Joan C. Rogers

The Association of Late-Life Depression and Anxiety With Physical Disability: A Review of the Literature and Prospectus for Future Research

Depression and anxiety disorders are associated with excess disability. The authors searched the recent geriatric literature for studies associating late-life depression or anxiety with physical disability. Studies showed depression in old age to be an independent risk factor for disability; similarly, disability was found to be a risk factor for depression. Anxiety in late life was also found to be a risk factor for disability, although not necessarily independently of depression. Increased disability due to depression is only partly explained by differences in socioeconomic measures, medical conditions, and cognition. Physical disability improves with treatment for depression; comparable studies have not been done for anxiety. The authors discuss how these findings inform current concepts of physical disability and discuss the implications for future intervention studies of late-life depression and anxiety disorders.

Improving Morning Care Routines of Nursing Home Residents with Dementia

OBJECTIVES: This study examined the effectiveness of a behavioral rehabilitation intervention for improving the performance of morning care activities of daily living (ADL) of nursing home residents with dementia.

Maintenance Treatment of Depression in Old Age: A Randomized, Double-blind, Placebo-Controlled Evaluation of the Efficacy and Safety of Donepezil Combined With Antidepressant Pharmacotherapy

CONTEXT Cognitive impairment in late-life depression is a core feature of the illness. OBJECTIVE To test whether donepezil hydrochloride and antidepressant therapy is superior to placebo and antidepressant therapy in improving cognitive performance and instrumental activities of daily living and in reducing recurrences of depression over 2 years of maintenance treatment. DESIGN Randomized, double-blind, placebo-controlled maintenance trial. SETTING University clinic. PARTICIPANTS One hundred thirty older adults aged 65 years and older with recently remitted major depression. INTERVENTIONS Random assignment to maintenance antidepressant pharmacotherapy and donepezil or to maintenance antidepressant pharmacotherapy and placebo. MAIN OUTCOME MEASURES Global neuropsychological performance, cognitive instrumental activities of daily living, and recurrent depression. RESULTS Donepezil and antidepressant therapy temporarily improved global cognition (treatment × time interaction, F₂,₂₁₆ = 3.78; P = .03), but effect sizes were small (Cohen d = 0.27, group difference at 1 year). A marginal benefit to cognitive instrumental activities of daily living was also observed (treatment × time interaction, F₂,₁₃₇ = 2.94; P = .06). The donepezil group was more likely than the placebo group to experience recurrent major depression (35% [95% confidence interval {CI}, 24%-46%] vs 19% [95% CI, 9%-29%], respectively; log-rank χ² = 3.97; P = .05; hazard ratio = 2.09 [95% CI, 1.00-4.41]). Post hoc subgroup analyses showed that of 57 participants with mild cognitive impairment, 3 of 30 participants (10% [95% CI, 0%-21%]) receiving donepezil and 9 of 27 participants (33% [95% CI, 16%-51%]) receiving placebo had a conversion to dementia over 2 years (Fisher exact test, P = .05). The mild cognitive impairment subgroup had recurrence rates of major depression of 44% with donepezil vs 12% with placebo (likelihood ratio = 4.91; P = .03). The subgroup with normal cognition (n = 73) showed no benefit with donepezil and no increase in recurrence of major depression. CONCLUSIONS Whether a cholinesterase inhibitor should be used as augmentation in the maintenance treatment of late-life depression depends on a careful weighing of risks and benefits in those with mild cognitive impairment. In cognitively intact patients, donepezil appears to have no clear benefit for preventing progression to mild cognitive impairment or dementia or for preventing recurrence of depression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00177671.

Direct assessment of activities of daily living in Alzheimer's disease. A controlled study.

The relationship between severity of dementia and performance in four experimental tasks was studied in nine patients with Alzheimers disease and nine age‐matched controls. The experimental tasks were developed in order to establish a direct measure of functional performance in common activities of daily living. In the Alzheimers patients, significant but moderate positive associations were found between the Clinical Dementia Rating Scale (CDR), a comprehensive rating tool designed specifically for Alzheimers disease, and performance on the experimental tasks. A significant correlation was also found between the results of the Short Portable Mental Status Questionnaire (SPMSQ), a less specific dementia assessment instrument, and the CDR but not between the SPMSQ and the performance measure. When compared to nine normal subjects matched for gender, age, and education, the cognitively impaired subjects required more assistance and time (P < .01) in completing the tasks. The findings support the conclusion that severity of dementia and performance on activities of daily living tasks are related but distinct concepts and should be measured separately.

Onset of Depression in Elderly Persons After Hip Fracture: Implications for Prevention and Early Intervention of Late‐Life Depression

OBJECTIVES: To identify predictors of onset of major depressive disorder (MDD) and of depressive symptoms in subjects who suffered a hip fracture.

