The longitudinal relationship between the use of long-term care and depressive symptoms in older adults

PURPOSE: The aim of this study was to estimate the longitudinal relationship between transitions in the use of long-term care and older adults' depressive symptoms and to investigate whether this relationship could be explained by markers of older adults' underlying health, or other variables including demographics, personality, and partner status. DESIGN AND METHODS: Data were from the Longitudinal Aging Study Amsterdam, which consists of a random, community-based sample of 3,107 older Dutch people (55-85 years of age) stratified by age and gender. The use of informal care, professional home care, and institutional care was recorded, and respondents were screened on depressive symptoms. Follow-up measurements took place at 3 and 6 years. RESULTS: Longitudinal analyses showed significant associations between the enduring use of professional long-term care and an increase in depressive symptoms. Transitions to professional home care or institutional care were also associated with considerably more depressive symptoms after 3 years, whereas transitions from professional home care or institutional care to no care or informal care only were not associated with a change in depressive symptoms. Most of the associations remained significant after indicators of underlying health and other covariates were adjusted for, and also after the data were reanalyzed for respondents with and without functional limitations. IMPLICATIONS: This study does not involve a controlled experiment of professional long-term care among older adults. However, the findings suggest the possibility that receiving professional long-term care could introduce new stressors and increase the risk of depressive symptoms. Our analyses illuminate the concerns of elders regarding their use of professional long-term care and may help in planning for more effective delivery of this type of care.     

Depressive symptoms and self-rated health in community-dwelling older adults: a longitudinal study

OBJECTIVES: To test whether baseline depressive symptoms in older adults increase the risk of subsequent decline in self-rated health and decrease the likelihood of subsequent improvement in self-rated health. DESIGN: A 2-year prospective cohort study. SETTING: Six thousand seven hundred fourteen community-dwelling older persons who completed the first and second wave of the Asset and Health Dynamics among the Oldest-Old Survey in the United States. PARTICIPANTS: Community-dwelling older people in the United States. MEASUREMENTS: Baseline depressive symptoms were measured using a short-form of the Center for Epidemiological Studies Depression Scale. Self-rated health was measured using a single item of global health rating. RESULTS: After adjustment for covariates, a high burden of depressive symptoms at baseline was predictive of greater decline in self-rated health (odds ratio (OR) for decline in those with high burden of depressive symptoms vs those without = 1.47, 95% confidence interval (CI) = 1.26-1.70). Likewise, high burden of depressive symptoms at baseline predicted less improvement in self-rated health (OR for improvement in those with high burden of depressive symptoms vs those without = 0.57, 95% CI = 0.50-0.65). CONCLUSIONS: Depressive symptomatology is an independent risk factor for subsequent changes in self-rated health in older adults. Thus, early prevention and intervention of depressive symptoms in community-dwelling older adults might be critical to promote and maintain their self-rated health.     

Are public care and services for older people targeted according to need? Applying the Behavioural Model on longitudinal data of a Swedish urban older population

The objectives were to identify factors that predict the use of home help services and transition into institutional care and to study to what extent care services were targeted according to the individuals’ needs. A further objective was to study whether people who had moved into institutional care facilities had received home help prior to institutionalisation. A community-dwelling sample (n=502) aged 81–100 was twice interviewed and assessed with medical examinations. Their use of public elderly care between 1994/1996 and 2000 was studied using survival analyses. Need factors, according to the Andersen Behavioural Model, were the most important predictors for the use of elderly care. Among people living alone, dementia, functional limitations, and depressive symptoms predicted the use of home help services and institutionalisation. Among non-demented cohabiting people, depressive symptoms and dependence in ADLs increased the likelihood of both home help and institutionalisation. Among cohabiting people with dementia, the effect of dementia was difficult to separate from the effects of ADL limitations and depression. Enabling factors were of importance among cohabiting people. A high level of education increased the likelihood of moving into institutional care, and informal extra-residential care increased the likelihood of both outcomes indicating that elderly care resources had not been targeted solely according to need. Predisposing factors such as age and gender were of importance only among people living alone. Basically the same factors predicted both the receipt of home help and institutionalisation. Only 4% of people living alone and 5% of those cohabiting moved to institutions without previously receiving home help.     

