Impact of screening old people with physical illness for depression?
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Aged↗
Biomedical subjects
G Livingston
Publications and source records attributed to G Livingston.
How useful are cholinesterase inhibitors in the treatment of Alzheimer's disease? A number needed to treat analysis.
OBJECTIVES: To report on a Numbers Needed to Treat (NNT) analysis of the literature identified through a systematic review of trials of cholinesterase inhibitors in Alzheimer's Disease. DESIGN: Search of Medline (1966-1998), EMBASE (1994-1999) and Psychlit (1974-1998) using the keywords cholinesterase and placebo dementia. SETTINGS: Double-blind, randomised, placebo-controlled trials. SUBJECTS: People with Alzheimer's Disease. INTERVENTIONS: Drug trials of acetylcholinesterase inhibitors (ChIs). Main outcome measuresAlzheimer's Disease Assessment Scale (Cognitive subscale), Clinician's Interview Based Impression of Change Plus, Mini Mental State Examination, Progressive Deterioration Scale. RESULTS: Small numbers of patients (in most cases between 3 and 7) need to be treated with appropriate dosages of ChIs to ameliorate the clinical symptoms, or postpone deterioration in one of them. CONCLUSIONS: These small NNTs suggest that, despite their expense, the cholinesterase inhibitors have a valuable place in the current clinical management of AD.
Alzheimer Disease↗
A nurse-coordinated educational initiative addressing primary care professionals' attitudes to and problem-solving in depression in older people--a pilot study.
This study assessed the feasibility and efficacy of an intervention focusing on primary care professionals' attitudes to, problem-solving in and practice relating to depression in old age before and after a nurse-implemented educational intervention. One hundred and twenty-one practices were approached, in which 297 doctors worked. Most practices did not want to be involved in this study. Evidence from previous studies and this one suggests that GPs are more amenable to interventions which are implemented by doctors rather than other health personnel. In addition, the lack of interest in this intervention may be a reflection of the therapeutic nihilism of primary care physicians regarding depression in older people. Sixteen surgeries expressed an interest in the study, of whom 14 participated in the study comprising 40 GPs. Thirty-one GPs and 24 nurses completed the baseline questionnaires. Only six GPs and no nurses returned completed questionnaires post-intervention. The only statistically significant before versus after change in the attitude questionnaire was found in 'I need more training to be able to deal effectively with depression in the elderly'. Mean scores were 0.73 and 0.47 respectively (p<0.05; 95%CI 3.2-47.1). Significant improvements post-intervention were, however, found in the answers to three questions (all p<0.05) addressing whether patients with depression complicated by or presenting with physical illness were referred appropriately and/or followed up. The results of our study do not indicate that the evaluation of nurse-led educational interventions in primary care is feasible in the field of depression in old age. The belief that all that is needed is the provision of accessible education of professionals by experts in the field to change attitudes and practice has not been reinforced. The high refusal rate suggests that such interventions are unlikely in any case to be generally acceptable.
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Acute confusional states during treatment with risperidone.
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Acute Disease↗
Who becomes depressed? The Islington community study of older people.
BACKGROUND: Depression in older people is common and debilitating and associated with physical ill health. This is the first study of risk factors for depression in a representative sample of older people selected for high vulnerability because of physical ill health. METHOD: Subjects identified in an epidemiological community survey of morbidity in people > or =65 years old, who had activity limitation (ADL) but no psychiatric morbidity were reinterviewed after 3 years. RESULTS: 79 (90%) of subjects were interviewed. Ten percent developed pervasive depression and 24% screened positive for depression. This latter group were more likely to consult doctors than others with similar levels of disability (P<0.005) mainly because of an acute physical illness. Frequent pain was associated with the development of depression (P<0.02). CONCLUSION: Older people who are ADL limited are known to be at high risk for depression. For the majority who do not become depressed, chronicity of illness does not lead to depression. Those who become depressed are most likely to be those with an acute illness and those who are in pain. They will usually increase their consultation rate with doctors but will not complain of depression. They may be undertreated for both pain and depression. Further studies are needed to confirm other risk factors.
Activities of Daily Living↗
A case of elevated spontaneous micronucleus frequency derived from chromosome 2.
