Psychiatric diagnoses made by the agecat system in residents of local authority homes for the elderly: Outcome and diagnostic stability after four years

Eighty-six residents of 12 local authority homes for the elderly were interviewed with the Geriatric Mental State (GMS) in 1985/6 after having been classed as depressed by a screening interview. The data so gathered were analysed by the computerized diagnostic program AGECAT in order to derive psychiatric diagnoses for these residents. All were traced after four years; 61 were dead. The 25 survivors were reinterviewed and given a second AGECAT diagnosis. In 1985/6 70 of the 86 examined were ‘diagnostic cases’ of psychiatric disorder. After four years 22 of the 25 survivors were classed as diagnostic cases. AGECAT diagnoses of organic psychosis were stable over four years within this population though the majority of subjects so diagnosed died within four years. Cases of depression had a more varied prognosis, with death, continunce as cases of depression or progression to organic psychosis being the most common outcomes. Recovery from any class of AGECAT disorder was an uncommon event.     

Diagnosis of psychiatric disorder in elderly general and geriatric hospital patients: Agecat and dsm-III-r compared

Physically ill elderly patients (N= 236) in a geriatric and a general hospital were interviewed with the Geriatric Mental State (GMS) schedule. Psychiatric diagnoses made by the computer programme ‘AGECAT’ were compared with those made by a psychiatrist who applied DSM-III-R diagnostic criteria to the GMS data. Overall kappa for all diagnostic groups was 0.78. Agreement was excellent for organic diagnoses and good for depression. GMS-AGECAT can be used with confidence to detect common psychiatric disorders in physically ill elderly general and geriatric hospital patients.     

Prevalence of sub-threshold depression in elderly patients with chronic obstructive pulmonary disease

OBJECTIVES: We hypothesized that COPD patients with sub-threshold depression would have levels of disability and impaired quality of life approaching that for major depression and significantly greater than for non-depressed COPD patients. SETTING: A university teaching hospital METHOD: 137 outpatients (69 men), with a mean age of 73 years (range 60-89 years) with symptomatic irreversible, moderate to severe COPD were recruited. Subjects were interviewed using the Geriatric Mental State Schedule (GMS), a structured psychiatric interview schedule, along with its diagnostic algorithm AGECAT. A GMS/AGECAT score of 3 or more is indicative of a case-level of depression, a GMS/AGECAT score of 1-2 indicates sub-threshold depression and GMS/AGECAT of 0, no depression. Physical disability was measured by the Manchester Respiratory Activities of Daily Living questionnaire (MRADL) and quality of life was assessed by the Breathing Problems Questionnaire (BPQ). RESULTS: Mean (SD) one second forced expiratory volume was 0.89 (0.33) litres. The prevalence of GMS/AGECAT case-level depression (>or= 3) was 57 cases (42%); of GMS/AGECAT sub-threshold depression (1-2) 34 (25%); and GMS/AGECAT non-depression (0) 46 (33%). Comparison of MRADL score in the three groups (mean, 95% confidence intervals) revealed [GMS >or= 3 = 9.9 (8.4 to 11.3) vs GMS = 1-2, 12.9 (11.2 to 14.4) vs GMS = 0, 15.6 (14 to 16.6) p < 0.0001]. BPQ scores (mean, 95% confidence intervals) showed [GMS >or= 3 = 54 (50 to 57) vs GMS = 1-2, 40 (36.3 to 44) GMS = 0, 33 (30.6 to 36.7) p < 0.0001]. There was no significant difference in FEV(1) between the three groups. CONCLUSION: Sub-threshold depression accounted for 25% of the sample. In this study disability associated with sub-threshold depression in patients with COPD was intermediate to that associated with case-level depression and no with depression and significantly worse than in the latter group. Sub-threshold depression is associated with substantial morbidity in COPD.     

