Relationship of physical disease and functional impairment to depression in older people.

Physical disease is commonly considered a risk factor for depression among older adults. However, this pattern is not consistently supported, and a theoretical framework for understanding such a relationship has not been articulated. P.M. Lewinsohn, H. Hoberman, L. Teri, and M. Hautzinger's (1985) integrative model of depression predicts that disease will be a risk factor for depression only when disease results in functional impairment, and that impairment in the absence of disease is also a risk factor for depression. The authors tested these predictions in a community-based sample of older adults followed longitudinally and found that functional impairment was a significant risk factor for depression, regardless of disease status. Disease was not a significant predictor of major depression, nor did it interact with impairment to predict depression.

An observational study of sexual behavior in demented male patients.

BACKGROUND: Concerns have been expressed that patients with dementia will display disinhibited, inappropriate sexual behavior. Retrospective research suggests that this is rare, but no observational research has been reported. The purpose of this study was to conduct such an observational study. METHODS: Subjects were 40 patients with a dementia diagnosis who were living in institutional settings; subjects ranged in age from 60 to 98. Coders observed subjects on nine separate occasions, three in the morning, three in the afternoon, and three in the evening. Subjects were observed in multiple situations; coding included appropriate, ambiguous, and inappropriate sexual behaviors. Reliability coding was obtained for 42% of the patients on 11% of coded episodes. RESULTS: Behaviors could be coded with high reliability (94% to 100% across categories of behavior). On average, patients displayed 43 appropriate sexual behaviors, 1.48 ambiguous behaviors, and .83 inappropriate behaviors across the nine observation periods. This was not evenly distributed across patients, however; only 18% of patients ever displayed a sexually inappropriate behavior, and these were usually brief and minor. Inappropriate sexual behavior was observed in only 1.6% of the observed one-minute time segments. CONCLUSIONS: Observational research documents what had been previously suggested by retrospective reports: inappropriate sexual behavior is uncommon in dementia patients and brief and minor even when it occurs. Ambiguous behaviors, such as appearing in public incompletely dressed, which could suggest exhibitionism but more likely reflects self-care deficits, were more common. Misinterpretation of these events may be the source for some of the persistent lore regarding sexually disinhibited behavior in dementia patients.

Coping with osteoarthritis by older adults.

OBJECTIVE: To extend to patients with osteoarthritis (OA) the coping model developed for patients with rheumatoid arthritis. METHODS: Relationship among appraisal, coping, and impact of OA were examined in a prospective study. Older men and women with OA (n = 82) were recruited from the community and were assessed at baseline, 1 month, and 4 months. Appraisal at baseline was measured by an interview addressing patients' beliefs about the intensity of their OA. Active, passive, and behavioral coping were assessed at 1 month, and the impact on OA pain, affective status, and mood was assessed at 4 months. RESULTS: Appraisal of OA as more intense was related to the use of more passive coping at 1 month, and was also related to more negative mood at 4 months. Active coping was predictive of less depressed affective status, whereas passive coping was predictive of subsequent worsening of negative mood. These relationships remained significant after controlling for demographic and medical history variables and functional status measures associated with dependent variables. No relation of either appraisal or coping to pain or positive mood was observed. CONCLUSIONS: The findings suggests that as patients' appraisals of the intensity of their OA decrease, less use of passive coping strategies, which are associated with poorer outcomes, should result. It is recommended that interventions to reduce OA impact should include both modification of appraisals of OA and modification of patients' coping strategies.

Personal models of osteoarthritis and their relation to self-management activities and quality of life.

We examined the personal models of osteoarthritis (OA) of 61 patients over 60 years of age. Models were elicited using a structured interview. Shared beliefs included perceiving OA as a serious, painful, chronic, and incurable condition that can be managed by recommended medical treatment. Considerable individual differences were found on six personal-model constructs: Symptoms, Seriousness, Cause, Control, Helpfulness of Treatment, and Negative Feelings about Treatment. The constructs of Symptoms and Seriousness were consistently related to a variety of important outcomes. For example, participants with higher scores on Symptoms and Seriousness reported higher levels of self-management (both concurrently and prospectively), reported more utilization of medical services, and experienced a poorer quality of life. The implications for the design of health-education materials and for patient-provider interactions are discussed.

Self-management of osteoarthritis.

Osteoarthritis is the most prevalent activity-limiting condition among older persons. In addition to, or instead of, taking nonsteroidal anti-inflammatory drugs, people use a variety of activities to manage their osteoarthritis. This study describes the self-management methods reported by 61 participants aged 60 years or older assessed on two occasions 8 months apart. A questionnaire was developed to assess levels of use of 10 self-management methods including low-impact activity, rest, range-of-motion exercises, relaxation, heat (or cold), taking medication, joint protection, massage, splints, and any other activity. On a typical day, participants used about four of these activities to manage osteoarthritis symptoms, and significantly more on a day that their arthritis was worse than usual. Three self-management scales were formed from groups of activities suggested by factor analysis (medication taking, typical management, and worse-day passive management) that demonstrated adequate internal consistency and stability across the two assessments. The findings are discussed in terms of the importance of developing a brief measure of osteoarthritis self-management, and the substantial individual variation in subsets of methods used.

Psychologic disorder and sexual dysfunction in elders.

These data, in combination with the literature reviewed above, demonstrate several important points for those who work in clinics where elders with sexual problems are seen: 1. The currently available literature on the relation of sexual dysfunction to psychiatric disorder in the elderly is not extensive, and much of the literature is limited by methodologic flaws. There is a clear need for improved research methods and a broader data base. Nonetheless, the existing studies indicate that psychologic disorders are found in conjunction with sexual dysfunction commonly enough that clinicians must regularly assess for their presence. 2. The cause of sexual problems is seldom simple or entirely clear. Diagnoses of psychologic concerns and disorders that might relate to sexual dysfunction are common, and most older patients' sexual dysfunction will have a mixed cause, with both medical and psychologic factors playing an important role in the development and maintenance of sexual dysfunction. In our series of patients, 52.8% had diagnosable psychologic difficulties that were assumed to be related to the sexual difficulties. Another large group (39.9%) had psychologic factors (although not diagnosable disorders) that were assumed to contribute to the current manifestation of sexual dysfunction. Thus, it should not be assumed, as it was in years past, that when one likely causative factor is identified (e.g, diabetes, performance anxiety, or depression), the cause of the dysfunction has been identified. 3. The types of psychopathology seen in sex clinics are typically fairly limited, with the largest proportions by far being alcohol abuse or depression (50.1% and 62.1%, respectively, of all psychologic diagnoses in our clinic). Major psychopathology is relatively underrepresented. We suspect this underrepresentation does not reflect a true population characteristic but, rather, a selection difference; patients with major psychopathology such as schizophrenia either do not complain of sexual dysfunction to their therapists or are not referred for treatment by their therapists. 4. The presenting complaints of patients with a psychologic disorder do not differ significantly from those of patients without a psychologic disorder in a general sexual dysfunction clinic. 5. Treatment outcome, especially the rate of successful treatment, does not differ between those with and those without psychologic diagnoses when physicians and psychologists work together on an interdisciplinary team to offer treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

The incidence and correlates of erectile problems in patients with Alzheimer's disease.

Loss of erection was reported in 53% of 55 male Alzheimer's disease patients with a mean age of 70.25. Loss of erection is not related to degree of cognitive impairment, age, or depression. Modal time of onset of erectile problems is concurrent with onset of Alzheimer's symptoms. Patients with erectile problems were not taking more medications overall than those without problems and had no greater overall incidence of concurrent physical problems. Thus, the evidence suggests that there may be an elevated incidence of erectile failure in patients with Alzheimer's disease as a primary problem not attributable to other age-related factors.

Sexual concerns of male spouses of female Alzheimer's disease patients.

Little is known about the impact of dementia on sexuality. The attendant cognitive changes that occur in the Alzheimer's patient present the caregiver with many, often conflicting, challenges to a couple's sexual functioning. This case study highlights these issues by describing a man who reported an erectile dysfunction directly stemming from stressful changes that had occurred in his relationship to his wife who had Alzheimer's disease. General themes and relevant hypotheses are derived and clinical practice implications are explored.

Probability of relapse after recovery from an episode of depression.

Examined relapse rates in those individuals who have experienced an episode of unipolar depression as a function of the number of previous episodes, gender, age at onset of the episode (less than 40 vs. greater than 40), time since a previous episode, and depression level at time of interview. From of 6,742 participants, 2,046 were interviewed; of these, 1,130 had at least one, 513 reported a second and 173 reported a third episode. The probability for relapse was positively related to number of previous episodes, being female, depression level at time of interview, but not to age at onset (less than 40 vs. greater than 40). Women were also more likely to have more severe episodes. Participants with elevated depression symptoms reported a greater number of previous episodes. Following the first episode, there was a decline in hazard rate for men but not women; following the second episode, there was no change in vulnerability for men; for women, the results were ambiguous.

Induction of depressed mood: a test of opponent-process theory.

Solomon's (1980) opponent-process theory of acquired motivation has been used to explain many phenomena in which affective or hedonic contrasts appear to exist, but has not been applied to the induction of depressed mood. The purpose of this study, therefore, was to determine whether opponent-process theory can be applied to this area. Velten's (1968) mood-induction procedure was used and subjects were assigned either to a depression-induction condition or to one of two control groups. Self-report measures of depressed mood were taken before, during, and at several points after the mood induction. Results were not totally consistent with a rigorous set of criteria for supporting an opponent-process interpretation. This suggests that the opponent-process model may not be applicable to induced depressed mood. Possible weaknesses in the experimental design, along with implications for opponent-process theory, are discussed.

A comparison of social skills training and contingent attention to improve behavioural deficits of chronic psychiatric patients.

Twelve chronic psychiatric patients were treated with either social skills training or contingent attention to improve behavioural assets or deficits noted on the ward by independently trained raters blind to experimental conditions. Treatment was applied across groups using a multiple-baseline format. Inspection of the data revealed that clinically significant improvements in socially appropriate assets and deficits observed on the ward resulted with social skills training but no substantiative change accrued due to the contingent attention. The behaviours selected for treatment were those which staff were most willing to reinforce. This variable may account, in part at least, for the generalization of treatment effects to the natural environment with persons who received social skills training.

Endogeneity and reactivity as orthogonal dimensions in depression.

Endogeneity and reactivity have long been considered polar opposites of a major dimension of depression. The present factor analytic study examines 35 distinct depressive symptoms in three depressed samples and supports the conceptualization of D. F. Klein (Endomorphic depression. Arch. Gen. Psychiatry, 31:447-454, 1974) that endogeneity and reactivity can be construed as orthogonal, independent dimensions. Symptoms consistently loading on an endogeneity factor are: 1) lacking in reactivity to environmental changes; 2)showing no interest in life; 3) retarded (slow, feeling tired, etc.); 4) feeling unable to act; 5) considering self lazy; 6) feeling helpless and powerless; and 7) perceiving depression as qualitatively different from ordinary sadness. Symptoms consistently loading on a reactivity factor are: 1) feeling that he or she is bearing troubles; 2) presence of precipitating stress; 3) crediting problems to excessive family and/or job responsiblitiies; 4) expressing concern for welfare of family and friends; 5) visceral symptoms; 6) feeling at "end of rope"; 7) having middle-of-the-night insomnia; and 8) showing self-pity. The results suggest a methodology for identifying depressives who are high-high, low-high, high-low, and low-low on the endogeneity and reactivity factors.

Sexual counseling for cerebral palsied adults: case report and further suggestions.

A mildly cerebral palsied woman was seen for premarital counseling regarding sexuality and the bearing and rearing of children. A multidisciplinary approach was used; sexual counselors, a gynecologist, an orthopedist, and a geneticist met with the client for a total of 8 hr counseling time. This approach is suggested for sexual counseling for the more severely handicapped, as well as in cases of mild and moderate disability.