Predictors of depression in geriatric medically ill inpatients.

OBJECTIVE: Depression in medically ill inpatients has been associated with increased morbidity and mortality. The purpose of this study was to identify variables that would successfully predict depression in this population. METHODS: The sample consisted of 314 male, medically ill veterans, age 60 and older, admitted to the acute medical service at Baltimore Veteran Administration Medical Center. Sixty of 314 patients met criteria for Major Depression and scored 11 or higher on the Geriatric Depression Scale. Variables assessing age, race, social support, severity of illness, degree of functional disability, life satisfaction, and hopelessness were included in a logistic regression analysis as predictors of depression. RESULTS: The variables that significantly predicted depression were derived from the Beck Hopelessness Scale, Life Satisfaction Score, and the Cumulative Illness Rating Score. CONCLUSIONS: The results indicated that medically ill inpatients who feel hopeless about the future, feel the best years of their lives are behind them, and have serious medical problems are likely to be clinically depressed.

Telemedicine and geriatric psychiatry: directions for future research and policy.

The use of telecommunications to provide mental health services at a distance has grown rapidly in the past 10 years. The overall experience has been positive, but evaluations and reliability studies have been preliminary. A fundamental question of what constitutes adequate technology for telepsychiatry remains unanswered. As technology and equipment capability change rapidly, a more important question may be what clinical decisions and behavioral observations are required to produce high standards of distance mental health care. Geriatric patients may have sensory impairments and unique aspects to their psychiatric problems that can make telemental health assessments more challenging. It is not clear what model of telepsychiatry constitutes the best practice for geriatric psychiatry. Future research and program evaluations should address these questions to guide the use of telepsychiatry in productive directions.

Psychiatric assessment of a nursing home population using audiovisual telecommunication.

The purpose of this study was to demonstrate that psychiatric assessment of nursing home residents could be reliably carried out remotely via telecommunications. Twenty-seven nursing home residents each had two interviews consisting of the following three rating scales: the Mini-Mental State Examination (MMSE), the Geriatric Depression Scale (GDS), and the Brief Psychiatric Rating Scale (BPRS). The interviews were conducted by three trained psychiatrists, each of whom interviewed two-thirds of the subjects. Subjects were sequentially assigned to have either two in-person interviews (in-person group) or one in-person and one remote interview via telecommunication (remote group). Inter-rater reliability was calculated separately for each condition (in-person vs remote group) for each of the three rating scales. Intraclass correlations on the MMSE were .95 for the remote group and .83 for the in-person group. On the GDS, they were .82 for the remote group and .86 for the in-person group. Finally, on the BPRS, they were .81 for the remote group and .49 for the in-person group. There were no statistically significant differences in intraclass correlation on any of the three scales for the remote group compared with the in-person group, indicating that nursing home residents can be reliably assessed remotely via telecommunication.

Religion and end of life treatment preferences among geriatric patients.

The purpose of this study was to determine if religious preference and religiosity influenced choosing end of life treatments in medically ill geriatric patients. The sample consisted of 374 males 60 years of age or older, hospitalized on the acute medical service at the Baltimore Veterans Affairs Medical Center. Choices for end of life treatment preferences were CPR, medical ventilation, tube feeding and IV fluids within six different illness scenarios. Patients indicated how often they attended religious services, how much strength and comfort they got from religion and how religious they would describe themselves. Analyses of variance were performed using as the dependent variables the summation scores across the six scenarios of a willingness to undergo each of the four life saving procedures. The religious preference, race and religiosity scores served as the independent variables. Only tube feeding showed a significant (p<0.05) relationship, with Catholics less willing to undergo this procedure than other Christians. The same trend was found for the other life saving procedures, but was not statistically significant.

Depression, hopelessness, and the desire for life-saving treatments among elderly medically ill veterans.

During a serious medical illness, several factors, including perceived quality of life, social support, functional disability, severity of illness, and presence of depressive symptoms, influence desire for life-saving treatments such as cardiopulmonary resuscitation (CPR), mechanical ventilation, tube feeding, and intravenous fluids. The authors examined the influence of depression and hopelessness on preferences for life- saving treatment in older, medically ill male patients in the medical service of a Veterans Administration Medical Center. Subjects with high levels of hopelessness desired less life-saving treatment during their current illness; they were at least five times more likely to refuse CPR if required during the current hospitalization. This effect remained statistically significant after removing confounds of race, education, and religiosity. The diagnosis of major depression did not significantly influence the desire for life-saving treatment. Our findings suggest that psychiatrists should assess patients for severity of hopelessness when evaluating decision-making capacity in the context of intervention refusal.

Racial differences in the prevalence of dementia among patients admitted to nursing homes.

