Mars and Venus: does gender matter in ageing?

Julie E Byles, Matthew Carroll and the Mars and Venus Writing Team Does ageing affect men and women equally? If not, how might differences affect research and subsequently clinical practice? To answer this and related questions, the Mars and Venus: Does Gender Matter in Ageing? conference was convened by the University of Newcastles Research Centre for Gender, Health and Ageing, in association with the Australian Association of Gerontology and the Healthy Ageing Theme of the Australian Research Council/National Health and Medical Research Council (NHMRC) Research Network in Ageing Well.1 The 2-day conference, held in Newcastle in July 2007, featured longitudinal studies of ageing that have given specific attention to the health of men or the health of women, and introduced an NHMRC-funded initiative to link two of these studies. The conference also included a 1-day research workshop, sponsored by the Ageing Well Network, which involved researchers from longitudinal studies of ageing being conducted in Australia, and considered how such studies might take greater account of gender in their design and analysis. The conference attracted 85 participants from across Australia and overseas, who came together to consider ways in which the effects of ageing are unequal between men and women, and how these differences might be further exaggerated through interactions with socieconomic status and background. Conference overview: seeking balanced debate The theme of the conference was set by Cherry Russell (School of Behavioural and Community Health Sciences, University of Sydney), who gave a keynote address, Ageing and the gender agenda: a critical reflection, which outlined gender differences in life expectancy, health, income, care needs, and level of social isolation, along with a discussion of gender biases in policy and service provision. Compared with men, women have more chronic illness and greater health service use at older ages; but they also live longer. Men have more fatal illness at younger ages.2 For instance, men have coronary artery disease earlier and have a higher death rate. Lung cancer is more common among men, who have had higher rates of smoking than women. Women have a higher incidence of musculoskeletal problems and a higher prevalence of incontinence, although these problems are also important for men. Although hip fracture also affects older men, the incidence increases at a later age and fewer men survive to the age of high risk. Women, therefore, dominate the clinical picture. Some health differences are related to biological sex; however, many differences are strongly linked to social influences of gender. These less obvious differences include environmental, occupational and behavioural risks, behaviour, and different adaptive techniques. There are also considerable differences in social roles and access to financial and social resources which significantly affect the experience of ageing. Cherry Russell noted that there has been little balanced debate as to what the unequal effects of ageing for men and women mean and where they stem from. Debates about gender and ageing have focused on loss of mens work roles, older womens double disadvantage from age and

gender inequality, and on a paradigm of competitive suffering. In contrast, this conference aimed for greater balance in considering how gender influences the health and wellbeing of men and women as they age. This theme was reflected in the proffered papers and workshops. Papers explored age and gender issues such as living arrangements; health and engagement for older men; gender bias in health service programs; retirement issues; and current research on gender differences, including results from the Household, Income and Labour Dynamics in Australia (HILDA) study and Melbourne Longitudinal Studies of Healthy Ageing (MELSHA). Workshop topics explored the needs of homosexual and transgender people, gender issues in dementia and sexuality in residential aged care, and the practicalities of conducting a large longitudinal study: the Australian Longitudinal Study on Womens Health. Longitudinal studies: a focus on gender Keynote addresses throughout the conference featured longitudinal studies of older men and women. The Concord Health and Ageing in Men Project (CHAMP), presented by Bob Cumming (Centre for Research and Education on Ageing, School of Public Health, University of Sydney), involves 1705 men aged 70 years and over. Early findings from this study show a sharp increase in multiple falls, and declines in continence, cognitive function, and activities of daily living starting after the age of 80.3 The Florey Adelaide Male Ageing Study (FAMAS), presented by Gary Wittert (School of Medicine, University of Adelaide), focuses on chronic physical and psychological disease and reproductive and sexual health.4 Measures of testosterone show an age-associated increase in sex-hormone-binding globulin and a decrease in free testosterone, a change that may be adaptive rather than pathological. The Health in Men Study (HIMS), presented by Leon Flicker (Graduate Research School, University of Western Australia), involves 4262 men, and focuses on physical and psychosocial morbidity (including depression), health risks, weight and body mass index, cognition and mortality. One finding from this study has been the importance of health and lifestyle factors in determining cognitive function, even in advanced old age.5 Emily Banks (National Centre for Epidemiology and Population Health, Australian National University) provided an overview of the United Kingdoms Million Women Study (MWS), which has shown increased risks of breast cancer,6 endometrial cancer,7 and ovarian cancer with use of hormone replacement therapy,8 and a protective effect on fracture.9 Annette Dobson (Division of Epidemiology and Social Medicine, University of Queensland) represented the Australian Longitudinal Study on Womens Health (ALSWH), which has been running since 1996, and has investigated many factors affecting womens health and ageing, particularly the influence of social context on health and health care use.10 Recent reports from this study emphasise the burden of illness associated with non-fatal conditions such as arthritis, the preventable burden of obesity, and safe levels of alcohol intake for older women.11 Leon Flicker, Annette Dobson and Julie Byles (Research Centre for Gender, Health and Ageing, University of Newcastle) also gave an overview of the recently funded Men, Women and Ageing Study, linking HIMS and ALSWH to generate cross-gender analyses. Additionally, Gita Mishra (University College, London) showed how gender interacts with effects of childhood

