Psychosocial stressors, physical illness and the spectrum of depression in elderly inpatients

Seeking medical services among rural empty-nest elderly in China: a qualitative study

Background

The number of empty-nest elderly in China is rapidly increasing. Empty-nest elderly could not receive adequate daily care, economic support and spiritual consolation from their children. Rural empty-nest elderly are facing more serious health challenges than those in urban areas.

Objective

This study aimed to understand the experiences of rural empty-nest elderly in seeking medical services in China.

Methods

The method of inductive content analysis was used to collect and analyze data. Data were collected by in-depth interviews. A total number of 16 participants were involved in this study. A semi-structured interview guideline, which was discussed in depth and agreed upon by all researchers, was used to encourage participants to talk about their experiences in seeking medical services.

Results

Rural empty-nest elderly is facing a great challenge in seeking medical services in China. There are some barriers for rural nest elderly to get access to healthcare services, such as low-income status, high expenditure of medical treatment and inadequate health insurance coverage. Due to the absence of the companionship of their adult children, empty-nest elderly have to rely on their neighbors and relatives to seek medical services.

Conclusions

Rural empty-nest elderly have great difficulty in seeking medical services in China. More efforts should be made to get medical services more accessible to rural empty-nest elderly.

Epidemiology of psychotic depression - systematic review and meta-analysis

Large amount of data have been published on non-psychotic depression (NPD), schizophrenia (SZ), and bipolar disorder, while psychotic depression (PD) as an own entity has received much smaller attention. We performed a systematic review and meta-analyses on epidemiology, especially incidence and prevalence, risk factors, and outcomes of PD. A systematic search to identify potentially relevant studies was conducted using four electronic databases and a manual search. The search identified 1764 unique potentially relevant articles, the final study included 99 articles. We found that the lifetime prevalence of PD varies between 0.35% and 1%, with higher rates in older age. Onset age of PD was earlier than that of NPD in younger samples, but later in older samples. There were no differences in gender distribution in PD v. NPD, but higher proportion of females was found in PD than in SZ or in psychotic bipolar disorder (PBD). Risk factors have rarely been studied, the main finding being that family history of psychosis and bipolar disorder increases the risk of PD. Outcomes of PD were mostly worse when compared with NPD, but better compared with SZ and schizoaffective disorder. The outcome compared with PBD was relatively similar, and somewhat varied depending on the measure of the outcome. Based on this review, the amount of research on PD is far from that of NPD, SZ, and bipolar disorder. Based on our findings, PD seems distinguishable from related disorders and needs more scientific attention.

Psychiatric disorders in ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group

OBJECTIVE

To identify factors associated with attempted suicide in the elderly.

DESIGN

Social, psychological, and psychiatric characteristics were compared in suicide attempters (70 years and older) and a representative population sample.

SETTINGS

Emergency departments at five hospitals in western Sweden and a representative sample of the elderly population.

PARTICIPANTS

Persons with Mini Mental State Examination (MMSE) score <15 were excluded. One hundred forty persons who sought hospital treatment after a suicide attempt were eligible and 103 participated (57 women, 46 men, and mean age 80 years). Comparison subjects matched for gender and age group (N = 408) were randomly selected among participants in our general population studies.

MEASUREMENTS

Symptoms were rated with identical instruments in cases and comparison subjects. The examination included the MMSE and tests of short- and long-term memory, abstract thinking, aphasia, apraxia, and agnosia. Depressive symptomatology was measured using the Montgomery-Asberg Depression Rating Scale, and major and minor depressions were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, using symptom algorithms.

RESULTS

Factors associated with attempted suicide included being unmarried, living alone, low education level, history of psychiatric treatment, and previous suicide attempt. There was no association with dementia. Odds ratios were increased for both major (odds ratio [OR]: 47.4, 95% confidence interval [CI]: 19.1-117.7) and minor (OR: 2.6, 95% CI: 1.5-4.7) depressions. An association was observed between perceived loneliness and attempted suicide; this relationship was independent of depression (OR: 2.8, 95% CI: 1.3-6.1).

CONCLUSIONS

Observed associations mirrored those previously shown for completed suicide. Results may help to inform clinical decisions regarding suicide risk evaluation in this vulnerable and growing age group.

