Service needs of depressed older adults following acute psychiatric care

Older persons with mental disorder need mental health services, but the extent to which they have service needs in other domains (medical, functional and psychosocial) is not established, although these needs may compromise the attainment of psychiatric outcomes. This study focuses on 169 older adults hospitalized for depression and documents their post-acute service needs in four domains: psychiatric, medical, functional and psychosocial. Seventy-five per cent of these psychiatric patients had medical conditions that required treatment. Eighty-four per cent needed assistance with routine activities. Nearly two-thirds (67%) were experiencing one or more psychosocial or environmental problems that warranted intervention. The mean number of service needs was 6.5 (SD=1.5). Fifty-seven per cent had needs in all four domains. Older adults admitted to acute care for depression have high levels of service needs stemming from multiple domains: psychiatric, medical, functional and psychosocial. We extend the biopsychosocial model, largely used to address the origins of psychopathology, to conceptualize the multiple domains of service that older adults with mental disorder need. This biopsychosocial model suggests that needs in each domain should be identified and addressed if desired psychiatric outcomes are to be attained.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Humor comprehension in older adults.

The goal of this study was to understand factors related to humor comprehension in old age. This study proposes that, in contrast to younger adults, older adults have greater difficulty with humor comprehension due to age-related cognitive decline. Tests of verbal and nonverbal humor comprehension and tests of cognitive flexibility, abstract reasoning, and short-term memory were administered to 40 younger and 41 older adults. In general, older adults scored lower than younger adults on tests of humor and cognitive abilities. Regression analyses support the idea that cognition affects humor comprehension, but the relative contribution of each specific mechanism remains unclear. The results of this study suggest that there may be age-related deficits in humor comprehension, but more importantly, that a more sophisticated model is needed to clarify the role of cognition in humor comprehension. Humor comprehension warrants further study because of the potential physical and psychological benefits of humor.     

The interpersonal needs questionnaire with a shortened response scale for oral administration with older adults

Objectives: The purpose of this paper is to examine the psychometric properties and construct validity of the interpersonal needs questionnaire (INQ) using a modified three-point response scale for oral administration with older adults.

Methods: In-home interviews were conducted with 269 participants aged 60 and older who were completing an eligibility interview for a randomized control trial. The INQ was administered orally, as were measures of social support, death and suicide ideation, and meaning in life.

Results: A confirmatory factor analysis demonstrated acceptable fit, with all of the items loading significantly onto the associated latent variable of thwarted belongingness or perceived burdensomeness. Construct validity of the measure was supported through an examination of discriminant validity using constructs hypothesized by the interpersonal theory of suicide to be related to the measured constructs, including social support and social integration for thwarted belongingness, social worth and death ideation for perceived burdensomeness, and meaning in life and suicide ideation for both.

Conclusion: The INQ yields reliable and valid scores of thwarted belongingness and burdensomeness when administered orally using a shortened response scale with older adults. These results help establish the measure as a valuable and practical tool for use in the field of late-life suicide prevention.     

Sleep and its disorders in older adults.

For many older adults, aging is associated with significant changes in sleep. There are a variety of potential causes, including primary sleep disorders, circadian rhythm disturbances, insomnia, depression, medical illness, and medications. As with younger adults, the diagnosis requires a thorough sleep history and an overnight sleep recording when appropriate. Treatment should address the primary sleep problem and can result in significant improvement in quality of life and daytime functioning in older adults.     

Suicide and its prevention among older adults.

OBJECTIVE: To review the research on the epidemiology, risk and resiliency, assessment, treatment, and prevention of late-life suicide. METHOD: I reviewed mortality statistics. I searched MEDLINE and PsycINFO databases for research on suicide risk and resiliency and for randomized controlled trials with suicidal outcomes. I also reviewed mental health outreach and suicide prevention initiatives. RESULTS: Approximately 12/100,000 individuals aged 65 years or over die by suicide in Canada annually. Suicide is most prevalent among older white men; risk is associated with suicidal ideation or behaviour, mental illness, personality vulnerability, medical illness, losses and poor social supports, functional impairment, and low resiliency. Novel measures to assess late-life suicide features are under development. Few randomized treatment trials exist with at-risk older adults. CONCLUSIONS: Research is needed on risk and resiliency and clinical assessment and interventions for at-risk older adults. Collaborative outreach strategies might aid suicide prevention.     

Cumulative exposure to traumatic events in older adults

Objectives: The present study examined the impact of cumulative trauma exposure on current posttraumatic stress disorder (PTSD) symptom severity in a nonclinical sample of adults in their 60s. The predictive utility of cumulative trauma exposure was compared to other known predictors of PTSD, including trauma severity, personality traits, social support, and event centrality.

Method: Community-dwelling adults (n = 2515) from the crest of the Baby Boom generation completed the Traumatic Life Events Questionnaire, the PTSD Checklist, the NEO Personality Inventory, the Centrality of Event Scale, and rated their current social support.

