'Socialised care futility' in the care of older people in hospital who call out repetitively: An ethnographic study.

BACKGROUND: People living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting. OBJECTIVES: To better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting. DESIGN: Ethnography. SETTINGS: Ten acute geriatric medical wards in two hospitals. PARTICIPANTS: 30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff. METHODS: Semi-structured interviews with hospital staff, 150 h of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status. RESULTS: Patients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to 'block' calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out is due to a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need. CONCLUSION: Calling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, often immobile and dependent on their professional carers. We argue that a form of socialised care futility is communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases.

Chair based exercise in community settings: a cluster randomised feasibility study.

BACKGROUND: Some older people who find standard exercise programmes too strenuous may be encouraged to exercise while remaining seated - chair based exercises (CBE). We previously developed a consensus CBE programme (CCBE) following a modified Delphi process. We firstly needed to test the feasibility and acceptability of this treatment approach and explore how best to evaluate it before undertaking a definitive trial. METHODS: A feasibility study with a cluster randomised controlled trial component was undertaken to 1. Examine the acceptability, feasibility and tolerability of the intervention and 2. Assess the feasibility of running a trial across 12 community settings (4 day centres, 4 care homes, 4 community groups). Centres were randomised to either CCBE, group reminiscence or usual care. Outcomes were collected to assess the feasibility of the trial parameters: level of recruitment interest and eligibility, randomisation, adverse events, retention, completion of health outcomes, missing data and delivery of the CCBE. Semi- structured interviews were conducted with participants and care staff following the intervention to explore acceptability. RESULTS: 48% (89 out of 184 contacted) of eligible centres were interested in participating with 12 recruited purposively. 73% (94) of the 128 older people screened consented to take part with 83 older people then randomised following mobility testing. Recruitment required greater staffing levels and resources due to 49% of participants requiring a consultee declaration. There was a high dropout rate (40%) primarily due to participants no longer attending the centres. The CCBE intervention was delivered once a week in day centres and community groups and twice a week in care homes. Older people and care staff found the CCBE intervention largely acceptable. CONCLUSION: There was a good level of interest from centres and older people and the CCBE intervention was largely welcomed. The trial design and governance procedures would need to be revised to maximise recruitment and retention. If the motivation for a future trial is physical health then this study has identified that further work to develop the CCBE delivery model is warranted to ensure it can be delivered at a frequency to elicit physiological change. If the motivation for a future trial is psychological outcomes then this study has identified that the current delivery model is feasible. TRIAL REGISTRATION: ISRCTN27271501 . Date registered: 30/01/2018.

How to deal with violent and aggressive patients in acute medical settings.

Dealing with violence and aggression is an area where health professionals often feel uncertain. Standing at the interface between medicine, psychiatry and law, the best actions may not be clear, and guidelines neither consistently applicable nor explicit. An aggressive, violent or abusive patient may be behaving anti-socially or criminally. But in acute medical settings it is more likely that a medical, mental health or emotional problem, or some combination thereof, is the explanation and usually we will not know the relative contribution of each element. We must assume that difficult behaviour represents the communication of distress or unmet need. We can prevent and de-escalate situations by understanding why they have arisen, identifying the need, and trying to anticipate or meet it. In these situations 'challenging behaviour' is much like any other presenting problem: the medical approach is to diagnose and treat, while trying to maintain safety and function. In addition, the person-centred approach of trying to understand and address psychological and emotional distress is required. Skilled communication, non-confrontation, relationship-building and negotiation represent the best way to manage situations and avoid harm. If an incident is becoming dangerous, doctors need to know how to act to defuse the situation, or make it safe. Doctors must know about de-escalation and non-drug approaches, but also be confident about when physical restraint and drug treatment are necessary, and how to go about using appropriate drugs, doses, monitoring and aftercare. There are necessary safeguards around using these approaches, from the perspectives of physical health, mental wellbeing, and human rights.

Feeding decisions in advanced dementia.

