Detecting depression in persons living in long-term care: a systematic review and meta-analysis of diagnostic test accuracy studies.

OBJECTIVE: Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings. METHODS: We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias. RESULTS: We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%-76.5%), specificity was 76.5% (95% CI 62.9%-86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%-90.0%) for persons in LTC living with dementia. CONCLUSIONS: There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses.

Barriers and facilitators to diagnosing and managing apathy in Parkinson's disease: a qualitative study.

BACKGROUND: Apathy is a prominent non-motor symptom in Parkinson's disease (PD). People with apathy show a lack of emotion, passion, and motivation. Between 17 and 70% of persons with PD have apathy; the extreme heterogeneity in these estimates is due to limited heterogeneous knowledge concerning how to diagnose PD. The lack of a widely utilized diagnostic process limits understandings on how to treat and manage apathy in PD. A scoping review of apathy in PD identified only one qualitative study investigating this symptom. It was our objective to assess perceived barriers and facilitators to diagnosing, treating, and managing apathy in PD, as described by key stakeholders. METHODS: This research applied qualitative methodology, utilizing focus groups and interviews with health care practitioners (HCPs), persons with PD, and caregivers. Evidence gathered from a scoping review on apathy in PD informed discussions that took place with participants. Data collection and analysis was conducted using framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel. RESULTS: Eleven HCPs and five persons with PD/caregivers participated. Themes included interdisciplinary teams and communication with family to facilitate diagnosis and treatment, and the use of education and increased awareness of apathy to facilitate management. Themes surrounding barriers included lack of initiative and motivation to maintain treatment plans, and a lack of evidence for apathy specific interventions. While a key barrier identified was the lack of information HCPs have access to, persons with PD and caregivers would prefer to receive a diagnosis of apathy even with limited management methods. Thus, education and awareness were noted as two of the most important facilitators, overall. CONCLUSION: These findings suggest that diagnosing, treating, and managing apathy in PD requires interdisciplinary teams, that include family and caregivers. We identified that where HCPs perceive lack of knowledge as a barrier to diagnosis, persons with PD and caregivers find being given a diagnosis facilitates understanding. These findings highlight the importance of qualitative research involving persons with PD and apathy, caregivers, and HCPs who aid in management of this symptom. Barriers reported suggest future research must aim to identify apathy specific treatments, both pharmacologic and non-pharmacologic.

Guidelines for dementia or Parkinson's disease with depression or anxiety: a systematic review.

BACKGROUND: Depression and anxiety remain under-diagnosed and under-treated in those with neurologic diseases such as dementia or Parkinson's Disease (PD). Our objectives were to first, to provide a synthesis of high quality guidelines available for the identification and management of depression or anxiety in those with dementia or PD. Second, to identify areas for improvement for future guidelines. METHODS: We searched MEDLINE, PsycINFO, and EMBASE (2009 to July 24, 2015), grey literature (83 sources; July 24-Sept 6, 2015), and bibliographies of included studies. Included studies were evaluated for quality by four independent reviewers the AGREE II tool. Guideline characteristics, statements and recommendations relevant to depression or anxiety for dementia and PD were then extracted. (PROSPERO CRD: 42016014584) RESULTS: 8121 citations were reviewed with 31 full text articles included for assessment with the AGREE II tool. 17 were of sufficient quality for inclusion. Mean overall quality scores were between 4.25 to 6.5. Domain scores were lowest in the areas of stakeholder involvement, applicability, and editorial independence. Recommendations for the screening and diagnosis of depression were found for PD and dementia. There was little evidence to guide diagnosis or management of anxiety. Non-pharmacologic therapies were recommended for dementia patients. Most advocated pharmacologic treatment for depression, for both PD and dementia, but did not specify an agent due to lack of evidence. CONCLUSIONS: The available recent high quality guidelines outline several recommendations for the management of comorbid depression or anxiety in PD or dementia. However there remain significant gaps in the evidence.

Non-pharmacologic interventions to treat apathy in Parkinson's disease: A realist review.

