Neuroticism predicts depression and disability in age-related macular degeneration.

OBJECTIVES: Age-related macular degeneration (AMD) is a common, disabling disorder of older age that is associated with depression. We investigated the incidence rate of depression and its risk factors and consequences in this 6-month longitudinal study. DESIGN: A prospective cohort study in which subjects were interviewed 6 weeks after the onset of bilateral vision loss and 6 months later. SETTING: The sample was recruited from the retinovascular clinic of a specialty eye hospital. PARTICIPANTS: Subjects were 51 patients with new onset bilateral AMD. MEASUREMENTS: We assessed depressive symptoms, personality traits, visual acuity, and vision and physical functioning. Additionally, we interviewed informants to obtain independent assessments of subjects' personality traits. RESULTS: The baseline prevalence rate of syndromal depression was 23.5% and high levels of depressive symptoms persisted over time. The 6-month incidence rate of depression was 27.8%. The strongest risk factors for incident depression were self-rated and informant-rated neuroticism. Patients who developed syndromal depression were 8.3 times (95% confidence interval = 1.1-63.4) more likely than nondepressed patients to become disabled in vision function, independent of change in visual acuity. CONCLUSION: AMD is associated with high rates of depression and visual disability independent of severity of vision loss. The personality trait of neuroticism is highly predictive of incident depression and identifies patients at high risk for excess disability. Psychotherapeutic treatments targeted to this group may prevent depression and reduce disability.

A comparison of self-reported function assessed before and after depression treatment among depressed geriatric inpatients.

The purpose of this study was to determine whether self-perception of function among depressed, geriatric psychiatry inpatients improved as their depression resolved. Sixty-four older adults diagnosed with major depression were asked to evaluate their function upon admission to an inpatient psychiatry unit, and then again 3 months post-discharge. Subjects' caregivers also rated the patients' function at admission and 3 months after being discharged. Self-perceptions of function improved over time, while caregivers' perceptions remained stable, suggesting that patients' perceptions of function is in part influenced by their depression. Further, correlations between patient and caregiver perceptions of function were higher at 3 months post discharge (when patients were not depressed) than they were at admission. The implication is that self-perceptions of function are more accurate when not depressed.

Development of a shorter version of the geriatric depression scale for visually impaired older patients.

OBJECTIVE: To validate a shorter version of the Geriatric Depression Scale (GDS) for older, visually impaired patients. PARTICIPANTS: Subjects were 70 visually impaired adults over age 65 who were presenting for services at a low vision clinic. METHOD: Subjects were interviewed by a geriatric nurse practitioner. A structured clinical interview was used to ascertain major depression, and the 15-item GDS was used to assess depressive symptoms. A multiple logistic regression was performed in which the dependent variable was clinical diagnosis of major depression and the independent variables were the 15 GDS items. Four items were significant, and were used to form the GDS-Abbreviated (GDS-A) scale. Sensitivity and specificity analyses were performed on various combinations of these four items to generate an effective cutoff score. RESULTS: Endorsing any two or more of the following four items--a) dissatisfied with life, (b) feeling helpless, (c) reporting problems with memory, and (d) lost activities and interests-yielded the best results with a sensitivity of .71 and a specificity of .88. This GDS-A cutoff score better differentiates depressed from nondepressed individuals than the cutoff score of 5 that is recommended for the GDS-15. CONCLUSION: The GDS-A's short format and strong discriminating ability make it an effective, convenient tool for screening visually impaired, older patients for depression.

Cisapride in the treatment of visual hallucinations caused by vision loss: the Charles Bonnet syndrome.

The authors describe the use of cisapride (Propulsid), a potent 5-HT(3) antagonist, in the treatment of visual hallucinations in two patients with vision loss (the Charles Bonnet syndrome).

Predictors of recovery from major depression among geriatric psychiatry inpatients: the importance of caregivers' beliefs.