The use of the selfCARE(D) as a screening tool for depression in the clients of local authority home care services—a preliminary study

Background. The home care population has high levels of depressive disorder which is unrecognized and untreated. In the UK, social services are charged with a full assessment of need but there appears to be little systematic assessment of depressed mood in their assessment and review procedures. The performance of the SelfCARE(D), a 12-item self-administered depression rating scale, was tested in this population. Method. Home care recipients in Lewisham East were invited to complete the SelfCARE(D). Random samples of groups scoring at different levels on the SelfCARE(D) were then interviewed using the GMS/AGECAT system in order to make a standardized psychiatric diagnosis. The sensitivity and specificity, and positive and negative predictive values (PPV and NPV) of the tests were calculated along with the area under ROC curves for different SelfCARE(D) cutpoints and definitions of disorder. Results. 75% of the target population completed the SelfCARE(D). The data suggest that the most efficient cutpoint to use in this population appears to be 7/8, since this gave an NPV of 0·90, a PPV of 0·50 and a yield of 83% of cases of depression. This was achieved with having to complete a second-stage assessment on 17% less of the total population when compared with the 5/6 cutpoint and 9% less than the 6/7 cutpoint. Conclusions. This study suggests that the SelfCARE(D) may be an acceptable and effective tool for the screening of depression in the home care population. The data presented here support an evaluation of its incorporation into social service assessment and review packages for their elderly home care clients. Copyright © 1998 John Wiley & Sons, Ltd.     

Concurrent validity of the GMS­AGECAT (A3) package in a Danish nursing home population

Aim. To validate the Danish version of the GMS–AGECAT (A3), the Standardized Mini Mental State Examination (SMMSE) and the Geriatric Depression Scale-15 (GDS-15) by comparing them to clinical ICD-10 criteria in a Danish nursing home population. Methods. With a participation of 91%, the study included 100 residents. All residents were interviewed with the GMS–AGECAT (A3), SMMSE and GDS-15 by an MD and then blindly diagnosed by a consultant geriatric psychiatrist. All residents approached for an interview were included, also those who were not able to communicate (the non-accessibles). Results. The prevalence of clinical psychiatric ICD-10 main diagnoses was 56%. The non-accessibles had significantly higher psychiatric morbidity and lower ADL scores (modified Barthel ADL index) compared to those who were able to communicate. With the non-accessibles (N=100) included, the optimal screening and diagnostic cutpoint for the GMS–AGECAT organic diagnoses was 2/3, with 96% sensitivity, 73% specificity, 77% predictive value of a positive test and 95% predictive value of a negative test. The SMMSE and GDS-15 had better screening properties compared to the GMS–AGECAT but only 60% of the residents were able to complete the SMMSE and 78% were able to complete the GDS-15. Conclusion. The Danish version of the GMS–AGECAT has relevant diagnostic and screening properties for organic disorders in Danish nursing home populations. © 1998 John Wiley & Sons, Ltd.     

Geriatric depression in Nigerian primary care attendees

OBJECTIVE: To determine the rate and correlates of geriatric depression in two primary care facilities within a teaching hospital in Nigeria. METHOD: 202 older people were screened using the Geriatric Depression Scale (GDS). The Geriatric Mental State schedule (GMS) was administered to participants who scored above the cut-off on the GDS in order to assess psychopathology. Diagnosis of depression was based on ICD-10 criteria as well as the GMS-AGECAT program. RESULTS: The rate of geriatric depression in primary care was found to be 7.4%. Severe depression was only 1.5%. Very low income and subjective report of poor health were significantly associated with depression in the cohort. AGECAT recognition of depression was comparable to that by the ICD-10 (k = 0.7). CONCLUSION: The study is the first known study of geriatric depression in primary care in Nigeria. The rates are comparable with rates obtained in other countries. Specific correlates of depression in the older Nigerians identified included poor self-assessed health and low income.     

A community study of mental disorders in elderly Singaporean Chinese using the GMS-AGECAT package.

