, as well as their interrelationships in home-dwelling elderly people with chronic pain.

METHODS

Forty-one elderly home-dwelling people who suffered from long-lasting pain, and who participated in a rehabilitation program, were enrolled. Severity of pain at rest and after pain-provoked motion was assessed on a visual analog scale (VAS, 0 to 100) and a 5-point verbal rating scale (VRS). Cognitive status was assessed with the mini-mental state examination (MMSE, 0 to 30), depression on the geriatric depression scale (GDS, 0 to 15), and functional ability in daily life was assessed with the Barthel Index (0 to 100).

RESULTS

VAS and VRS scores correlated positively with each other. Rating pain at rest on the VRS (mean 1.0, median 1) correlated with severity of depression (GDS mean 5.4) (r = 0.3997, P < 0.01), while scores on the VAS did not. Pain ratings at rest did not correlate with the Barthel Index (mean 87.7), but the latter correlated positively with motion-evoked VRS pain scores (mean 2.8, median 3) (r = 0.42829, P < 0.01). The MMSE (mean 25.3) did not correlate with any pain parameter, but it correlated positively with the Barthel Index (r = 0.3660, P < 0.05). The Barthel Index correlated negatively with the GDS (r = -0.39969, P < 0.01).

CONCLUSION

In home-dwelling elderly people, chronic pain states do not seem to reduce daily activities as much as cognitive dysfunction and depression. The seemingly controversial finding of a positive correlation between daily activities and pain in motion, and lack of correlation with pain at rest, may be explained by a relatively low intensity of pain in our study people.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

Functional Outcomes for Older Adults with Cognitive Impairment in a Comprehensive Outpatient Rehabilitation Facility

The purpose of the study was to examine functional outcomes of a nurse-managed, community-based Comprehensive Outpatient Rehabilitation Facility (CORF) for frail older adults and to compare the outcomes between two groups: older adults with cognitive impairment and those with intact cognition. A retrospective cohort design using healthcare record abstraction was used for the study. Two hundred and one older adults who were admitted to the CORF from the end of 1997 to early 1999 were included in the study. Data were abstracted from healthcare records, including clinician-generated Mini-Mental State Examination, Geriatric Depression Scale, and Functional Independence Measure scores from the healthcare records and investigator-constructed measures of functional gain, rehabilitation efficiency, days of service, and discharge location. Multivariate regression analyses were performed to compare rehabilitation outcomes between the two groups. Regardless of cognitive status, all subjects improved significantly in their levels of functional dependence through participating in this outpatient rehabilitation program (P<.001). Subjects with cognitive impairment exhibited more functional dependence at baseline and discharge than did their cognitively intact counterparts. Nevertheless, there was no difference between the two groups in functional gain (P=.63), rehabilitation efficiency (P=.66), days of service (P=.83), or discharge location (P=.69). Therefore, despite their greater degree of functional dependence on admission, older adults with cognitive impairment benefited from this CORF without requiring more days of service and should thus be referred for rehabilitation services.

State of the art in geriatric rehabilitation. Part II: clinical challenges

OBJECTIVES

To examine common clinical problems in geriatric rehabilitation and to make recommendations for current practice based on evidence from the literature.

DATA SOURCES

A CINAHL database and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search was completed by using the Cochrane database.

STUDY SELECTION

One author reviewed the references for relevance and another for quality. A total of 336 articles were considered relevant. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports on a small number of patients.

DATA EXTRACTION

The following areas were the major geriatric rehabilitation subtopics identified in the search: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. This article focuses on the latter 5 subtopics. The literature was reviewed by using a level-of-evidence framework. Level 1 evidence was a randomized controlled trial (RCT) or meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts, descriptive studies, or reports of expert committees.

DATA SYNTHESIS

Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic according to the level of evidence in the specific area. In cases in which several articles were written on a topic with similar conclusions, we selected the articles with the strongest level of evidence, thereby reducing the total number of references.

CONCLUSIONS

Frail older patients with hip fracture should receive geriatric rehabilitation. They should also be screened for nutrition, cognition, and depression. Older persons should receive nutritional supplementation when malnourished. If severe dysphagia occurs in stroke patients, gastrostomy tube feeding is superior to nasogastric tube feeding.