When close to death, people stop eating. In neurodegenerative conditions swallowing may become unsafe, and artificial nutrition and hydration (ANH) may be proposed or requested. But nutrition is surrounded by other considerations: opportunity, help, environment, enjoyment, mood, social being and symbolic importance. Poor care or deliberate attempts to end life might also result in poor nutrition and dehydration. Decisions about ANH are open to conventional ethical analysis and subject to mental capacity law. Most people with appetite or swallowing failure have advanced dementia and lack capacity. Determining someone's best interests means considering values and preferences, previous and current wishes, and requires consultation with families and other carers. Short-term prognosis is difficult to judge in non-malignant conditions. We often do not know the views of the individual. Moreover, we are unsure if ANH can achieve the goals intended of it - there is little evidence that tube feeding prolongs life, prevents aspiration or improves wellbeing. Palliative care and best practice dementia care have much in common. Open communication, good relationships with families and carers, skilled approaches to problems and respect for individuals and their diversity. Modified oral feeding will be appropriate for most; ANH is rarely appropriate, but some individuals and their families feel differently. Careful assessment for potentially treatable causes of swallowing and appetite problems, honest communication about uncertainties over prognosis and the impact of interventions and ascertainment of individuals' values and beliefs make for better care for people with dementia and better decisions about feeding.

Caring for cognitively impaired older patients in the general hospital: a qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards.

BACKGROUND: Around half of people aged over 70 years admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A Medical and Mental Health Unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. OBJECTIVES: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. DESIGN: Field notes were analysed using the constant comparison method. SETTING: A large hospital within the East Midlands region of the United Kingdom. PARTICIPANTS: Patient participants were aged over 65, and identified by Admissions Unit physicians as being 'confused'. Most patients had delirium or dementia. RESULTS: Sixty observations (360 h) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. CONCLUSION: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward.

The evidence for treating hypertension in older people with dementia: a systematic review.

Hypertension and dementia commonly co-exist in older people, yet guidance is lacking on how to manage these co-existing conditions. The aim of this systematic review was to assess the evidence for the treatment of hypertension in older people with dementia. Medline, EMBASE, Cochrane Library and the national research register archives were searched. Inclusion criteria were: randomised controlled trial of hypertension treatment, included participants aged 65+ years, participants had a diagnosis of dementia (global cognitive decline for at least 6 months affecting daily function), and the study assessed cognitive outcomes using validated tools. Dementia prevention studies and poor quality studies were excluded. The initial search revealed 1178 papers of potential interest, of which 24 were selected for review and six met the full inclusion criteria. Trials included people with mild-to-moderate but not severe dementia; exclusion criteria for the trials were extensive. Four trials were placebo-controlled RCTs; the remaining two compared different antihypertensives. All trials reported MMSE scores at baseline and follow-up; four reported blood pressure changes at follow-up; and only three reported cardiovascular morbidity or mortality at follow-up. Only one of four placebo-controlled studies showed evidence of blood pressure reduction, but no clear evidence for benefit (or harm) from antihypertensives on cognition, physical function or other cardiovascular outcomes. We found no evidence to confirm or refute the hypothesis that treatment of hypertension in people with dementia leads to overall health benefit.

Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial.

AIM: The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery. METHODS: A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D. RESULTS: The operated group had costs which were, on average, pound646 more than the control group (95% confidence interval, pound16-1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, -0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was pound44,263 over the 1-year trial period. In an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was pound17,299, under conservative assumptions. CONCLUSIONS: Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

The SF-36: a simple, effective measure of mobility-disability for epidemiological studies.

BACKGROUND: Mobility disability is a major problem in older people. Numerous scales exist for the measurement of disability but often these do not permit comparisons between study groups. The physical functioning (PF) domain of the established and widely used Short Form-36 (SF-36) questionnaire asks about limitations on ten mobility activities. OBJECTIVES: To describe prevalence of mobility disability in an elderly population, investigate the validity of the SF-36 PF score as a measure of mobility disability, and to establish age and sex specific norms for the PF score. METHODS: We explored relationships between the SF-36 PF score and objectively measured physical performance variables among 349 men and 280 women, 59-72 years of age, who participated in the Hertfordshire Cohort Study (HCS). Normative data were derived from the Health Survey for England (HSE) 1996. RESULTS: 32% of men and 46% of women had at least some limitation in PF scale items. Poor SF-36 PF scores (lowest fifth of the gender-specific distribution) were related to: lower grip strength; longer timed-up-and-go, 3m walk, and chair rises test times in men and women; and lower quadriceps peak torque in women but not men. HSE normative data showed that median PF scores declined with increasing age in men and women. CONCLUSION: Our results are consistent with the SF-36 PF score being a valid measure of mobility disability in epidemiological studies. This approach might be a first step towards enabling simple comparisons of prevalence of mobility disability between different studies of older people. The SF-36 PF score could usefully complement existing detailed schemes for classification of disability and it now requires validation against them.