Caregiver support is an important factor in recovery from depression among older patients. We examined whether caregivers' perceptions regarding patients' ability to control depressive symptoms were related to depression recovery. Depression treatment, demographics, number of depressive symptoms, and health were controlled. The sample comprised 51 geriatric psychiatry inpatients who met DSM-IV criteria for major depression and who had a primary caregiver. Depression was assessed at both admission and discharge. Caregivers were asked to indicate whether they believed their patient-relatives could control their depressive symptoms. At discharge, 33 patients (64.7%) were "remitted" and 18 (35.3%) were "nonremitted." Multivariate analyses indicated that receiving electroconvulsive treatment, having fewer depressive symptoms caregivers perceived to be within patient control, and being female predicted depression remission at discharge. This study highlights the important relationship between family dynamics and course of depression.

Psychiatric consultation in the nursing home. A survey of six states.

The authors examined availability, characteristics, and perceived adequacy of psychiatric consultation in nursing homes, as reported by directors of nursing, who returned 899 questionnaires. Thirty-eight percent of nursing home residents were judged to need a psychiatric evaluation; current frequency of consultation was rated as adequate by half of nursing directors. Nearly two-thirds reported that psychiatrists adequately provided diagnostic and medication recommendations; however, advice on nonpharmacologic management techniques, staff support, and dealing with staff stress and family conflicts was largely viewed as inadequate. Findings suggest that perceived need for psychiatric services is far greater than the level actually provided. Overall, more attention must be directed to identifying incentives for psychiatrists to practice in nursing homes, determining clinical effectiveness of mental health services, and examining effects of alternative payment mechanisms on level of care.

Depression and disability associated with impaired vision: the MoVies Project.

OBJECTIVE: To assess how depression and impaired vision relate to disability in older people. DESIGN: An epidemiological survey of an age-stratified random community sample. SETTING: The rural mid-Monongahela Valley in South-western Pennsylvania. PARTICIPANTS: A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education. MEASUREMENTS: Demographics, self-reported vision impairment, OARS Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies-Depression scale to assess depression. RESULTS: Compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2). The number of depressive symptoms (1-4: OR = 2.4, CI = 1.8, 3.4) and (5+: OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender. CONCLUSIONS: Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment. Treating depression may reduce excess disability associated with impaired vision.

Screening for depression in low-vision elderly.

OBJECTIVE: To determine the sensitivity and specificity of the Geriatric Depression Scale (GDS) in older low-vision patients, and to compare GDS scores with the diagnosis of major depression in statistical models examining the interrelationships of vision, depression and disability. DESIGN: Cross-sectional survey. PARTICIPANTS: Community-residing older persons attending the low-vision clinic of Wills Eye Hospital, Philadelphia, PA, USA. MEASUREMENTS: Geriatric Depression Scale, DSM-III-R Checklist for Depression, Community Disability Scale and Snellen Visual Acuity. RESULTS: The sensitivity and specificity of the GDS (GDS = 11) were 63% and 77%, respectively. A receiver operating characteristic curve showed that the GDS's ability to discriminate patients with and without major depression was no better than chance. Although the GDS was limited as a screen for major depression, it was useful in statistical models examining the interrelationships of vision, depression and disability. CONCLUSION: Depressive symptoms are common among elderly patients with impaired vision attending a low-vision clinic. Although the GDS is unable to discriminate patients with and without major depression in this population, it is valuable as a continuous measure of depressive symptomatology to examine the interrelationships of vision, depression and disability.

Screening for depression in older persons with low vision. Somatic eye symptoms and the Geriatric Depression Scale.

The authors compared the sensitivity and specificity of a somatic eye symptoms question with the Geriatric Depression Scale (GDS) to detect depression in older patients with low vision. The sample was 70 patients (65+ years) attending a low-vision clinic. A geriatric nurse-practitioner examined all patients, diagnosed major depression by DSM-III-R criteria, and completed the GDS and an eye symptoms (ES) questionnaire. Twenty-seven patients (38.6%) met criteria for major depression. Although the sensitivity of the ES and GDS were identical (63%), the GDS was more specific (77% vs. 54%) and had higher positive predictive value (63% vs. 46%). Both measures identified patients who were more functionally disabled than patients without ES or depression, but with similar vision. Depression frequently accompanies visual impairment in this population. Inquiring about ES appears to be less specific than the GDS, although neither method is highly sensitive. However these screening tools identify distressed persons whose disability is high relative to the severity of their vision loss.