The prevention of depression in nursing home residents: a randomized clinical trial of cognitive-behavioral therapy

The prevention of depression in individuals who are at risk is important for affected individuals, their family members, and for society at large. This study presents the results of a randomized clinical trial aimed at the prevention of depression in nursing home residents. Residents were screened with the Geriatric Depression Scale (GDS) and a diagnostic interview. Those with elevated GDS scores who did not meet diagnostic criteria for depression were randomly assigned to a treatment or control (treatment as usual, TAU) condition. The treatment was an adaptation of the Coping with Stress program developed by Clarke et al. (1995; Journal of the American Academy of Child and Adolescent Psychiatry, 34, 312-321), and focused on various components typical of cognitive-behavioral treatment (CBT) programs (e.g. increasing pleasant events, reducing negative cognitions). Both groups were assessed on measures of depression before treatment, after treatment, and at 3- and 6-month follow-up points. Compared with the TAU group, residents receiving the intervention showed considerable improvement over the 6-month follow-up on the GDS. Average scores on the GDS, for example, went from 14.0 to 9.4 in the CBT group over the course of treatment and follow-up, vs. scores from 13.4 to 12.3 for the TAU group over the same time. However, results on the Center for Epidemiological Studies Depression Scale at 3 months were nonsignificant. Overall, the results of this study suggest that a brief, group-based CBT program can have significant benefit in nursing home residents at risk for depression.

Stemming the Tide of Suicide in Older White Men: A Call to Action

Preventing suicide has been identified as a national priority by recent commissions in the United States. Despite increased awareness of suicide as a public health problem, suicide in older adults remains a neglected topic in prevention strategies and research. This is especially true regarding elderly White men, who in terms of suicide rates have represented the most at-risk age group for the past half century. In light of the unprecedented aging of the United States as the baby boom generation enters late adulthood, suicide prevention initiatives that focus on aging males are needed to prevent a national crisis in geriatric mental health. This article provides a brief review of the perennially under-recognized reality of suicide in older men and prevention strategies that, if implemented, might help stem this rising tide of suicide in this vulnerable population.

Long-term effects of childhood abuse on the quality of life and health of older people: results from the Depression and Early Prevention of Suicide in General Practice Project

OBJECTIVES

To determine whether childhood physical and sexual abuse are associated with poor mental and physical health outcomes in older age.

DESIGN

Cross-sectional, postal questionnaire survey.

SETTING

Medical clinics of 383 general practitioners (GPs) in Australia.

PARTICIPANTS

More than 21,000 older adults (aged > or = 60) currently under the care of GPs participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) Study. Participants were divided into two groups according to whether they acknowledged experiencing childhood physical or sexual abuse.

MEASUREMENTS

Main outcome measures targeted participants' current physical health (Medical Outcomes Study 12-item Short Form Survey, Version 2 and Common Medical Morbidities Inventory) and mental health (Patient Health Questionnaire-9 and Hospital Anxiety and Depression Scale).

RESULTS

One thousand four hundred fifty-eight (6.7%) and 1,429 participants (6.5%) reported childhood physical and sexual abuse, respectively. Multivariate models of the associations with childhood abuse indicated that participants who had experienced either childhood sexual or physical abuse had a greater risk of poor physical (odds ratio (OR)=1.35, 95% confidence interval (CI)=1.21-1.50) and mental (OR=1.89, 95% CI=1.63-2.19) health, after adjustments. Older adults who reported both childhood sexual and physical abuse also had a higher risk of poor physical (OR=1.60, 95% CI=1.33-1.92) and mental (OR=2.40, 95% CI=1.97-2.94) health.

CONCLUSION

The effects of childhood abuse appear to last a lifetime. Further research is required to improve understanding of the pathways that lead to such deleterious outcomes and ways to minimize its late-life effects.

Comparison of suicide in people aged 65-74 and 75+ by gender in England and Wales and the major Western countries 1979-1999

BACKGROUND

The factors most strongly associated with suicide are age and gender--more men than women, and, more people over 65 kill themselves. As a number of Governments have targets to reduce suicide levels we compare elderly suicide rates over a 20-year period in England and Wales. And the major Western countries focusing upon age and gender.