Development of a new measure of health-related quality of life for people with dementia: DEMQOL.

BACKGROUND: We identified the need to develop a scientifically rigorous measure of health-related quality of life (HRQL) in dementia that would be appropriate for use at all stages of dementia severity and would be available in both self- and proxy-report versions. METHOD: We used standard psychometric methods to eliminate items with poor psychometric properties (item-reduction field test) and to assess the acceptability, reliability and validity of the item-reduced instruments (psychometric evaluation field test). We developed and validated two versions of DEMQOL: a 28-item interviewer-administered questionnaire that is self-reported by the person with dementia (DEMQOL) and a 31-item interviewer-administered questionnaire that is proxy-reported by a caregiver (DEMQOL-Proxy). RESULTS: DEMQOL shows high reliability (internal consistency and test-retest) and moderate validity in people with mild/moderate dementia. DEMQOL-Proxy shows good acceptability and internal consistency and moderate evidence of validity in people with mild/moderate and severe dementia. Test-retest reliability and performance in people with severe dementia need further testing. CONCLUSIONS: DEMQOL and DEMQOL-Proxy show psychometric properties that are comparable with the best available dementia-specific measures of HRQL. We recommend that DEMQOL and DEMQOL-Proxy are used together. Reliability and validity need to be confirmed in independent samples and responsiveness needs to be evaluated.

Quality of life in dementia: more than just cognition. An analysis of associations with quality of life in dementia.

OBJECTIVES: To explore the extent to which commonly used measures of specific outcomes in dementia are an appropriate proxy for quality of life in dementia. METHODS: This was a cross sectional study set in communities in London and Nottingham, comprising 101 people with dementia and their 99 main family caregivers. The main outcome measures were health related quality of life in dementia (measured by the DEMQOL-Proxy), cognition (Mini Mental State Examination), functional impairment (Barthel Index), behavioural and psychological symptoms in dementia (Neuropsychiatric Inventory; NPI), and carer mental health (General Health Questionnaire). RESULTS: On univariate analysis, decreased quality of life was statistically significantly correlated with higher levels of behavioural and psychological disturbance (NPI total score and its agitation, depression, anxiety, disinhibition, and irritability subscales); younger age of the person with dementia; and poorer mental health of the carer. Quality of life was not statistically significantly associated with cognition or carer age. In a multivariate model, psychological and behavioural disturbance and patient age remained statistically significantly associated with quality of life. Carer mental health was no longer statistically significantly associated, and cognition and functional limitation remained statistically insignificant. CONCLUSIONS: These data suggest that quality of life in dementia is complex, and that simple proxy substitutions of discrete measures such as cognition or function are likely to miss important factors.

Economic analysis of an early discharge rehabilitation service for older people.

OBJECTIVE: to measure the cost-effectiveness of an early discharge and rehabilitation service (EDRS) in Nottingham, UK. DESIGN: data were collected during a randomised controlled trial. METHODS: cost and cost-effectiveness analyses were conducted from the perspective of service providers (health and social services) over a period of 12 months. Resource variables included were the EDRS intervention, the initial acute hospital admission (from randomisation), readmission to hospital, hospital outpatient visits, stays in nursing and residential homes, general practitioner contact, community health services and social services. The effectiveness measure was the EuroQol EQ-5D score, from which quality-adjusted life years (QALY) were calculated. Cost-effectiveness was calculated as cost per QALY gained. RESULTS: at 12 months the mean untransformed total cost for the EDRS was 8,361 pound sterling compared to 10,088 pound sterling for usual care, a saving of 1,727 pound sterling (P = 0.05). Cost-effectiveness acceptability curves showed a high probability that the EDRS was cost effective across a range of monetary values for a QALY. CONCLUSIONS: the Nottingham EDRS was likely to be more cost effective than usual care.

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial.

BACKGROUND/AIM: A third of elderly people fall each year. Poor vision is associated with increased risk of falls. The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain. METHODS: 306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow up every 3 months. Health status was measured after 6 months. RESULTS: Visual function improved in the operated group (corrected binocular acuity improved by 0.25 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls). Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once. 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once. Rate of falling was reduced by 34% in the operated group (rate ratio 0.66, 95% confidence interval 0.45 to 0.96, p = 0.03). Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group. Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 0.04). CONCLUSION: First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status.