Physician rationale for benzodiazepine prescriptions to elderly hospitalized patients.

The authors (within 24 hours of the order) administered a telephone questionnaire to physicians prescribing benzodiazepines to patients over age 65 admitted to a tertiary care university hospital (N = 81 consecutive medical and surgical admissions). Data were obtained from 50 physicians. Prescriptions were most commonly written for preoperative relaxation (26%), pain (14%), nausea (12%), to aid intubation (12%), or facilitate a medical test (10%). Dosages were chosen on the basis of subjective experience (32%), lowest effective dose (28%), considerations of age/sex/weight (16%), and drug manual recommendations (8%). Ten percent of patients were prescribed a benzodiazepine before hospitalization, and their dosages were tapered (6%) or maintained (4%). There is considerable variation in physicians rationale for benzodiazepine prescriptions to hospitalized elderly patients. Benzodiazepines are used to treat symptoms rather than disorders. Age is infrequently considered in dosing judgments despite the pharmacodynamic and pharmacokinetic changes known to be associated with aging.

Sedative-hypnotic use by the elderly: effects on hospital length of stay and costs.

Sedative-hypnotic medications are often used to treat anxiety and sleep disorders, although they may not be used appropriately. Relationships between hospital length of stay (LOS), costs, and levels of sedative-hypnotic use were examined. Charts of 856 elderly patients were reviewed for sedative hypnotic use and categorized into three groups: those whose use exceeded Health Care Financing Administration (HCFA) guidelines, those who used sedative-hypnotic medications but did not exceed HCFA guidelines, and those who did not receive any sedative-hypnotic medications. Patients whose sedative-hypnotic use exceeded guidelines had longer LOS (21.5 exceeding guidelines vs. 12.3 within guidelines vs. 6.7 no use, p < or = .001) and higher costs ($29,245 exceeding guidelines vs. $15,219 within guidelines vs. $7,516 no use, p < = or .001.) Even after controlling for severity of illness and comorbid conditions, differences in LOS and costs persisted. This study indicates that sedative-hypnotic medications are frequently prescribed to elderly patients, often in doses exceeding proposed guidelines, and are associated with longer hospital stays and higher hospital costs.

Sedative-hypnotic use and increased hospital stay and costs in older people.

OBJECTIVE: To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital. DESIGN: Retrospective review of computerized hospital and pharmacy data bases. SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994. MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs. RESULTS: Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001). CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

Depression and disability in older people with impaired vision: a follow-up study.

OBJECTIVE: To determine the prevalence of depressive symptoms and their relationship to disability in older low vision patients. DESIGN: Panel study with 2-year follow-up. PARTICIPANTS: Community-residing older people (N = 31). MEASUREMENTS: Geriatric Depression Scale, Community Disability Scale, and Snellen visual acuity. RESULTS: Twelve of 31 patients (38.7%) had GDS scores > or = 11 at baseline. Two years later, 10 of these 12 patients remained depressed, and three of the 19 (15.8%) previously nondepressed patients had become depressed. Depressed patients tended to be more disabled functionally than nondepressed patients at follow-up. The correlation of disability with depression and with vision were examined for the entire sample and revealed a strong correlation between disability and depression (r = .40; P = .013) compared with that of disability and vision (r = .34; P = .032) at baseline and at follow-up: depression (r = .68; P = .001), vision (r = .45; P = .006). There was no significant correlation between depression and vision at baseline (r = .06; P = .383), but there was a trend toward correlation at follow-up (r = .28; P = .067). CONCLUSION: Depressive symptoms are prevalent and persistent among low vision patients and appear more highly related to disability than is vision. The frequent occurrence of depression and the availability of effective treatment argue for its recognition and treatment as possible ways to reduce disability in older persons with low vision.

Benzodiazepine use in the elderly prior to psychiatric hospitalization.