This work tested the hypothesis that the content of spontaneous micronuclei in lymphocytes in an apparently healthy normal human subject, who exhibited an unusually high micronucleus frequency, was non-random. Several DNA probes were used in fluorescent in-situ hybridization (FISH), beginning with a probe generated from the subject's micronuclei. Micronuclei obtained from peripheral blood lymphocytes by microdissection were subjected to random amplification of polymorphic DNA (RAPD-PCR), and a unique PCR product was then used to isolate a cosmid clone from a human genomic library. This clone hybridized to chromosome 2. Subsequently, commercial probes were included in FISH analyses of micronuclei from the subject and age- and sex-matched controls. No significant differences were found between subject and controls in the percentages of micronuclei hybridizing with a centromere probe for the X chromosome or a painting probe for chromosome 3. However, the subject had a very highly significant increase (p<0.0001) in chromosome 2 in micronuclei over a level that might be expected to be present by chance. Characterization of micronuclei may be a promising tool in studies of mechanisms of inherited or induced chromosome instability. The strength of the strategy employed in this study is that, by characterizing the chromosomes present in micronuclei, this work has advanced from an observation of chromosomal instability to a foundation for study of the mechanism underlying the observation.
Adult↗
Drug treatment of older people with affective disorders in the community: lessons from an attempted clinical trial.
BACKGROUND: Depression and phobic anxiety disorders are the most common psychiatric disorders in people aged 65 and over. SSRI antidepressants are effective in treating both conditions in younger people, and in treating depression in hospital samples of older subjects. No studies have investigated the efficacy of SSRIs in older people with these conditions living in the community. OBJECTIVES: To evaluate the efficacy and feasibility of treating older people suffering from depression and/or phobic anxiety in the community with fluoxetine alone. DESIGN: Subjects identified as depressed and/or anxious at screening were offered open-label fluoxetine and were reassessed for affective illness at 3 and 6 months. MEASURES: Outcome was assessed using the depression subscale of the Short Comprehensive Assessment and Referral Evaluation (Short-CARE) Scale and the Anxiety Disorder Scale. RESULTS: Of 67 subjects with depression and/or phobic anxiety, 55 (81%) were eligible to take fluoxetine. Fifty-four (98%) of these agreed to follow-up but only six (11%) agreed to take medication. No subject was still taking medication by the end of the study. Among those subjects on whom follow-up data were available, 70% of subjects depressed at screening and 97% of those with phobic anxiety retained their diagnoses at 3 months; at 6 months, the figures were 65% and 92% respectively. CONCLUSIONS: Drug treatment alone is not acceptable to older patients in the community with depression and phobic anxiety disorders. Discussion of symptoms with an appropriate professional is insufficient therapy on its own. Further work is needed to evaluate the effectiveness of a key worker such as a mental health nurse in coordinating treatment of patients with these disorders.
Aged↗
An informant interview for the diagnosis of dementia and depression in older adults (IDD-GMS).
BACKGROUND: There has been no instrument developed for the differential diagnosis of psychiatric conditions using an informant. The present study describes the development and validation of an informant interview for the diagnosis of dementia and depression in older adults (IDD-GMS). The IDD-GMs, as its name indicates, is based upon the well-established Geriatric Mental State Schedule (GMS). METHOD: Thirty older adults with psychiatric illnesses were identified. An informant/career was interviewed using the IDD-GMS. Questions from the GMS were altered to reflect the informant nature of interview. Validity was compared to ICD-10 diagnoses. Interrater reliability was determined. RESULTS: Using a hierarchical diagnostic system, receiver operating characteristics demonstrated one optimal cutpoint for sensitivity, > 13 for dementia and > 16 for depression, and one for specificity, > 13 for dementia and > 10 for depression. CONCLUSION: The validity and reliability of the IDD-GMS falls within acceptable limits and indicates that the IDD-GMS can be used as a diagnostic instrument for dementia and depression. The IDD-GMS represents the first informant interview to achieve this.
Adult↗
Do health and use of services differ in residents of sheltered accommodation? A pilot study.