A random sample of 612 elderly Chinese aged 65 and over living in the community in Singapore was assessed with the community version of the Geriatric Mental State (GMS) and the data analysed by the AGECAT program to provide computerised diagnoses. The prevalence of organic disorder (dementia) was 2.3%, depression 5.7%, neuroses 1.5% and paranoid disorder 0.5%. The results were generally lower compared to the study of elderly people in Liverpool using the GMS-AGECAT package. Concordance between AGECAT and the psychiatrist's diagnoses for organic disorder, depression, neuroses and paranoid disorder achieved kappa values of 0.87, 0.88, 0.58 and 1.0 respectively.     

COMORBIDITY OF DEPRESSION IN THE ELDERLY—AN EPIDEMIOLOGICAL STUDY IN A CHINESE COMMUNITY

This is an epidemiological study on the comorbidity of depression in a random sample of 1062 elderly Chinese aged 65 and over in Singapore, using the Geriatric Mental State (GMS) schedule and the data analysed by the computerized diagnostic program AGECAT. The overall prevalence of current (30-day) depression was estimated to be 6.0% (males 5.9%, females 6.1%). There were comorbid psychiatric disorders, predominantly anxiety, in 45.3% of depressed elderly. Using DSM-III-R criteria, the prevalence of major depression was 5.2% and dysthymia 0.2%, with comorbid psychiatric disorders, mainly generalized anxiety disorder, in 40% of major depression. The risk factor profile of the elderly with pure and comorbid depression showed significant differences. A past history of depression and lower level of education were risk factors for comorbid depression—but there was no significant difference between the two groups in sex, age, marital status or living arrangement.     

Anxiety and mood disorders in primary care practice

Anxiety and mood disorders are common conditions in primary health care service. Primary care physicians (PCPs) have a privileged role in the early recognition of these conditions. In this study, the prevalence rates of threshold and subthreshold mood and anxiety disorders were surveyed among 1815 primary care attendees in 12 PCPs’ offices in Budapest, using the Diagnostic Interview Schedule (DIS). The 1-year prevalence of DIS/DSM-III-R anxiety and/or mood disorders was 16.8%, and the 1-month prevalence was 12.5%. The occurrence rates of subthreshold anxiety and/or depression were 25.7 and 13.1%, respectively. The impact of threshold anxiety and mood disorders on work performance was considerably higher than the impact of subthreshold symptoms. At the time of the interview, 6.7% of the patients received mood and/or anxiety disorder diagnoses by their PCPs. The measure of agreement between the diagnoses generated by the DIS and the ones given by the PCPs was low. The presence of an acute or chronic physical illness made it more difficult for the PCPs to recognize a psychiatric disorder. Conversely, patients’ psychological complaints significantly improved the recognition of anxiety and/or mood disorders. The use of the Beck Depression Inventory (BDI) brief version would help the patients to reveal their psychological symptoms, and the physicians to recognize an underlying psychiatric disorder.     

Behavioral and psychological symptoms of dementia in developing countries

BACKGROUND: Little is known about the prevalence of, or associations with behavioral and psychological symptoms of dementia (BPSD) in developing countries. METHODS: Individuals diagnosed as having dementia according to DSM-IV criteria (mild and moderate cases as defined by the Clinical Dementia Rating scale only), together with their main caregiver, were recruited from 21 centers in 17 developing countries. People with dementia were directly assessed with the Community Screening Interview for Dementia and the Geriatric Mental State Schedule (GMS); GMS data were processed by the AGECAT computer program to yield diagnostic information on 8 psychiatric syndromes. Caregivers answered direct questions about behavioral symptoms of dementia (BSD) and completed the Zarit Burden Inventory. RESULTS: At least one BSD was reported in 70.9% of the 555 participants. At least one case-level AGECAT psychiatric syndrome (not including the organic syndrome) was exhibited by 49.5% of people with dementia. Depression syndromes (43.8%) were most common followed by anxiety neurosis (14.2%) and schizophreniform/paranoid psychosis (10.9%). Caregivers were more likely to report BSD in people with dementia who were married, younger and better educated. More advanced dementia, poorer functioning and the presence of depression or anxiety were each associated with BSD. BSD, and psychiatric syndromes (anxiety neurosis and schizophreniform/paranoid psychosis) predicted caregiver strain after controlling for cognitive impairment. BPSD are poorly understood, leading to shame and blame. CONCLUSIONS: BPSD are common among people with dementia in developing countries, though we found marked regional variations. Representative population studies are needed to clarify prevalence and impact, but our research suggests considerable unmet need, with much scope for intervention. Raising awareness of the problem should be the first step.     

