Older
patients’
depressive
symptoms
6
months
after
prolonged
hospitalization:
Course
and
interrelationships
with
major
associated
factors
Chun-Min
Chen
a,
Guan-Hua
Huang
b,
Cheryl
Chia-Hui
Chen
c,*
a
DepartmentofHealthCareManagement,UniversityofKangNing,No.188,Section5,An-ChungRoad,Tainan,Taiwan,ROC
b
InstituteofStatistics,NationalChiaoTungUniversity,1001TaHsuehRoad,Hsinchu300,Taiwan,ROC
c
DepartmentofNursing,NationalTaiwanUniversityandNationalTaiwanUniversityHospital,1,Jen-AiRoad,Section1,Taipei100,Taiwan,ROC
1. Introduction
Depressivesymptomsarecommoninolderpatients hospital-izedforacuteillness.Theprevalenceofdepressivesymptomsin thesepatientshasbeenestimatedfrom8%to44%(Cullum,Tucker, Todd, & Brayne, 2006), with approximately one-third having moderatetoseveredepressivesymptoms(Pierluissietal.,2012). Notably,depressivesymptomsareamajorriskfactorforlong-term disabilityandmortalityinolderpatients(Blazer,Hybels,&Pieper, 2001;Hamer,Bates,&Misbra,2011),evenatsubthresholdlevels (Vahiaetal.,2010).
Treating older patients’ depressive symptoms, however, is difficult because late-life depression has different etiologies (Tiemeier, 2003). Forexample,associated factorsfor depressive symptomsinlatelifeincludehealthcondition,functionalstatus, nutritional status, cognitive status, social support, and other
psychosocial factors, in contrast to genetic factorsfor younger adults(Fiske,Wetherell,&Gatz,2009;Helvik,Skancke,&Selbaek, 2010;Tsai,2013).Thisdiversityinassociatedfactorsmightexplain why fewer than half of older patients with major depression achieved remission when treated with pharmacotherapy alone (Wilkins,Kiosses,&Ravdin,2010).
To improve treatment efficacy for depressed older adults, a focusedmultimodal,non-pharmacologicalinterventionneedstobe developed (Naismith, Norrie, Mowszowski, & Hickie, 2012). However, interrelationships first need to be established among majorassociatedfactorsanddepressivesymptomsafteracritical eventsuchasacute,prolongedhospitalization.Inparticular,clinical practiceshouldbeinformedwhethermajorassociatedfactors,such asfunctional,cognitive,andnutritionalscorespredictconcurrent andsubsequentdepressivesymptomatologyorviceversa,overthe course of hospitalization. Thus, the aims of this study were to describethecourseofdepressivesymptomsinolderpatientfrom acute,prolongedhospitalizationto6monthsafterdischargeandto determine the directional interrelationships among depressive symptomsandtheirmajorassociatedfactorsusingpathanalysis.
ARTICLE INFO
Articlehistory:
Received14October2013
Receivedinrevisedform17December2013 Accepted19December2013
Availableonline2January2014
Keywords: Depressivesymptoms Nutritionalstatus Functionalstatus Olderadults Geriatricsyndrome ABSTRACT
Theaimofthisstudywastoexaminethecourseofdepressivesymptomsinolderpatients6months following a prolonged, acute hospitalization, especially the interrelationships among depressive symptomsanditsmajorassociatedfactors.Forthisstudy,weconductedasecondaryanalysisofdata fromaprospectivecohortstudyof351patientsaged65yearsandolder.Participantswererecruited fromfivesurgicalandmedicalwardsatatertiarymedicalcenterinnorthernTaiwanandassessedat threetimepoints:within48hofadmission,beforedischarge,and6monthspost-discharge.Thecourse ofdepressivesymptomswasdynamicwithsymptomsincreasedspontaneouslyandsubstantiallyduring hospitalizationandsubsidedat6monthsafterdischarge,butstillremainedhigherthanatadmission. Overall,26.7%ofolderpatientsathospitaldischargemetestablishedcriteriaforminordepression (15-itemGeriatricDepressiveScale(GDS-15)scores5–9)and21.2%formajordepression(GDS-15scores >10).Asthe strongestassociated factors,functionaldependenceand nutritionalstatus influenced depressivesymptomsfollowinghospitalization.Depressivesymptomsatdischargeshowedsignificant cross-laggedeffectson functionaldependence and nutritionalstatusat 6months after discharge, suggestingareciprocal,triadicrelationship.Thus, treatingonecondition mightimprove theother. Targetingthetriadofdepressivesymptoms,functionaldependence,andnutritionalstatus,therefore,is essentialfortreatingdepressivesymptomsandimprovingtheoverallhealthofolderadultshospitalized foracuteillness.