Change of depressive symptoms in a French nine-year longitudinal study of aging: Gender differences and relationships between social support,health status and depressive symptoms

ObjectivesThe aims of this study were to examine the trajectory of depressive symptoms among older French people, to investigate the role of gender in the developmental trajectory of depressive symptoms and to explore whether the linear increase in depressive symptoms might be accentuated or attenuated at time points during which the older adults’ scores on social support and health satisfaction scales were higher than their individual averages.Methods/materialsData were used from a subsample of older adults living at home who participated in a longitudinal study initiated by researchers from the University of Tours. They were collected at five time points over a 9-year period (T1: 2003; T2: 2005; T3: 2007; T4: 2009; T5: 2011). This study included 707 participants, and multilevel growth curve analysis was used on measures of depressive symptoms, gender differences, social support and health satisfaction.ResultsResults indicated (1) a significant positive linear effect of age on depressive symptoms; (2) that women reported significantly higher scores of depressive symptoms than men at 63 years old (i.e., intercept) and that this gender difference remained constant across age; (3) that the slope of depressive symptoms appeared to increase at time points during which participants had higher levels of social support and to decrease when they had greater health satisfaction.ConclusionThis study provides pertinent information about the change of depressive symptoms in older people living at home and particularly highlights the interest in studying gender, social support and health satisfaction.     

The effect of spousal mental and physical health on husbands' and wives' depressive symptoms, among older adults: longitudinal evidence from the Health and Retirement Survey

OBJECTIVE: To estimate the effect of spousal depressive symptoms and physical health on respondents' depressive symptoms in a national sample of older married couples. METHOD: We used data on 5,035 respondent husbands and wives from the 1992 and 1994 waves of the Health and Retirement Survey. Multivariate regression models were estimated to examine the impact of spousal depressive symptoms and physical health on respondents' depressive symptoms. RESULTS: Adjusting for respondent mental and physical health and sociodemographic traits, having a spouse with more depressive symptoms was associated with significantly higher follow-up depressive symptoms in the respondent (p < .001). Controlling for spousal depressive symptoms, a decline in the spouses' physical health was associated with a significant reduction in respondent depressive symptoms (p < .05). DISCUSSION: Our findings suggest that health care providers treating older adults should be sensitive to the possibility that spouses may be affected when clients suffer poor mental or physical health.     

Longitudinal associations of depressive symptoms,subjective memory decline,and cognitive functioning among Chinese older adults: Between-person and within-person perspective

ObjectivesWe examined between- and within-person associations between depressive symptoms and cognitive functioning among Chinese older adults (aged 60+) over time. Furthermore, we also investigated whether subjective memory decline (SMD) is uniquely associated with cognitive functioning above and beyond depressive symptoms for both between-person and within-person associations.MethodsAbout 7385 older adults from the China Health and Retirement Longitudinal Study reported their demographic and health status, and completed self-report measures of depressive symptoms and SMD, as well as a battery of cognitive tests, every two years at three times between 2011 and 2015.ResultsThere were significant between-person and within-person associations between depressive symptoms and cognitive functioning. Furthermore, SMD was uniquely associated with cognitive functioning for both within-person and between-person associations after controlling for depressive symptoms.ConclusionsThe results highlight the importance of careful screening and monitoring of depressive symptoms and SMD for the benefits of cognitive functioning among Chinese older adults. More importantly, SMD has practical implications for the care of Chinese older adults given significant cultural stigma attached to mental illness within Chinese culture.     

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns

Background

Rapidly aging populations with an increased desire to remain at home and changes in health policy that promote the transfer of health care from formal places, as hospitals and institutions, to the more informal setting of one's home support the need for further research that is designed specifically to understand the experience of home among older adults. Yet, little is known among health care providers about the older adult's experience of home. The aim of this study was to understand the experience of home as experienced by older adults living in a rural community in Sweden.

Methods

Hermeneutical interpretation, as developed by von Post and Eriksson and based on Gadamer's philosophical hermeneutics, was used to interpret interviews with six older adults. The interpretation included a self examination of the researcher's experiences and prejudices and proceeded through several readings which integrated the text with the reader, allowed new questions to emerge, fused the horizons, summarized main and sub-themes and allowed a new understanding to emerge.