INTRODUCTION: There is a diverse body of evidence investigating non-pharmacological treatment options for apathy in Parkinson's disease (PD). We aimed to better understand the context and mechanisms by which non-pharmacological interventions may improve apathy in persons with PD. METHODS: We conducted a realist review of the body of evidence investigating treatment options for apathy in PD. Study authors used findings from a preceding scoping review to identify initial program theory. We then update the scoping review, which was originally conducted in 2017. Two authors independently reviewed and extracted data from studies that discussed non-pharmacological treatment options for apathy in PD. Any data concerning context, mechanisms, and outcomes of interventions for apathy in PD were extracted, synthesized, and analyzed. RESULTS: Our review included nine studies. We categorized studies into two categories, exercise and mindfulness. There were seven exercise interventions included. Exercise interventions evaluated group exercise compared to individual exercise, aerobic exercise, dance, Nordic walking, and an equine program. There were two mindfulness interventions. CONCLUSION: Exercise interventions work best for persons with PD and apathy who are not significantly physically or cognitively impaired, and who have access to transportation, adapted programs, and specialized coaches. Exercise may improve apathy through goal-directed behaviour change and engagement in social interactions. Mindfulness interventions work best for persons with PD and apathy who are not significantly cognitively impaired, have caregiver support, and may improve apathy by targeting the emotional, cognitive, and goal-directed domains that define apathy.

Healthcare workers' perception of gender and work roles during the COVID-19 pandemic: a mixed-methods study.

OBJECTIVES: A high functioning healthcare workforce is a key priority during the COVID-19 pandemic. We sought to determine how work and mental health for healthcare workers changed during the COVID-19 pandemic in a universal healthcare system, stratified by gender factors. DESIGN: A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey (7 May-15 July 2020). Phase 2 was semistructured interviews offered to all respondents upon survey completion to describe how experiences may have differed by gender identity, roles and relations. SETTING: National universal healthcare system (Canada). PARTICIPANTS: 2058 Canadian healthcare worker survey respondents (87% women, 11% men, 1% transgender or Two-Spirit), including 783 health professionals, 673 allied health professionals, 557 health support staff. Of the 63 unique healthcare worker types reported, registered nurses (11.5%), physicians (9.9%) and pharmacists (4.5%) were most common. Forty-six healthcare workers were interviewed. MAIN OUTCOME MEASURES: Reported pandemic-induced changes to occupational leadership roles and responsibilities, household and caregiving responsibilities, and anxiety levels by gender identity. RESULTS: Men (19.8%) were more likely to hold pandemic leadership roles compared with women (13.4%). Women (57.5%) were more likely to report increased domestic responsibilities than men (45%). Women and those with dependents under the age of 10 years reported the greatest levels of anxiety during the pandemic. Interviews with healthcare workers further revealed a perceived imbalance in leadership opportunities based on gender identity, a lack of workplace supports disproportionately affecting women and an increase in domestic responsibilities influenced by gender roles. CONCLUSIONS: The COVID-19 pandemic response has important gendered effects on the healthcare workforce. Healthcare workers are central to effective pandemic control, highlighting an urgent need for a gender-transformative pandemic response strategy.

Diagnosis, treatment and management of apathy in Parkinson's disease: a scoping review.

OBJECTIVE: To conduct a scoping review of the literature on apathy in Parkinson's disease (PD), to better understand how apathy in Parkinson's disease is diagnosed, treated and managed. METHODS: MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Central Register of Control Trials and Cochrane Database of Systematic Reviews were searched to 17 May 2017. An updated review was run from 17 May 2017 to 28 January 2019. The grey literature was searched using the CADTH Grey Matters tool. Original peer-reviewed research was included if it included individuals with PD and apathy. Non-original data was only included if it was in the form of meta-analysis. All information regarding diagnosis, treatment and management of PD was extracted. Citation screening and extraction were performed in duplicate. RESULTS: From 11 375 citations, 362 articles were included in the final review. The majority of included studies focussed on prevalence, with few studies examining treatment. Twenty screening tools for apathy were identified. Fifty per cent of treatment studies were randomised control trials (RCTs). RCTs applied treatment methods including: exercise, mindfulness, rotigotine (Neupro) transdermal patch and rivastigmine (Exelon). CONCLUSIONS: This review identified a large body of literature describing current knowledge on diagnosing, treating and managing apathy in PD. Future research should aim to detect an ideal screening tool for apathy in PD, to identify the best treatment options for apathy and the variety of comorbidities it may present with and finally aim to better understand postoperative apathy in those with deep brain stimulation.

Developing and Validating a Primary Care EMR-based Frailty Definition using Machine Learning.