ß2014ElsevierIrelandLtd.Allrightsreserved.
* Correspondingauthor.Tel.:+886223123456x88438;fax:+886223219916. E-mailaddress:cherylchen@ntu.edu.tw(C.-H.Chen).
ContentslistsavailableatScienceDirect
Archives
of
Gerontology
and
Geriatrics
j ou rna l h om e pa ge : w w w. e l s e v i e r. co m/ l oc a t e / a rch ge r
0167-4943/$–seefrontmatterß2014ElsevierIrelandLtd.Allrightsreserved.
2. Methods
2.1. Designandsetting
Thisstudywasasecondaryanalysisofdatafromaprospective, interview-basedcohortstudyoffactorsassociatedwithfunctional declineinolderhospitalizedpatients.From24med-surgicalwards ata2200-bedmedicalcenterinnorthernTaiwan,threesurgical (outof14)andtwomedical(outof10)wardswererandomlyand proportionallyselectedafterclustersampling.Participantsfrom those five wards were enrolled and evaluated in face-to-face encountersuponadmission,beforedischarge,and6monthsafter discharge(atoutpatientclinics)bytwotrainedresearchnurses. TheResearchEthicsCommitteeofthemedicalcenterapprovedthe studyandeveryparticipantprovidedwritteninformedconsentfor studyparticipation.
2.2. Studysample
Participantswererecruitedfromolderpatientsconsecutively admittedtoanyofthefivestudymedical-surgicalwardsbetween August2004andMay2006.Thesefivewardsgenerallyenrolled patients withnephrology and endocrine medical conditions,as well patients who are scheduled for upper abdominal and urological surgical procedures. Focusing on the most affected, werecruitedonlyolderpatientswhohadprolonged hospitaliza-tion,definedasthelengthofstay(LOS)over5days.Participants werenotrecruited iftheir expectedhospital staywas<5 days (n=1091),theirMini-MentalStateExam(MMSE)scorewas<20 (n=43), were isolated within the infection control protocol (n=56), were intubated or unable to communicate due to profound sensory loss (n=140). Of 439 eligible subjects, 351 were enrolled (response rate 80.0%). The average LOS was 16.612.1 days inthissample. The reasonsfornonparticipation includednotinterested(n=57),notfeelingwell(n=20),andprivacy protection(n=11).Theparticipants(N=351)didnot significantly differedfromthenonparticipants(n=88)inage(P=0.30),gender (P=0.72),andeducationlevels(P=0.43).
2.3. Datacollectionandmeasures
Dataondepressivesymptomsanditsassociatedfactorswere collectedfrom351participantsinface-to-faceassessmentsbytwo trainedresearchnursesusingvalidatedinstruments(seebelow)at threetimes:admission(T0),beforedischarge(T1),and6months afterdischarge(T2).Depressivesymptomsweremeasuredbythe GDS-15 requiring yes/no answers (Yesavage et al., 1982). The summedscoresrangefrom0(best)to15(worst);scoresfrom5to 9arecategorizedasminordepression,andscores310represent majordepression (Almeida & Almeida, 1999; Thompson et al., 2011;Wongetal.,2002).
