Onset of Depression in Elderly Persons After Hip Fracture:
Implications for Prevention and Early Intervention of Late-Life
Eric J. Lenze, MD,?wMichael C. Munin, MD,wElizabeth R. Skidmore, PhD,zMary Amanda Dew,
F. Reynolds III, MD?
(See editorial comments by Drs. Barbara Kamholz and Ju ¨rgen Unu ¨tzer on pps 125–126.)
OBJECTIVES: To identify predictors of onset of major de-
pressive disorder (MDD) and of depressive symptoms in
subjects who suffered a hip fracture.
DESIGN: Prospective naturalistic study.
SETTING: University of Pittsburgh Medical CenterF
Shadyside, a large urban hospital in Pittsburgh, Pennsyl-
PARTICIPANTS: One hundred twenty-six elderly patients
who received surgical fixation for hip fracture and who
were not experiencing a major depressive episode at the
time of the fracture; severely cognitively impaired persons
MEASUREMENTS: Subjects were evaluated at the time of
hospital discharge using a battery of clinical measures (in-
cluding apathy measured using the Apathy Evaluation Scale
(AES), delirium, cognitive measures, social support, and
disability level). Depression was assessed at the end of the
surgical stay, 2 weeks later, and then monthly for 6 months,
evaluate symptomatology and the Primary Care Evaluation
of Mental Disorders to evaluate diagnosis of MDD.
RESULTS: Eighteen of 126 subjects (14.3%) developed
MDD after hip fracture. Of these, 11 developed MDD by
the end of the hospitalization, and seven developed MDD
between 2 and 10 weeks later. Logistic regression showed
that baseline apathy score, as measured using the AES, was
the only clinical measure associated with the development
of MDD (odds ratio51.09, 95% confidence inter-
val51.03–1.16, P5.003); 46.2% of those with high AES
scores developed MDD, versus 10.9% of those with lower
scores. In contrast, cognitive variables, delirium, disability
after hip fracture, and other factors related to the fracture
(e.g., fracture type) were not associated with MDD. A re-
peated-measures analysis with Ham-D over time as a de-
pendent variable generally confirmed these findings;
depressive symptoms were highest immediately after the
fracture, and apathy and delirium scores were associated
with higher depressive symptom levels.
CONCLUSION: The onset of MDD is common after hip
fracture, and the greatest period of risk is immediately after
the fracture. Individuals with clinical evidence of apathyare
at high risk for developing MDD, and evaluation and close
follow-up of such individuals is warranted. However, fur-
(e.g., clinical measures or biomarkers) to model adequately
the risk for MDD after hip fracture and other disabling
medical events. J Am Geriatr Soc 55:81–86, 2007.
Key words: geriatric depression; apathy; hip fracture
ive disorder (MDD).1–3For example, hip fracture has the
characteristics of a highly depressogenic stressor4because
of the sequelae of pain, immobilization, hospitalization,
surgery, and uncertain prospects of recovery.5–7Disabling
medical events are common, occurring in more than 6 mil-
lion elderly persons per year in the United States;8one study
foundthat more thanhalf of community-livingolder people
had at least one disabling medical event during a median 4-
year follow-up.9Furthermore, depression in the context of
a disabling medical event can interfere with functional re-
covery.10–16Thus, after the onset of a disabling medical
event, theremaya period ofhighrisk forlate-life depression
during which early detection or prevention strategies would
be of considerable public health benefit. To inform such
depression,17–19yet although many studies have examined
the cross-sectional rates of depressive symptoms or MDD
or elderly persons, a disabling medical event is a signif-
icant risk factor for the development of major depress-
Addresscorrespondence toDr.EricJ.Lenze, WesternPsychiatricInstituteand
Clinic, Room BT748, 3811 O’Hara Street, Pittsburgh, PA 15213.
From the?Advanced Center for Interventions and Services Research and John
A. Hartford Center of Excellence in Geriatric Psychiatry, Department of
Psychiatry,wDepartment of Physical Medicine and Rehabilitation, School of
Medicine, andzDepartment of Occupational Therapy, University of Pitts-
burgh, Pittsburgh, Pennsylvania.
r 2006, Copyright the Authors
Journal compilation r 2007, The American Geriatrics Society
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LENZE ET AL.
JANUARY 2007–VOL. 55, NO. 1JAGS