Grief and loss in old age: Exploration of the association between grief and depression

BACKGROUND

The proportion of older adults is increasing due to demographic changes. Depression belongs to the most common mental disorders in late life. The loss of an emotionally significant person is a risk factor for the development of depression. The aim of this study is to analyze the association between depression and grief burden resulting from loss. Based on prior evidence, we examined loneliness as a possible mediator and social support as possible moderator of this association.

METHODS

The cross-sectional analyses are based on a sample (N = 863) of study participants aged 75+ (M = 81.4 years, SD = 4.4, 62.2% female) with loss experience deriving from the multicenter prospective German cohort study AgeMooDe. Regression analyses (moderated mediation) were performed.

RESULTS

With increasing age (β = 0.10, p = .005) and grief burden (β = 0.33, p <. 001) depression severity increased. There was an indirect mediating effect of loneliness on the correlation of grief burden and depression (b = 0.04, CI [0.03, 0.05]), but no moderating effect of social support on the correlation of grief burden and loneliness. People living alone had a significantly higher risk of depression, increased loneliness and lack of social support.

LIMITATIONS

Assessments were based on self-reporting and recorded dimensionally. The cross-sectional design limits conclusions about directions and causality of associations. Sampling bias cannot be completely excluded.

CONCLUSION

The study provides empirical evidence and a better understanding of the association between grief and depression among the very old and the mediating role of loneliness.

[Informal care for dementia according to type of service]

BACKGROUND

Dementia is a major challenge for society and its impact will grow in the future. Informal care is an essential part of dementia care. Previous studies considered informal care as a whole and not by its components.

OBJECTIVE

We aimed to assess the degree of association between specific informal care services and dementia.

MATERIAL AND METHODS

This analysis is based on data from the seventh wave of the AgeCoDe/AgeQualiDe study. Dementia was diagnosed based on the DSM-IV criteria. Severity of dementia was assessed and categorized by means of the Clinical Dementia Rating and eight individual informal care services were considered. Logistic regression models were used to assess associations.

RESULTS

Of the 864 participants 18% suffered from dementia (very mild: 4%; mild: 6%; moderate: 5%; severe: 3%). All informal care services were significantly associated with dementia, with an emphasis on "supervision", "regulation of financial matters" and "assistance in the intake of medication". Considering different degrees of dementia severity, similar results arose from the analyses. All three aforementioned services showed a pronounced association with all degrees of dementia severity, except for supervision and very mild dementia.

CONCLUSION

The provision of all types of informal care services is associated with dementia. The association is pronounced for services that can be more easily integrated into the daily routines of the informal caregiver. Policy makers who plan to integrate informal care into the general care arrangements for dementia should consider this.

Longitudinal Analysis of Outpatient Physician Visits in the Oldest Old: Results of the AgeQualiDe Prospective Cohort Study

OBJECTIVES

The aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally.

DESIGN

Multicenter prospective cohort "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe).

SETTING

Individuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves).

PARTICIPANTS

Primary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85-100 years).

MEASUREMENTS

Self-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale).

RESULTS

Fixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables.

CONCLUSION

Our findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

Factors Affecting Functional Impairment among Elderly Germans - Results of a Longitudinal Study

OBJECTIVE

To investigate causal factors of functional impairment in old age in a longitudinal approach.

DESIGN

A population-based prospective cohort study.

SETTING

Elderly individuals were recruited via GP offices at six study centers in Germany. They were observed every 1.5 years over six waves.

PARTICIPANTS

Three thousand two hundred fifty-six people aged 75 years and older at baseline.

MEASUREMENTS

Functional impairment was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale (IADL) and the Barthel-Index (BI).

RESULTS

Fixed effects regressions revealed that functional impairment (IADL; BI) increased significantly with ageing (β=-.2; β=-1.1), loss of a spouse (β= .5; β=-3.1), not living alone in private household (β=-1.2; β=-5.5), depression (solely significant for IADL: β= .6) and dementia (β=-2.3; β=-18.2). The comorbidity score did not affect functional impairment.

CONCLUSION

Our findings underline the relevance of changes in sociodemographic variables as well as the occurrence of depression or dementia for functional impairment. While several of these causal factors for functional decline in the oldest old are inevitable, some may not be, such as depression. Therefore, developing interventional strategies to prevent depression might be a fruitful approach in order to delay functional impairment in old age.

Does Visual Impairment Affect Social Ties in Late Life? Findings of a Multicenter Prospective Cohort Study in Germany

OBJECTIVE

To investigate how visual impairment affects social ties in late life longitudinally.

DESIGN

Population-based prospective cohort study.

SETTING

Individuals in old age were recruited via general practitioners' offices (at six study centers) in Germany. They were interviewed every 18 months.