Associated factors for depressive symptoms, which were selected from the literature (Fiske et al., 2009; Helvik et al., 2010;Tam & Lam,2012; Tiemeier, 2003; Tsai,2013), included demographics(age,gender,educationlevel,income,andmarital status),co-morbidities,medicationstaken,socialsupport, cogni-tivestatus, functional status (performanceof activitiesof daily living [ADL] and role functions; ADL level and functional dependenceastwo empiricalindicators),andnutritionalstatus. Specifically, co-morbidities were assessed by a standardized comorbidity checklist soliciting in 20 self-report conditions includinghypertension,diabetes,kidneyand lungdiseases.The numberofcomorbiditieswasusedasaproxyfordiseaseburden.In addition,sensorymorbidities(visual andhearing impairments), cardiovascularmorbidities(coronaryheartdisease,hypertension, congestive heart failure, and hyperlipidemia), neurological
morbidities(strokeandParkinsonism),anddiabeteswerefurther categorizedandstudiedforpossibleassociationwithdepressive symptoms.Medications,i.e.,thenumberofprescriptionand over-the-countermedicationstakencurrentlybyparticipants,werealso codedasanumericalvariable.Socialsupportwasmeasuredbythe 6-item Social Support Questionnaire-Short Form (SSQ-SF) ( Sar-ason, Sarason, Shearin, & Pierce, 1987). Cognitive status was measured by the11-itemMMSE (Folstein, Folstein,&McHugh, 1975). ADL level was measured by the 10-item Barthel Index (Mahoney & Barthel, 1965). Functional dependence, defined as needing help from others to perform roles and activities, was measuredbythe10-itemEnforcedSocialDependencyScale(ESDS;
Benoliel, McCorkle, & Young, 1980). The ESDS has been used widely,withscoresrangingfrom10to51;higherscoresindicate greaterfunctionaldependence.Nutritional statuswasmeasured bythe18-itemMini-NutritionalAssessment(MNA),theoriginal scoring of which is scaled so higher scores indicate better nutritionalstatus(Guigoz,Vellas,&Garry,1996).Forthisstudy, we re-scaled the MNA so that higher scores indicated poor nutritionalstatus.Thus,higherscoresindicatedpoorstatusinall measuresofourstudy.
2.4. Statisticalanalysis
Data were double-checked for accuracy and completeness. Sample characteristics and prevalence of depressive symptoms wereanalyzedoverthreetimepoints(admission,discharge,and6 months after discharge). Interrelationships between depressive symptomsand12potentialassociatedfactors,includingfunctional status (included ADL level measure by the Barthel Index and functionaldependencemeasuredbytheESDS),nutritionalstatus, aswellasphysiologicalandcognitivecovariates,wereexamined bypathanalysisinAMOS.Pathanalysishasthemajorbenefitof estimatingtherelativeimportanceofdirectandindirectfactorsso itisrobusttoexaminecomplexandreciprocalrelationshipsover time (Byrne,2001; Kline, 2005). Factorsfor path analysiswere selectedinthreesteps.First,weidentifiedfactorsassociatedwith depressive symptoms at baseline. In this step, 12 variables identifiedaspotentialassociatedfactorswereevaluatedvialinear regression.Second,variablessignificantlyassociatedwithbaseline depressive symptoms were then regressed with depressive symptomsateachtimepoint,adjusted fordemographic covari-ates.Consistentlysignificantvariablesatallthreetimepointswere thenselectedforconstructingthefinalmodel.Inthefinalmodel buildingstep,depressivesymptomsandvariablesselectedinstep 2fromalltheretimepointswerejointlyanalyzed.Weusedpath analysis to test a hypothesized directional relationship of depressive symptoms and selected variables over time while controllingforimportantcovariates.Tovalidatethedirectionof each cross-sectional path, we compared it with an alternative model withreverse direction.If thereversedirectionremained significant,thepathwascorrelational(i.e.,bidirectional). Good-nessoffitwasdeterminedbythechi-squarevalue,comparativefit index(CFI),Tucker–Lewisindex(TLI),androotmeansquareerror ofapproximation(RMSEA).Furthermore,parametervalueswere estimatedusingmaximumlikelihoodmodelbasedonAMOSand datawereanalyzedusingSPSS17.0(Chicago,IL,USA)andAMOS 8.0(Chicago).
3. Results 3.1. Participants
The study sample (N=351) was relatively diverse in age, gender,educationallevelandincomestatus,whilemost partici-pantsweremarried.Asexpected,co-morbidityburdenwashigh
withmeannumberofcomorbiditiesbeing4.11.8.Detailsofthe samplecharacteristicsarepresentedinTable1.
3.2. Courseofdepressivesymptoms
Depressive symptoms spontaneously and substantially in-creased during hospitalization, subsided at 6 months after discharge,butwerestillworsethanatadmissionbaseline.Overall, 26.7%ofolderpatientsmetGDS-15criteriaforminordepression (scores5–9) and 21.2%for majordepression (310)byhospital discharge.At6monthsafterdischarge,23.3%and24.3%ofolder patientsstillexperiencedsignificantminorandmajordepressive symptoms, respectively (Table 2). Furthermore, following a
prolongedhospitalization,37.7%ofnewcasesofdepressionwere identified at discharge. Although remission of depression was noted,8.7%ofnewcasesofdepressiondevelopedby6monthsafter discharge.
