Associations of Resilience, Perceived Control of Health, and Depression with Geriatric Outcomes after Surgery.

OBJECTIVE: To identify if depression, resilience, and perceived control of health are related to 2.5-year mortality and instrumental activities of daily living (IADL) decline among older adults after surgery. SUMMARY BACKGROUND DATA: The relationships of psychosocial factors with postoperative mortality and IADL decline among older adults are understudied. METHODS: We identified 3778 community-dwelling older adults in the Health and Retirement Study (HRS) with Medicare claims for surgery (mean [SD] age: 75.4 [7.8] years, 53.9% women, and 86.0% non-Hispanic White). We assessed associations of depression, resilience, and perceived control of health with 2.5-year postoperative mortality and IADL decline using cox and modified Poisson regression analyses, adjusting for sociodemographic and health variables. RESULTS: The incidence of 2.5-year postoperative mortality was 18.5% and IADL decline was 9.4%. Depression was associated with a higher incidence and adjusted hazard [95% CI] of mortality (26% vs. 16%, aHR:1.2[0.9, 1.5]), but high resilience was associated with a lower incidence and adjusted hazard of mortality (9% vs. 21%, aHR:0.6[0.5, 0.8]). Those with depression had higher incidence and adjusted relative risk [95% CI] of IADL decline (17% vs. 7%, aRR:1.6[1.2, 2.2]), but lower incidence and adjusted relative risk of IADL decline was identified for those with high resilience (4% vs. 11%, aRR:0.6[0.4, 1.0]) and high perceived control of health (7% vs. 10%, aRR:0.6[0.4, 1.0]). CONCLUSION: While depression confers greater risk of mortality and IADL decline, higher resilience and perceived control of health may be protective. Addressing psychosocial factors in the peri-operative period may improve outcomes among older adults.

"There's So Much That They're Enduring": Experiences of Older Adults Undergoing Major Elective Surgery.

OBJECTIVE: This qualitative study aimed to explore the psychosocial experience of older adults undergoing major elective surgery from the perspective of both the patient and family caregiver. SUMMARY BACKGROUND DATA: Older adults face unique psychological and social vulnerabilities that can increase susceptibility to poor health outcomes. How these vulnerabilities influence surgical treatment and recovery is understudied in the geriatric surgical population. METHODS: Adults aged 65 and older undergoing a high-risk major elective surgery at the University of California, San Francisco and their caregivers were recruited. Semi-structured interviews were conducted at three time points: 1-2 weeks before surgery, and at 1- and 3-months following surgery. An inductive qualitative approach was used to identify underlying themes. RESULTS: Twenty-five older adult patients (age range 65-82 years, 60% male) and 11 caregivers (age range 53-78 years, 82% female) participated. Three themes were identified. First, older surgical patients experienced significant challenges to emotional well-being both before and after surgery, which had a negative impact on recovery. Second, older adults relied on a combination of personal and social resources to navigate these challenges. Lastly, both patients and caregivers desired more resources from the healthcare system to address "the emotional piece" of surgical treatment and recovery. CONCLUSIONS: Older adults and their caregivers described multiple overlapping challenges to emotional well-being that spanned the course of the perioperative period. Our findings highlight a critical component of perioperative care with significant implications for the recovery of older surgical patients.

Protocol for a randomized controlled trial of brief behavioral activation among older adult cancer survivors.

INTRODUCTION: As many as 35% of older adult cancer survivors (OACS; i.e., ≥65 years old) have clinically significant depression. OACS often experience fatigue, mild cognitive impairment, and increased medical comorbidities post-cancer that make them susceptible to depression. Behavioral activation (BA) is an empirically supported depression treatment in geriatric psychiatry that guides individuals to reengage in pleasurable and rewarding activities and has great potential for addressing the needs of OACS. This manuscript presents the protocol for a pilot randomized controlled trial (RCT) testing the efficacy of a brief BA intervention adapted to address the needs of OACS (BBA-OACS) by telephone and videoconference delivery. MATERIALS AND METHODS: An RCT will be conducted at Memorial Sloan Kettering Cancer Center (MSK) in New York City. Participants will be randomized to either BA as a target intervention or supportive psychotherapy (SP) as a standard of care control intervention for outpatient oncology. The target intervention includes 10 weekly sessions of BA consisting of psychoeducation about depression and the rationale for BA, life areas and values assessment, compilation of a list of enjoyable and important activities across values, activity scheduling, and self-monitoring of satisfaction and mood. The standard of care control intervention includes 10 weekly sessions of SP consisting of reassurance, guidance, encouragement, and support for patients with cancer. OACS who have a history of cancer, report elevated depressive symptoms, are fluent in English, and can communicate via telephone or videoconference will be recruited from the MSK Survivorship Clinics across all disease types. Seventy participants will be recruited for the study (10 training cases, 30 in each RCT arm). The primary aim is to evaluate implementation outcomes (i.e., acceptability, feasibility, and fidelity) of BA, relative to SP, for cancer survivorship. The secondary aim is to determine the preliminary effects of BA on depressive symptoms (primary outcome), anxiety, coping, and increased activity level (secondary outcomes) compared to SP. Participants will be asked to complete a set of three surveys pre- and post-intervention. DISCUSSION: If successful, BBA-OACS would provide frontline clinicians with an accessible, evidence-based treatment for OACS. Future research will evaluate the efficacy of BA in a larger trial and its impact on depression and other healthcare outcomes. TRIAL REGISTRATION: This study is registered under ClinicalTrials.gov (ID NCT05574127).