PARTICIPANTS

Individuals aged 75 years and above at baseline. Follow-up wave 2 (36 months after baseline, n=2,443) and wave 4 (72 months after baseline, n=1,618) were used for the analyses presented here.

MEASUREMENTS

Social ties were assessed using the 14-item form of the questionnaire for social support (F-SozU K-14). Visual impairment was self-rated on a three level Likert scale (no impairment, mild visual impairment, or severe/profound visual impairment).

RESULTS

Adjusting for sociodemographic factors, hearing impairment and comorbidity, fixed effects regressions revealed that the onset of mild visual impairment decreased the social support score, in particular the emotional support score. Additionally, the onset of mild hearing impairment decreased the social support score in men. Moreover, increasing age decreased the social support score in the total sample and in both sexes. Loss of spouse and increasing comorbidity did not affect the social support score.

CONCLUSION

Our results highlight the importance of visual impairment for social ties in late life. Consequently, appropriate strategies in order to delay visual impairment might help to maintain social ties in old age.

Predictors of Frailty in Old Age - Results of a Longitudinal Study

OBJECTIVES

To investigate time-dependent predictors of frailty in old age longitudinally.

DESIGN

Population-based prospective cohort study.

SETTING

Elderly individuals were recruited via GP offices at six study centers in Germany. The course of frailty was observed over 1.5 years (follow up wave 4 and follow up wave 5).

PARTICIPANTS

1,602 individuals aged 80 years and older (mean age 85.4 years SD 3.2, with mean CSHA CFS 3.5 SD 1.6) at follow up wave 4.

MEASUREMENTS

Frailty was assessed by using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS), ranging from 1 (very fit) to 7 (severely frail).

RESULTS

Fixed effects regressions revealed that frailty increased significantly with increasing age (β=.2) as well as the occurrence of depression (β=.5) and dementia (β=.8) in the total sample. Changes in marital status and comorbidity did not affect frailty. While the effects of depression and dementia were significant in women, these effects did not achieve statistical significance in men.

CONCLUSION

Our findings highlight the role of aging as well as the occurrence of dementia and depression for frailty. Specifically, in order to delay frailty in old age, developing interventional strategies to prevent depression might be a fruitful approach.

Mortality in incident dementia - results from the German Study on Aging, Cognition, and Dementia in Primary Care Patients

OBJECTIVE

Dementia is known to increase mortality, but the relative loss of life years and contributing factors are not well established. Thus, we aimed to investigate mortality in incident dementia from disease onset.

METHOD

Data were derived from the prospective longitudinal German AgeCoDe study. We used proportional hazards models to assess the impact of sociodemographic and health characteristics on mortality after dementia onset, Kaplan-Meier method for median survival times.

RESULTS

Of 3214 subjects at risk, 523 (16.3%) developed incident dementia during a 9-year follow-up period. Median survival time after onset was 3.2 years (95% CI = 2.8-3.7) at a mean age of 85.0 (SD = 4.0) years (≥2.6 life years lost compared with the general German population). Survival was shorter in older age, males other dementias than Alzheimer's, and in the absence of subjective memory complaints (SMC).

CONCLUSION

Our findings emphasize that dementia substantially shortens life expectancy. Future studies should further investigate the potential impact of SMC on mortality in dementia.

Apolipoprotein E epsilon 4 genotype and a physically active lifestyle in late life: analysis of gene-environment interaction for the risk of dementia and Alzheimer's disease dementia

BACKGROUND

As physical activity may modify the effect of the apolipoprotein E (APOE) ε4 allele on the risk of dementia and Alzheimer's disease (AD) dementia, we tested for such a gene-environment interaction in a sample of general practice patients aged ⩾75 years.

METHOD

Data were derived from follow-up waves I-IV of the longitudinal German study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). The Kaplan-Meier survival method was used to estimate dementia- and AD-free survival times. Multivariable Cox regression was used to assess individual associations of APOE ε4 and physical activity with risk for dementia and AD, controlling for covariates. We tested for gene-environment interaction by calculating three indices of additive interaction.

RESULTS

Among the randomly selected sample of 6619 patients, 3327 (50.3%) individuals participated in the study at baseline and 2810 (42.5%) at follow-up I. Of the 2492 patients without dementia included at follow-up I, 278 developed dementia (184 AD) over the subsequent follow-up interval of 4.5 years. The presence of the APOE ε4 allele significantly increased and higher physical activity significantly decreased risk for dementia and AD. The co-presence of APOE ε4 with low physical activity was associated with higher risk for dementia and AD and shorter dementia- and AD-free survival time than the presence of APOE ε4 or low physical activity alone. Indices of interaction indicated no significant interaction between low physical activity and the APOE ε4 allele for general dementia risk, but a possible additive interaction for AD risk.