Results: Cumulative trauma exposure predicted greater PTSD symptom severity in hierarchical regression analyses consistent with a dose–response model. Neuroticism and event centrality also emerged as robust predictors of PTSD symptom severity. In contrast, the severity of individuals’ single most distressing life event, as measured by self-report ratings of the A1 PTSD diagnostic criterion, did not add explanatory variance to the model. Analyses concerning event categories revealed that cumulative exposure to childhood violence and adulthood physical assaults were most strongly associated with PTSD symptom severity in older adulthood. Moreover, cumulative self-oriented events accounted for a larger percentage of variance in symptom severity compared to events directed at others.

Conclusion: Our findings suggest that the cumulative impact of exposure to traumatic events throughout the life course contributes significantly to posttraumatic stress in older adulthood above and beyond other known predictors of PTSD.     

Informal caregiving to older adults hospitalized for depression

This study addresses the following questions: (l) What are the caregiving needs stemming from functional dependency of older adults hospitalized for depression and discharged home?; (2) Who are the informal caregivers, and what assistance do they provide?; and (3) How adequate is this informal care? On a sample of 45 depressed older adults, in-hospital information was collected from medical records and discharge planners; and one month post-discharge, a telephone interview was completed. These data indicate that older adults hospitalized for depression are discharged home with high levels of functional dependency. Eighty-nine per cent of these patients have the assistance of an informal caregiver. Despite high levels of involvement, concerns remain about the adequacy of the care informal caregivers are able to provide in the face of such need. Yet mental health research, policy and practice have largely ignored the role of the family with depressed elders. Increased attention should be paid to the topic of informal caregiving to older adults with depression.     

Predicting cognitive decline in healthy older adults.

OBJECTIVE: Authors performed a neuropsychological determination of which individuals in a group of community-dwelling, healthy elderly volunteers would develop cognitive decline. METHODS: A group of 155 volunteers reporting good memory and thinking participated in a prospective study over 4 years. Authors monitored cognitive functioning and incidence of Mild Cognitive Impairment (MCI)/Alzheimer disease (AD). RESULTS: Baseline assessment revealed a subgroup of participants with deficits in associative learning and naming; subsequent cognitive decline was more precipitous in these individuals, who also showed higher relative risk of MCI/AD. CONCLUSION: Cognitive measures may be useful in community and clinical dementia screening and applicable for identifying enriched samples for trials of anti-dementia treatments.     

Emergency care avoidance: Ethnic matching and participation in minority-serving programs

Using data from a county level mental health service system, relationships were examined between ethnic matching, program involvement and emergency service use. When clients were matched with an ethnically similar clinician who was also proficient in their preferred language, they had fewer emergency service visits than did clients who were unmatched on the basis of ethnicity and language. Equally if not more significant than ethnicity or language matching was the client's program and the proportion of minority clients it served. Clients in programs serving a relatively large proportion of minority clients had fewer emergency service visits than those in programs serving a smaller proportion of minority clients. More research is needed to document the impact of matching along with greater attention to minority oriented programs.Center for Research on the Organization and Financing of Care for the Severely Mentally Ill. Teh-wei Hu is affiliated with the School of Public Health, University of California, Berkeley and the Center for Research on the Organization and Financing of Care for the Severely Mentally Ill.This research was supported by National Institute of Mental Health Grant # 1 RO1 MH46618-01.     

Epidemiology of apathy in older adults: the Cache County Study.

OBJECTIVES: The objectives of this study are to describe the distribution of apathy in community-based older adults and to investigate its relationships with cognition and day-to-day functioning. METHODS: Data from the Cache County Study on Memory, Health and Aging were used to estimate the frequency of apathy in groups of elders defined by demographic, cognitive, and functional status and to examine the associations of apathy with impairments of cognition and day-to-day functioning. RESULTS: Apathy was measured with the Neuropsychiatric Inventory. Clinical apathy (Neuropsychiatric Inventory score > or = 4) was found in 1.4% of individuals classified as cognitively normal, 3.1% of those with a mild cognitive syndrome, and 17.3% of those with dementia. Apathy status was associated with cognitive and functional impairments and higher levels of stress experienced by caregivers. Among participants with normal cognition, apathy was associated with worse performance on the Mini-Mental State Examination, the Boston Naming and Animal Fluency tests, and the Trail Making Test-Part B. The association of apathy with cognitive impairment was independent of its association with Neuropsychiatric Inventory depression. CONCLUSIONS: In a cohort of community-based older adults, the frequency and severity of apathy is positively correlated with the severity of cognitive impairment. In addition, apathy is associated with cognitive and functional impairments in elders adjudged to have normal cognition. The results suggest that apathy is an early sign of cognitive decline and that delineating phenotypes in which apathy and a mild cognitive syndrome co-occur may facilitate earlier identification of individuals at risk for dementia.