3.3. Pathwaymodelestimation
Among 12 associated factors for depressive symptoms (age, gender,education,income,maritalstatus,co-morbidity, medica-tionstaken,socialsupport,cognitivestatus,ADLlevel,functional dependence,andnutritionalstatus),fourfactors(socialsupport, cognitive status, functional dependence,and nutritionalstatus) weresignificantlyassociatedwithbaselinedepressivesymptoms (regressioncoefficients withP<0.05).Twoofthefourselected factors(functionaldependenceandnutritionalstatus)werefound to be consistently associated with depressive symptoms in all threetimepoints,andwerefurtheradoptedforconstructingthe final model while controllingfor important covariates (include demographics,socialsupport,andcognitivestatus).
Fig.1presentsafinalpathdiagramfordepressivesymptoms, nutritional status and functional dependence.The 14 solid-line pathwaysrepresentsignificantlongitudinal(sixlageffectswith horizontal arrows and two cross-lagged effects with diagonal arrows)andcross-sectional(sixcorrelationswithverticalarrows) relationshipsamongthethreefactors.Wetestedthealternative modelswithreversedirectiontofurthervalidatethedirectionof eachcross-sectionalpath(resultsnotshown).Theresultssupport that thedirectionsofthesecross-sectional pathscouldgoboth waysandtherelationshipsareindeedcorrelationalinnature.
Specificallyinlongitudinalrelationships,lageffectswerefound amongallthreefactorssuggestingthatstatuswithineachhealth domainpredictsfuturestatuswithinthatdomain.Furthermore, two significant cross-lagged effects were found in the post-discharge phase, suggesting that older patients with more depressive symptoms before discharge were more likely to experience deteriorations in functional dependence (0.25) and nutritional status (0.16) at 6 months after hospital discharge. Althoughcross-sectionalrelationshipsweresubstantiatedinthe finalpathmodel,thedirectionoftheassociationfailstopassthe validation tests suggesting that functional dependence and nutritional status correlated with depressive symptoms and nutritionalstatuscorrelatingthedegreeofdepressivesymptoms inolderpatientsduringandafterhospitaldischarge.
4. Discussion
Forolderpatients,depressivesymptomsincreased spontane-ouslyand substantiallyduring hospitalization, andsubsided by 6monthsafterdischargebutwerestillworsethanatadmission
Table1 Sampledemographics(N=351). Frequency % Age,mean(SD) 71.9(5.7) 65–69 143 40.7 70–74 93 26.5 75 115 32.8 Gender Male 195 55.6 Female 156 44.4 Education,years Illiterate 89 25.4 1–6 138 39.3 7 124 35.3 Monthlyincome,NTDa <5000 17 4.8 5001–10,000 188 53.6 10,001–20,000 106 30.2 20,001–30,000 39 11.1 Maritalstatus Unmarried 88 25.1 Married 224 63.8 Comorbiditiesburden Numberofcomorbidities,b mean(SD) 4.1(1.8)
Sensorymorbiditiesc Yes 264 75.2
Cardiovascularmorbiditiesd Yes 305 86.9 Neurologicalmorbiditiese Yes 36 10.3 Diabetes Yes 107 30.5 Notes: a
NTD,NewTaiwanDollars;1NTD=0.03USD.
b
Comorbiditiesweresolicitedin20conditionsincludinghypertension,coronary heartdisease,congestiveheartfailure,hyperlipidemia,stroke,diabetes,kidney disease,lungdisease,gastrointestinaldisease,osteoporosis,arthritis,hipfracture, spinal cord disease, cancer, dementia, Parkinsonism, pressure ulcer, visual impairment,hearingimpairment,andothers.
c
Sensorymorbiditiesincludedvisualandhearingimpairments.
d
Cardiovascularmorbidities includedhypertension, coronaryheart disease, congestiveheartfailure,andhyperlipidemia.
e NeurologicalmorbiditiesincludedstrokeandParkinsonism.
Table2
Thecourseofdepressivesymptomsfromhospitalizationto6monthslater(N=351).