socioeconomic status in determining early mortality in the 1946 British Birth Cohort. For example, a fathers occupation had a strong effect in women, but no significant effect in men. Studies of men and studies of women What are the similarities and the differences? A workshop involving investigators from longitudinal studies and other researchers compared and contrasted issues, approaches and findings of longitudinal studies of men and women. Identified commonalities and differences between studies of men and women are shown in the Box. The main differences were conditions that could not be experienced by the opposite sex, such as hysterectomy for women and prostate disease for men. However, studies of men had a focus on testosterone and sexual function that was not mirrored by female equivalents. Studies of women measured oestrogen levels and sexual problems in relation to menopausal changes, not in relation to health in later life. Other differences were more subtle. For instance, while prostatism is a male issue, lower urinary tract symptoms are also experienced by women. It was agreed that more emphasis on these symptoms may be appropriate for studies involving women. As a general observation, studies involving men applied a biological framework, whereas studies of women applied a social model. For instance, caring has been emphasised in womens studies but caring may be an equally important, although different, issue for men. Health after the death of a spouse has also been given greater emphasis in studies of women. Men are more likely to repartner, but this comparison is confounded by the construction of relationships, with men preferring to cohabit and women preferring to live apart from a new partner. Transport and mobility were also identified as major issues for women. This need may be experienced differently by men, for whom loss of a drivers licence may present more than a practical problem of how to get around, as it may also lead to depression and general decline. Cross-gender analyses: what are the opportunities? The workshops also explored how longitudinal studies of ageing can be analysed from a gendered perspective. It seems that almost any question on the ageing research agenda can be subjected to a gendered analysis. For instance, comparing genders:

Which differences exist at a biological level, and which are socially determined? Does socioeconomic disadvantage have a differential effect on health? Does caring by men and women involve different activities and dimensions? What is the effect of ageing on sexual function, sensuality and spirituality? Is there a differential change in the importance of these outcomes with age?

How do men and women engage with the health care system? Does health care need to become more gender-sensitive? Are there differences in diet and nutrition? Does nutrition have a differential effect on health outcomes according to gender? Are the predictors of survival and longevity different among women and men? For example, does comorbidity have a stronger effect in men? Do men and women have different health goals? If health is seen not as an end, but as a means to achieving life goals, then health will have different effects in men and women if their life goals are not the same.

Gendered comparisons: simple or complex? However, gendered comparisons may not be as simple as stratifying variables by age and sex. Men and women may exhibit different levels of accuracy and reliability in reporting exposures and outcomes, and many measures have a strong gender bias. For instance, caring appears to have very different meanings and manifestations for men and women. Physical activity has a different nature, context, and inherent value. Even when the same measures can be used, different categorisations may be needed, especially if underlying distributions and associations vary by gender. Further, influences of gender may interact strongly with cognitive status, marital status and other socioeconomic factors. Cohort effects are also likely to be important, with changes in the social meaning of gender over time (for instance, disparities in education, employment, occupation, and assets have changed over the past century). The power that can be achieved by combining data from existing longitudinal studies, as will occur in the Men, Women and Ageing Study referred to above and in the Dynamic Analyses to Optimize Ageing (DYNOPTA) project led by Kaarin Anstey of the Australian National University, will allow robust statistical analysis of gender interactions and, in the case of DYNOPTA, the use of nested cohorts to control for cohort and geographical effects. Closing remarks Julie Byles and Hal Kendig (Faculty of Health Sciences, University of Sydney) noted that the discussion from the conference and the longitudinal studies workshop provided valuable insights into basic gender differences and will inform research for years to come. Sex and gender differences matter not only to the experience of ageing, but are also manifested in the design of the research projects which, to date, have shown a clear gender-specific focus. Participants agreed that gender is more than just a variable to be controlled for in statistical analyses it needs to be understood within a social context and be included in all future analyses. In this way, we may achieve not only greater understanding but also greater benefits in future clinical practice. Commonalities and differences between studies of men and women identified at the workshop