The objective of this study was to assess benzodiazepine use and the treatment of depression before admission to an inpatient geriatric psychiatry unit in a sample of elderly patients. The study design was a retrospective chart review, and the setting was a university hospital inpatient geriatric psychiatry unit. The subjects included 131 consecutively admitted patients. Preadmission benzodiazepine drug regimens were reviewed in relation to the Health Care Financing Administration (HCFA) guidelines for benzodiazepine use in nursing homes and in relation to psychiatric diagnoses. Psychiatric diagnoses were made based on DSM-III-R criteria. The preadmission benzodiazepine regimens of 38 of 59 patients receiving benzodiazepines (64.0%) were outside the HCFA guidelines. Also, 30 of 76 patients (39.5%) with depressive disorders received benzodiazepines as sole treatment of depression prior to their admission. This study suggests that benzodiazepines may be misused in the elderly and indicates the need for education and research on the appropriate use of benzodiazepines in the treatment of depression.

A randomized trial of dementia care in nursing homes.

OBJECTIVE: To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia. DESIGN: Randomized controlled clinical trial with 6-month follow-up. SETTING: A 250-bed community nursing home. PATIENTS: The nursing home was screened to identify patients with dementia and behavior disorders. A total of 118 patients were eligible for randomization. Of these, 89 (75.4%) were randomized, and 81 of these (91.0%) completed the trial. INTERVENTION: The A.G.E. dementia care program consisted of Activities, Guidelines for psychotropic medications, and Educational rounds. The control treatment was usual nursing home care. MEASUREMENTS: Behavior disorders, antipsychotic drug and physical restraint use, patient activity levels, and cognitive and functional status. RESULTS: After 6 months, 12 of 42 (28.6%) intervention patients exhibited behavior disorders compared with 20 of 39 (51.3%) controls (OR = 0.38; 95% CI [0.15, 0.95]; P = .037). Controls were more than twice as likely to receive antipsychotics (OR = 2.55, 95% CI [0.96, 6.76]; P < .056), to be restrained during activity times (OR = 2.98, 95% CI [1.10, 8.04]; P < .028), and to be restrained on nursing units (OR = 2.14, 95% CI [0.9, 5.3]; P < .10). Intervention patients were much more likely to participate in activities (OR = 13.71; 95% CI [4.51, 41.73]; P = .001). CONCLUSIONS: The A.G.E. program reduces the prevalence of behavior disorders and the use of antipsychotic drugs and restraints. It is practical, feasible, and appears to improve the lives of patients with dementia in nursing homes.

A pet therapy intervention with geriatric psychiatry inpatients.

OBJECTIVE: The purpose of this study was to evaluate the effects of pet therapy on geriatric psychiatry inpatients. A demonstrable impact could lead to more widespread or targeted use of animal companionship programs for hospitalized older persons. METHOD: The study design was a randomized, parallel-group control treatment trial with pretreatment and posttreatment measures. Fifty-eight subjects with chronic age-related disabilities who were patients of the Wills Eye Hospital Geriatric Psychiatry Unit were assigned to a pet therapy intervention group or an exercise control group for 1 hr a day for 5 consecutive days. Every subject was blindly evaluated with the Multidimensional Observation Scale for Elderly Subjects (MOSES) before and after the intervention week. RESULTS: No significant differences in MOSES scores were found between or within groups before and after the interventions. There was a nonsignificant tendency for subjects who received the pet intervention to have less irritable behavior after treatment. However, women with dementia who received either pet therapy or exercise intervention had improved irritable behavior scores after treatment. CONCLUSION: This pilot study demonstrates the need for further research on animal-assisted interventions with hospitalized elderly persons. Differential improvement in women with dementia also requires further investigation.

Depression and anxiety in an 85-year-old woman with a toxic nodular goiter.

Depression is commonly encountered in medical settings and often may be a symptom of an underlying medical illness. This case report illustrates the disabling symptoms of anxiety and depression that can accompany a toxic nodular goiter, and underscores the importance of both accurate psychiatric diagnosis and appropriate medical evaluation in the assessment of psychiatric disorders in the elderly.

Neuroleptic use and behavioral disturbance in nursing homes: a 1-year study.

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.