John Snowdon

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.

Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial.

Abstract Objective: To evaluate the effectiveness of a population based, multifaceted shared care intervention for late life depression in residential care. Design: Randomised controlled trial, with control and intervention groups studied one after the other and blind follow up after 9.5 months. Setting: Population of residential facility in Sydney living in self care units and hostels. Participants: 220 depressed residents aged ≥65 without severe cognitive impairment. Intervention: The shared care intervention included: (a) multidisciplinary consultation and collaboration, (b) training of general practitioners and carers in detection and management of depression, and (c)depression related health education and activity programmes for residents. The control group received routine care. Main outcome measure: Geriatric depression scale. Results: Intention to treat analysis was used. There was significantly more movement to “less depressed” levels of depression at follow up in the intervention than control group (Mantel-Haenszel stratification test, P=0.0125). Multiple linear regression analysis found a significant intervention effect after controlling for possible confounders, with the intervention group showing an average improvement of 1.87 points on the geriatric depression scale compared with the control group (95% confidence interval 0.76 to 2.97, P=0.0011). Conclusions: The outcome of depression among elderly people in residential care can be improved by multidisciplinary collaboration, by enhancing the clinical skills of general practitioners and care staff, and by providing depression related health education and activity programmes for residents. Key messages Large numbers of depressed elderly people live in residential care but few receive appropriate management A population based, multifaceted shared care intervention for late life depression was more effective than routine care in improving depression outcome The outcome of late life depression can be improved by enhancing the clinical skills of general practitioners and care staff and by providing depression related health education and activity programmes for residents The intervention needs further refining and evaluation to improve its effectiveness and to determine how best to implement it in other residential care settings

Falls, Depression and Antidepressants in Later Life: A Large Primary Care Appraisal

Background Depression and falls are common and co-exist for older people. Safe management of each of these conditions is important to quality of life. Methods A cross-sectional survey was used to examine medication use associated with injurious and non-injurious falls in 21,900 community-dwelling adults, aged 60 years or over from 383 Australian general practices recruited for the DEPS-GP Project. Falls and injury from falls, medication use, depressive symptoms (Primary Health Questionnaire (PHQ-9)), clinical morbidity, suicidal ideation and intent, health status (SF-12 Health Survey), demographic and lifestyle information was reported in a standardised survey. Findings Respondents were 71.8 years (sd 7.7) of age and 58.4% were women. 24% 11% and 8% reported falls, fall related injury, and sought medical attention respectively. Antidepressant use (odds ratio, OR: 1.46; 95% confidence interval, 95%CI: 1.25, 1.70), questionable depression (5–14 on PHQ OR: 1.32, 95%CI: 1.13, 1.53) and clinically significant symptoms of depression (15 or more on PHQ OR: 1.70, 95%CI: 1.14, 1.50) were independently associated with multiple falls. SSRI use was associated with the highest risk of multiple falls (OR: 1.66, 95%CI: 1.36, 2.02) amongst all psychotropic medications. Similar associations were observed for injurious falls. Over 60% of those with four accumulated risk factors had multiple falls in the previous year (OR: 3.40, 95%CI: 1.79, 6.45); adjusted for other demographic and health factors. Interpretation Antidepressant use (particularly SSRIs) was strongly associated with falls regardless of presence of depressive symptoms. Strategies to prevent falls should become a routine part of the management of older people with depression.

Factors associated with suicidal thoughts in a large community study of older adults.

BACKGROUND Thoughts about death and self-harm in old age have been commonly associated with the presence of depression, but other risk factors may also be important. AIMS To determine the independent association between suicidal ideation in later life and demographic, lifestyle, socioeconomic, psychiatric and medical factors. METHOD A cross-sectional study was conducted of a community-derived sample of 21 290 adults aged 60-101 years enrolled from Australian primary care practices. We considered that participants endorsing any of the four items of the Depressive Symptom Inventory -Suicidality Subscale were experiencing suicidal thoughts. We used standard procedures to collect demographic, lifestyle, psychosocial and clinical data. Anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale. RESULTS The 2-week prevalence of suicidal ideation was 4.8%. Male gender, higher education, current smoking, living alone, poor social support, no religious practice, financial strain, childhood physical abuse, history of suicide in the family, past depression, current anxiety, depression or comorbid anxiety and depression, past suicide attempt, pain, poor self-perceived health and current use of antidepressants were independently associated with suicidal ideation. Poor social support was associated with a population attributable fraction of 38.0%, followed by history of depression (23.6%), concurrent anxiety and depression (19.7%), prevalent anxiety (15.1%), pain (13.7%) and no religious practice (11.4%). CONCLUSIONS Prevalent and past mood disorders seem to be valid targets for indicated interventions designed to reduce suicidal thoughts and behaviour. However, our data indicate that social disconnectedness and stress account for a larger proportion of cases than mood disorders. Should these associations prove to be causal, then interventions that succeeded in addressing these issues would contribute the most to reducing suicidal ideation and, possibly, suicidal behaviour in later life.