Commonalities

Medication Obesity and weight Cardiovascular outcomes (heart attack, stroke) Health risks: smoking and alcohol Diabetes and the metabolic syndrome Falls Fracture and osteoporosis Hearing and vision Anxiety and depression Sleep Other medical history Quality of life Mobility and dependence Housing and neighbourhood Social support Health service availability, access and use

Living arrangements and marital status Differences Men (Mars) Testosterone levels

Women (Venus) Effects of hormone replacement therapy Hysterectomy

Dementia and Alzheimers disease Sarcopenia (age-related muscle loss) Incontinence: urine flow Lower urinary tract symptoms

Prostate cancer

Incontinence: leaking urine Dysuria Widowhood Caring Transport Breast cancer

Endometrial cancer Ovarian cancer

Erectile dysfunction

Through Life

Chronic illness in older people

Leonard C Gray and Ian A Scott The majority of older people remain in good health until a relatively short period before their death. Most of those who acquire chronic illness tend to have only mild to moderate disability and are not dependent on others for lifes basic tasks. Common chronic diseases associated with mild disability include arthritis, hypertension, ischaemic heart disease and diabetes mellitus. However, the minority of older people who have chronic illness associated with severe disability have a large impact on our healthcare and welfare systems. Depression, Alzheimers disease and other dementias, stroke with residual disability, and various progressive neurological disorders contribute greatly to the overall burden of disability experienced by our society. Although circulatory, neoplastic and respiratory diseases are the most common causes of death, nervoussystem disorders contribute the greatest proportion of years of life lost to disability in the older population.1 Disability-adjusted life-years (DALYs), which combine the effects of shortened life expectancy and years lost to disability, enable an assessment of the overall burden of illness. In terms of DALYs, ischaemic heart disease and stroke rank first and second, respectively, in both sexes, followed by lung cancer in men and dementia in women.1 While the experience of chronic illness is different for each individual, its impact may be experienced in two broad dimensions, depending on the nature of the illness and the type of disability it produces. The patient may experience predominantly somatic symptoms, such as dyspnoea, pain, weakness, lethargy or nausea. The resulting discomfort interferes with enjoyment of life. Many people with conditions such as cardiac, respiratory and neoplastic disorders may remain relatively independent, at least in the confines of their own home, until late in the progression of the illness. However, they live with the constant threat of exacerbation and associated visits to hospital, and uncertainty about their life expectancy. Our challenge with these patients is to ameliorate distressing symptoms, halt progression of the disease, and prevent complications and unnecessary hospital admissions. On the other hand, the patient experience may be dominated by disability and handicap. Patients in this situation become distressed by their lack of independence in various life skills, which ultimately reduces their ability to survive in their usual living environment. Chronic conditions such as stroke and degenerative neurological disorders cause profound disturbances of personal functioning that increase as the illness progresses, such that dependence on others becomes continuous. Basic tasks such as walking, bathing, dressing and feeding become impaired. The situation is exacerbated by the presence of cognitive dysfunction. Ultimately, survival at home is

dependent on the support of family members, often with the assistance of community services. It is these illnesses that drive the demand for nursing home places. Some 70% of residents of nursing homes have moderate to severe cognitive impairment. These clinical scenarios highlight the predicament that faces all societies as the proportion of older people increases. With smaller families, and greater numbers of people entering old age either divorced or never married, there is a considerable challenge to provide the care that is so vitally needed. The paucity of family-member carers will be accompanied by declining numbers of people in the workforce. Similarly, the number of taxpayers who provide funds for care will decline in relation to those requiring it.2 Ultimately, the challenge will be to minimise the period of discomfort and dependence on others towards the end of life. This will require advances in prevention, management of disability and technology to reduce the reliance on others. It will also require robust social service support networks and public utility infrastructure that are sensitive to the needs of elderly people and provide adequate high-quality residential care for people who can no longer live independently.
(Received 5 Nov 2002, accepted 1 May 2003)

Preventing Depression

Potential for community programs to prevent depression in older people

Michael J Bird and Ruth A Parslow Abstract Depression is one of the most common mental health disorders in older people. Sequelae include unnecessary suffering, excess physical and social disability, exacerbation of co-existing illness, earlier death, and overuse of services.