Depressivesymptoms Admission Discharge 6monthspost-discharge
n=351 n=334a n=300b GDS-15score,mean(SD) 4.7(3.5) 7.6(3.7) 5.9(4.1) Nodepression(GDS-15<5),n(%) 212(60.4) 78(23.4) 157(52.3) Minordepression(GDS-155–9),n(%) 94(26.8) 131(39.2) 70(23.3) Majordepression(GDS-15310),n(%) 45(12.8) 125(37.4) 73(24.3)
Newcaseofdepressionc
– 126(37.7) 26(8.7)
Remissionofdepressiond
– 12(3.6) 90(30.3)
Notes:
a
Thereasonsforattritionatdischargeweredeath(n=16)andwithdrewconsent(n=1).
b
Thereasonsforattritionat6monthsafterweredeath(n=44),withdrewconsent(n=3),intubatedatthetimeoffollow-upassessment(n=3),andisolatedfor tuberculosis(n=1).
cNewcaseofdepressionreferstotheattainmentofahighercategorizationofdepressivesymptoms(i.e.,upfromnodepressiontominorormajordepression). d Remissionofdepressionreferstotheattainmentofalowercategorizationofdepressivesymptoms(i.e.,downfrommajortominordepressionordownfromminortono
baseline.Byhospitaldischarge,26.7%ofolderpatientsmetGDS-15 criteriaforminordepression(scores5–9)and21.2%metcriteria formajordepression(310).At6monthsafterdischarge,47.6%of olderpatientsstill experiencedsignificantdepressivesymptoms (23.3%and 24.3% met criteria forminor and majordepression, respectively). These findings are consistent with reports that higherlevelsofdepressivesymptomsassociatedwith hospitaliza-tionofolderpatientshaveadynamiccourseandinterventionsare indicatedfortreating worseningorpersistentdepressive symp-toms (Cole, 2012). We however, did not collect treatment or readmissiondataafterhospitaldischargesoitisunclearwhether thesepatients with significant depressive symptoms had been treatedor whetherany newhospitalizationoccur which might acceleratedepressivesymptomsduringfollow-up.
In thepresentstudy, weproposedan underlyingtheoretical pathwayinwhichfunctionaldependenceandnutritionalstatus, both arewell-known correlates ofdepressive symptoms, influ-enceddepressivesymptomsfor olderhospitalizedpatients. Our findingsindicatethatolderpatients’healthfollowing hospitaliza-tionisacomplexprocess,withthreehealthdomains(depressive symptoms,functionaldependence,and nutritionalstatus)often simultaneouslyortemporallyinfluencingeachother.Threepoints are of interest. First, greater functional dependence and lower nutritionalstatus arecross-sectionally correlated withelevated depressive symptoms during and following hospitalization. Second, all three health domains show lagged effects on subsequent measures in the same domain. Third, effects of previousdepressivesymptomsonsubsequentfunctional depen-denceandnutritionalstatusfurthersuggestareciprocal interrela-tionship. Although both cross-sectional and longitudinal relationshipsbetweenvariables(i.e.,allsolidlines)are substanti-atedintheproposedmodel,inthevalidationanalyseswhenthe alterativemodelsweretestedforcross-sectionalassociation,we foundevidenceinfavorofabidirectionalcorrelationbetweenboth functional dependence and nutritional status and depressive
symptoms.Collectively,thesefindingssuggestatriadic relation-ship among depressive symptoms, functional dependence, and nutritionalstatus inolderpatients and thattreating depressive symptoms can improve function and nutrition in the post-dischargephase.
In fact, awareness of greater functional dependence and deterioratingnutritionalstatusmaycausedepressivesymptoms asapsychologicalreactiontothelossoffunctioning.Inaddition, analysisofpopulation-baseddata(N=2524)indicatesthatolder patientswithnutritionaldeficienciessuchaslackoffolicacidtend to have more depressive symptoms than those with adequate nutritionalstatus(Beydoun,Shroff,Beydoun,&Zonderman,2010). SupplementationwithfolicacidandvitaminB12,astheadjunctive treatmenthasbeenshowntoimprovemoodinpatientswithmajor depression(Fordetal.,2010).Alongthesameline,thepresenceof depressivesymptomshasbeensignificantlyassociatedwithdiet quality(Kuczmarskietal.,2010;Tsai,Chang,&Chi,2011),food insufficiency(Germanetal.,2011), andmalnutrition (Smoliner, Norman, Wanger, Hartig, & Lochs, 2009). As deteriorated nutritional status and functional dependence may be an early sign rather than a risk factor for depressive symptoms, the temporal relation between nutritional status/functional depen-dence and depressive symptoms in olderpatients needs to be furthertested.
Nevertheless, the presence of depressive symptoms by discharge may negatively impact older patients’ subsequent functionaldependenceandnutritionalstatusbydecreasingtheir motivationtomaintainhealthyandself-carebehaviorssuchas adequate eating, physical rehabilitation, and engaging in role activities. Treating one condition might improve another so targetingthistriadwithamultimodal interventionalongwith necessarypharmacologicaltherapymightnotonlymore effec-tively treat depressive symptoms but also improve overall function and nutrition in older adults following an acute hospitalization for medical and surgical services. In fact, multimodalinterventions, suchasthe ModifiedHospitalElder LifeProgramcomprisingearlyambulation,nutritionalassistance, and orienting communication was shown in a pilot trial to ameliorate older surgical patients’ depressive symptoms by hospitaldischarge (Chenet al.,2011).Theseresults should be verifiedinrandomizedtrials,butargueforfurtherdevelopment andtestingofsuchmultimodalinterventionstomanage depres-sivesymptomsinolderhospitalizedpatients.
4.1. Strengthsandweaknessesofthestudy
Amajorstrengthofourstudyisthatitexaminedthecourseof depressivesymptomsandtheirinterrelationshipswithfunctional dependence and nutritional status, adjusted for important covariates, in a large sample of older patients from prolonged, acute hospitalization to 6 months afterward. The study had important limitations. First, there are debates as whether depressive symptoms preceded functional dependence and nutritionalstatusinthismodelratherthanthedirectionwehave proposed. Indeed, assumption relative to temporal order, non-recursivepaths,andcausaldirectionatthesametimepointinpath analysisisapriordecision.Itisthereforepossiblethatthedirection of the association may be reversed. In fact, we could not statisticallyruleoutthereversepathsinthevalidationanalyses. Clearly, all three domains have complex etiologies and are interacted so the causalrelationships are difficult toassert. In addition,given that ourstudydesign wasobservational, causal interpretations in this regard are limited. Second,12 potential associatedfactorswereexamined,assuggestedintheliterature, butthepossibilityofundetected factors(forexample,caregiver issues) cannot be excluded. Third, the sample was selective
Admission (T0) Before discharge (T1) After discharge (T2) Functional Dependence Functional Dependence Functional Dependence Depressive Symptoms Depressive Symptoms Depressive Symptoms Nutritional Status Nutritional Status Nutritional Status 0.99*** 0.40*** 0.33*** 0.09* 0.58*** 0.30*** 0.20*** 0.37*** 0.30*** 0.31*** 0.26*** 0.48*** 0.25*** 0.16** (Sig=*p<.05, **p<.01, ***p<.001)
Fig.1.Apathwaymodeloftheeffectsoffunctionaldependenceandnutritional statusondepressivesymptoms with time-constantpredictors. Notes:1. This proposedpathwaymodeladjustedfordemographicvariables(age,gender,levelsof educationandincome,andmaritalstatus)andtwoimportantcovariatesincluding socialsupportandcognitivestatus.2.Single-headedarrowsdisplayhypothesized directionalrelationship. Allofthepaths wereestimated.Aftercontrollingfor covariates,somepathsbecamenonsignificantandwerepresentedasthedotted lines.The14solid-linepathwayswithstandardizedregressioncoefficientsalong thepathsrepresentsignificantrelationships.3.Allcross-sectionalpaths(vertical arrows)werefurthermarkedwithreversearrowswhenthereversedirectionsof pathsweresignificantinthevalidationanalyses.4.Thisfinalmodelhadagoodfit (chi-square=2.342,TLI=0.914,CFI=0.953,RMSEA=0.062).
becausewerecruitedparticipantsfromonemedicalcenterwith inclusioncriteriaofexpectedLOS>5days,abletocommunicate, andhavenoscreenedcognitivedysfunction,whichmightlimitthe generalizability of our findings. Lastly, our categorization and identificationofdepressionanddepressivesymptomswerebased onGDS-15scoresandnotdiagnosticinterviews.Thislimitationis minimized by the widespread use of the GDS-15 and other depressionratingscalestoreliablymeasuredepressivesymptoms and depression using cut-off scores in lieu of structure-based clinicaldiagnosis.Nevertheless,thestrengthsofourinvestigation are its longitudinal design, large sample of older hospitalized patientsincludingbothmedicalandsurgicalpatients,anduseof validatedmeasures.