Results

Two main and six sub-themes emerged. Home was experienced as the place the older adult could not imagine living without but also as the place one might be forced to leave. The older adult's thoughts vacillated between the well known present and all its comforts and the unknown future with all its questions and fears, including the underlying threat of loosing one's home.

Conclusions

Home has become so integral to life itself and such an intimate part of the older adult's being that when older adults lose their home, they also loose the place closest to their heart, the place where they are at home and can maintain their identity, integrity and way of living. Additional effort needs to be made to understand the older adult's experience of home within home health care in order to minimize intrusion and maximize care. There is a need to more fully explore the older adult's experience with health care providers in the home and its impact on the older adult's sense of "being at home" and their health and overall well-being.     

Measurement properties of the Minimal Insomnia Symptom Scale (MISS) in an elderly population in Sweden

Background

The purpose of this study was to identify predictors of health decline among older adults with clinically diagnosed community acquired pneumonia (CAP). It was hypothesized that older adults with CAP who had lower levels of social support would be more likely to report a decline in health.

Methods

A telephone survey was used to collect detailed information from older adults about their experiences with CAP. A broader determinants of health framework was used to guide data collection. This was a community wide study with participants being recruited from all radiology clinics in one Ontario community.

Results

The most important predictors of a health decline included: two symptoms (no energy; diaphoresis), two lifestyle variables (being very active; allowing people to smoke in their home), one quality of life variable (little difficulty in doing usual daily activities) and one social support variable (having siblings).

Conclusions

A multiplicity of factors was found to be associated with a decline in health among older adults with clinically diagnosed CAP. These findings may be useful to physicians, family caregivers and others for screening older adults and providing interventions to help ensure positive health outcomes.     

Non-pharmacological prevention of major depression among community-dwelling older adults: A systematic review of the efficacy of psychotherapy interventions

Depression is a major public health burden among the aging population. While older adults prefer non-pharmacological treatment, few options for psychotherapy are available in primary care settings, which is where older adults tend to receive mental health services. Indicated prevention is a cost-effective, public health approach to prevent major depressive disorder among people with depressive symptoms who do not yet meet standard criteria for major depression. We critically reviewed randomized controlled trials (RCTs) that assessed the efficacy of psychotherapy among community-dwelling older adults with subthreshold depression (depressive symptoms that do not meet standard criteria for major depression). We examined the intervention types, results, internal validity, and external validity of five studies. We used the United States Preventive Services Task Force (USPSTF) guidelines to rate the quality of the studies and to provide recommendations. Results suggest that psychotherapy is a safe and cost-effective method to reduce the public health burden of depression among older adults with subthreshold depression.     

Frailty differences in older adults’ use of informal and formal care

ObjectivesThis study examines different combinations of informal and formal care use of older adults and investigates whether these combinations differ in terms of need for care (physical and psychological frailty) and enabling factors for informal and formal care use (social and environmental frailty).MethodsUsing cross-sectional data from the Belgian Ageing Studies (survey, N = 38,066 community-dwelling older adults), Latent Class Analysis (LCA) is used to identify combinations of informal and formal care use. Bivariate analyses are used to explore the relationship between the different combinations of care use and frailty.ResultsLatent Class Analysis (LCA) identified 8 different types of care use, which vary in combinations of informal and formal caregivers. Older adults who are more likely to combine care from family and care from all types of formal caregivers are more physically, psychologically and environmentally frail than expected. Older adults who are more likely to receive care only from nuclear family, or only from formal caregivers are more socially frail than expected.ConclusionsOlder adults with a higher need for care are more likely to receive care from different types of informal and formal caregivers. High environmental frailty and low social frailty are related with the use of care from different types of informal and formal caregivers. This study confirms that informal care can act as substitute for formal care. However, this substitute relationship becomes a complementary relationship in frail older adults. Policymakers should take into account that frailty in older adults affects the use of informal and formal care.     