There are currently no reported public health approaches to prevent late-life depression. Five risk factors appear susceptible to community-level prevention programs: recurrent depression, commonly undertreated precipitants, vascular disease, functional impairments, and metabolite abnormalities. We propose three broad but interacting prevention methods: increasing literacy about late-life depression, exercise, and dietary supplements.

Depression is one of the most common psychiatric disorders in late life, is costly in human suffering and service use, and has severe effects on physical health. There is currently no public health approach to this serious community problem. This article canvasses prospects for community-level prevention of late-life depression by discussing why it is worthwhile, examining malleable risk factors, and examining how it could be done.

Rationales for prevention Prevalence of late-life depression Epidemiological studies suggest that the prevalence of major depression in community-dwelling older people (usually defined as above 60 years) is between 1% and 3%.1 This has led to speculation that depression declines in old age,2 but the point is controversial.3 Objections are based on sampling and measurement. Most studies find much greater non-response rates among people with health or cognitive problems,4,5 which are important risk factors in this population. Major depression occurs in up to 25% of older people with comorbid conditions such as ischaemic heart disease, stroke, cancer, chronic lung disease, arthritis, and Parkinson's disease.6 Major depression is also very common in other important subpopulations commonly excluded from epidemiological studies, such as nursing home residents.7 Different methods of measurement produce very different results.3 One study (using self-report, not diagnostic interview) found an 8.7% community prevalence of DSM-IV major depression.1 Other studies using age-specific instruments or not using strict DSM or ICD cut-off scores find a very high rate of disabling depressive symptoms in older people. For example, a large community-based study, using the Centre for Epidemiological Studies Depression Scale (CESD),4 found the prevalence of major depression to be 2.02%, but 12.9% had "minor depression", and a further 14.9% had significant depressive symptoms. Other researchers find similar rates, and one author has noted that, together with dementia and anxiety, depression is the most common psychiatric disorder in late life.4 Costs of late-life depression Health services exist to reduce suffering, and there is no reason why older people should endure depression more than younger populations. Unfortunately, they do. There is chronic undertreatment of depression in all populations, but older people are the most vulnerable.8 One cause is primary healthcare providers' failure to recognise symptoms,9 which can present or be described differently in older patients,10 or be seen as side effects of medical illness.11 However, even when major depression is diagnosed, it often remains untreated or wrongly treated (eg, with benzodiazepines, or not long enough).12,13 A commonly cited reason for nontreatment is the nihilistic belief that depression is normal and to be expected in old age,14 although this hypothesis remains untested. In any case, whatever the cause of depression, the symptoms are no less intense, nor any less deserving of treatment.11 In addition to costs in terms of unnecessary suffering, there is good evidence that late-life depression is a risk factor for other negative events. A prospective study showed that self-rated health at baseline is strongly associated with depression at follow-up.15 Another study showed that depressive symptoms predict both onset of impairments in mobility and functioning, and declines in physical health.16 Depressive symptoms also have an interactive effect with physical illness in old age, compounding associated disability.17 Depressed older people are much more likely to commit suicide than younger people with depression,18 with rates as high as 67 suicides per 100 000 among white men aged over 85 years.6 The presence of depression also greatly increases the risk for non-suicide mortality in