The prevalence of psychiatric disorders and subsyndromal mental illness in low-income, medically ill elderly

OBJECTIVE

This study estimated the past and current prevalence of psychiatric illness and subsyndromal mental illness (both pre-relapse and new onset) in a sample of low-income, medically ill older adults.

METHOD

A convenience sample of 95 public sector medical patients aged 55 and older were assessed for the presence of psychiatric diagnosis and symptoms using the Geriatric Depression Scale, Beck Anxiety Inventory, the Short Michigan Alcohol Screening Test, and the Computerized Diagnostic Interview Schedule (DIS-C).

RESULTS

Dysthymia and Major Depression were the most prevalent current disorders and Alcohol Dependence the most prevalent past disorder. Overall, 25 percent met criteria for at least one Axis I disorder. An additional 44 percent of patients had subsyndromal mental illness: 14 percent had subsyndromal depression, 17 percent were significantly anxious, and 30 percent were problem drinkers. A prior model predicting current Axis I disorder in younger people was found to be predictive of current Axis I but did not predict to subsyndromal disorder.

CONCLUSIONS

The rates of psychiatric disorders and symptoms in this older, low-income population were similar to those in other samples of older medical patients. The findings from this research suggest the need for larger epidemiological studies of the prevalence of psychiatric disorders in this disadvantaged aging population. The complexities of this type of research are also discussed.

Depressive disorder as a predictor of physical disability in old age

OBJECTIVES

To determine whether the occurrence of depression predicts physical disability in older people.

DESIGN

A longitudinal epidemiological study with a follow-up of 5 years.

SETTING

A comparison between depressed and nondepressed participants.

PARTICIPANTS

The series consisted of the persons who participated in the longitudinal epidemiological study on depression in old age performed in Ahtari, Finland. The first round of interviews and examinations was performed in 1984/1985 and the second round in 1989/1990. The study series (N = 786) was composed of persons functionally independent in activities of daily living (ADLs) during the first round and alive and participating in both rounds.

MEASUREMENTS

Depression was determined according to DSM-III criteria. Physical functional abilities were measured with self-assessments of ability to manage ADLs.

RESULTS

In bivariate analyses, depression at the baseline did not predict lowering of functional abilities during follow-up, but the occurrence of depression with a long-term or relapsing course during follow-up and the onset of depression during follow-up in persons not depressed at the baseline predicted lowering of functional abilities during follow-up. The logistic regression analyses showed the presence of the following variables measured during the first round--older age, low basic education, poor self-perceived health, and occurrence of a physical disease--and the onset of the following diseases during follow-up--any physical disease, neurological disease, cerebrovascular disease, or depressive symptoms (in persons nondepressed at the baseline)--predicted lowered functional abilities after a follow-up of 5 years.

CONCLUSION

Depression that developed during the follow-up in previously nondepressed persons was associated with an increased risk for lowering of functional abilities, even when controlling for age, sociodemographic factors, physical diseases, and baseline disabilities. Depressed older people are at high risk for physical disability, and an individually planned program to maintain their functional abilities by training in ADLs and instrumental activities of daily living (IADLs) and physical exercise should be included in their treatment.

Depression following traumatic brain injury

OBJECTIVE

Review the existing literature on the incidence, neurobiological and psychosocial correlates, and methods of assessment and treatment of depression following traumatic brain injury (TBI).

DATA SOURCES

Computerized database searches of the English-language literature from Index Medicus, Psychological Abstracts, Excerpta Medica, and Cumulative Index of Nursing and Allied Health Literature.

STUDY SELECTION

Given the relatively small number of publications specifically related to TBI and depression, all studies appearing in the peer-reviewed literature were included in the review. In addition, studies examining depression and other neurologic diseases (eg, stroke) were also reviewed as to the potential applicability of the theoretical model or methodology used.

CONCLUSIONS

Depression occurs with sufficient frequency to be considered a significant consequence after TBI. Depression can impede the achievement of optimal functional outcome, whether in the acute or chronic stages of recovery. It appears that a combination of neuroanatomic, neurochemical, and psychosocial factors is responsible for the onset and maintenance of depression. Its treatment is typically psychopharmacologic, with best results obtained from nontricyclic antidepressants. These results have not been confirmed in double-blind clinical trials, however. Future research should use comprehensive, integrative models of depression that include demographic, biologic, and psychosocial factors; enhanced functional neuroimaging techniques; controlled studies of psychopharmacologic and other interventions; and prospective designs with long-term follow-up.

