American Association for Geriatric Psychiatry (AAGP) 2012 Annual Meeting
March 16-19, 2012; Washington, DC
Older Patients Report High Rate of Loneliness
A cross-sectional survey finds that loneliness and feelings of being a burden are not uncommon among older adult primary care patients, and that patients who indicate either are more likely to report an unhappy mood. Kimberly Van Orden, PhD, postdoctoral fellow, University of Rochester Medical Center, NY, who led the study and presented its data during a poster session at the AAGP meeting, notes that future research should investigate the hypothesis that assessment of loneliness and feelings of burdensomeness may enable early identification of patients at risk of depression.
Social connectedness, which is a strong contributor to depression onset and maintenance, has not been well characterized among older adult primary care patients. Two forms of social disconnectedness may be especially relevant to the prevention of depression and suicide among older adults: loneliness and perceived burdensomeness. Given the potential for social connectedness to serve as a target in collaborative care models, the investigators sought to estimate the prevalence of these constructs and identify their correlates in a sample of 541 primary care patients who were 60 years or older (average age, 72 years).
The cross-sectional survey was performed as an inclusion screen for a clinical trial of a peer support intervention. The screening tool included three statements designed to screen for social disconnectedness and unhappy mood, each rated for a 2-week period using a 3-point scale (not at all true for me; somewhat true for me; very true for me). The statements were: “I feel lonely,” “I feel like a burden on the people in my life,” and “I feel happy.”
Over the 2-week period, 90 patients (16.67%) reported loneliness. Neither age nor sex predicted loneliness. Living alone increased the odds of expressing loneliness (odds ratio [OR], 3.17). Subjects who indicated loneliness were 2.84 times more likely to report an unhappy mood during the 2-week period. Of those who reported loneliness, 31% also noted feelings of burdensomeness. Overall, 51 (9.44%) patients reported perceived burdensomeness over the study period. Increasing age significantly increased the likelihood of expressing burdensomeness (OR, 1.08); the mean age of those reporting burdensomeness was 78 years, whereas participants not reporting burdensomeness had a mean age of 72 years. Being a man or woman was not associated with perceived burden. Subjects who expressed perceived burden were 5.23 times more likely to report an unhappy mood. Of those who noted burdensomeness, 56% also reported loneliness.
“Future research is needed to examine these constructs in long-term care residents, given that residence in a long-term care facility may, for some older adults, increase risk for feeling disconnected with others due to moving out of one’s home and neighborhood,” Van Orden said. “Perceived burdensomeness may also be a salient construct for long-term care residents given that feelings that one is a burden on others are associated with increased functional impairment. Importantly, both low belongingness and feelings of burdensomeness can be targeted with behavioral interventions and thereby, through their amelioration, should improve well-being.”—Wayne Kuznar
Vascular Depression More Common in African Americans
Vascular depression, a subtype of depression in late life in which cerebrovascular disease precipitates or perpetuates certain geriatric depressive symptoms, is more prevalent among the African American population. The finding is consistent with a higher rate of cardiovascular risk factors and vascular dementia among African Americans, said authors of an open-treatment study, who presented their data during a poster session at the AAGP meeting. The investigators, led by Michelle Reinlieb, MA, doctoral candidate, Graduate Center, City University of New York, NY, also found that patients with vascular depression are less likely to respond to antidepressant medication than are depressed patients without the vascular subtype.
The open-treatment trial assessed the rate of vascular depression in an outpatient clinic sample of 40 men and women 50 years or older, who met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) criteria for nonpsychotic unipolar major depressive disorder, dysthymia, or depressive disorder. A baseline Hamilton Rating Scale for Depression (HRSD)-24 score ≥14 was required for entrance into the study; participants were treated with open-label escitalopram or duloxetine for 8 weeks. Of the 40 patients enrolled (intent-to-treat sample), 36 underwent structural magnetic resonance imaging (MRI) at baseline, 14 of whom were classified as having vascular depression (based on the presence of deep white matter lesions ≥2 on a modified Coffey scale), and 22 as having nonvascular depression.
Approximately 61% of African Americans and only 14% of whites had vascular depression. Logistic regression analysis demonstrated that African Americans were 9.4 times more likely to have vascular depression than whites.
Demographic and clinical variables were compared between patients with vascular depression and patients with nonvascular depression using logistic regression analyses and t-tests. Patients with vascular depression were significantly more likely to have hypertension (P=.01) and had a significantly lower familial history of affective disorder (P=.02) compared with patients with nonvascular depression. Using t-tests, vascular depression was found to be associated with worse performance on all executive function measures at baseline (the Stroop Color-Word Test, the Initiation-Perseveration subtest of the Mattis Dementia Rating Scale, and the Trail Making Test B) and on one measure of psychomotor speed.
Logistic regression analyses on response (50% reduction in HRSD) and remission (HRSD ≤7) demonstrated that patients with nonvascular depression were 3.86 times as likely as those with vascular depression to be classified as responders at week 8 (P=.06) and 1.43 times as likely as those with vascular depression to meet remission criteria by week 8 (P=.63).—Wayne Kuznar
The study was supported by the National Institute of Mental Health.
Even Modest Elevations in Fasting Blood Glucose Levels Increase Risk of Depression in Older Adults
Fasting blood glucose levels were found in a regression analysis to predict depression in a geriatric population without diabetes. Investigators, who presented their findings during a poster session at the AAGP meeting, said that their data indicate that clinicians should have a heightened awareness of the possibility of depression in prediabetic geriatric patients.
It has been known that individuals with diabetes are more prone to having depression than are those without diabetes. In a meta-analysis of 42 studies, Anderson and colleagues (Diabetes Care. 2001;24:1069-1078) demonstrated that the odds of comorbid depression were doubled in persons with diabetes. It has also been shown that depression increases the risk of developing diabetes.
To explore the relationship between fasting blood glucose levels and symptoms of depression in nondiabetic older adults, 45 adults 65 years and older were recruited from internal medicine and geriatrics practices at Nova Southeastern University, Fort Lauderdale, FL. Persons with a medical history of diabetes were excluded. All participants had their mood measured using the Center for Epidemiologic Studies Depression (CES-D) Scale questionnaire, a self-report scale designed to measure depressive symptomatology in the general population. The 20 items in the CES-D are each assigned a value of 0, 1, 2, or 3, with the total score ranging from 0 to 60; higher scores indicate higher levels of distress. A score of 16 or higher suggests a clinically significant level of psychological distress.
Adjusting for age, sex, insulin levels, and body mass index (BMI), a regression model revealed that fasting blood glucose levels were a significant predictor of depressive symptoms (t=2.41; P=.02; mean fasting glucose, 95.7 mg/dL; range, 72-135 mg/dL, standard deviation [SD], 14.1; CES-D mean, 11.7; range, 0-35; SD, 8.9; mean age, 76.2 years; range: 65-93 years; SD, 8.7; mean BMI=27.5 kg/m2; range, 17.4-41.0 kg/m2; SD, 5.7).
“The most clear clinical relevance for the findings in long-term care is the study’s suggestion that even borderline or minor elevations in fasting glucose may be important in the development of depression,” said Raymond L. Ownby, MD, PhD, study coauthor, and professor and chair, Department of Psychiatry and Behavioral Medicine, College of Osteopathic Medicine, Nova Southeastern University. “Since other authors have suggested that depression is itself a risk for developing diabetes, the finding that these elevations are related to depressive symptoms may imply that the process of developing diabetes can be detected early and might be a target for early or preventive interventions.”—Wayne Kuznar