Psychiatric disorders in a U.S. community THE APPLICATION OF RESEARCH DIAGNOSTIC CRITERIA TO A RESURVEYED COMMUNITY SAMPLE

Point prevalence rates of psychiatric disorders, risk factors, and treatment sought for the disorders are presented, based on a 1975–1976 follow-up of a community probability sample originally surveyed in 1967. These data, while preliminary because of the limitations of a follow-up study, demonstrate the first application to a community sample of new psychiatric diagnostic techniques (SADS-RDC), which are being used with increasing frequency in the United States. The forthcoming DSM-III will be based on these diagnostic techniques. These results, consistent with other reports, show that depression is the most common psychiatric disorder in the community; that schizophrenia and bipolar disorders both have low frequency; and that psychiatric disorders are heterogeneous by age, sex, race, social class, marital status. While persons with a psychiatric disorder tend to use the health care system in the United States, they do not specifically seek help for emotional problems. Since the majority of psychiatric disorders are untreated in the mental health system, prevalence rates of psychiatric disorders based on cases receiving treatment in psychiatric facilities are a gross underestimate.     

The effect of somatic symptom attribution on the prevalence rate of depression and anxiety among nursing home patients

The validity of diagnostic psychiatric instruments for depression and anxiety disorders may be compromised among patients with complex physical illness and disability. The objective of this study was to determine the effect on the prevalence rate of depression and anxiety in a nursing home population of attributing somatic symptoms of depression and anxiety to either somatic or psychiatric disorder. Symptoms of major depression (MD), generalized anxiety disorder (GAD) and panic disorder (PD) were measured using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Somatic symptoms of MD, GAD and PD were attributed to somatic causes when the interviewer was not sure about a psychiatric cause. To analyse the effect of this attribution on the prevalence rate of MD, GAD and PD, a sensitivity analysis was undertaken in which symptoms that were attributed to somatic causes were recoded as symptoms attributed to psychiatric disorder. Prevalence rates of MD, GAD and PD were calculated before and after recoding. The prevalence of MD after recoding rose from 7.5% to 8.1%. The prevalence of GAD did not change. The prevalence of PD rose from 1.5% to 1.8%. Attribution of somatic symptoms to either somatic or psychiatric disorder when the interviewer was not sure about a psychiatric cause of the somatic symptoms had only a very modest effect on the prevalence rate of major depression, generalized anxiety disorder and panic disorder in a nursing home population.     

Prospective data on the prevalence of abnormal involuntary movements among elderly people living in the community

Trained raters from the Liverpool Continuing Health in the Community study interviewed 1070 people over the age of 65 in 1982–1983 using the Geriatric Mental State (GMS) examination. Three years later the cohort was re-interviewed, this time by psychiatrists trained in the GMS, who used the GMS and the History and Aetiology Schedule (HAS). The cohort had fallen in size to 875, because of mortality; 701 were re-interviewed. The cohort was followed up again 6 years after the first interview by trained nurse raters using the GMS (A3) and the Mini-Mental State Examination. Cases of mental disorder identified by the computer diagnostic program AGECAT were re-interviewed by psychiatrists along with a number of controls using the GMS and the HAS on the remaining 450 individuals. Observational behavioural ratings from the GMS and summary sheets were analysed along with AGECAT diagnoses and data on medication gained at the 3 assessments. The community prevalence of tardive dyskinesia and other movement disorders in elderly people over a 6-year follow-up appears to be very low (the community prevalence of tardive dyskinesia being 0.22% and akathisia 1.57%). is usually associated with organic mental disorder (and consequently higher mortality) and is furthermore not usually associated with antipsychotic medication.     

