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

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriatr. Psychiatry 2007; 22: 974–979.

Published online 14 February 2007 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/gps.1773

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

Kenneth Wilson1*,z, Patricia Mottram2 and Maryyum Hussain2

1Acadmeic Unit, St Catherine’s Hospital, Birkenhead, UK2Cheshire and Wirral Partnership NHS Trust, Wirral, UK

SUMMARY

Objectives To examine the prevalence and associated risk factors of depression in older patients discharged home fromacute 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-controlledstudy of depressed and psychiatrically asymptomatic sub groups, exploring the relationship between depression, associatedrisk 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 WirralHospitals Trust serving Wirral and West Cheshire, England.Participants Three hundred and eleven patients were entered into the prevalence study. One hundred and fifty-eightpatients (54 depressed and 104 asymptomatic) were entered into the prospective case controlled study and followed up for upto two years.Measurements Depression was defined by GMS/AGECAT criteria. Demographic details, handicap, pain, forcedexpiratory volume and social network were measured as dependent variables in the prevalence study and included inthe analysis of risk factors potentially associated with duration of survival in the community.Results A depression prevalence rate of 17.4% was found. Age ( p¼ 0.049, CI; 0.813, 0.999), forced expiratory volume( p¼ 0.034, CI; 0.991, 1.000) and handicap ( p¼ 0.000, CI; 1.268, 1.723) were associated with depression but depression( p¼ 0.040, CI; 1.039, 4.915) was the only base-line variable associated with reduced survival in the community as defined bymortality and re-admission.Conclusions Depression is common in older people discharged from acute medical care and is a major risk factor forreduced duration of community survival. Copyright # 2007 John Wiley & Sons, Ltd.

key words—depression prevalence; medical inpatient care; mortality; re-admission; very old

INTRODUCTION

A wide variety of depression prevalence rates havebeen reported in inpatient settings. McCusker et al.

*Correspondence to: Prof. K. C. M. Wilson, Academic Unit,St Catherine’s Hospital, Birkenhead, Wirral, CH2 0LQ, UK.E-mail: [email protected] abstract was presented at the British Liaison Old Age Psy-chiatry Conference, Leeds, England, 2006.zProfessor Wilson contributed to design, methodology, analysis andpreparation of the manuscript. Dr Mottram contributed to design,methodology, analysis and preparation of the manuscript. Dr Hus-sain was responsible for conducting interviews and contribution topreparation of the manuscript.

Copyright # 2007 John Wiley & Sons, Ltd.

(2005) found a 14.2% prevalence rate of majordepression in one hospital and 44.5% in a secondhospital. Equally high prevalence rates have beenfound in older patients recently discharged intocommunity settings (Gerson et al., 2004). Suchpatients are likely to experience cumulative riskfactors including handicap (Charney et al., 2003),reduced pulmonary function (Yohannes et al., 2003),pain (Geerlings et al., 2002) and reduced socialnetworks (Netuveli et al., 2006). Under half of suchpatients are likely to improve following discharge(Fenton et al., 1997). The relationship betweendepression in discharged inpatients and mortality ismore contentious. Shah (1998) failed to find a

Received 6 September 2006Accepted 2 January 2007

depression, mortality and re-admission in elderly 975

relationship over an 18month period. However, overnine years Koenig et al. (1992) found a highermortality rate.

This study tests the hypothesis that depression andassociated risk factors in patients recently dischargedfrom acute medical inpatient care reduce survival timein community settings as a consequence of earliermortality or re-admission to hospital.

METHODS

The study was carried out with approval from theLocal Research Ethics Committee. The study consistsof a prevalence study of depression in patientsdischarged from medical care. This was followedby a 24-month, prospective, case-controlled study ofdepressed and psychiatrically asymptomatic patientswith view to exploring the role of depression andassociated risk factors in terms of predicting survivalduration in the community, terminated by death orhospital re-admission.

Sample

The prevalence sample consisted of a consecutiveseries of patients 75 and older, discharged to their ownhomes from two general hospitals. ‘Medical care’ wasdefined as admission to a medical or geriatric unit,lasting 48 h or longer. Patients were identified throughmonthly discharge lists. Post-discharge, patients werecontacted by letter for consent purposes. Patientsidentified as depressed or psychiatrically asympto-matic were entered in a 2-year prospective case-controlled study.