Association of the Serotonin Transporter Gene-Linked Polymorphic Region (5-HTTLPR) Genotype With Depression in Elderly Persons After Hip Fracture

OBJECTIVE The authors examined the serotonin transporter gene-linked polymorphic region (5-HTTLPR) as a predictor of major depressive disorder and depressive symptoms after hip fracture, a common stressful medical event. METHODS This was a prospective, observational study of 23 elderly rehabilitation-hospital patients during their inpatient stay. Depressive symptoms were assessed by Hamilton Rating Scale for Depression (Ham-D) and PRIME-MD. Subjects were also genotyped for 5-HTTLPR. RESULTS Survival analysis showed that genotype significantly predicted time-to-major depressive episode. Subjects with an s allele (genotype s/l or s/s) had significantly higher Ham-D scores over 14 weeks of follow-up than those with the l/l genotype. CONCLUSION Depressive symptoms and major depressive disorder in elderly persons after a stressful medical event may be associated with 5-HTTLPR genotype. This finding requires confirmation in a larger sample.

The Use and Effectiveness of Assistive Devices Possessed by Patients Seen in Home Care

The use and effectiveness of 54 selected assistive devices were studied in 30 recipients of home care services. Of these 54 devices, 82% were used and 69% were used routinely for the intended purpose. Twenty patients had bedside commodes and nine had bathtub benches or shower chairs. Only a few patients had long-handled shoe horns, reachers, raised toilet seats, sock aids, elastic shoelaces, commode armrests, or long-handled scrub sponges. No patient had a rocker knife, even though stroke was the most common medical condition. Device training, done inconsistently, generally took 30 minutes or less, spanned 1 to 2 sessions, occurred within 6 months of impairment or 1 year after onset, was carried out by a home health agency, and was judged adequate by the patient. Family members were as apt as not to be included in the training. No association was discerned between training and usage or timing of training in relation to length of impairment and usage. A substantive amount of human help was needed to complete the tasks involving the device. Device disuse was attributed to functional improvement, misprescription, and ineffectiveness.

Role of Social Support in Predicting Caregiver Burden

OBJECTIVE To examine the unique contribution of social support to burden in caregivers of adults aging with spinal cord injury (SCI). DESIGN Secondary analyses of cross-sectional data from a large cohort of adults aging with SCI and their primary caregivers. SETTING Multiple community locations. PARTICIPANTS Caregivers of community-dwelling adults aging with SCI (n=173) were interviewed as part of a multisite randomized controlled trial. The mean age ± SD of caregivers was 53±15 years and of care-recipients, 55±13 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome was caregiver burden measured with the Abridged Version of the Zarit Burden Interview. A hierarchical multiple regression analysis examined the effects of social supports (social integration, received social support, and negative social interactions) on burden in caregivers of adults aging with SCI while controlling for demographic characteristics and caregiving characteristics. RESULTS After controlling for demographic characteristics and caregiving characteristics, social integration (β=-.16, P<.05), received social support (β=-.15, P<.05), and negative social interactions (β=.21, P<.01) were significant independent predictors of caregiver burden. CONCLUSIONS Findings demonstrate that social support is an important factor associated with burden in caregivers of adults aging with SCI. Social support should be considered for assessments and interventions designed to identify and reduce caregiver burden.

Excess Disability During Morning Care in Nursing Home Residents With Dementia

Excess disability was examined in 17 nursing home residents with dementia by comparing their performance of morning care tasks under two activities of daily living (ADL) caregiving approaches-a dependence-supportive one under usual care and an independence-supportive one under functional rehabilitation. The results suggest that excess disability in severely cognitively impaired and functionally disabled residents can be reduced by increasing opportunities for independent activity, and substituting nondirective and directive verbal assists for physical assists. Further, the findings indicate that increased independence in ADL can be achieved without increasing disruptive behaviors and can foster appropriate requests for task-related help during caregiving. Functional rehabilitation, however, requires more time than usual care.

Control-Relevant Intervention in the Treatment of Minor and Major Depression in a Long-Term Care Facility

The authors assessed the effect of a control-relevant psychosocial intervention in 31 nursing home residents with either major depressive episode or minor depression. An initial group of 22 residents were randomized to either active treatment or waiting list. Four of 11 residents randomized to active treatment were deemed Responders, compared with 0 of 11 on the waiting list (P < 0.05). Of the total of 31 residents who participated in the intervention, 14 (45%) were deemed Responders during the intervention period. For these Responders, the Hamilton Rating Scale for Depression (Ham-D) and Geriatric Depression Scale scores improved significantly during the intervention. The improvement in the Ham-D was not sustained 2 months after intervention was terminated. These findings suggest that a psychosocial intervention enhancing socialization according to each residents choice had a positive therapeutic impact on almost half of the nursing home residents with major or minor depression. However this effect could not be sustained by the residents without the support of the structured program.