METHOD

WHO mortality data were used to calculate three-year average General Population Suicide Rates (GPSR) for 1979-1981 to 1997-1999 and rates of people aged 65-74 and 75+ suicide by gender to provide ratios of change and a statistical comparison of England and Wales and the Major Western countries over the period.

RESULTS

Male GSPR: '65-74' suicide ratios fell significantly in six countries and in three for the '75+'. Female GSPR: '65-74' suicide ratios fell in every country except Spain. Proportionately, there were more suicides in the over 65s in countries with an 'extended family' tradition, Spain, Italy, Germany, France and Japan, than in the five 'secular' countries. England and Wales male '65-74' suicide fell significantly more than Canada, France, Germany, Italy, Japan, Spain, Netherlands and the USA, and did significantly better than the other countries for all female senior citizen suicides.

CONCLUSION

Suicide of the over-65s has improved in seven countries, especially in England and Wales, who had the greatest proportional reduction, which reflects well upon the psycho-geriatric and community services. However, in all countries, male 65-74 rates did not match the female out so extra efforts are needed to improve male rates.

Unrecognized medical disorders in older psychiatric inpatients in a senior behavioral health unit in a university hospital

Medical disorders may cause psychiatric symptoms. This study investigated the frequency and nature of previously unrecognized medical disorders associated with behavioral disturbances in acute geriatric psychiatry inpatients. Data came from a chart review of 79 consecutive admissions to the University of California, San Diego, Senior Behavioral Health Unit from May 1999 to October 1999. The most common Axis I admission diagnoses were depression and psychosis. At admission, 27 of 79 cases (34%) had unrecognized medical disorders. Comparison of these cases with the cases that did not have unrecognized medical disorders found no differences in age, education, gender, or cognitive abilities. The group with unrecognized medical disorders had more medical disorders (mean 5.0 vs 3.6; P = .002). Unrecognized conditions (n) included constipation (7), urinary infection (7), and hypothyroidism (5). Elderly psychiatric patients are more likely to have physical comorbidity. A large number of medical disorders should alert clinicians to look carefully for unrecognized medical disorders.

Evolution of depressive symptoms in Alzheimer disease: one-year follow-up

The current longitudinal study analyzes the natural course of depressive symptoms in patients with Alzheimer disease (AD). The goals were to identify the clinical and sociodemographic variables related to depressive symptoms, to assess the effect of depressive symptoms on the course of cognitive and functional impairment and on associated neuropsychiatric disorders, and to identify which factors are associated with remission, persistence, and emergence of depressive symptoms at 12 months. A sample of 150 patients with mild or moderate severity was assessed at baseline and at 12 months using the neuropsychologic battery Cambridge Cognitive Examination. The Neuropsychiatric Inventory and Rapid Disability Rating Scale were administered to the caregiver. Prevalence, persistence, and emergence of depressive symptoms at baseline were 51%, 55%, and 20%, respectively. Remission of depressive symptoms at 12 months leads to a decreased frequency of other noncognitive disorders and to a slight improvement in the assessment of global function. The presence of depressive symptoms does not affect the course of cognitive impairment at 12 months, and a psychiatric history of the patient and the number of depressive symptoms at baseline are risk factors for the emergence and persistence of depressive symptoms at 12 months.

Elderly suicide rates in Asian and English-speaking countries

OBJECTIVE

Asian culture venerates elderly people. It was hypothesized that elderly suicides would be proportionately lower in Asian societies than in English-speaking countries (ESC).

METHOD

Elderly (i.e. aged 75 years or more) to general population suicide ratios were compared for six Asian societies and six ESC, based upon the latest 5-year suicide rates.

RESULTS

Males: The general population suicide rate was highest in rural China (227 per million) and third highest in Japan (217 per million), but other countries with high rates were all ESC (ranging from 224 to 198 per million). Asian countries had the six highest elderly suicide rates, 1327-1373 per million, whilst the highest ESC elderly rate was in the United States (507 per million). Asian societies had the widest range of elderly/general ratios, ranging from 6.62 to 2.6. Females: The overall suicide rates were higher in Asian countries (57-95 per million) than in ESC (40-56 per million). Asian elderly suicide rates differed (932 per million in rural China to 154 per million in Korea) but the highest ESC rate was in Australia (76 per million). The Asian countries elderly/general ratios ranged from 5.82 : 1 to 2.70 : 1, but the widest ESC ratio was 1.71 : 1, in the United Kingdom.