Survival in the community of the very old depressed, discharged from medical inpatient care

OBJECTIVES: To examine the prevalence and associated risk factors of depression in older patients discharged home from acute medical care and their influence on duration of survival in the community. DESIGN: A cross-sectional, prevalence study of depression in recently discharged patients and a prospective, case-controlled study of depressed and psychiatrically asymptomatic sub groups, exploring the relationship between depression, associated risk factors, and duration of survival in the community. SETTING: A community study of patients aged 75 and older discharged from the Countess of Chester Hospital and Wirral Hospitals Trust serving Wirral and West Cheshire, England. PARTICIPANTS: Three hundred and eleven patients were entered into the prevalence study. One hundred and fifty-eight patients (54 depressed and 104 asymptomatic) were entered into the prospective case controlled study and followed up for up to two years. MEASUREMENTS: Depression was defined by GMS/AGECAT criteria. Demographic details, handicap, pain, forced expiratory volume and social network were measured as dependent variables in the prevalence study and included in the analysis of risk factors potentially associated with duration of survival in the community. RESULTS: A depression prevalence rate of 17.4% was found. Age (p = 0.049, CI; 0.813, 0.999), forced expiratory volume (p = 0.034, CI; 0.991, 1.000) and handicap (p = 0.000, CI; 1.268, 1.723) were associated with depression but depression (p = 0.040, CI; 1.039, 4.915) was the only base-line variable associated with reduced survival in the community as defined by mortality and re-admission. CONCLUSIONS: Depression is common in older people discharged from acute medical care and is a major risk factor for reduced duration of community survival.     

The relationship between mortality and mental disorder: Evidence from the Liverpool longitudinal study

In 1982/83 a random community sample of 1070 people aged 65 years and over resident in Liverpool was identified. GMS data from this sample were analysed using the AGECAT computer diagnostic program and reliable and valid rates for the different mental illnesses were determined. One hundred and seventy-nine subjects have died during the first three years of follow-up in the longitudinal study and form the basis of the mortality data presented here. The results demonstrate a significant relationship between mortality rates and mental disorder and we discuss these findings for different diagnostic categories as well as using the ability of the AGECAT system to look at case levels.     

Psychiatric disorders in elderly from the Indian sub-continent living in Bradford

In our community study of the prevalence of psychiatric disorders among elderly South Asian immigrants from the Indian sub-continent (India, Pakistan and Bangladesh) living in Bradford (UK), we found depression in 20%, dementia in 4% and anxiety neurosis in 4%. Subjects were interviewed at their place of residence by a consultant psychiatrist familiar with their culture and language. The Hindi translation of the community version of the Geriatric Mental State schedule (GMS-A) was also administered. Psychiatrist's ICD-9 diagnosis was compared with GMS–AGECAT computerized diagnosis. We found low-level agreement in dementia cases (kappa 0.33) whereas the agreement in subjects with depression was high (kappa 0.81). In many subjects GMS-A made a diagnosis of dementia not diagnosed as cases by the psychiatrist, who had the benefit of additional history information from carers in this population from a different culture and educational background. These findings are discussed along with suggestions and present limitations of GMS-A in the diagnosis of dementia in cross-cultural research. Larger studies are needed in this population (a) to find out prevalence rates in countries of origin and (b) to investigate the author's (KB) observation of low rates of Alzheimer's type dementia in this population, which may have aetiological significance. © 1997 John Wiley & Sons, Ltd.     

Psychiatric disorders among elderly patients attending a geriatric medical day hospital: Prevalence according to clinical diagnosis (DSM-III-R) and agecat

One hundred and fourteen elderly medically ill day patients were interviewed in order to assess the prevalance of DSM-III-R main psychiatric disorders. Dementia affected 14.0% of the subjects, major depression 20.3%, dysthymic disorder 4.4%, atypical depression 13.2%, other disorders 3.6%. Overall, 60.5% of the patients had a psychiatric disorder. The computerized case designation (AGECAT) showed an acceptable concordance with clinical diagnoses (kappa value for dementia 0.59, for depression 0.58). Some issues related to the high prevalence of major depression are discussed.     

A community-based study of depression in older people in Hefei, China--the GMS-AGECAT prevalence, case validation and socio-economic correlates

OBJECTIVE: Previously published studies of prevalence of depression in older people in China showed much variation in the results, while the pooled prevalence is low. In this study we used a standardised method, the Geriatric Mental State (GMS) to investigate the prevalence of depression in older people in China, validate the GMS-AGECAT depression cases and examine the relationship between depression and socio-economic deprivation. METHODS: 1736 subjects aged > or =65 were recruited from Hefei city, China. They were interviewed at home by a survey team from Anhui Medical Universtiy using the GMS and other interviews. Their mental disorders were diagnosed by the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT). Chinese psychiatrists re-examined depression cases and their controls. RESULTS: 39 depressed cases were diagnosed by the GMS-AGECAT. Age-standardised prevalence was 2.2% (95% CI 1.5-2.9), which was about five-times lower than that of older people in Liverpool, UK. Agreement on depression diagnoses between the GMS-AGECAT and local Chinese psychiatrists was 83.6%, with a Kappa of 0.67 (p<0.001). Depression was significantly related to socio-economic deprivation. CONCLUSIONS: This community-based study suggested a low prevalence of depression in older people in urban China. Approved training in the use of the GMS-AGECAT in mainland China should make it possible to carry out a large scale epidemiological study on depression in the Chinese elderly population to investigate its geographic variation and risk factors. The dose-response relation between socio-economic deprivation and depression indicates that strategies for tackling inequality in depression in elderly are urgently needed in China.     

RELIABILITY AND VALIDITY OF THE SPANISH VERSION OF THEGMS–AGECAT PACKAGE FOR THE ASSESSMENT OF DEMENTIA AND COGNITIVE DISTURBANCES

This report confirms the reliability and validity of the Geriatric Mental State–Automated Geriatric Examination for Computer Assisted Taxonomy (GMS–AGECAT) package in a Spanish elderly population. No changes in the original English version are considered necessary. A representative sample (N=1080) of the elderly (65+ years) community in Zaragoza, Spain, stratified by age and sex was assessed. A two-phase screening was designed: phase I (lay interviewers): Spanish versions of GMS–AGECAT and Mini-Mental (MMSE); phase II (psychiatrists,N=324): the same instruments and History and Aetiology Schedule (HAS). Diagnosis: DSM-III-R criteria. Stringent test–retest reliability coefficients were calculated by comparing lay interviewers’ (phase I) vs psychiatrists’ (phase II) ratings. DSM-III-R psychiatric diagnoses in phase II were the gold standards for the validity study. Test–retest reliability coefficients of the cognitive sections of GMS were: case/no case distinction, mean kappa=0.71; dementia/no dementia distinction, mean kappa=0.80. GMS validity coefficients: detection of cases, sensitivity=98.4%; specificity=76.5%. Test–retest reliability coefficients of AGECAT: case/no case distinction, mean kappa=0.59; organic syndrome, dementia, mean kappa=0.68. Validity coefficients of AGECAT (psychiatrists’ outputs): case/no case distinction, sensitivity=90.6%; specificity=89.3%; dementia/no dementia distinction, sensitivity=86.4%; specificity=94.3%.