5. Conclusion
Depressivesymptomsinolderhospitalizedpatientsrepresent anentitythatmeritsclinicalvigilance(Cole,2012).Targetingthe triad of depressive symptoms, functional dependence, and nutritionalstatusmaymaximizetreatmentsuccessfordepressive symptomsandpotentiallyimproveolderpatients’qualityoflife. Theburdenisnowonclinicalresearcherstorigorouslytest the effectsofpreventiveandtherapeutictriadicinterventionsonthis devastatingmedicalfoe.
Conflictofintereststatement
None.
Acknowledgement
This study was supported by the National Science Council Grants#93-2314B002-293&94-2314B002-226andinpartby# 102-2314B002-145-MY3attimeofpublication.
References
Almeida,O.P.,&Almeida,S.A.(1999).ShortversionsoftheGeriatricDepression Scale:Astudyoftheirvalidityforthediagnosisofamajordepressionepisode accordingtoICD-10andDSM-IV.InternationalJournalofGeriatricPsychiatry,14, 858–865.
Benoliel,J.Q.,McCorkle,R.,&Young,K.(1980).Developmentofasocialdependency scale.ResearchinNursingandHealth,3,3–10.
Beydoun,M.A.,Shroff,M.R.,Beydoun,H.A.,&Zonderman,A.B.(2010).Serumfolate, vitaminB-12, and total homocysteineand theirassociation withdepressive symptomsamongtheU.S.adults.PsychosomaticMedicine,72,862–873.
Blazer,D.G.,Hybels,C.F.,&Pieper,C.F.(2001).Theassociationofdepressionand mortalityinelderlypersons:Acaseformultiple,independentpathways.Journalof Gerontology:BiologicalandMedicalSciences,56A,M505–M509.
Byrne,B.(2001). StructuralequationmodelingwithAMOS.Mahwah,NJ:Lawrence ErlbaumAssociatesInc.
Chen,C.C.H.,Lin,M.T.,Tien,Y.W.,Yen,C.J.,Huang,G.-H.,&Inouye,S.K.(2011).
ModifiedHospitalElderLifeProgram:Effectsonabdominalsurgerypatients. JournaloftheAmericanCollegeofSurgeons,213,245–252.
Cole,M.G.(2012).Preventingmajordepressioninoldermedicalinpatients:Innovation orflightoffancy?InternationalPsychogeriatrics,24,193–1196.
Cullum,S.,Tucker,S.,Todd,C.,&Brayne,C.(2006).Screeningfordepressioninolder medicalinpatients.InternationalJournalofGeriatricPsychiatry,21,469–476.
Fiske,A.,Wetherell,J.L.,&Gatz,M.(2009).Depressioninolderadults.AnnualReviewof ClinicalPsychology,5,363–389.
Folstein,M.F.,Folstein,S.E.,&McHugh,P.R.(1975).‘‘Mini-mentalstate’’apractical methodforgradingthecognitivestateofpatientsfortheclinician.Journalof PsychiatricResearch,12,189–198.
Ford,A.H.,Flicker,L.,McCaul,K.,Bockxmeer,F.V.,Hegarty,S.,Hirani,V.,etal.(2010).
TheBuVitagetrial:Arandomizedtrialofhomocysteineloweringtreatmentof depressioninlatelife.Trials,11,1–8.
German,L.,Kahana,C.,Rosenfeld,V.,Zabrowsky,I.,Wiezer,Z.,Fraser,D.,etal.(2011).
Depressive symptoms areassociatedwith food insufficiencyand nutritional deficienciesinpoor community-dwelling elderlypeople.Journal ofNutrition, Health,andAging,15,3–8.
Guigoz,Y.,Vellas,B.,&Garry,P.J.(1996).Assessingthenutritionalstatusoftheelderly: TheMiniNutritionalAssessmentaspartofthegeriatricevaluation.Nutrition Review,54,S59–S65.
Hamer,M.,Bates,C.,&Misbra,G.D.(2011).Depression,physicalfunction,andriskof mortality:NationalDietandNutritionSurveyinadultsolderthan65years. AmericanJournalofGeriatricPsychology,19,72–78.
Helvik,A.-S.,Skancke,R.H.,&Selbaek,G.(2010).Screeningfordepressioninelderly medicalinpatientsfromruralareaofNorway:Prevalenceandassociatedfactors. InternationalJournalofGeriatricPsychiatry,25,150–159.