OBJECTIVE: To compare the rates of mental health problems, disability and use of health and social services of older people living in sheltered accommodation with those of the rest of the community in the same age group. DESIGN: Door-to-door survey in randomly selected enumeration districts. The districts contained three sheltered accommodation complexes. Residents from these addresses were compared with the others. SETTING: London Borough of Islington. SUBJECTS: 700 men and women aged 65 or over. MAIN OUTCOME MEASURES: Short-CARE depression, dementia and activity scales; the Guy's/Age Concern anxiety scale; individual items detailing problems with mobility, vision and hearing; use of a number of health and social services. RESULTS: The only difference in mental health variables on univariate analysis was a greater severity of cognitive impairment and dementia symptoms in sheltered accommodation. When demographic differences were taken into account, the association with cognitive impairment became statistically insignificant. There were significant associations between residence in sheltered accommodation and several of the disability variables. Increased use of health and social services by sheltered residents remained significant after disability and living alone were taken into account. CONCLUSIONS: The residents of sheltered accommodation were more disabled than the general elderly population but, in contrast to those in residential care, did not have a great excess of mental health problems. Indeed, the possibility was raised that sheltered accommodation may protect against depression in people who live alone.
Aged↗
Closure of an asylum: the Friern study of older people.
This article reports a naturalistic study following the closure of Friern Hospital and the movement of elderly long-stay patients, who in the main suffered from severe dementia, to psychiatric nursing homes and hospital beds. It describes changes in the environments and in the patients' cognition, behaviour and use of medical services. The results suggest that psychiatric nursing homes seem able to care for the majority if patients with severe dementia. Future studies should consider whether long-stay hospital beds may, however, be necessary for those with both psychiatric and physical health needs, where increased contact with health service personnel is essential. Prospective examination of the reasons for breakdown of placements in nursing homes and the differences between those placed in various settings may help future planning of services. Relatives' opinions of the long-stay settings also require study.
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An intervention study with husband and wife carers of older people with a psychiatric illness.
BACKGROUND: Individual packages of care were devised for spouses of older people with psychiatric illness. METHOD: Randomised controlled trial with blind follow up. Intervention group members were offered multidisciplinary packages while controls received no extra help. Both groups were reassessed 12-14 weeks later. The initial control group then received intervention; both were reassessed at 24-28 weeks. RESULTS: Although no significant differences emerged in group mean scores for affective illness or social difficulties, carers who were mentally ill at outset improved significantly. CONCLUSION: Interventions targeted at caregiving spouses with affective disorder are acceptable and efficacious. LIMITATION: It was impossible to compare treatment with no treatment.
Aged↗
The natural history of depression and the anxiety disorders in older people: the Islington community study.
BACKGROUND: This study reports the outcome of depression and anxiety disorders in older people. METHODS: Follow-up of 165 subjects age 65 or over, initially identified in a community study in inner London as depressed or having an anxiety disorder. RESULTS: 117 subjects still living in the area; 25 had died. Death was predicted only by activity limitation at first interview and not by other demographic or morbidity variables. Eighty-six subjects reinterviewed; 21 males, 65 females. Of the depressed, 34% had recovered, 39% were depressed and 27% were dead. Predictors from initial interview of continuing depression were female gender and more severe depression. Of those with phobic anxiety, 16% had recovered, 18% died and 66% were still phobic. Predictors of continuing phobic anxiety from initial interview were female gender and "stand-alone" phobic anxiety, i.e., not being depressed at initial interview. Sixty percent of those with early onset phobias had specific phobias; 82% of those with late-onset phobias had agoraphobia. Twenty-two subjects were prescribed psychotropics. The only significant predictor of psychotropic prescription was having sleep disturbance at initial interview. A low score on life satisfaction was significantly correlated with depression but not with phobic disorder. A high score was correlated with not having a current psychiatric disorder. LIMITATIONS: Some subjects were lost to follow-up. Those on psychotropics were particularly likely to refuse an interview. CONCLUSION AND CLINICAL RELEVANCE: In older people, neither depression nor the anxiety disorders generally remit spontaneously. Those with a particularly poor prognosis are women and those with a more severe depression. Agoraphobia may be precipitated in older people by stressful events and interferes with life satisfaction. There is potential for increased pharmacological treatment of older people with affective disorders.
Age Factors↗
The symptomatology of depression in the elderly.