OBJECTIVE: The purpose of this study was to determine the prevalence of dementia among black and white residents on admission to nursing homes and to determine whether demographic and health characteristics known to be associated with dementia were correlated with dementia in this population. METHODS: Data from medical records and structured interviews with family members, nursing staff, and nursing home residents were gathered for 2,285 persons newly admitted to nursing homes in Maryland from 1992 to 1995. A stratified sample of 59 nursing homes was used. An expert panel of five physicians classified each resident as demented, nondemented, or indeterminate. Associations between dementia status, race, and selected characteristics were examined. RESULTS: Black residents (77 percent) were significantly more likely than white residents (57 percent) to be classified as demented. Older age was associated with dementia in both races. Less education, male gender, and a history of a cerebrovascular accident were associated with an increased prevalence of dementia among white residents only. After demographic and health characteristics associated with dementia were controlled for, black race remained independently associated with a diagnosis of dementia. CONCLUSIONS: The rate of dementia on admission to nursing homes was higher among black residents than among white residents, a finding that has implications for the delivery of care. The higher rate may be due to psychosocial factors operating differently in blacks and whites that influence the timing of admission to a nursing home.

Posttraumatic stress disorder in the elderly: a review.

Posttraumatic disorder (PTSD) in elderly persons impairs their ability to deal with subsequent life stress and to negotiate the developmental stages of late life successfully. It can stem from trauma at any point in life. Symptoms may be persistent or intermittent, and the disorder may be time-limited or chronic. Increasing severity of trauma and premorbid psychiatric illness predispose to the development of PTSD, and certain personality traits and good psychosocial support protect against it. Elderly individuals do not appear more predisposed than young persons to develop PTSD, and symptoms of the disorder are similar across age groups: reexperiencing the trauma, avoidance, and hyperarousal. Dysfunctions of the adrenergic system and the hypothalamic-pituitary-adrenal axis have been implicated in the neurobiology of PTSD, although there is no current evidence that the changes seen in these systems with aging affect the development or presentation of PTSD in older individuals. Antidepressants, group therapy, and cognitive-behavioral therapy are presently the mainstays of treatment, although to date no systematic and controlled research has been done on the treatment of PTSD in this age group.

Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology.

The reliability of psychiatric diagnoses made remotely by telecommunication was examined. Two trained interviewers each interviewed the same 30 psychiatric inpatients using the Structured Clinical Interview for DSM-III-R. Fifteen subjects had two in-person interviews, and 15 subjects had one in-person and one remote interview via telecommunication. Interrater reliability was calculated for the four most common diagnoses: major depression, bipolar disorder, panic disorder, and alcohol dependence. For each diagnosis, interrater reliability (kappa statistic) was identical or almost identical for the patients who had two in-person interviews and those who had an in-person and a remote interview, suggesting that reliable psychiatric diagnoses can be made via telecommunication.

Competency evaluations in a VA hospital. A 10-year perspective.

The authors reviewed all 228 competency evaluations performed at the Baltimore VA Medical Center during a 10-year period. Between 1980 and 1984 and 1985 and 1989, the rate of inpatients who had competency evaluations increased from 0.20% to 0.42%, and the average number of competency evaluations per year doubled from 12 to 24.6. The percentage of all psychiatric consultations which were for competency evaluation nearly doubled from 5% to 9.4%. The rate of competency evaluations was slightly but not significantly higher for patients over age 65 than the rate for younger patients (0.44% vs. 0.33%). However, older patients were significantly more likely to be judged incompetent.

Alcoholism in older persons: a review of the literature.

Alcohol abuse and dependence in elderly persons is of growing social concern. The most consistent findings of cross-sectional and longitudinal studies are that the quantity and frequency of alcohol consumption is higher in elderly men than in elderly women, as is the prevalence of alcohol-related problems. Most studies show a decrease with age in consumption and alcohol-related problems among heavy drinkers. Longitudinal studies show no changes in consumption among light drinkers. Elderly persons with lower incomes consume less alcohol than those with higher incomes. Hospitalized and outpatient populations have more problem drinkers, and the elderly alcoholic is at greater risk for medical and psychiatric comorbidity. About one-third to one-half of elderly alcoholics experience the onset of problem drinking in middle or late life. Outcomes seem to be better for those who have late-onset drinking and may be improved for those treated in same-age rather than mixed-age groups.

Discontinuation of neuroleptic medication in older, outpatient schizophrenics. A placebo-controlled, double-blind trial.

Thirty-five schizophrenic outpatients over the age of 52 who had been stable on neuroleptic medication were all switched to haloperidol. Ten patients were unable to tolerate the haloperidol and two dropped out of the study. The remaining 23 patients were randomly and blindly assigned to haloperidol or placebo and then followed for 6 months. Five patients did not complete the study due to medical or administrative reasons. Among the patients who completed the study, five of 10 randomized to placebo relapsed compared with only one of eight randomized to haloperidol. However, three of 10 patients randomized to placebo have remained stable without medication for 2.5 years.

Vitamin E in the treatment of tardive dyskinesia.

Eight subjects with persistent tardive dyskinesia were treated with vitamin E and placebo in a randomized, double-blind crossover study. Their mean score on the Abnormal Involuntary Movement Scale (AIMS) was significantly lower after treatment with vitamin E than after placebo administration.