Lea C. Watson

Depression in Assisted Living: Results From a Four-State Study

OBJECTIVE Assisted living is a rapidly-growing sector of long-term care, but little research has been done on depression in this setting. Using data from a large sample of assisted-living residents, the authors sought to 1) describe the prevalence of depression and depressive symptoms; 2) identify resident characteristics associated with depression; and 3) examine the relationship between depression and the rate of nursing home placement and mortality. METHODS A group of 2,078 residents age 65 and older were enrolled from 193 assisted-living facilities across four states (Florida, Maryland, New Jersey, and North Carolina). Residents were classified as depressed if their score on the Cornell Scale for Depression in Dementia (CSDD) exceeded 7. RESULTS Using this criterion, 13% were depressed, and only 18% of those were on antidepressants. Over one-third of residents had symptoms of depression, such as anxious expression, rumination, or worrying, and 25% displayed sad voice, sad expression, or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, agitation, and length of residence in the facility. Depressed residents were discharged to nursing homes at 1.5 times the rate of nondepressed residents. Rates of mortality were also higher for depressed residents, but only those with severe depression (CSDD >12) had a statistically significant increased rate of death. CONCLUSION The mission of assisted living is to help older adults retain autonomy, privacy, and quality of life in a personalized environment. Greater effort should be made to detect and treat depression in this setting, both to reduce suffering and prolong the residents ability to remain in their preferred environment.

Factors associated with potentially inappropriate drug utilization in a sample of rural community-dwelling older adults.

BACKGROUND Many medications present special risks when used by older adults (ie, those aged > or = 65 years) and are considered potentially inappropriate for this population. The Beers criteria are often used to identify such medications. Past research has documented that use of Beers drugs is common among older adults. OBJECTIVE The aim of this work was to examine factors associated with potentially inappropriate drug use among rural community-dwelling older adults using a conceptual framework adapted from the Andersen-Newman behavioral model of health service use. METHODS This was a population-based, cross-sectional survey. Data were collected via face-to-face home interviews between 2002 and 2004. Rural community-dwelling older adults residing in a single county in North Carolina were eligible. Potentially inappropriate drug use was operationalized using the Beers criteria. Data concerning predisposing (ie, age, sex, race, education, and marital status), enabling (ie, social support and insurance status), need (ie, disability and history of major depression, hypertension, osteoarthritis, back problems, or other comorbidities), and utilization factors (ie, number of medications used) were collected. RESULTS Data were gathered from 892 people, with information on medication use available for 800. Two hundred thirteen of these 800 participants (26.6%) used > or = 1 Beers drug. Compared with individuals who used no Beers drugs, those who used > or = 1 Beers drug reported lower levels of social support (odds ratio [OR], 0.94; 95% CI, 0.90-0.99) and higher levels of disability (OR, 1.48; 95% CI, 1.11-1.97), used more medications (OR, 1.07; 95% CI, 1.01-1.13), and were more likely to have a history of major depression (OR, 1.67; 95% CI, 1.05-2.66), hypertension (OR, 1.58; 95% CI, 1.07-2.33), osteoarthritis (OR, 1.58; 95% CI, 1.09-2.29), and back problems (OR, 1.72; 95% CI, 1.19-2.47). CONCLUSION As suggested by the Andersen-Newman model, the risk of potentially inappropriate drug use is highest among those with the greatest medication needs, as evidenced by poorer health status in this sample of rural community-dwelling older patients.

Depression in assisted living is common and related to physical burden

OBJECTIVE The objective of this study was to obtain a direct estimate of the prevalence of depression, its associated factors, and rates of treatment among residents of assisted living (AL) facilities in central Maryland. METHOD One hundred ninety-six AL residents were recruited from 22 (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. Chart review, staff and family history, comprehensive in-person resident evaluation, and the Cornell Scale for Depression in Dementia (CSDD) were administered by an experienced team of geriatric psychiatry clinicians. Those scoring >7 on the CSDD, a cut point repeatedly associated with poor outcomes, were considered clinically depressed. RESULTS Participants had an average age of 86 years, most were female and widowed, and 68% met consensus criteria for dementia. Twenty-four percent (47 of 196) of the sample was depressed. In bivariate analyses, depression was significantly related to medical comorbidity, need for activities of daily living (ADLs) assistance, more days spent in bed, and less participation in organized activities. After controlling for pertinent covariates in a regression model, only need for ADL assistance remained significantly associated with depression. Forty-three percent of those currently depressed were receiving antidepressants and were more likely to receive them if they lived in a large AL facility. Sixty percent of depressed residents had no regular source of psychiatric care. CONCLUSIONS In the first clinical study implemented by geriatric psychiatry professionals in AL, depression was found to be common, undertreated, and related to physical burden. AL is a rapidly growing segment of long-term care and represents an important setting in which to find and treat serious depression.

Systematic Review: Effective Characteristics of Nursing Homes and Other Residential Long-Term Care Settings for People with Dementia

In response to the need for an evidence‐based review of factors within long‐term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long‐term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes.

Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting A Systematic Review and Meta-Analysis

Background: Depression concomitant with chronic medical conditions is common and burdensome in primary care. Objective: To assess the effectiveness of practice-based interventions for improving depression and chronic medical outcomes. Data Sources: MEDLINE, Embase, the Cochrane Library, CINAHL, and PsycINFO from inception to June 11, 2012. Study Selection, Appraisal, and Synthesis: Two reviewers independently selected, extracted data from, and rated the quality of trials and systematic reviews. Strength of evidence (SOE) was graded using established criteria. Results: Twenty-four published articles reported data from 12 studies, all at least 6 months long. All studies compared a form of collaborative care with usual or enhanced usual care. Studies evaluated adults with arthritis, cancer, diabetes, heart disease, HIV, or multiple medical conditions. Meta-analyses found that intervention recipients achieved greater improvement than controls in depression symptoms, response, remission, and depression-free days (moderate SOE); satisfaction with care (moderate SOE); and quality of life (moderate SOE). Few data were available on outcomes for chronic medical conditions. Meta-analyses revealed that patients with diabetes receiving collaborative care exhibited no difference in diabetes control compared with control groups (change in HbA1c: weighted mean difference 0.13, 95% confidence interval = −0.22 to 0.48 at 6 months; 0.24, 95% confidence interval = −0.14 to 0.62 at 12 months; low SOE). The only study to use HbA1c as a predefined outcome measure and a “treat-to-target” intervention for diabetes as well as depression, TEAMcare, reported significant reductions in HbA1c (7.42 vs 7.87 at 6 months; 7.33 vs 7.81 at 12 months; overall P < .001). Limitations: Few relevant trials reported on medical outcomes. Conclusions: Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with varying medical conditions. Few data were available on medical outcomes. Future studies of concomitant depression and chronic medical conditions should consider measures of medical outcomes as primary outcomes.

Perceptions of depression among dementia caregivers: findings from the CATIE-AD trial

For patients with Alzheimers disease complicated by behavioral disturbances, to use single questions about perceived depression and assess patient and caregiver accuracy in recognizing patient depression.

Identifying Priorities for Patient-Centered Outcomes Research for Serious Mental Illness

OBJECTIVE The purpose of this project was to engage a diverse group of stakeholders (N=38) to help establish priorities to guide patient-centered outcomes research (PCOR) in serious mental illness. METHODS Three meetings, two Web-based and one on site, were held to generate and prioritize an initial list of topics. Topics were then sorted and organized into common themes. RESULTS About 140 topics were identified and sorted into 21 main themes, ranked by priority. Three of the top four themes focused on how research was conducted, particularly the need to develop consensus measurement and outcomes definitions; improving infrastructure for research, longitudinal studies, and new data sets and investigators; and developing PCOR methodology. Stakeholders also identified a need to focus on service delivery, treatment settings, and structure of the delivery of care. CONCLUSIONS Engagement by a broad group of stakeholders in a transparent process resulted in the identification of priority areas for PCOR. Stakeholders clearly indicated a need to fundamentally change how research on serious mental illness is conducted and a critical need for the development of methodology and infrastructure. Most current PCOR has been focused on relatively short-term outcomes, but real world, long-term studies providing guidance for treatment over the lifetime of a serious mental illness are needed.

Asking family about memory loss. Is it helpful

OBJECTIVE: To compare a family informant’s report of memory loss in an older family member to standardized clinical diagnoses of cognitive impairment.SETTING: Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), a 10-year longitudinal study of community dwellers aged 65 and greater in five counties of North Carolina.PARTICIPANTS: A stratified random sample of potentially demented participants was selected from the second wave of the Duke EPESE using responses to a brief cognitive screen. A neuropsychological battery was administered to these participants, and their family informants were asked whether they recognized memory loss in the participant. One hundred fifty-seven participants completed the full evaluation and also had an available family informant.MAIN OUTCOME MEASURES: Family informant’s report of memory loss (yes, no, sometimes) compared to expert consensus diagnosis of cognitive impairment or dementia.RESULTS: There was poor concordance between the clinical diagnoses of cognitive impairment or dementia and the family informant’s recognition of memory loss (κ=−0.05; P=.74). When informants reported memory loss, 30% of participants were found not to have a cognitive loss. Among participants in whom family informants reported no memory loss, 75% were diagnosed with dementia or cognitive impairment (sensitivity, 0.70, 95% confidence interval [CI], 0.61 to 0.78; specificity, 0.24, 95% CI, 0.13 to 0.40; positive predictive value, 70%; negative predictive value, 25%).CONCLUSIONS: Asking family members about memory loss in a patient may be an unreliable strategy to detect dementia.

Enhancing Quality in Psychiatry with Psychiatrists (EQUIPP)—Results from a Pilot Study

OBJECTIVES To pilot a pharmacist-led, patient centered medication management program. DESIGN Prospective, single arm trial. SETTING Academic geriatric psychiatry outpatient clinic. PARTICIPANTS Outpatients at least 65 years old, proxy available if demented, and on two or more psychiatric medications. INTERVENTION A clinical pharmacist completed a baseline medication review and made evidence-based recommendations that were implemented by the pharmacist after discussion with the physician. The pharmacist made a minimum of monthly contact for 6 months to review medications and related issues. MEASUREMENTS The primary outcome was the change in number of medication related problems over time (3 and 6 months) as defined by a predetermined classification system. RESULTS The mean age of the 27 patients was 75 years, 10 of whom required a proxy to participate. On average, patients had nine chronic conditions and were taking 14 medications. The mean number (SD; range) of medication related problems at baseline was 4.1 (2.2; 0-8) and at 3 and 6 months were 3.6 (2.4, 0-9) and 3.4 (2.1; 0-8), respectively. Most follow-up problems were new (80% and 89% at 3 and 6 months, respectively). CONCLUSION Using a pharmacist to deliver a medication management program was feasible and addressed existing problems. New problems, however, developed over a short interval (3-6 months), suggesting that ongoing intervention is required.