Trajectories of Postoperative Depressive Symptoms in Older Patients Undergoing Major Surgery.

This cohort study examines the trajectories of postoperative depressive symptoms in older patients undergoing major surgery and the differences in patient characteristics between the trajectory groups.

Two Interventions for Patients with Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Dyspnea-Related Disability.

OBJECTIVE: The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles. METHODS: In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS: The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline. CONCLUSION: Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.

Two Behavioral Interventions for Patients with Major Depression and Severe COPD.

OBJECTIVE: Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. DESIGN: Randomized controlled trial. SETTING: Acute inpatient rehabilitation and community. PARTICIPANTS: A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. INTERVENTION: Fourteen sessions of PID-C versus PSA over 26 weeks. MEASUREMENTS: 24-item Hamilton Depression Rating Scale. RESULTS: PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. CONCLUSIONS: Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions. .

Concordance Between Clinical Diagnosis and Medicare Claims of Depression Among Older Primary Care Patients.

OBJECTIVE: To identify patient characteristics associated with concordance of Medicare claims with clinically identified depression. METHODS: The authors studied a cohort of 742 older primary care patients linked to Medicare claims data using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder and clinically significant minor depression. RESULTS: Among 474 patients with depression, 198 patients had a Medicare claim for depression (sensitivity: 42%; 95% confidence interval [CI]: 37%-46%). Among 268 patients who did not meet criteria for depression, 235 patients did not have a Medicare claim for depression (specificity: 88%; 95% CI: 83%-91%). After adjustment for demographic and clinical characteristics, non-white participants were nearly twice as likely not to have Medicare claims for depression among patients who met criteria for depression ("false negatives"). Smoking status, depression severity (Hamilton Depression Rating Scale), cardiovascular disease, and more primary care physician office visits were also significantly associated with decreased odds to be false negatives. In contrast, after covariate adjustment, white race and chronic pulmonary disease were associated with increased odds of a Medicare claim for depression among patients who did not meet criteria for depression ("false positives"). Using weights based on the screened sample, the positive predictive value of a Medicare claim for depression was 66% (95% CI [63%, 69%]), whereas the negative predictive value was 77% (95% CI [76%, 78%]). CONCLUSION: Investigators using Medicare data to study depression must recognize that diagnoses of depression from Medicare data may be biased by patient ethnicity and the presence of medical comorbidity.

Race, stigma, and mental health referrals among clients of aging services who screened positive for depression.

OBJECTIVES: This study examined rates of anticipated stigma and its impact on successful mental health referrals among elderly clients of home-delivered nutrition services who met criteria for depression. METHODS: Elderly clients (N=732) admitted to a home meal program between December 2004 and June 2006 were assessed for depression, cognitive impairment, and anticipated stigma. Gender and race comparisons were conducted, and predictors of receiving a mental health referral were identified. RESULTS: African Americans were more likely than Caucasians to report high anticipated stigma, and African-American men reported the highest mean scores for anticipated stigma. There were no significant differences between African Americans and Caucasians in rates of depression or mental health referrals. For clients with depression, low anticipated stigma, younger age, and an interaction of race and gender predicted receipt of a mental health referral. CONCLUSIONS: Anticipated stigma can hinder the process of referring older adults for mental health treatment.

The PHQ-2 on OASIS-C: a new resource for identifying geriatric depression among home health patients.

Since Medicare first implemented the home care Outcome and Assessment Information Set (OASIS) in 1999, we have learned a great deal about depression among the homebound elderly. First, we know that major depression is a highly prevalent illness in home care. With depression rates at almost 15%, home care-along with nursing homes-has among the highest rates of any healthcare setting.

Screening performance of the 15-item geriatric depression scale in a diverse elderly home care population.

OBJECTIVE: To empirically evaluate the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15); determine the optimal cutoff points and screening performance for the detection of major depression; and examine differential item functioning (DIF) to determine the variability of item responses across sociodemographics in an elderly home care population. DESIGN: A secondary analysis of data collected from a random sample study. SETTING: Homebound subjects newly admitted over a 2-year-period to a large visiting nurse service agency in Westchester, New York. PARTICIPANTS: Five hundred twenty-six subjects over age 65, newly admitted to home care for skilled nursing. MEASUREMENTS: Major depression was diagnosed using both patient, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and best estimate procedures. Self-report measures included the GDS-15, activities of daily living (ADL), instrumental ADL, and pain intensity. Cognitive impairment was assessed using the Mini-Mental State Examination and medical morbidity using the Charlson Comorbidity Index. RESULTS: Optimal cutoff (5) yielded sensitivity 71.8% and specificity of 78.2%, however, the accuracy of the GDS-15 was not influenced by severity of medical burden. Persons with a cluster of ailments were twice as likely (Adj odds ratio = 2.47; 95% confidence interval = 1.49-4.09) to be diagnosed with depression. DIF analyses revealed no variability of item responses across sociodemographics. CONCLUSION: Main findings suggest that the accuracy of the GDS-15 was not influenced by severity of clinical or functional factors, or sociodemographics. This has broad implications suggesting that the very old, ill, and diverse populations can be appropriately screened for depression using the GDS-15.