Impact of informal care levels on discontinuation of living at home in community-dwelling dependent elderly using various community-based services

The aim of the study was to examine the effect of informal care levels on overall discontinuation of living at home, all-cause death, hospital admission, and long-term care placement for community-dwelling older people using various community-based services during a 3-year period. Prospective cohort study of 1582 community-dwelling disabled elderly and paired informal caregivers was conducted. Baseline data included the recipients and caregivers’ demographic characteristics, comorbidities, informal care levels (sufficient, moderate, and insufficient care), which were evaluated by trained visiting nurses, and the level of formal community-based service use. Among 1582 participants, 97 died at home, 692 were admitted to hospitals, 318 died during their hospital stay, and 117 were institutionalized in long-term care facilities during 3 years of follow-up. A multivariate Cox hazard model demonstrated that when compared with a sufficient informal care level, an insufficient informal care level was associated with overall discontinuation of living at home, all-cause mortality, hospitalization, and institutionalization during 3 years of follow-up (hazard ratio: 1.65, 95% confidence interval: 1.15-2.36; 1.98, 1.17-3.34; 1.56, 1.04-2.35; 2.93, 1.25-6.86, respectively). The results suggested that informal caregiving is an important factor in the prevention of overall discontinuation of living at home in a population of disabled older people.     

Effect of depression treatment on depressive symptoms in older adulthood: the moderating role of pain

OBJECTIVES: To investigate whether pain severity and interference with normal work activities moderate the effects of depression treatment on changes in depressive symptoms over time in older adults in primary care. DESIGN: Patient-randomized, clinical trial. SETTING: Multisite: three clinics located in Veterans Affairs Medical Centers. PARTICIPANTS: Adults aged 60 and older (n=524) who screened positive for depression and participated in the Primary Care Research in Substance Abuse and Mental Health for the Elderly Study. INTERVENTION: Integrated care versus enhanced specialty referral care. MEASUREMENTS: Pain severity, the degree to which pain interferes with work inside and outside of the home, and depressive symptoms were examined at baseline and 3, 6, and 12 months. RESULTS: Intention-to-treat analyses revealed that both treatment groups showed reduced depressive symptoms over time, although self-reported pain moderated reductions in depressive symptoms. At higher levels of pain severity and interference with work activities, improvements in depressive symptoms were blunted. Furthermore, pain interference appeared to have a greater effect on depressive symptoms than did pain severity; in individuals with major depression, pain interference fully accounted for the moderating effects of pain severity on changes in depressive symptoms over time. CONCLUSION: Pain and its interference with functioning interfere with recovery from depression. Findings highlight the importance of addressing multiple domains of functioning (e.g., physical and social disability) and the degree to which pain and other forms of physical comorbidity may hinder or minimize treatment-related improvements in depressive symptoms.     

Estimating the Quantity and Economic Value of Family Caregiving for Community-Dwelling Older Persons in the Last Year of Life

OBJECTIVES: To estimate the quantity and economic value of informal care provided to older persons during their final year of life in the community.
DESIGN: Retrospective analysis of publicly available nationally representative survey data.
SETTING: This retrospective study used data from the Health and Retirement Study, a nationally representative, longitudinal study of community-dwelling older people.
PARTICIPANTS: Older people who died between 2000 and 2002.
MEASUREMENTS: Data were extracted from the 2002 "exit survey" and linked with characteristics of caregivers from the helper file. Ordinary least squares regression was used to estimate hours of informal caregiving for community-dwelling older people (N=990). Adjusted hours were multiplied by the 2002 national average home aide wage ($9.16 per hour). Sensitivity tests were performed using the 10th percentile wage rate ($6.56) and 90th percentile wage rate ($12.34).
RESULTS: Older people who died in the community received on average 65.8 hours per week of informal care in the last year of life. The estimated economic value ranges from $22,514 to $42,351, which is equivalent to the annual direct replacement cost with a home aide in 2002.
CONCLUSION: Family members provide substantial assistance during the last year of life for older people who die in the community. If the informal care provided in the last year of life is replaced with a home aide, the total economic value for the United States would be approximately $1.4 billion (in 2002).     