important subpopulations (eg, people who have had myocardial infarction, or nursing home residents).19,20 Depression may even be a prodrome of dementia, although the relationship remains complex.21 Important psychosocial sequelae commonly found are grossly reduced activities and social isolation.12 A final cost of depression in older people is service use. Although actual treatment of depression is underutilised, there is excess use of non-mental health treatments.12,22 Summary There is a large population of older people with significant depressive symptoms, and consequences of these symptoms include development of other illnesses, exacerbation of coexisting illnesses, excess use of health services, severe restriction of quality of life, and unnecessary suffering because of inadequate, wrong or no treatment. Clearly, there is scope for prevention, if feasible. To do this, it is necessary to find risk factors that might be ameliorated. Risk factors for depression in older people Chronological age per se is not a risk factor. Incident depression does increase with each advancing age cohort over 60 years, but when other relevant variables are controlled the age effect disappears.1,5 Risk factors commonly cited include female sex, recent bereavement, other stressful life events, chronic medical conditions, social isolation, and prior history of depression.1,4,5 Recent large prospective cohort studies show that the situation is much more complex than appears from cross-sectional data. They suggest, for example, that the greater prevalence of depression among older women may be a result of chronicity in those who are depressed, not that being female and older itself increases risk of incident depression. One study found that being female, having low social support, and being unmarried did predict prevalence of depression in cross-sectional data at baseline, but did not predict incident cases at three-year follow-up.5 It is also clear that different factors interact. The same study showed that being unmarried did predict incident cases when there was also functional disability and lack of social support. The risk-factor picture should become clearer in the next decade. Our purpose is to examine prospects for prevention programs that could be implemented at a community level. We therefore expand upon those risk factors which:

show reasonably clear evidence that they are a direct risk for depression in older people; and are sufficiently malleable to suggest that preventive interventions might be possible; and for which preventive programs could realistically be tried now.

These criteria exclude fixed factors such as sex, and other important risk factors over which no control can be exerted, such as frequency of adverse life events. Also excluded are factors whose amelioration would involve an impossible level of social engineering, such as reducing social isolation, important though this may be in treating individual cases. Public health programs

aimed at reducing community prevalence require a broad-brush approach that cannot take account of aetiology at the individual level. Five risk factors potentially fit our criteria: currently suffering from depression or history of recurrent depression; conditions which commonly precipitate depression in older people, but which are undertreated; presence or risk of vascular disease; functional impairment; and nutritional deficiencies. Current or recurrent depression In prospective studies, the biggest predictor of depression at follow-up is depression at baseline.23 A history of depression is also an important risk factor.1,5 Sixty per cent of older people with prior depression have at least one late-life episode, and 40% remain chronically affected.24 Previous episodes are obviously not malleable, but the current episode often is. Depression in later life has been characterised as following a chronic relapsing course, with slow recovery and increasingly brief periods between episodes.25 A critical factor is the risk, already canvassed, that older people face of not being treated, being treated wrongly, or not being treated intensely enough for long enough. Even frail very old people can respond to antidepressants or psychotherapy, and, with adequate treatment, rate of recovery and relapse for many older people is the same as in younger cohorts.13 Predisposing conditions commonly undertreated in older adults Chronic insomnia,26 pain,27 and incontinence28 are common in older adults, commonly precipitate depression, and are commonly undertreated. Primary insomnia afflicts 5%10% of the aged community population,26 significant chronic pain 25%50%,27 and incontinence 15% 30%.28 Rates are much higher in residential care. Each condition also has medical and psychosocial sequelae, such as limited mobility, falls, and earlier entry to residential care, which are themselves risks for depression. These conditions are treatable in many patients, and it is not clear why they are undertreated. Likely reasons are reluctance to admit to these difficulties, or nihilistic views about the inevitability of suffering in later life. Vascular disease and stroke Post-stroke depression is common, with prevalence estimates of 10%64%.29 One study reported a 23% one-year prevalence of post-stroke major depression, and 18% for minor depression.30 Vascular disease, or even risk of vascular disease in the absence of stroke, is also a major risk factor for late-onset depression. Patients with late-onset depression are significantly more likely than younger subjects to have two or more risk factors for vascular disease.31 The term "vascular depression" has been proposed, emphasising the fact that depression is not necessarily a unitary syndrome.