Predictors of functional ability in geriatric rehabilitation patients

This study explored the impact that motivation, cognitive status, depression, age, and physical status have on the functional ability of older adults in a rehabilitation program. The study was based on a hypothesized model and was conducted with 200 patients on a geriatric rehabilitation unit. Structural equation modeling was done to test the hypothesized model. The average age of participants was 78 years, and the majority were female, Caucasian, unmarried, and had been admitted for rehabilitation after an orthopedic event. The data fit the hypothesized model; however, only five paths were significant. Mental status was a significant predictor of function on admission and a direct and indirect predictor of function at discharge, and diagnosis and age directly predicted function at discharge.

Differences in psychosocial and health correlates of major and minor depression in medically ill older adults

OBJECTIVES

To compare the differences in correlates of different levels of depression in medically ill hospitalized older adults.

DESIGN, SETTING, AND PARTICIPANTS

A consecutive series of 542 patients aged 60 or older admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist.

MEASUREMENT

A wide range of demographic, social, psychiatric, and physical health data were collected, and associations with major and minor depression were assessed.

RESULTS

Compared with patients without depression, those with major depression were more likely to have a history of prior episodes of depression, higher dysfunctional attitude scores, greater overall severity of medical illness, cognitive impairment, and symptoms of pain or other somatic complaints. Specific medical diagnosis was less important a predictor of major depression than overall severity of medical illness. Compared with patients without depression, those with minor depression were more likely to report non-health-related stressors during the year before hospital admission, have a diagnosis of immune system disorder, and have greater severity of medical illness. When major and minor depression were compared directly, on the other hand, no significant differences were observed except for history of depression, and that relationship was weak and present only when the etiologic approach to diagnosis was used.

CONCLUSION

During hospital admission, certain psychosocial, psychiatric, and physical health characteristics of older medical patients place them at high risk for different levels of depression. Patients with major and minor depression resemble each other more than they do patients without depression. These findings may help clinicians better understand the causes of different types of depression in this setting and lead to improved diagnosis and treatment.

Relapse prevention by means of paroxetine in ECT-treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy

In-patients with severe major depression were treated in the acute phase with electroconvulsive therapy (ECT) in combination with antidepressants. The drug treatment consisted of two randomized trials which were both extended into the post-ECT continuation phase. Patients with electrocardiological impairment were randomized to either 30 mg paroxetine daily or placebo under blind conditions. Patients without electrocardiological impairment were randomized to either 30 mg paroxetine daily or 150 mg imipramine daily. There was a high level of agreement between the Hamilton Depression Scale and the Melancholia Scale, demonstrating that the patients treated with ECT plus imipramine in the acute phase showed greater symptom reduction than those treated with ECT plus paroxetine. However, in the post-ECT phase paroxetine was superior to both imipramine and placebo in preventing relapse. Thus in the post-ECT phase 65% of the placebo-treated patients relapsed, compared to 30% of the imipramine-treated patients and 10% of the paroxetine-treated patients. The psychometric analysis of the Melancholia Scale in the continuation or post-ECT phase showed that relapsing patients displayed a pattern with lack of interests, impaired concentration, depressed mood and anxiety among the less severe symptoms (first-compartment symptoms). In other words, these symptoms represent the gate to full-blown depression (second-compartment symptoms). Serotonin-selective antidepressants such as paroxetine appear to be more effective in controlling the first-compartment symptoms.

Geriatric depression: a survey of nurses' knowledge and assessment practices

A sample of 149 registered nurses were surveyed to determine their knowledge of the symptoms of depression in the elderly and their assessment practices. Respondents were able to identify not only the traditionally associated symptoms but also two other behaviors, irritability and blaming others, which are not usually designated by other health care providers as associated with geriatric depression. These additional observations may reflect nurses' providing extensive physical as well as verbal care over much longer time periods for patients in inpatient and home settings than do other professionals. Recent findings in nursing research support the presence of these other behaviors as symptoms of depression. An additional finding revealed that nurses were not assessing their patients for depression even though they had a knowledge base of the symptoms.

Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores

OBJECTIVE

To compare case-finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance.

DESIGN

Cross-sectional survey.

SETTING

One academic and four community homes.

SUBJECTS

One hundred thirty-four randomly selected, mildly cognitively impaired, functionally dependent residents.

METHODS AND MEASURES

The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM-III-R diagnoses was administered independently,. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of "optimal" threshold scores was guided by Kraemer's quality indices and clinical judgment.

RESULTS

Thirty-five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74-0.89), specificity (range 0.62-0.77), or area under the receiver operating curve (ROC) (range 0.85-0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES-D achieved only fair agreement. No change in threshold scores was warranted.

CONCLUSIONS

The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case-finding and severity instrument, it is preferred. Use of brief, interviewer-administered tools may improve detection of depression in the nursing home.

Depression in hospitalized medically ill elders: evolution of the concept

Recent research confirms high prevalence rates of major depression and appreciable depressive symptoms in hospitalized medically ill elders. Evidence also exists supporting that depressive symptoms, when combined with medical illness, have additive effects on patient function and well-being, in addition to raising the older person's risk of death from suicide as well as from nonsuicidal causes. Appropriate nursing identification and management of this problem is currently hindered by an unclear description of depression in these patients. The focus of this article will be a synthesis of the existing knowledge of depression in elderly patients hospitalized with medical illness. An evolving concept of depression will be described that is amenable to clinical nursing research with this population.

Decrease of depression during stroke and amputation rehabilitation

Clinical observation had suggested that mild depression occurs after admission for acute medical treatment and then decreases during further hospitalization for rehabilitation treatment. The Geriatric Depression Scale (GDS) was given on admission and discharge to 14 stroke and 17 amputee rehabilitation patients. Each of the two groups showed decreasing GDS scores from beginning to end of the rehabilitation admission. Suggested reasons included: (1) the gradually diminishing effects of stroke and amputation as life crises during the 1-2 month admission, (2) effects of physical improvement on mood and affect, (3) milieu effects of the medical ward, and (4) tendencies for all psychopathology scale scores to decrease on retest.

Physical consequences of depression in the stroke patient

The past literature suggests the hypothesis that depression is associated with decreased physical functional ability in stroke patients. On a medical rehabilitation ward, 21 stroke patients were evaluated for depression by psychiatric interview and self-report, and were also rated on the Barthel's Functional Index (BFI). The hypothesis was supported: Patients scoring 17 or higher on the Beck Depression Inventory (BDI) (N = 7) had lower initial scores on the BFI than patients with lower BDI scores. There was a trend for these seven depressed patients to improve more slowly as ascertained by the BFI. Depression was suggested to lower functional ability by increasing fatigue, hopelessness, and decreasing motivation.

Hospital utilization and readmission rates for geriatric and young adult patients with major depression: results from a historical cohort study

Late-life depression may have different clinical features, hospital utilization patterns, and natural history, depending on whether the illness begins in midlife or late life. This historical cohort study examined three patient groups, late-onset geriatric depressed patients, early-onset geriatric depressed patients, and young adult depressed patients, to determine hospital utilization patterns, readmission rates, and whether specific clinical symptoms on admission predisposed patients to readmission. The two geriatric patient groups had similar demographic, medical comorbidity, and hospital utilization profiles, except that the early-onset geriatric depressed group had longer hospital lengths of stay. Hospital utilization patterns for the young adult patients were different from the geriatric patients, but in the expected direction, ie, less medical comorbidity and shorter lengths of stay. Patients with late-onset geriatric depression had the highest 24-month readmission rate (47.4%), followed by early-onset geriatric depression patients (23.1%) and young adult patients (16.7%). Delusional symptoms and agitation were similar across the three patient groups and, as expected, somatic complaints were more frequent in the geriatric patient groups. The relative risk for readmission was greatest for geriatric patients who were somatic. Readmission risk was increased for agitated late-onset geriatric depressed patients and young adult patients, but not for early-onset geriatric depressed patients. Delusional symptoms did not predict readmission for any patient group.

Antidepressant use in elderly medical inpatients: lessons from an attempted clinical trial

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was balted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was conducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antidepressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy.