Comorbidity of late life depression: An opportunity for research on mechanisms and treatment

Weill Medical College of Cornell University, Cornell Institute of Geriatric Psychiatry, White Plains, New York 10605, USA.
Biological Psychiatry (Impact Factor: 10.26). 10/2002; 52(6):543-58. DOI: 10.1016/S0006-3223(02)01468-3
Source: PubMed


Late life depression principally affects individuals with other medical and psychosocial problems, including cognitive dysfunction, disability, medical illnesses, and social isolation. The clinical associations of late life depression have guided the development of hypotheses on mechanisms predisposing, initiating, and perpetuating specific mood syndromes. Comorbidity studies have demonstrated a relationship between frontostriatal impairment and late life depression. Further research has the potential to identify dysfunctions of specific frontostriatal systems critical for antidepressant response and to lead to novel pharmacological treatments and targeted psychosocial interventions. The reciprocal interactions of depression with disability, medical illnesses, treatment adherence, and other psychosocial factors complicate the care of depressed older adults. Growing knowledge of the clinical complexity introduced by the comorbidity of late life depression can guide the development of comprehensive treatment models. Targeting the interacting clinical characteristics associated with poor outcomes has the potential to interrupt the spiral of deterioration of depressed elderly patients. Treatment models can be most effective if they focus on amelioration of depressive symptoms, but also on treatment adherence, prevention of relapse and recurrence, reduction of medical burden and disability, and improvement of the quality of life of patients and their families.

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    • "Depression has been shown to accelerate the pathway of disablement and multimorbidity among older people (van Gool et al., 2005) and to increase the burden of somatic complaints (Härter et al., 2007) and subjective suffering (Goldney et al., 2000). Although only a few studies have examined implications of depression in the context of physical comorbidity, available evidence indicates worse health outcomes, impaired functioning and increased health care utilisation (Aragonès et al., 2004; Alexopoulos et al., 2002; Katon and Ciechanowski, 2002; Wittchen et al., 1999; Schäfer et al., 2012; Lehnert et al., 2011). Therefore, early detection and successful treatment of depression is essential. "
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    ABSTRACT: Background The objective of the study was to compare General Practitioners׳ (GPs) diagnosis of depression and depression diagnosis according to Geriatric Depression Scale (GDS) and to identify potential factors associated with both depression diagnosis methods. Methods The data were derived from the baseline wave of the German MultiCare1 study, which is a multicentre, prospective, observational cohort study of 3177 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Depressive symptoms were assessed with a short version of the Geriatric Depression Scale (15 items, cut-off 6). Cohen׳s kappa was used to assess agreement of GP and GDS diagnoses. To identify factors that might have influenced GP and GDS diagnoses of depression, binary logistic regression analyses were performed. Results Depressive symptoms according to GDS were diagnosed in 12.6% of the multimorbid subjects, while 17.8% of the patients received a depression diagnosis by their GP. The agreement between general practitioners and GDS diagnosis was poor. To summarize we find that GPs and the GDS have different perspectives on depression. To GPs somatic and psychological comorbid conditions carry weight when diagnosing depression, while cognitive impairment in form of low verbal fluency, pain and comorbid somatic conditions are relevant for a depression diagnosis by GDS. Conclusions Each depression diagnosing method is influenced by different variables and therefore, has advantages and limitations. Possibly, the application of both, GP and GDS diagnoses of depression, could provide valuable support in combining the different perspectives of depression and contribute to a comprehensive view on multimorbid elderly in primary care setting.
    Journal of Affective Disorders 10/2014; 168(08/09):276–283. DOI:10.1016/j.jad.2014.06.020 · 3.38 Impact Factor
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    • "A number of studies have demonstrated the association between quality of life and physical illness [15], indicating that the higher the medical burden the higher the risk for depression [22,23]. Studies have confirmed associations between depression and heart disease [24-26]; diabetes [27]; chronic obstructive pulmonary disease, bronchitis and asthma [28,29]; cancer [30] and arthritis [31]. "
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    ABSTRACT: With a rapidly ageing population and increasing life expectancy, programs directed at improving the mental health and quality of life (QOL) of older persons are extremely important. This issue may be particularly relevant in the aged-care residential sector, where very high rates of depression and poor QOL are evident. This study aims to investigate the fixed and modifiable risk factors of psychological distress and QOL in a cohort of Australians aged 60 and over living in residential and community settings. The study examined the relationship between demographic, health and lifestyle factors and the outcome variables of self-reported QOL and psychological distress (K10 scores) based on data from 626 Australians aged 60 and over from the 45 and Up Study dataset. Univariate and multivariate regression analyses (performed on a subset of 496) examined risk factors related to psychological distress and QOL adjusting for age and residential status. Significant psychological distress was experienced by 15% of the residential sample and 7% of the community sample and in multivariate analyses was predicted by older age, more functional limitations, more time spent sleeping and lower levels of social support (accounting for 18.2% of the variance). Poorer QOL was predicted by more functional limitations and greater levels of psychological distress. Together these variables accounted for 35.0% of the variance in QOL ratings. While psychological distress was more common in residential settings, programs targeting modifiable risk factors have the potential to improve QOL and reduce psychological distress in older persons living in both residential and community settings. In particular, promoting health and mobility, optimising sleep-wake cycles and increasing social support may reduce levels of psychological distress and improve QOL.
    BMC Psychiatry 10/2013; 13(1):249. DOI:10.1186/1471-244X-13-249 · 2.21 Impact Factor
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    • "In addition, more than half of the aged care population is estimated to demonstrate Behavioural and Psychological Symptoms of Dementia (BPSD), such as agitation, verbal and physical aggression, sleep disturbance, and wandering [1]. Research has demonstrated that these disturbances are not well managed by staff in the aged care sector [3]. This is of particular concern as the failure to adequately care for older people with BSPD is associated with serious adverse outcomes, including increased falls and injury, the use of restraints, social isolation, admission to a psychiatric inpatient ward, and stress and burnout among care staff [4,5]. "
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    ABSTRACT: The high occurrence and under-treatment of clinical depression and behavioral and psychological symptoms of dementia (BPSD) within aged care settings is concerning, yet training programs aimed at improving the detection and management of these problems have generally been ineffective. This article presents a study protocol to evaluate a training intervention for facility managers/registered nurses working in aged care facilities that focuses on organisational processes and culture as well as knowledge, skills and self-efficacy. A Randomised Control Trial (RCT) will be implemented across 18 aged care facilities (divided into three conditions). Participants will be senior registered nurses and personal care attendants employed in the aged care facility. The first condition will receive the training program (Staff as Change Agents -- Enhancing and Sustaining Mental Health in Aged Care), the second condition will receive the training program and clinical support, and the third condition will receive no intervention. Pre-, post-, 6-month and 12-month follow-up measures of staff and residents will be used to demonstrate how upskilling clinical leaders using our transformational training approach, as well as the use of a structured screening, referral and monitoring protocol, can address the mental health needs of older people in residential care. The expected outcome of this study is the validation of an evidence-based training program to improve the management of depression and BPSD among older people in residential care settings by establishing routine practices related to mental health. This relatively brief but highly focussed training package will be readily rolled out to a larger number of residential care facilities at a relatively low cost.Trial registration: Australia and New Zealand Clinical Trials Register (ANZCTR): The Universal Trial Number (UTN) is U1111-1141-0109.
    BMC Geriatrics 09/2013; 13(1):95. DOI:10.1186/1471-2318-13-95 · 1.68 Impact Factor
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