Alcohol Consumption Among Older Adults in Primary Care

Background Alcohol misuse is a growing public health concern for older adults, particularly among primary care patients. Objectives To determine alcohol consumption patterns and the characteristics associated with at-risk drinking in a large sample of elderly primary care patients. Design Cross-sectional analysis of multisite screening data from 6 VA Medical Centers, 2 hospital-based health care networks, and 3 Community Health Centers. Participants Patients, 43,606, aged 65 to 103 years, with scheduled primary care appointments were approached for screening; 27,714 (63.6%) consented to be screened. The final sample of persons with completed screens comprised 24,863 patients. Measurements Quantity and frequency of alcohol use, demographics, social support measures, and measures of depression/anxiety. Results Of the 24,863 older adults screened, 70.0% reported no consumption of alcohol in the past year, 21.5% were moderate drinkers (1–7 drinks/week), 4.1% were at-risk drinkers (8–14 drinks/week), and 4.5% were heavy (>14 drinks/week) or binge drinkers. Heavy drinking showed significant positive association with depressive/anxiety symptoms [Odds ratio (OR) (95% CI): 1.79 (1.30, 2.45)] and less social support [OR (95% CI): 2.01 (1.14, 2.56)]. Heavy drinking combined with binging was similarly positively associated with depressive/anxiety symptoms [OR (95%): 1.70 (1.33, 2.17)] and perceived poor health [OR (95% CI): 1.27 (1.03, 1.57)], while at-risk drinking was not associated with any of these variables. Conclusions The majority of participants were nondrinkers; among alcohol users, at-risk drinkers did not differ significantly from moderate drinkers in their characteristics or for the 3 health parameters evaluated. In contrast, heavy drinking was associated with depression and anxiety and less social support, and heavy drinking combined with binge drinking was associated with depressive/anxiety symptoms and perceived poor health.     

A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults

OBJECTIVES: To test the efficacy of a multicomponent intervention to reduce functional difficulties, fear of falling, and home hazards and enhance self-efficacy and adaptive coping in older adults with chronic conditions. DESIGN: A prospective, two-group, randomized trial. Participants were randomized to a treatment group or no-treatment group. SETTING: Urban community-living older people. PARTICIPANTS: Three hundred nineteen community-living adults aged 70 and older who reported difficulty with one or more activities of daily living. INTERVENTION: Occupational and physical therapy sessions involving home modifications and training in their use; instruction in strategies of problem-solving, energy conservation, safe performance, and fall recovery techniques; and balance and muscle strength training. MEASUREMENTS: Outcome measures included self-rated functional difficulties with ambulation, instrumental activities of daily living, activities of daily living, fear of falling, confidence performing daily tasks, and use of adaptive strategies. Observations of home hazards were also conducted. RESULTS: At 6 months, intervention participants had less difficulty than controls with instrumental activities of daily living (P=.04, 95% confidence interval (CI)=-0.28-0.00) and activities of daily living (P=.03, 95% CI=-0.24 to -0.01), with largest reductions in bathing (P=.02, 95% CI=-0.52 to -0.06) and toileting (P=.049, 95% CI=-0.35-0.00). They also had greater self-efficacy (P=.03, 95% CI=0.02-0.27), less fear of falling (P=.001, 95% CI=0.26-0.96), fewer home hazards (P=.05, 95% CI=-3.06-0.00), and greater use of adaptive strategies (P=.009, 95% CI=0.03-0.22). Benefits were sustained at 12 months for most outcomes. CONCLUSION: A multicomponent intervention targeting modifiable environmental and behavioral factors results in life quality improvements in community-dwelling older people who had functional difficulties, with most benefits retained over a year.     

Palliative Access Through Care at Home: Experiences with an Urban, Geriatric Home Palliative Care Program

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end-of-life care needs. Certain groups, such as African-American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home-based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed-methods study consisting of chart review, telephone interviews, and face-to-face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African-American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.     

Transitions in formal and informal care utilisation amongst older Europeans: the impact of national contexts

The objective of this study was to explore how long-term care systems, and in particular the incorporation of needs-based entitlements to care services or benefits, influence formal and informal care utilisation dynamics. We used the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 1 and 2 data, restricting the sample to persons 65+ from 9 European countries (N = 6,293). The effects of changes in health and household composition on formal and informal care transitions were estimated using logistic regression, allowing these effects to vary across countries. The results indicated that, in all countries, formal and informal care were more often complements than substitutes. The likelihood of becoming a formal or informal care user varied significantly between countries. In the Scandinavian countries and in several continental European countries with needs-based entitlements, the transition to formal care was strongly related to informal support being or becoming unavailable. We found little evidence of country differences in the effect of health variables on the transition to formal care. The analysis suggested that, whilst rates of formal care utilisation continue to differ considerably between European countries, formal care allocation practices are not very dissimilar across Northern and continental European welfare states, as we found evidence for all countries of targeting of older persons living alone and of the most care-dependent older people.