Kline,R.B.(2005).Principlesandpracticeofstructuralequationmodeling(2nded.).New York:GuilfordPress.
Kuczmarski,M.F.,Sees,A.C.,Hotchkiss,L.,Cotugna,N.,Evans,M.K.,&Zonderman,A.B. (2010).HigherHealthyEatingIndex-2005scoresassociatedwithreduced symp-tomsofdepressioninanurbanpopulation:FindingsfromtheHealthyAgingin Neighborhoods ofDiversityAcrossthe LifeSpan(HANDLS) study.Journal of AmericanDieteticAssociation,110,383–389.
Mahoney,F.I.,&Barthel,D.W.(1965).Functionalevaluation:TheBarthelIndex. MarylandStateMedicalJournal,14,61–65.
Naismith,S.L.,Norrie,L.M.,Mowszowski,L.,&Hickie,I.B.(2012).Theneurobiologyof depressioninlater-life:Clinical,neuropsychological,neuroimagingand patho-physiologicalfeatures.ProgressinNeurobiology,98,99–143.
Pierluissi,E.,Metha,K.M.,Kirby,K.A.,Boscardin,W.J.,Fortinsky,R.H.,Palmer,R. M.,etal.(2012).Depressivesymptomsafterhospitalizationinolderadults: Functionandmortalityoutcomes.JournaloftheAmericanGeriatricsSociety,60, 2254–2262.
Sarason,I.G.,Sarason,B.R.,Shearin,E.N.,&Pierce,G.R.(1987).Abriefmeasureof socialsupport:Practicalandtheoreticalimplications.JournalofSocialandPersonal Relationship,4,497–510.
Smoliner,C.,Norman,K.,Wanger,K.-H.,Hartig,W.,&Lochs,H.(2009).Malnutrition anddepressionintheinstitutionalisedelderly.BritishJournalofNutrition,102, 1663–1667.
Tam,C.W.C.,&Lam,L.C.W.(2012).Cognitivefunction,functionalperformanceand severityofdepressioninChineseolderpersonswithlate-onsetdepression.East AsianArchivesofPsychiatry,22,12–17.
Thompson,A.W.,Liu,H.,Hays,R.D.,Katon,W.J.,Rausch,R., Diaz,N.,etal.(2011).
Diagnosticaccuracyandagreementacrossthreedepressionassessmentmeasures forParkinson’sdisease.ParkinsonismandRelatedDisorders,17,40–45.
Tiemeier,H.(2003).Biologicalriskfactorsforlatelifedepression.EuropeanJournalof Epidemiology,18,745–750.
Tsai,A.C.,Chang,T.-L.,&Chi,S.-H.(2011).Frequentconsumptionofvegetablespredicts lowerriskofdepressioninolderTaiwanese–Resultsofaprospective population-basedstudy.PublicHealthNutrition,15,1087–1092.
Tsai,H.J.(2013).Nutritionalrisk,functionaldependence,andcomorbiditiesaffect depressivesymptomsinTaiwaneseaged53yearsandover:Apopulation-based longitudinalstudy.JournalofPsychosomaticResearch,75,173–177.
Vahia,I.V.,Meeks,T.W.,Thompson,W.K.,Depp,C.A.,Zisook,S., Allison,M.,etal. (2010).Subthresholddepressionandsuccessfulaginginolderwomen.American JournalofGeriatricPsychiatry,18,212–220.
Wilkins,V.M.,Kiosses,D.,&Ravdin,L.D.(2010).Late-lifedepressionwithcomorbid cognitiveimpairmentanddisability:Nonpharmacologicalinterventions.Journalof ClinicalInterventionsinAging,5,323–331.
Wong,M.T.,Ho,T.P.,Ho,M.Y.,Yu,C.S.,Wong,Y.H.,&Lee,S.Y.(2002).Development andinter-raterreliabilityofastandardizedverbalinstructionmanualforthe ChineseGeriatricDepressionScale—ShortForm.InternationalJournalofGeriatric Psychiatry,17,459–463.
Yesavage,J.A.,Brink,T.L.,Rose,T.L.,Lum,O.,Huang,V., Adey,M.,etal.(1982).
Developmentandvalidationofageriatricdepressionscale:Apreliminaryreport. JournalofPsychiatricResearch,17,37–49.