INTRODUCTION: Individuals who have been identified as frail have an increased state of vulnerability, often leading to adverse health events, increased health spending, and potentially detrimental outcomes. OBJECTIVE: The objective of this work is to develop and validate a case definition for frailty that can be used in a primary care electronic medical record database. METHODS: This is a cross-sectional validation study using data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in Southern Alberta. 52 CPCSSN sentinels assessed a random sample of their own patients using the Rockwood Clinical Frailty scale, resulting in a total of 875 patients to be used as reference standard. Patients must be over the age of 65 and have had a clinic visit within the last 24 months. The case definition for frailty was developed using machine learning methods using CPCSSN records for the 875 patients. RESULTS: Of the 875 patients, 155 (17.7%) were frail and 720 (84.2%) were not frail. Validation metrics of the case definition were: sensitivity and specificity of 0.28, 95% CI (0.21 to 0.36) and 0.94, 95% CI (0.93 to 0.96), respectively; PPV and NPV of 0.53, 95% CI (0.42 to 0.64) and 0.86, 95% CI (0.83 to 0.88), respectively. CONCLUSIONS: The low sensitivity and specificity results could be because frailty as a construct remains under-developed and relatively poorly understood due to its complex nature. These results contribute to the literature by demonstrating that case definitions for frailty require expert consensus and potentially more sophisticated algorithms to be successful.

Detecting Apathy in Individuals with Parkinson's Disease: A Systematic Review.

BACKGROUND: Individuals experiencing apathy in Parkinson's disease (PD) have a lack of emotion and motivation. Apathy often overlaps with comorbidities such as depression, and is sometimes difficult to detect. OBJECTIVE: To examine diagnostic accuracy of apathy-screening tools compared with a gold standard (clinician diagnosis) among adult outpatients with PD. METHODS: A systematic review was conducted. Six research databases were searched to May 23, 2018. Diagnostic accuracy measures, including sensitivity and specificity were gathered. RESULTS: 1,007 full-text articles were reviewed with seven full-text articles included. The gold standard was considered a clinician diagnosis as apathy is not defined in the DSM/ICD. Diagnostic accuracy measures were reported for the Lille Apathy Rating Scale (LARS) both informant- and observer-rated, Unified Parkinson's Disease Rating Scale (UPDRS), Apathy Scale (AS), Apathy Evaluation Scale (AES), Non-Motor Symptoms Questionnaire (NMS-Q), and Dimensional Apathy Scale (DAS). The AES had the best reported sensitivity and specificity values, both 90%. The AS had the highest reported specificity at 100%, with 66% sensitivity. Pooled prevalence of apathy was 29.1% (95% CI 21.5%-36.6%). CONCLUSIONS: While 18 screening tools exist to screen for apathy in PD, only six have been validated against clinician diagnosis. The AES had the highest reported sensitivity and specificity and is a brief, easy to use tool. The AS was designed specifically for use in PD populations and has the highest reported specificity. Future research should focus on the development of an accepted gold standard, to further understand accuracy measures of all available apathy screening tools.

Impact of pharmacological treatment of diabetes mellitus on dementia risk: systematic review and meta-analysis.

BACKGROUND: The association between diabetes mellitus (DM) treatment and dementia is not well understood. OBJECTIVE: To investigate the association between treatment of diabetes, hypoglycemia, and dementia risk. RESEARCH DESIGN AND METHODS: We performed a systematic review and meta-analysis of pharmacological treatment of diabetes and incident or progressive cognitive impairment. We searched Ovid MEDLINE, Embase, Cochrane Central Registry of Controlled Trials, and PsychINFO from inception to 18 October 2017. We included cross-sectional, case-control, cohort, and randomized controlled studies. The study was registered with PROSPERO (ID CRD42017077953). RESULTS: We included 37 studies into our systematic review and 13 into our meta-analysis. Ten studies investigated any antidiabetic treatment compared with no treatment or as add-on therapy to prior care. Treatment with an antidiabetic agent, in general, was not associated with incident dementia (risk ratio (RR) 1.01; 95% CI 0.93 to 1.10). However, we found differential effects across drug classes, with a signal of harm associated with insulin therapy (RR 1.21; 95% CI 1.06 to 1.39), but potentially protective effects with thiazolidinedione exposure (RR 0.71; 95% CI 0.55 to 0.93). Severe hypoglycemic episodes were associated with a nearly twofold increased likelihood of incident dementia (RR 1.77; 95% CI 1.35 to 2.33). Most studies did not account for DM duration or severity. CONCLUSIONS AND LIMITATIONS: The association between treatment for diabetes and dementia is differential according to drug class, which is potentially mediated by hypoglycemic risk. Not accounting for DM duration and/or severity is a major limitation in the available evidence base.