Assessments

Each patient was interviewed six weeks afterdischarge. Subsequent assessments (on patientsentering the prospective study) were conducted at2 months, between 6–8 months and 12–14 monthsafter the initial interview. Monthly telephone inter-views were carried out up to 2 years after initialinterview; monitoring hospital admission andmortality. The initial assessment included demo-graphic data, the Geriatric Mental State Examination(GMS) supported by the Automated Geriatric Exam-ination for Computer Assisted Taxonomy software(AGECAT) (Copeland et al., 1986), the GeriatricDepression Scale (GDS) (Sheikh and Yesavage,1986), the London Handicap Scale (LHS) (Jenkinsonet al., 2000), the Wenger Social Network Scale(Wenger, 1995), the Severity Scale (Part 4) of the


McGill Pain Scale (Melzack, 1975) and the forcedexpiratory volume was measured. Subsequent followup interviews excluded the GMS/AGECAT.The GMS is a semi-structured interview. The

supporting AGECAT system generates syndromeclusters (organic; (predominantly dementia), schizo-phrenia, mania, depression, obsessional, phobia,hypochondriasis and anxiety). Each syndrome clusteris allocated a ‘case level’ of between 0 and 5. Caselevel 3 and above is defined as a clinical ‘case’.‘Asymptomatic’ patients are defined as those with arating of 0 for each syndrome. A hierarchical schemeselects a single syndrome cluster as a diagnosis.Organicity and schizophrenia take precedence overdepression which in turn takes precedence overremaining syndromes. Consequently a primary diag-nosis of depression precludes cases of organicity andschizophrenia but may include co-morbid cases ofanxiety, obcessionality, hypochondriasis and phobicconditions.The 15-item GDS was used to rate severity of

depression. The LHS was used to rate handicap, ascore was generated by summation (Jenkinson et al.,2000). However, the LHS rating is independent ofrespiratory impairment (Prince et al., 1997) which isfrequently associated with depression (Yohanneset al., 2003). Hence the forced expiratory volume(FEV) was measured using compact C spirometer.Three readings were taken 1min apart and the highestresult recorded. The Wenger Social Network Scalewas used to categorise social networks. Five socialnetwork types are generated; ‘family dependent’,‘local integrated’, ‘local self contained’, ‘widercommunity focus’ and ‘private’. The social networktype with highest score is identified as the main typefor each patient. When two or more social networktypes score the same; ‘mixed network type’ isassigned. The severity scale of the McGill PainQuestionnaire was used to rate severity of pain.Subsequent assessments excluded the GMS.

Outcomes

The prevalence of depression was defined by GMS/AGECAT case level 3 and above. The primaryoutcome of the follow-up study was the duration ofsurvival in the community determined by mortality orhospital re-admission. The GDS score was used todescribe the nature of depressive symptoms over thefirst year of follow-up. Patients were categorised assuffering from clinically significant depressive symp-toms if scoring 5 or more (Herrmann et al., 1996).


DOI: 10.1002/gps

Table 1. AGECAT syndrome prevalence

Male Female Total

Asymptomatic (well) 54 (38.3%) 50 (29.4%) 104 (33.4%)Depression Cases 22 (15.6%) 32 (18.8%) 54 (17.4%)Depression Subcases 31 (22.0%) 32 (18.8%) 63 (20.3%)Organic Cases 8 (5.7%) 6 (3.5%) 54 (17.4%)Organic Subcases 0 10 (5.9%) 10 (3.2%)Anxiety Cases 0 1 (0.6%) 1 (0.3%)Anxiety Subcases 23 (16.3%) 30 (17.6%) 53 (17.0%)Hypochondrias Cases (0.7%) 0 1 (0.3%)Hypochondrias Subcases 0 0 0Schizophrenia Cases 0 0 0Schizophrenia Subcases 2 (1.4%) 1 (0.6%) 3 (1.0%)Phobia Cases 0 0 0Phobia Subcases 0 7 (4.1%) 7 (2.3%)Mania Cases 0 1 (0.6%) 1 (0.3%)Mania Subcases 0 0 0Total 141 (100%) 170 (100%) 311 (100%)

976 k. wilson ET AL.

Analysis

The sample characteristics and prevalence of caselevel depression is described. Significant risk factorsassociated with prevalence depression were identifiedthrough using SPSS 13.0, binary logistic regressioncomparing asymptomatic and depressed cases: Age,gender, LHS score, FEV, McGill Pain Scale severityscore and the Wenger Social Network type wereentered into the analysis. A survival analysis wasundertaken using the same base-line variables.Outcome events were; duration of survival in thecommunity, determined by mortality or hospitalis-ation. A Cox’s regression analysis was performed inorder to identify base-line variables associated withoutcomes. Finally; the course of depression in terms ofGDS scores in patients completing the first year of thefollow-up study is described.

RESULTS

Cross-sectional prevalence study

One thousand, seven hundred first contact letters wereissued of which 57% percent were unanswered. Justover half of the responders refused to participate and0.75% of patients had died by first contact (six weekspost discharge).One hundred and fifty-two males (mean age 82.95,

SD 7.59) and 179 females (mean age 81.69 SD 10.06)generated 311 data sets included in the prevalenceanalysis. Case level psychiatric syndromes were foundin 28.8% and just over 33% were asymptomatic.Fifty-four depression cases were identified (preva-lence rate of 17.4%). A further 20.3% of patients hadevidence of depressive symptoms but did not fulfilcase level criteria (subcases) (Table 1). Twenty-seven

Table 2. Logistic regression: base-line risk factors associated with c

Variable DF Significance

Age 1 0.049*LondonHandicap Scale 1 0.000*FEV 1 0.034*Gender 1 0.154McGill score 1 0.369Wenger socialNetworkFamily dependent 1 0.782Self contained 1 0.434Integrated 1 0.879Private 1 0.653Wider community 1 0.175

*Significant at p< 0.05.


patients (8%) were in receipt of antidepressants atinitial interview. Seven of these (4.4% of thosefollowed up) continued on antidepressants for at least2 months and a further three were commenced onantidepressants during the follow-up period.

Psychiatric asymptomatic and depressed cases wereentered into a logistic regression which included allbase-line variables with the exception of mixed socialnetwork types. Age, LHS score and FEV weresignificantly associated with prevalence case leveldepression (Table 2).

Prospective case controlled study

A total of 158 were entered into the analysis, 54 ofwhich were depressed and 104 were psychiatrically

ase level depression

Expected (B) 95% Confidence Interval

0.902 0.813, 0.999

1.487 1.268, 1.7230.995 0.991, 1.0001.294 0.908, 1.8440.614 0.211, 1.782

1.281 0.221, 7.4440.552 0.113, 2.7000.904 0.248, 3.2981.511 0.250, 9.1122.874 0.625, 13.219


DOI: 10.1002/gps


asymptomatic. Fourteen asymptomatic patients(13.5%) and 11 (20.30%) depressed patients withdrewfrom the study. A further 21 (20.20%) asymptomaticpatients and nine (16.7%) depressed patients were lostto follow-up. Seven patients died in the community(four in the asymptomatic group and three in thedepressed group) and 23 of the asymptomatic groupand 19 of the depressed group were hospitalised. Onepatient (depressed) was admitted to a nursing homeand was counted as staying in the community. AKapan-Mieir survival analysis was conducted usingthe mortality in the community and re-admission tohospital as events. There was a significant differencebetween the asymptomatic group and the depressedgroup in terms of survival in the community. Theasymptomatic group had a mean survival of18.45 months [Confidence Intervals (CI) 16.42,20.48] and the depressed group had a mean survivaltime of 12.74 months (CI 10.89, 14.58). The base-linevariables, including depression status were included ina Cox’s regression analysis. Case level depression wasthe only variable predicting reduced survival durationin a community setting (Table 3).

After excluding withdrawn and lost-to-follow-uppatients (n¼ 55) longitudinal examination of GDSscores demonstrated that 15 (44.1%) patients diag-nosed as depressed at initial interview intermittentlyachieved GDS scores of less than 5 during the periodof follow-up. Of these, three patients (8.8%) had asustained score of less than 5 throughout the follow-upperiod. The remainder had sustained GDS scores of 5or greater over the follow-up period. Ten (8.1%)patients identified as asymptomatic at initial interviewintermittently scored 5 or more during the follow-up

Table 3. Cox’s regression: Outcome: hospital re-admission and deat

Variable DF Significance

Age 1 0.107LondonHandicap Scale 1 0.920FEV 1 0.176Gender 1 0.570AGECAT depression 1 0.040*McGill score 1 0.073Wenger Social NetworkFamily dependent 1 0.844Self contained 1 0.774Integrated 1 0.767Private 1 0.491Wider community 1 0.685

*Significance at p< 0.05.


period. None of this later group sustained scores of 5or more for more than one follow-up assessment.

DISCUSSION

This study has confirmed a high prevalence ofdepression in older people discharged home frommedical care. It has demonstrated that increased age,handicap and reduced FEV are risk factors in thissample. The follow-up study has demonstrated thatdepression is a risk factor for reducing the duration ofsurvival in the community.