CONCLUSIONS

Physical activity even in late life may be effective in reducing conversion to dementia and AD or in delaying the onset of clinical manifestations. APOE ε4 carriers may particularly benefit from increasing physical activity with regard to their risk for AD.

[Potentially inappropriate medication in elderly primary care patients : A retrospective, longitudinal analysis]

BACKGROUND

Elderly people are often burdened by several diseases. This accounts for a higher medication intake and increases the risk of adverse drug events. To minimize this risk, several lists (Beers, PRISCUS) have been published of drugs that elderly patients should not take. We present a longitudinal analysis of the use of potentially inappropriate medication (PIM) over a period 4.5 years in a cohort of patients aged 75 years or more.

METHODS

Data were collected from the prospective, multicenter, observational study "German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)," initially enrolling 3,327 patients. We investigated the prevalence of PIM by checking medications during visits to patients' homes. Furthermore, we analyzed the use of individual PIM agents over time.

RESULTS

At baseline, we found a PIM prevalence of 29 % according to the PRISCUS list, which decreased to 25.0 % 4.5 years later (χ(2): 7.87, p = 0.004). The Beers list yielded a prevalence of 21 % at baseline, decreasing after 4.5 years to 17.1 % (χ(2): 10.77, p = 0.000). A time-dependent multilevel model confirmed these results. Older age, depression, and the use of numerous prescribed agents are independent risk factors for using a PRISCUS-PIM.

CONCLUSION

Our results seem to support a trend toward a more rational drug therapy because fewer patients were prescribed PIM. Thus, for the individual patient, the risk of adverse effects and side effects is reduced as are the costs of these effects.

A hierarchy of predictors for dementia-free survival in old-age: results of the AgeCoDe study

OBJECTIVE

Progression from cognitive impairment (CI) to dementia is predicted by several factors, but their relative importance and interaction are unclear.

METHOD

We investigated numerous such factors in the AgeCoDe study, a longitudinal study of general practice patients aged 75+. We used recursive partitioning analysis (RPA) to identify hierarchical patterns of baseline covariates that predicted dementia-free survival.

RESULTS

Among 784 non-demented patients with CI, 157 (20.0%) developed dementia over a follow-up interval of 4.5 years. RPA showed that more severe cognitive compromise, revealed by a Mini-Mental State Examination (MMSE) score < 27.47, was the strongest predictor of imminent dementia. Dementia-free survival time was shortest (mean 2.4 years) in such low-scoring patients who also had impaired instrumental activities of daily living (iADL) and subjective memory impairment with related worry (SMI-w). Patients with identical characteristics but without SMI-w had an estimated mean dementia-free survival time of 3.8 years, which was still shorter than in patients who had subthreshold MMSE scores but intact iADL (4.2-5.2 years).

CONCLUSION

Hierarchical patterns of readily available covariates can predict dementia-free survival in older general practice patients with CI. Although less widely appreciated than other variables, iADL impairment appears to be an especially noteworthy predictor of progression to dementia.

Age of major depression onset, depressive symptoms, and risk for subsequent dementia: results of the German study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe)

BACKGROUND

Whether late-onset depression is a risk factor for or a prodrome of dementia remains unclear. We investigated the impact of depressive symptoms and early- v. late-onset depression on subsequent dementia in a cohort of elderly general-practitioner patients (n = 2663, mean age = 81.2 years).

METHOD

Risk for subsequent dementia was estimated over three follow-ups (each 18 months apart) depending on history of depression, particularly age of depression onset, and current depressive symptoms using proportional hazard models. We also examined the additive prediction of incident dementia by depression beyond cognitive impairment.

RESULTS

An increase of dementia risk for higher age cut-offs of late-onset depression was found. In analyses controlling for age, sex, education, and apolipoprotein E4 genotype, we found that very late-onset depression (aged ≥ 70 years) and current depressive symptoms separately predicted all-cause dementia. Combined very late-onset depression with current depressive symptoms was specifically predictive for later Alzheimer's disease (AD; adjusted hazard ratio 5.48, 95% confidence interval 2.41-12.46, p < 0.001). This association was still significant after controlling for cognitive measures, but further analyses suggested that it was mediated by subjective memory impairment with worries.

CONCLUSIONS

Depression might be a prodrome of AD but not of dementia of other aetiology as very late-onset depression in combination with current depressive symptoms, possibly emerging as a consequence of subjectively perceived worrisome cognitive deterioration, was most predictive. As depression parameters and subjective memory impairment predicted AD independently of objective cognition, clinicians should take this into account.

Assessing cognitive changes in the elderly: reliable change indices for the Mini-Mental State Examination

OBJECTIVE

The diagnosis of dementia includes evidence of decline in cognitive functioning over time measured by objective cognitive tasks. Normative data for changes adjusted for the impact of socio-demographic factors on cognitive test performance are lacking to interpret changes in Mini-Mental State Examination (MMSE) test scores.