Is depression more prevalent in old age

Objective: To examine the prevalence of depression in old age and to review cross-age studies that reported age-related differences in prevalence. Method: Reports of studies that included data on the prevalence of depression in old age were reviewed, and conclusions from review articles were considered. Results: Findings have been inconsistent, but majority opinion holds that depression (especially ‘subsyndromal’) is common in old age. There may be two peaks in the prevalence rate of major depression, one in late old age and the other in middle age or earlier. Conclusions: The allocation of health care resources should not be determined by survey findings concerning the prevalence of major depression and dysthymia.

The use of the Cohen-Mansfield Agitation Inventory in the assessment of behavioral disorders in nursing homes

ehavioral disorders are common among residents of nursB ing homes. In a study’ of 1139 elderly subjects from skilled nursing facilities, 64.2% were found to have a behavioral disturbance, 41.6% being classified as moderate and 22.6% as serious disturbances. In an Australian study a behavioral disturbance was reported in 47% of 301 patients recommended for nursing home care. Ouslander et aL3 listed behavior problems that are commonly seen in nursing home residents. “Disruptive” behaviors included shouting, breaching the privacy of others, and deliberately trying to interfere with staff activities. “Demanding” behaviors included food refusal and continuous seeking of reassurance. “Offensive” behaviors were characterized by verbal abuse, undressing in public and sexually inappropriate behavior, and “distressful” behaviors included hitting, biting, and crying. Cohen-Mansfield et aL4.’ considered many of these disturbed behaviors to be forms of agitation and subsequently developed the Cohen-Mansfield Agitation Inventory (CMAI), which can be used in identifying the nature and frequency of specific behaviors. Cohen-Mansfield et aL6 stated that they used the term “agitation” rather than “disruptive behavior” because the former was used more commonly by professionals involved in long-term care for older persons. In their definition of agitation, they referred to inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion per se. Reliable quantification of behavior is desirable to facilitate documentation of symptoms, provide a tool for follow-up of behavioral changes over time, and enable researchers to measure the effects of behavioral and pharmacological interventions.’ We included the CMAI and the Rating Scale for Aggressive Behavior in the Elderly (RAGE)’ in our assessments of a nursing home population because of their comprehensiveness and to enable comparison of results with the considerable body of data already obtained using these scales. The CMAI provides caregiver ratings of 29 operationally defined observable behaviors, each rated on a 7-point frequency scale (1 = never; 7 = several times an hour), for a 2-week rating period. Although Cohen-Mansfield et al. provide instructions regarding 29 agitated behaviors, there are in

Depressive symptoms in older adults with hearing impairments: the Blue Mountains Study.

1. Scheffer AC, Schuurmans MJ, van Dijk N et al. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37:19–24. 2. Friedman SM, Munoz B, West SK et al. Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc 2002;50:1329–1335. 3. Legters K. Fear of falling. Phys Ther 2002;82:264–272. 4. Podsiadlo D, Richardson S. ‘‘The Timed Up & Go’’: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–149. 5. Brodaty H, Pond D, Kemp NM et al. The GPCOG: A new screening test for dementia designed for general practice. J Am Geriatr Soc 2002;50: 530–534. 6. Lord SR, Ward JA, Williams P et al. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc 1994;42:1110– 1117. 7. Fried LP, Bandeen-Roche K, Kasper JD et al. Association of comorbidity with disability in older women: The Women’s Health and Aging Study. J Clin Epidemiol 1999;52:27–37.

A STUDY OF DEPRESSION IN NURSING HOMES

The Geriatric Depression Scale (GDS) was used to screen for depression among residents of six nursing homes in Sydney. Of the 61% who could answer the questionnaire, more than one third were depressed. Those who were physically disabled, and those admitted in the previous 3 months scored higher on the GDS. Many of the severely demented patients could be tested with the GDS.

The prevalence of anxiety disorders in nursing homes

Residents in five nursing homes in central Sydney were asked to take part in a study of depression and anxiety. One hundred and seven subjects who scored 18 or more on the Mini‐Mental State Examination (MMSE) were interviewed using an anxiety questionnaire devised by Lindesay et al. (1989) as well as the Geriatric Depression Scale (GDS). Lindesay et al. found that 3.7% of elderly people in the community had generalized anxiety. Based on scores obtained on the anxiety questionnaire, 12 of the 107 (11.2%) were considered to have generalized anxiety. When subsequently these 12 were seen by a psychiatrist, the following DSM‐III‐R diagnoses were made: generalized anxiety disorder (3), panic disorder plus anxiety (one), mood disorder (three), schizophrenia (one), personality disorder (one) and no psychiatric disorder— realistic worries (3). As in previous studies, a strong association was shown between anxiety and depression; seven of the 12 (58%) were rated on the GDS as definitely depressed, compared with only 24% of the non‐anxious. More of them were taking antidepressants. Phobic disorders were common (14% of subjects) but without causing persistent distress in most cases. Only two subjects had panic disorder.

A comparison of written and postbox forms of the Leyton Obsessional Inventory.

Two groups of medical students answered a modified version of the Leyton Obsessional Inventory twice, with 8 weeks between tests. On one occasion it was administered in its original card-sorting (postbox) form; on the other, it was given as a written questionnaire. Fifty students answered the postbox form first, 50 the questionnaire first. Correlation between the 2 tests was reasonably good (r = 0.73-0.77). Scores on the first occasion of testing were significantly higher than on the second, but differences between scores on the 2 forms were not significant. Mean scores of male and female students were similar.