Onset of Depression in Elderly Persons After Hip Fracture: Implications for Prevention and Early Intervention of Late-Life Depression

Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
Journal of the American Geriatrics Society (Impact Factor: 4.57). 02/2007; 55(1):81-6. DOI: 10.1111/j.1532-5415.2006.01017.x
Source: PubMed


To identify predictors of onset of major depressive disorder (MDD) and of depressive symptoms in subjects who suffered a hip fracture.
Prospective naturalistic study.
University of Pittsburgh Medical Center-Shadyside, a large urban hospital in Pittsburgh, Pennsylvannia.
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 were excluded.
Subjects were evaluated at the time of hospital discharge using a battery of clinical measures (including 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, using the Hamilton Rating Scale for Depression (Ham-D) to evaluate symptomatology and the Primary Care Evaluation of Mental Disorders to evaluate diagnosis of MDD.
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 ratio=1.09, 95% confidence interval=1.03-1.16, P=.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 repeated-measures analysis with Ham-D over time as a dependent 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.
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 apathy are at high risk for developing MDD, and evaluation and close follow-up of such individuals is warranted. However, further research is needed to examine other candidate variables (e.g., clinical measures or biomarkers) to model adequately the risk for MDD after hip fracture and other disabling medical events.

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    • "The prevalence of depressive symptoms in the present study is in line with previous reports (Nightingale et al., 2001). Although mood disorders, especially depression, have been well studied in older patients with fractured neck of femur (Holmes and House, 2000; Lenze et al., 2007), this study has demonstrated for the first time that elevated depressive symptoms in these patients are associated with immune suppression. Crucially, neutrophil superoxide production was only impaired in those hip fracture patients that developed depressive symptoms; those with hip fracture alone showed neutrophil superoxide production equivalent to that of the healthy age-matched controls. "
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    ABSTRACT: Hip fracture is a common trauma in older adults with a high incidence of depression, which relates to poorer prognosis including increased risk of infection. Ageing is accompanied by reduced immunity, termed immunesenescence, resulting in increased susceptibility to infection. We examined whether physical trauma (hip fracture) and psychological distress (depressive symptoms) had additive effects upon the aged immune system that might contribute to poor outcomes after injury. Neutrophil function was assessed in 101 hip fracture patients (81 female) 6 weeks and 6 months after injury and 43 healthy age-matched controls (28 female). 38 fracture patients had depressive symptoms at 6 weeks. No difference in neutrophil phagocytosis of E. coli was observed between controls and hip fracture patients, but superoxide production was significantly reduced in hip fracture patients with depressive symptoms compared with patients without symptoms (p = .001) or controls (p = .004) at 6 weeks. Superoxide production improved 6 months following fracture to the level seen in controls. We detected elevated serum cortisol, reduced dehydroepiandrosterone sulphate (DHEAS) and an increased cortisol:DHEAS ratio in fracture patients with depressive symptoms compared with patients without depressive symptoms or controls at 6 weeks and 6 months after injury. Serum IL6, TNFα and IL10 were higher among patients with depressive symptoms at 6 weeks. The cortisol:DHEAS ratio and IL6 levels related to depressive symptom scores but not to neutrophil function. In conclusion, depressive symptoms related to poorer neutrophil function after hip fracture, but this was not driven by changes in stress hormone or cytokine levels.
    Full-text · Article · Jul 2013 · Brain Behavior and Immunity
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    • "Delirium may persist for months and patients with cognitive impairment at follow-up may in fact experience persistent delirium (Cole et al., 2009). Alternatively, patients with cognitive impairment at follow-up may have depression or have neurodegenerative disease (Lenze et al., 2007; Krogseth et al., 2011). The few studies that examined the neuropsychological profiles of elderly patients after an episode of delirium (Katz et al., 2001; Benoit et al., 2005; Jankowski et al., 2011) have not adequately addressed the possibility that the presence of delirium symptoms or depression may have influenced performance on cognitive tests at follow-up. "
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    ABSTRACT: Background: Delirium is a risk factor for long-term cognitive impairment and dementia. Yet, the nature of these cognitive deficits is unknown as is the extent to which the persistence of delirium symptoms and presence of depression at follow-up may account for the association between delirium and cognitive impairment at follow-up. We hypothesized that inattention, as an important sign of persistent delirium and/or depression, is an important feature of the cognitive profile three months after hospital discharge of patients who experienced in-hospital delirium. Methods: This was a prospective cohort study. Fifty-three patients aged 75 years and older were admitted for surgical repair of acute hip fracture. Before the surgery, baseline characteristics, depressive symptomatology, and global cognitive performance were documented. The presence of delirium was assessed daily during hospital admission and three months after hospital discharge when patients underwent neuropsychological assessment. Results: Of 27 patients with in-hospital delirium, 5 were still delirious after three months. Patients with in-hospital delirium (but free of delirium at follow-up) showed poorer performance than patients without in-hospital delirium on tests of global cognition and episodic memory, even after adjustment for age, gender, and baseline cognitive impairment. In contrast, no differences were found on tests of attention. Patients with in-hospital delirium showed an increase of depressive symptoms after three months. However, delirium remained associated with poor performance on a range of neuropsychological tests among patients with few or no signs of depression at follow-up. Conclusion: Elderly hip fracture patients with in-hospital delirium experience impairments in global cognition and episodic memory three months after hospital discharge. Our results suggest that inattention, as a cardinal sign of persistent delirium or depressive symptomatology at follow-up, cannot fully account for the poor cognitive outcome associated with delirium.
    Full-text · Article · May 2013 · International Psychogeriatrics
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    • "Previous work suggest that approximately 50% of the patients who experience in-hospital delirium have clinically significant depressive symptoms after hospital discharge, while other work suggests that depressive symptoms may be evident up to two years afterward (Dolan et al., 2000; Olofsson et al., 2005; Lenze et al., 2007; Davydow, 2009). "
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    ABSTRACT: Background: Delirium in elderly patients is associated with various long-term sequelae that include cognitive impairment and affective disturbances, although the latter is understudied. Methods: For a prospective cohort study of elderly patients undergoing hip fracture surgery, baseline characteristics and affective and cognitive functioning were assessed preoperatively. During hospital admission, presence of delirium was assessed daily. Three months after hospital discharge, affective and global cognitive functioning was evaluated again in patients free from delirium at the time of this follow-up. This study compared baseline characteristics and affective functioning between patients with and without in-hospital delirium. We investigated whether in-hospital delirium is associated with increased anxiety and depressive levels, and post-traumatic stress disorder (PTSD) symptoms three months after discharge. Results: Among 53 eligible patients, 23 (43.4%) patients experienced in-hospital delirium after hip fracture repair. Patients who had experienced in-hospital delirium showed more depressive symptoms at follow-up after three months compared to the 30 patients without in-hospital delirium. This association persisted in a multivariate model controlling for age, baseline cognition, baseline depressive symptoms, and living situation. The level of anxiety and symptoms of PTSD at follow-up did not differ between both groups. Conclusion: This study suggests that in-hospital delirium is associated with an increased burden of depressive symptoms three months after discharge in elderly patients who were admitted to the hospital for surgical repair of hip fracture. Symptoms of depression in patients with previous in-hospital delirium cannot be fully explained by persistent (sub)syndromal delirium or baseline cognitive impairment.
    Full-text · Article · Nov 2012 · International Psychogeriatrics
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