Older people may have a different pattern of depressive symptoms to that found earlier in life, in particular having more somatic symptoms and less overt low mood symptoms. Few attempts have been made to relate such differences to more general aspects of cognitive or emotional processing, such as the presence of dysfunctional attitudes or of alexithymia. Symptom differences within depression in old age have also received relatively little study, as has the ability of individual symptoms to distinguish between depressed and non-depressed elderly populations. These issues have been examined in two studies. In the first, a random sample of 700 subjects aged 65 years and over were identified through door-knocking in randomized enumeration districts in Islington, a socially deprived region of inner city London, and evaluated using a shortened version of the Comprehensive Assessment and Referral Evaluation (Short-CARE), which incorporates a depression subscale (DPDS). All 18 DPDS items distinguished significantly between depressed and non-depressed subjects (P < 0.0001). Depressed men were significantly more pessimistic than depressed women (63 versus 40%; P < 0.05); non-significant trends suggested that depressed women are more worried (39 versus 22%) and more restless (50 versus 31%), and depressed men more likely to be 'not very happy' or 'not happy at all' (53 versus 36%). There were no significant differences between older (age > 74 years) and younger subjects. Several other Short-CARE items, predominantly addressing subjective memory and disability, also distinguished significantly between the depressed and non-depressed groups. Logistic regression analysis identified eight items of the DPDS contributing significantly to the predictive ability of the total scale. In the second study, the Toronto Alexithymia Scale (TAS) and the Dysfunctional Attitudes Scale (DAS; 3) were administered to primary-care attenders aged > 64 years, and those with significant depressive symptoms were matched by age and sex to a depression-free control group. Depressed subjects had higher scores on both the TAS (Mann-Whitney U-test z = -4.71, P < 0.0001) and on the DAS (z = -2.49, P < 0.02).
Affective Symptoms↗
Cost of community care for older people.
BACKGROUND: There has been no published study that considers actual costs in a representative sample of people aged > or = 65 years. The present study describes the financial costs of formal community services for elderly people with dementia, depression, anxiety disorder or physical disability. METHOD: Psychiatric morbidity, physical disability and services received were assessed by standardised questionnaire in randomly selected Islington enumeration districts. Subjects were interviewed at home (n = 700). RESULTS: Dementia was the most expensive disorder per sufferer in terms of formal services. Those with depression were also high users of health services. Despite presenting to health services, 90% were not treated with appropriate drugs. In contrast, social services were received by people who were activity-limited or with dementia. The highest service cost for the population as a whole was for the physically disabled. In multivariate analysis the significant predictors of high service costs were living alone, being physically ill, depression, dementia and increasing age. CONCLUSIONS: Failure to detect and treat depression and the anxiety disorders in older people, despite their presentation to medical services, may have major economic consequences as well as contributing to individual suffering.
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Screening for alcohol misuse in older people.
OBJECTIVES: To evaluate whether the CAGE, MAST-G or an abnormally high MCV are effective screening instruments for alcohol misuse and if not to devise a new instrument. DESIGN: Questionnaire survey of randomly selected patients. SETTING: Acute admission wards of two district general hospitals. PERIOD: 9 months. SUBJECTS: Randomly selected patients, aged 65 and over, admitted as emergencies. MAIN OUTCOME MEASURES: Excessive alcohol intake, alcohol dependence. RESULTS: The sensitivities of the CAGE, MAST-G and an abnormally high MCV for excess alcohol intake and alcohol abuse are low, ranging from 0.13 to 0.54. CONCLUSION: The results confirm previous UK studies which indicate that the CAGE and an abnormally high MCV are poor screening instruments for alcohol misuse in older patients and also indicate that the MAST-G is an insensitive screening instrument. A new two-step instrument with five questions in total was generated. This requires further validation.
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Depression in carers of elderly people living at home.
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Caregivers↗
Depression and other psychiatric morbidity in carers of elderly people living at home.
OBJECTIVE: To describe the mental health of a community sample of carers of elderly people with dementia, depression, or physical disability and to compare that with the mental health of other adults living in the household and of those living alone. DESIGN: Assessment of psychiatric morbidity and physical disability with standardised questionnaire in randomly selected enumeration districts; subjects were interviewed at home. SETTING: London Borough of Islington. SUBJECTS: 700 people aged > or = 65 and other coresidents. MAIN OUTCOME MEASURE: Depression measured with standardised interview. RESULTS: The prevalence of depression was not significantly higher in carers overall (15%) than in coresidents (11%). Being a woman carer was a significant predictor of psychiatric illness. Depression was more common in the carers of people with a psychiatric disorder than in coresidents (24% v 11%, P < 0.05) and in those living alone (19%). Depression was most common (47%) in women carers of people with dementia. CONCLUSION: The increase in psychiatric morbidity reported in carers of people with psychiatric disorders may reflect the lack of a confiding relationship.
Adult↗
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.
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