The validity, reliability and responsiveness of the Nottingham Extended Activities of Daily Living scale in patients undergoing total hip replacement.

PURPOSE: The Nottingham Extended Activities of Daily Living (EADL) scale is a popular outcome measure in stroke research. Its psychometric properties have not been tested in other conditions. METHODS: EADL has been measured before, three and six months after hip arthroplasty. A sample was retested for reliability. Comparisons were made with the SF-36 and London Handicap Scale. Standard psychometric parameters were calculated. RESULTS: The sub-scales and total score were approximately unidimensional on factor analysis and Cronbach's alpha, but did not form an adequate hierarchical (Guttmann) scale. Associations with other scales were in the expected direction and of approximately the expected strength, supporting concurrent and construct validity. Reliability was good. Responsiveness was poor compared with the other scales. CONCLUSIONS: The EADL is valid in patients with arthritis of the hip, and is reliable. However, it underestimates the size of health gain after hip arthroplasty compared with other scales.

Hypovitaminosis D and 'functional hypoparathyroidism'-the NoNoF (Nottingham Neck of Femur) study.

BACKGROUND: calcium and vitamin D deficiency are common in elderly people and lead to increased bone loss, with an enhanced risk of osteoporotic fractures. Although hip fractures are a serious consequence, few therapeutic measures are given for primary or secondary prevention. A combination of calcium and vitamin D may not be the most effective treatment for all patients. OBJECTIVE: to investigate the effects of hypovitaminosis D on the calcium-parathyroid hormone endocrine axis, bone mineral density and fracture type, and the optimal role of combination calcium and vitamin D therapy after hip fracture in elderly patients. DESIGN: a population-based, prospective cohort study. METHODS: 150 elderly subjects were recruited from the fast-track orthogeriatric rehabilitation ward within 7 days of surgery for hip fracture. This ward accepts people who live at home and are independent in activities of daily living. All subjects had a baseline medical examination, biochemical tests (parathyroid hormone, 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) and were referred for bone densitometry. RESULTS: at 68%, the prevalence of hypovitaminosis D (25-hydroxyvitamin D<30 nmol/l) was high. However, only half the patients had evidence of secondary hyperparathyroidism, the rest having a low to normal level of parathyroid hormone ('functional hypoparathyroidism'). Patients with secondary hyperparathyroidism and hypovitaminosis D had a higher mean corrected calcium, higher 1,25-dihydroxyvitamin D, lower hip bone mineral density and an excess of extracapsular over intracapsular fractures than the 'functional hypoparathyroid' group (P<0.01). CONCLUSION: there is a high prevalence of hypovitaminosis D in active, elderly people living at home who present with a hip fracture. However, secondary hyperparathyroidism occurs in only half of these patients. This subgroup attempts to maintain calcium homeostasis but does so at the expense of increased bone turnover, leading to amplified hip bone loss and an excess of extracapsular over intracapsular fractures. Combination calcium and vitamin D treatment may be effective in preventing a second hip fracture in these patients, but its role in patients with hypovitaminosis D without secondary hyperparathyroidism and 'vitamin D-replete' subjects needs further evaluation.

Effect of experience of severe stroke on subjective valuations of quality of life after stroke.

Previous work suggests that the quality of life associated with severe disability after stroke is rated very poorly by members of the public, often as being worse than death. Other evidence suggests that experience of illness alters perceptions of its severity. This was tested for severe stroke. Eleven patients with severely disabling stroke, but able to complete a standard gamble interview, 22 age and sex matched controls, and 20 health professionals participated. A standard gamble interview was carried out to determine the quality of life (utility) associated with three hypothetical scenarios representing mild, moderate, and severe stroke, and current health. A sample was retested for reliability, and comparisons were made with other measures of health status. All three subject groups showed wide variation in the utilities they attached to each of the scenarios. The control subjects' valuations were lower than those of either patients or staff members, especially for moderate stroke (median 0.30, 0.73, and 0.68 respectively). There were weak to moderate correlations between utilities and other measures of health status including the Barthel index (r=0.51) and Rivermead mobility score (r=0.24). Test retest-reliability was modest (reliability coefficient 0.75), but indicators of the internal validity of the results were good. In conclusion, it cannot be assumed that general population valuations are valid for patient groups. In clinical practice it is unsafe to make any assumption about subjective quality of life after stroke, due to the wide range of valuations given, although many people rate severe and moderate stroke at least as bad as death.

