Robert Blizard

Social support deficits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI.

BACKGROUND A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focuses on the cross-sectional relationship between depression and demographic variables, social support, and life events. METHOD A community survey of all residents over the age of 65 years of an electoral district in London, UK. RESULTS There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12.4 (7.6-20.0). CONCLUSIONS Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

Is the cognitive function of older patients affected by antihypertensive treatment ? Results from 54 months of the Medical Research Council's treatment trial of hypertension in older adults

Abstract Objective: To establish whether initiation of treatment with diuretic or β blocker is associated over 54 months with change in cognitive function. Design: A cognitive substudy, nested within a randomised, placebo controlled, single blind trial. Setting: 226 general practices from the Medical Research Councils general practice research framework. Subjects: A subset of 2584 subjects sequentially recruited from among the 4396 participants aged 65-74 in the trial of treatment of hypertension in older adults. The 4396 subjects were randomised to receive diuretic, β blocker, or placebo. Subjects had mean systolic pressures of 160-209 mm Hg and mean diastolic pressures <115 mm Hg during an eight week run in. Outcome measures: The rate of change in paired associate learning test (PALT) and trail making test part A (TMT) scores (administered at entry and at 1, 9, 21, and 54 months) over time. Results: There was no difference in the mean learning test coefficients (rate of change of score over time) between the three treatments: diuretic -0.31 (95% confidence interval -0.23 to -0.39), β blocker -0.33 (-0.25 to -0.41), placebo -0.30, (-0.24 to -0.36). There was also no difference in the mean trail making coefficients (rate of change in time taken to complete over time) between the three groups: diuretic -2.73 (95% confidence interval -3.57 to -1.88), β blocker -2.08 (-3.29 to -0.87), placebo -3.01, (-3.69 to -2.32). A less conservative protocol analysis confirmed this negative finding. Conclusion: Treating moderate hypertension in older people is unlikely to influence, for better or for worse, subsequent cognitive function. Key messages Key messages Studies have shown that treating hypertension in older adults reduces cardiovascular mortality and morbidity Treating moderate hypertension with either diuretic or β blocker does not seem to influence cognitive function Concerns about damaging cognition should not deter doctors from treating hypertension in older patients Age should no longer be a factor in the decision to initiate antihypertensive treatment

The REACT study: randomised evaluation of assertive community treatment in north London

Abstract Objective To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses. Design Non-blind randomised controlled trial. Setting Two inner London boroughs. Participants 251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services. Interventions Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants). Main outcome measures Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services. Results No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval −16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4). Conclusions Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V

BACKGROUND An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient. METHODS A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps. RESULTS Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24.2 (8.8-66.6). The population attributable fraction (PAF) for depression attributable to handicap was 0.78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone. CONCLUSIONS Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

The incidence of delirium associated with orthopedic surgery: a meta-analytic review

BACKGROUND The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery. METHODS Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias. RESULTS 26 publications reported an incidence of postoperative delirium of 4-53.3% in hip fracture samples and 3.6-28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6-28.8] vs. 12.1% [95% CI = 9.6-14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7-34.7] vs. 8.8% [95% CI = 4.1-13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%. CONCLUSIONS Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

The Gospel Oak Study stage IV : the clinical relevance of subjective memory impairment in older people

The prevalence rate of subjective memory impairment (SMI) and its value as a predictor of future depression or dementia was studied in a community sample of elderly residents in one electoral ward using the short-CARE. SMI was found to be common, occurring in 25% of subjects. Subjects with SMI were more likely to be suffering from either dementia or depression than those without the complaint, although 60% of subjects with SMI did not have evidence of either disorder. When followed up over a 2-year period, subjects with SMI were found to be at four-fold greater risk of developing future dementia and two-fold greater risk of developing a depression compared with those without SMI. The SMI scale was not found to be useful as a population screen for dementia or depression, although two of the nine items might have value as screening questions in clinical circumstances to determine those with memory complaints at risk for dementia.

Abuse of people with dementia by family carers: representative cross sectional survey.

Objective To determine the prevalence of abusive behaviours by family carers of people with dementia. Design Representative cross sectional survey Setting Community mental health teams in Essex and London. Participants 220 family carers of people newly referred to secondary psychiatric services with dementia who were living at home. Main outcome measure Psychological and physical abuse (revised modified conflict tactics scale). Results 115 (52%, 95% confidence interval 46% to 59%) carers reported some abusive behaviour and 74 (34%, 27% to 40%) reported important levels of abuse. Verbal abuse was most commonly reported. Only three (1.4%) carers reported occasional physical abuse. Conclusions Abusive behaviour by family carers towards people with dementia is common, with a third reporting important levels of abuse and half some abusive behaviour. We found few cases of physical or frequent abuse, although those with the most abusive behaviour may have been reluctant to report it.

Older adults' attitudes to death, palliative treatment and hospice care:

Background: Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by agerelated differences in attitudes to end-of-life care. Objective: To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. Design: Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. Setting: General practices in London. Subjects: 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. Methods: A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. Results: Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged <74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. Conclusions: The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.

Randomized, single-blind, controlled trial of a specialist behavior therapy team for challenging behavior in adults with intellectual disabilities.

OBJECTIVE Community-based specialist behavior therapy teams may be helpful in managing challenging behavior, but evidence of their effectiveness is limited. This study was designed to examine the effectiveness and costs associated with treatment by a specialist behavior therapy team. METHOD This was a parallel-group, randomized, single-blind controlled trial carried out in an intellectual disabilities service in England. Participants were 63 male and female service users with mild to severe intellectual disability who presented with challenging behavior. The interventions were standard treatment plus applied behavioral analysis (N=32) and standard treatment only (N=31). The primary outcome measure was challenging behavior, as measured by total and subscale scores on the Aberrant Behavior Checklist 3 and 6 months after randomization. Secondary outcome measures were psychiatric comorbidity assessed at 3 and 6 months using the Psychiatric Assessment Schedule for Adults With a Developmental Disability Checklist (PAS-ADD) and total costs recorded at 6 months. Multilevel modeling was used to compare square root transformations of Aberrant Behavior Checklist scores. RESULTS Significant differences were found in the transformed total scores on the Aberrant Behavior Checklist (difference=-0.89, 95% CI=-1.74 to -0.04) and transformed lethargy and hyperactivity subscale scores (common intervention effect=-0.56, 95% CI=-0.97 to -0.15). Standard care participants fared worse on the PAS-ADD comorbid organic disorder subscale. There was a clear trend for lower overall costs of the intervention. CONCLUSIONS Use of a specialist behavior therapy team in addition to standard treatment appears to be more effective in improving challenging behavior and may have financial advantages over standard treatment.

The Gospel Oak Study stage III: the incidence of dementia

Of an original sample of 705 elderly (aged over 65) community residents 71% were rescreened after two years and four months using Short CARE. Thirty-one (6.7%) subjects were identified as possible new cases of dementia, implying a mean annual inception rate among the survivors of 26 per 1000. These were subjected to full clinical assessment, which yielded 10 cases of Alzheimers disease (8 per 1000) and 5 multi-infarct dementia (4 per 1000). The remainder of the cases consisted of 6 with a dementia secondary to other causes, 1 case of mixed dementia and there was insufficient information to classify the remaining 3. Six were found not to be suffering from dementia. This yields an overall annual incidence rate for dementia among the survivors of 20 per 1000.