Study limitations

A 6-week interval was employed prior to initialcontact with patients to enable access to dischargelists, facilitate return of patient correspondence andpromote relative stability of discharge arrangements.European studies have indicated that approximately11% of patients may be re-admitted within a month ofdischarge (Comette et al., 2005). Such patients wereexcluded from this study. A large number of potentialpatients were excluded as they failed to respond tocontact or refused participation. A further minoritywere excluded from the case controlled study throughwithdrawal or loss. Consequently the representativenature of the sample is questionable.The study did not address discharge arrangements

and other than measuring handicap and FEV, noattempt was made to characterise medical burden. It isalso important to note that patients with case level oforganicity or schizophrenia with concomitant depres-sion were classed as suffering from the primary

h

Expected (B) 95% Confidence Interval

1.064 0.987, 1.148

1.005 0.904, 1.1181.002 0.999, 1.0060.812 0.395, 1.6692.259 1.039, 4.9151.206 0.979, 1.622

1.141 0.309, 4.2151.234 0.295, 5.1891.220 0.328, 4.5351.527 0.458, 5.0950.722 0.150, 3.480


DOI: 10.1002/gps

KEY POINTS

� A high prevalence of depression is found in olderpeople recently discharged home from acutemedical care.

� Depression is associated with handicap, reducedFEV and extreme old age in this population.

� Depressed, discharged patients living at homesurvive for a shorter time prior to death orre-admission to hospital.

978 k. wilson ET AL.

diagnosis. With regard to use of antidepressants, toofew were prescribed for this to be relevant to theanalysis.

Cross-sectional prevalence study

A relatively low overall prevalence of psychiatriccases of 22.8% was found. Gerson et al. (2004) founda prevalence of psychiatric morbidity of 58.6% in aslightly younger, principally male, post dischargepopulation. Despite difficulty in comparing studies, itis evident that organic cases are relatively underrepresented in our sample (4.5%). This may reflect therequirement to initiate contact through correspon-dence and secondly; that cognitively impaired olderpeople are more likely to be discharged to institutions.It is difficult to compare our findings with other studiesin that AGECAT depression includes the DSM-IVspectrum disorders of major depressive disorder,dysthymia, adjustment disorder with depressed mood,or mixed anxiety and depressed mood and depressivedisorder not otherwise specified (Copeland et al.,1990; Newman et al., 1998; Schaub et al., 2003).Notably having two or more physical illnesses has

been associated with increased prevalence of depres-sion (Osborn et al., 2003). However, as opposed tospecific physical illnesses, handicap is recognised asbeing of central significance to late life depression(Prince et al., 1997). This study confirms the relativeimportance of both handicap and reduced FEV interms of risk factors for depression in this age group.As in community studies, age was a risk factor(Osbourn et al., 2003), however, there was noassociation with female gender (Djernes, 2006);perhaps a reflection of the sampling technique. Whatwas more surprising was the failure to identify limitedsocial network as a risk factor as it has been associatedwith depression in community studies (Prince et al.,1997).

Prospective case controlled study

Social isolation is associated with re-admission inolder people (Mistry et al., 2001). The lack of findingsin this study may reflect the definition of socialnetwork type by highest score with subsidiary networktypes being excluded. Likewise, increased anxietyhas been identified as a risk factor for hospitalre-admission (Mistry et al., 2001). As AGECAT caselevel depression subsumes co-morbid case levelanxiety, the prevalence and potential risk profile ofanxiety is likely to be masked in this study.


The importance of post discharge case leveldepression as a risk factor, despite fluctuations inGDS scores across time, is consistent with relatedstudies demonstrating that depression is associatedwith high levels of medical care utilization (Pearsonet al., 1999) and higher health care costs even afteradjusting for chronic medical illness (Katon et al.,2003). Our findings are of particular importance asemerging evidence suggests that depressed, highutilizers of medical care (Katzelnick et al., 2000)are amenable to treatment and are relatively easilyrecognised.

CONFLICT OF INTEREST

Financial disclosure

Professor Kenneth Wilson n

Int. J. Geriatr. P

one
Dr Patricia Mottram n one Dr Maryyum Hussain n one
ACKNOWLEDGEMENTS

This study was sponsored by the University of Liver-pool and funded by the University of Liverpool,Division of Psychiatry. The Sponsoring body hadno role in design, management, subject recruitment,data collection, analysis or preparation of the manu-script.

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DOI: 10.1002/gps

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

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