Christopher M. Callahan

Six-item screener to identify cognitive impairment among potential subjects for clinical research.

Objective. To design a brief cognitive screener with acceptable sensitivity and specificity for identifying subjects with cognitive impairment Design. Cohort one is assembled from a community-based survey coupled with a second-stage diagnostic evaluation using formal diagnostic criteria for dementia. Cohort two is assembled from referrals to a specialty clinic for dementing disorders that completed the same diagnostic evaluation. Setting. Urban neighborhoods in Indianapolis, Indiana and the Indiana Alzheimer Disease Center. Patients. Cohort one consists of 344 community-dwelling black persons identified from a random sample of 2212 black persons aged 65 and older residing in Indianapolis; cohort two consists of 651 subject referrals to the Alzheimer Disease Center. Measurements. Formal diagnostic clinical assessments for dementia including scores on the Mini-mental state examination (MMSE), a six-item screener derived from the MMSE, the Blessed Dementia Rating Scale (BDRS), and the Word List Recall. Based on clinical evaluations, subjects were categorized as no cognitive impairment, cognitive impairment-not demented, or demented. Results. The mean age of the community-based sample was 74.4 years, 59.4% of the sample were women, and the mean years of education was 10.1. The prevalence of dementia in this sample was 4.3% and the prevalence of cognitive impairment was 24.6%. Using a cut-off of three or more errors, the sensitivity and specificity of the six-item screener for a diagnosis of dementia was 88.7 and 88.0, respectively. In the same sample, the corresponding sensitivity and specificity for the MMSE using a cut-off score of 23 was 95.2 and 86.7. The performance of the two scales was comparable across the two populations studied and using either cognitive impairment or dementia as the gold standard. An increasing number of errors on the six-item screener is highly correlated with poorer scores on longer measures of cognitive impairment. Conclusions. The six-item screener is a brief and reliable instrument for identifying subjects with cognitive impairment and its diagnostic properties are comparable to the full MMSE. It can be administered by telephone or face-to-face interview and is easily scored by a simple summation of errors.

Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Background:Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care. Methods:This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart. Results:The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (−1.3 versus −0.9) and equivalent at 6 months (−1.3 versus −1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale. Conclusions:Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

Longitudinal Study of Depression and Health Services Use Among Elderly Primary Care Patients

OBJECTIVE: To describe the prevalence and 9‐month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.

Improving primary care for depression in late life: the design of a multicenter randomized trial.

Background.Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. Research Design. A randomized controlled trial of a disease management program for late life depression. Subjects.Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. Intervention.Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient’s regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. Evaluation.Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. Conclusions.The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

Depression Treatment in a Sample of 1,801 Depressed Older Adults in Primary Care

OBJECTIVES: To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients

Outcomes of Percutaneous Endoscopic Gastrostomy Among Older Adults in a Community Setting

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

The Effect of Gender and Race on the Measurement Properties of the Ces-d in Older Adults

Having observed a three-fold difference in the prevalence of significant symptoms of depression among four race-gender groups of elderly adults attending an urban primary care practice, we investigated the extent to which these differences might be explained by variability in the measurement properties of the Centers for Epidemiologic Studies depression scale (CES-D). Although the internal consistency of the CES-D was acceptable for all groups, 5% of our patients were excluded for inability to complete the minimum required number of CES-D items, and nearly 40% of patients required response imputation for the allowable one to four items that they could not answer. Imputation was most frequently required for items tapping positive affect. Principal components factor analysis was performed separately for respondents answering all items and for respondents with imputed values. In both analyses we found important race-gender differences in factor structure. Moreover, the factor structure for those with imputed values was markedly different from that of respondents answering all items, including a dissolution of the positive affect dimension. Neither the race-gender differences in factor structure nor the differences among those with and without imputed data were resolved by eliminating respondents with poor education, cognitive impairment, or alcoholism, or by varying the assumptions for data imputation. However, the disparities in factor structure were essentially resolved by eliminating five CES-D items, suggesting the need to modify the CES-D in populations like ours. Although eliminating these five items results in a more pure factor structure, it does not resolve the differences in prevalence of depressive symptoms. These differences may, however, be partially due to differential response tendencies among the race-gender groups.

Comorbidity profile of dementia patients in primary care: Are they sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care.

Treatment of depression improves physical functioning in older adults

Objectives: To determine the effect of collaborative care management for depression on physical functioning in older adults.

Geriatric Resources for Assessment and Care of Elders (GRACE): A new model of primary care for low-income seniors

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low‐income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long‐term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community‐based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patients PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patients goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.