Visual problems and falls.

Visual impairment is a risk factor for falls, on average approximately doubling falls risk in a wide variety of studies. Falls risk increases as visual impairment worsens. The relationship is almost certainly causal. Vision accounts for perhaps a quarter to a half of all falls, although this estimate is imprecise. Visual impairment in 70% or more of elderly people is remediable with relatively simple interventions (correcting refractive errors and cataract surgery), making it an important potential target for intervention at the population level. However, no intervention has yet been proven to reduce falls risk in a randomized controlled trial.

Measuring the outcomes of day hospital attendance: a comparison of the Barthel Index and London Handicap Scale.

OBJECTIVE: To assess the ability of two scales to measure the effects of attendance at a geriatric day hospital. DESIGN: 'Before-and-after' measurements. SETTING: Day hospital serving a defined, urban, catchment area. SUBJECTS: One hundred and three consecutive new patients over a three-month period. INTERVENTION: Day hospital attendance for as long as the multidisciplinary team thought warranted. OUTCOME MEASURES: Barthel Index and London Handicap Scale. RESULTS: Seventy-six patients (74%) attended for broadly defined 'rehabilitation'. Measurements on the Barthel Index and London Handicap Scale were completed on 54 of these. Repeat measurements after discharge from the day hospital were achieved on 37 patients. Patients attended between two and 57 times, with a median of eight. Mean Barthel Index did not change over the period of attendance. There was a small improvement in mean handicap score. Eight patients were identified post hoc who attended for 10 or more sessions, and they experienced a large mean reduction in handicap. CONCLUSION: Overall, neither the Barthel Index nor the London Handicap Scale changed much during attendance at the day hospital. Generally very short lengths of attendance may have explained this. For patients with more prolonged attendance, who might be expected to change more, the London Handicap Scale proved more responsive than the Barthel Index.

A comparison of the responsiveness of the Nottingham extended activities of daily living scale, London handicap scale and SF-36.

PURPOSE: Clinical trials require scales which are sensitive to the effects of intervention. This study examined the sensitivity to change of three generic health status measurement scales commonly used in evaluations of interventions in chronic, disabling disease. METHODS: Questionnaires comprising the SF-36, London Handicap Scale and Nottingham Extended Activities of Daily Living scale were administered to 81 patients before and after hip replacement. Changes were quantified as 'effect sizes'. RESULTS: Eighty nine per cent of patients reported improvements three months after surgery. The largest changes were seen on the SF-36 pain scale (effect size 1.2 at three months, 1.5 at 6-12 months), physical function (1.1, 1.3) and role limitation--physical (0.8, 1.2) scales. The London Handicap Scale also measured large changes (effect sizes 0.6, 0.9), but the Extended Activities of Daily Living scale was insensitive to change (effect sizes 0.1, 0.2). CONCLUSIONS: Some of the SF-36 dimensions were very sensitive to change. The London Handicap Scale was also reasonably responsive, and has the advantage of being a single, utility-based, score. The simpler Extended ADL score was poorly responsive.

A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII.

BACKGROUND: Population-based studies suggest substantial co-morbidity between physical illness and depression in late-life. However, a causal relationship has not been established. If a relationship exists, it is important to establish which aspects of poor health determine risk for depression, and which factors confer vulnerability or resilience in the face of poor health. We investigate the role of disablement, measured as impairment, disability and handicap. METHODS: A prospective population-based cohort study, comprising an index assessment and 1 year follow-up, of all residents aged 65 years or over, of an electoral ward in London, UK (N = 889). RESULTS: The prevalence of SHORT-CARE pervasive depression was 17.7% at index assessment. The 1 year onset rate for pervasive depression was 12.0%, and the 1 year maintenance rate 63.2%. There was a high mortality rate among the depressed. Disablement, particularly handicap was the most important predictor of the onset of depression (population attributable fraction, 0.69). Lack of contact with friends was a direct risk factor but also modified the association between handicap and depression. Marriage was protective for men, but a risk factor for women. Maintenance of depression was predicted by low levels of social support and social participation, rather than by disablement. CONCLUSIONS: It seems likely that disablement, specifically handicap, is the chief cause of onsets of depression in late-life. Genetic predisposition, early adversity and serious life events may play a less prominent role than in earlier life. Effective prevention of late-life depression requires attention at the structural level to the sources of handicap within communities.