METHOD

As part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study), a sample of 1090 cognitively healthy individuals, aged 75 years and older, was assessed at 1.5-year intervals over a period of 4.5 years using the MMSE. Age- and education-specific Reliable Change Indices (RCIs) were computed.

RESULTS

Age and education were significantly associated with MMSE test performance, and gender indicated no impact. Across different age and education subgroups, changes from at least 2 up to 3 points indicated significant (i.e., reliable) changes in MMSE test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated.

CONCLUSION

This study provides age- and education-specific MMSE norms based upon RCI methods to interpret cognitive changes in older age groups. The computation of RCI scores improves the interpretation of changes in MMSE test scores by controlling for measurement error, practice effects, or regression to the mean.

Net costs of dementia by disease stage

OBJECTIVE

To estimate net costs of dementia by degree of severity from a societal perspective, including a detailed assessment of costs of formal and informal nursing care.

METHOD

In a cross-sectional study, costs of illness were analysed in 176 dementia patients and 173 matched non-demented control subjects. Healthcare resource use and costs were assessed retrospectively by means of a questionnaire. Dementia patients were classified into three disease stages, and linear regression models were applied to estimate net costs of dementia by degree of severity.

RESULTS

Annual net costs of dementia by stage were approximately €15 000 (mild), €32 000 (moderate) and €42 000 (severe), corresponding to US-$21 450, 45 760 and 60 060 respectively. Across disease stages, nursing care accounted for approximately three-quarters of total costs, of which half resulted from informal care. In sensitivity analyses using different valuation methods for nursing care, total costs decreased or increased by more than 20%.

CONCLUSION

Net costs more than double across stages of dementia. Informal care accounts for a considerable share of nursing care costs, and the approach to valuation of informal care has a large impact on cost-of-illness estimates.

Risk factors for incident mild cognitive impairment--results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

OBJECTIVES

To provide age- and gender-specific incidence rates of MCI among elderly general practitioner (GP) patients (75+ years) and to identify risk factors for incident MCI.

METHOD

Data were derived from the longitudinal German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). Incidence was calculated according to the 'person-years-at-risk' method. Risk factors were analysed using multivariate logistic regression models.

RESULTS

During the 3-year follow-up period, 350 (15.0%) of the 2331 patients whose data were included in the calculation of incidence developed MCI [person-years (PY) = 6198.20]. The overall incidence of MCI was 56.5 (95% confidence interval = 50.7-62.7) per 1000 PY. Older age, vascular diseases, the apoE epsilon4 allele and subjective memory complaints were identified as significant risk factors for future MCI.

CONCLUSION

Mild cognitive impairment is frequent in older GP patients. Subjective memory complaints predict incident MCI. Especially vascular risk factors provide the opportunity of preventive approaches.

[Prevention of falls in elderly osteoporotic women: conception and effects of an intervention program]

Falls can result in physical injuries as well as anxieties about falling and decreases in physical activities. For elderly osteoporotic people falls are a serious problem. In the progression of impairment the loss of bone density decreases the resistance of bone structure. Prevention of falls is therefore an important task for patients with osteoporosis. Numerous studies document the positive effects of physical activities and exercise on muscular strength, on balance, and gait; other studies focussed on the efficacy of intervention programs in consideration of the use of medication. But the studies did not consider the specific situation of osteoporotic people. In our study we focussed on the strengthening of sensorimotor functions, which can be expected in a short period of time and may therefore motivate for long-term intervention programs to increase bone density. This program was applied to a sample of 42 osteoporotic women with an average age of 66 participating in a training program for 90 minutes once a week over a period of 10 weeks. The effectiveness of the program was assessed by a battery including differential sensorimotor functions. Regarding the initial test results, there were only small differences between the study sample and a control group tested with the identical assessment. We used a pre-post-training design which enabled us to control the effects of the training program. Sensorimotor functions were tested three times: 3 months before the program started, at the beginning and at the end of the intervention program. The significant improvements from the first to the second testing were most likely due to repeated measurement. Further significant improvements, measured at the end of the program, can be interpreted as effects of the training. We conclude that sensorimotor functions of elderly with osteoporosis could be trained effectively in a rather short time.

[Exercise and sports therapy for patients with head and neck tumors]

Important aspects in the aftercare of patients with cancer of head and neck can be realized by physical training in a sports group. The aftermath of operative therapy, e.g. loss of motion, imbalances of muscular activity or respiratory movements, can be reduced. The main importance of physical training in a group is the patient's reintegration in a social environment. Evaluating the quality of life of the individual patient we found that this method of psychosocial aftercare can improve subjective quality of life. Therefore, this conception of rehabilitation should not be missing in the aftercare of patients with malignant cancer.