Detecting anxiety in individuals with Parkinson disease: A systematic review.

OBJECTIVE: To examine diagnostic accuracy of anxiety detection tools compared with a gold standard in outpatient settings among adults with Parkinson disease (PD). METHODS: A systematic review was conducted. MEDLINE, EMABASE, PsycINFO, and Cochrane Database of Systematic Reviews were searched to April 7, 2017. Prevalence of anxiety and diagnostic accuracy measures including sensitivity, specificity, and likelihood ratios were gathered. Pooled prevalence of anxiety was calculated using Mantel-Haenszel-weighted DerSimonian and Laird models. RESULTS: A total of 6,300 citations were reviewed with 6 full-text articles included for synthesis. Tools included within this study were the Beck Anxiety Inventory, Geriatric Anxiety Inventory (GAI), Hamilton Anxiety Rating Scale, Hospital Anxiety and Depression Scale-Anxiety, Parkinson's Anxiety Scale (PAS), and Mini-Social Phobia Inventory. Anxiety diagnoses made included generalized anxiety disorder, social phobia, and any anxiety type. Pooled prevalence of anxiety was 30.1% (95% confidence interval 26.1%-34.0%). The GAI had the best-reported sensitivity of 0.86 and specificity of 0.88. The observer-rated PAS had a sensitivity of 0.71 and the highest specificity of 0.91. CONCLUSIONS: While there are 6 tools validated for anxiety screening in PD populations, most tools are only validated in single studies. The GAI is brief and easy to use, with a good balance of sensitivity and specificity. The PAS was specifically developed for PD, is brief, and has self-/observer-rated scales, but with lower sensitivity. Health care practitioners involved in PD care need to be aware of available validated tools and choose one that fits their practice.

Depression Case Finding in Individuals with Dementia: A Systematic Review and Meta-Analysis.

OBJECTIVES: To compare the diagnostic accuracy of depression case finding tools with a criterion standard in the outpatient setting among adults with dementia. DESIGN: Systematic review and meta-analysis. SETTING: Studies of older outpatients with dementia. PARTICIPANTS: Elderly outpatients (clinic and long-term care) with dementia (N = 3,035). MEASUREMENTS: Prevalence of major depression and diagnostic accuracy measures including sensitivity, specificity, and likelihood ratios. RESULTS: From the 11,539 citations, 20 studies were included for qualitative synthesis and 15 for a meta-analysis. Tools included were the Montgomery Åsberg Depression Rating Scale, Cornell Scale for Depression in Dementia (CSDD), Geriatric Depression Scale (GDS), Center for Epidemiologic Studies Depression Scale (CES-D), Hamilton Depression Rating Scale (HDRS), Single Question, Nijmegen Observer-Rated Depression Scale, and Even Briefer Assessment Scale-Depression. The pooled prevalence of depression in individuals with dementia was 30.3% (95% CI = 22.1-38.5). The average age was 75.2 (95% CI = 71.7-78.7), and mean Mini-Mental State Examination scores ranged from 11.2 to 24. The diagnostic accuracy of the individual tools was pooled for the best-reported cutoffs and for each cutoff, if available. The CSDD had a sensitivity of 0.84 (95% CI = 0.73-0.91) and a specificity of 0.80 (95% CI = 0.65-0.90), the 30-item GDS (GDS-30) had a sensitivity of 0.62 (95% CI = 0.45-0.76) and a specificity 0.81 (95% CI = 0.75-0.85), and the HDRS had a sensitivity of 0.86 (95% CI = 0.63-0.96) and a specificity of 0.84 (95% CI = 0.76-0.90). Summary statistics for all tools across best-reported cutoffs had significant heterogeneity. CONCLUSION: There are many validated tools for the detection of depression in individuals with dementia. Tools that incorporate a physician interview with patient and collateral histories, the CSDD and HDRS, have higher sensitivities, which would ensure fewer false-negatives.