CONCLUSION

There is a need for country-specific prevention measures in elderly people, and particularly for older women in Asian countries.

Depressive syndromes and functional disability in dementia

The goals of this study were to assess (1) the prevalence of major and minor depression in Alzheimer's disease (AD), ischemic vascular dementia (IVD), and mixed dementia (AD/IVD); (2) demographic and clinical variables that may be associated with depression; and (3) the relationship between depression severity and the level of functional impairment and cognitive decline. Demographic variables, depression diagnoses, Mini-Mental State Examination scores, and Blessed Roth Dementia Rating Scale scores were compared in patients with AD (N = 582), IVD (N = 48), and mixed dementia (N = 61) using analysis of variance and linear regression models. Data were collected using standardized rating instruments at the time of the patients' initial evaluations at the University dementia clinics. The results were that (1) depression was related to lower education, (2) major depression was more prevalent in IVD compared to probable AD, and (3) functional impairment was greater in patients with minor or major depression compared to patients without depression. Our data suggest that the level of functional disability in dementia may be related to severity of depression. Additional studies are needed to validate our results and examine the contribution of additional neurobiologic factors to the pathophysiology of depression in dementia.

Effects of age and gender on elderly suicide rates in Catholic and Orthodox countries: an inadvertent neglect?

When compared to suicide rates in the general population, it may be expected that elderly suicide rates would be lower in Catholic and Orthodox societies than in non-Catholic or non-Orthodox countries because of religious affiliations and extended family traditions. National suicide rates in the general population were compared with rates in the sub-population of those aged over 75 years. Proportionately, there are significantly higher suicide rates in elderly men in Catholic and Orthodox countries, compared to rates in other countries, with a trend for similar findings among women. There may be important implications on health and social policy and clinical practice in the efforts to reduce suicide rates among elderly people.

Atypical antipsychotics in older adults

Psychotic symptoms are common in older adults and reflect a variety of psychiatric and medical conditions. Antipsychotic drugs form the core of the treatment of these symptoms; however, treatment of the elderly is complicated by a high frequency of comorbid medical illnesses, risk of side effects, and age-related changes in pharmacodynamics and pharmacokinetics. The superior safety and efficacy of atypical antipsychotics makes them first-line agents for managing psychotic patients with schizophrenia. Their uses now extend to other conditions such as schizoaffective disorders, delusional disorder, and mood disorders with psychotic features. Although the drugs have been studied extensively in young subjects, well-designed, double-blind, placebo-controlled studies are relatively lacking in the elderly. Our knowledge of their safety, efficacy and dosage in older adults is based on a few studies with small samples or extrapolated from studies of younger patients. Several psychiatric and medical conditions that are associated with psychotic symptoms in older people are reviewed, as well as how these patients may benefit from treatment with these agents.

Late-onset minor and major depression: early evidence for common neuroanatomical substrates detected by using MRI

The purpose of our study was to examine the neuroanatomical correlates of late-onset minor and major depression and to compare them with similar measures obtained from nondepressed controls. Our study groups were comprised of 18 patients with late-onset minor depression, 35 patients diagnosed with late-onset major depression, and 30 nondepressed controls. All subjects were scanned by using a 1. 5-tesla MRI scanner. Absolute whole brain volume and normalized measures of prefrontal and temporal lobe volumes were obtained and used for comparison among groups. Our findings indicate that patients with minor depression present with specific neuroanatomical abnormalities that are comparable with the major depression group but significantly different from the controls. Normalized prefrontal lobe volumes show a significant linear trend with severity of depression, with volumes decreasing with illness severity. Whole brain volumes did not differ significantly among groups. These findings have broad implications for the biology of late-life depression and suggest that there may be common neurobiological substrates that underlie all clinically significant forms of late-onset mood disturbances.