Disability and functional impairment Lack of mobility, and consequent inability to perform activities of daily living (ADL), is both a direct and an indirect predictor of depression.1,32 A recent large prospective study found that functional impairment, rather than disease, predicted onset of depression by follow-up.32 Inability to perform ADL is also a predictor of nursing home placement,33 where there is a very high prevalence of depression. Nutritional deficiencies There is a well-established link between depression and certain metabolites, in particular deficient folate and vitamin B12 and elevated homocysteine levels.34 The risk is much greater for older people because the incidence of these abnormalities increases rapidly with age. For example, in a sample of older women, those with deficient vitamin B12 levels were 2.05 times more likely to have major depression.35 Importantly, elevated homocysteine level is a major risk factor for both vascular disease36 and dementia,37 a possible common causal link between vascular depression and dementia.31 Summary Prevalence of disabling depressive symptoms increases with age, but this is mainly attributable not to age itself, but to multiple medical, physical and psychosocial factors whose occurrence exponentially increases with age. Some of these factors might be modified in preventive programs. Potential for preventive programs The following discussion is necessarily speculative. There is little or no empirical literature on primary or secondary prevention of depression in later life. However, three broad strategies present themselves. Increasing literacy about depression in old age Probably the largest effect on prevalence could be made by increasing the chances, currently not high, that depressed older people will actually be treated for depression. A smaller effect could be made by increasing the chances that older people suffering conditions that often lead to depression, such as pain, primary insomnia or incontinence, receive adequate treatment. For depression, because of the alarming chronicity and relapse rates, maintenance pharmacological therapy has been advocated for people with recurring symptoms.6 For practitioners treating medical conditions, a more inclusive diagnostic process might be introduced, so that neurovegetative symptoms are explicitly investigated as evidence of depression rather than side effects of physical illness.11 How might chronic undertreatment be changed? Obviously, there are outstanding issues, including clarification of how geriatric depression differs from depression in younger people,

development of better instruments to identify depression co-existing with medical illness, and more trials to identify effective treatments both for late-life depression and for common conditions that precipitate it. Nevertheless, treatments are available now and, even when identified, depression, insomnia, pain and incontinence often remain untreated. There is clear scope for a campaign to increase literacy about these issues. Prime targets would be GPs, who provide the bulk of consultations, and other healthcare practitioners dealing with chronic illness in older people. With respect to depression itself, the primary information to be conveyed would be the high prevalence and costs of late-life depression, how to recognise it, the fact that it is not inevitable, available treatments that are supported by evidence, and how not to treat it. An essential adjunct, given that GP educational efforts have variable success,25 would be a matching campaign to increase literacy among older people, so that they are able to recognise symptoms in themselves or other family members, not be ashamed of them, know where to go for help, and know what help is likely to be effective. "Mental health literacy" is low in the general public.38 Increased literacy might embolden people to ask for help, even if they have to educate the healthcare professional whose help they seek. The purpose is to assist people suffering from depression to become more discerning and assertive consumers of services. Groups at particular risk for depression could be targeted besides the population at large for example, people who have lost a spouse or those acting as informal carers. Exercise The strongest lifestyle candidate for prevention is exercise. There is excellent evidence that, for older people suffering mild to moderate depression, regular physical exercise produces alleviation of symptoms equal to the effects of antidepressant medication. Exercise has also been an important adjunct in major depression.39,40 A meta-analysis of 30 studies found an overall mean effect size of 0.72.41 The long-term effects of exercise may also alleviate two important risk factors for depression: vascular disease,42 and physical and functional mobility or falls, with attendant risk of disability.43 Exercise for older people is already an area of specialisation in several Australian centres, and there are a number of community programs. Exercise does not have to involve major lifestyle changes; it can involve simply a walk every day, or resistance training at home.40 However, all studies on depression are with clinical samples, and a recent meta-analysis of controlled trials44 concluded that what is now needed is "A well-designed randomised controlled trial with longterm follow-up". Nutritional supplements A recent comprehensive review of nutritional and vascular risk factors for late-life depression concluded that, as folate and vitamin B12 are cheap, easily taken and readily correct elevated homocysteine levels, a more intensive evaluation of their effects is required in a large sample of older patients, and, prospectively, in people at risk of late-life depression.31 Given the consistent

associations between these metabolites and both depression and vascular disease (a major risk factor for late-life depression), this is an extremely plausible preventive measure. Nutrition supplementation is already occurring in several countries, including the US, where folate is added to grains. The hope is for reduction in prevalence of a number of disorders, including cardiovascular disease.45 Conclusion It is important to differentiate between the desirable and the feasible in prevention. Suggestions of routine cognitive behavioural therapy for patients who are recently bereaved25 would be an example of the former. We suggest that the three broad approaches canvassed here represent the latter. The evidence suggests that, given the will, increasing literacy about late-life depression in the aged population and treatable causes (among healthcare professionals and the elderly population), expansion of community-based exercise programs, and provision of readily available dietary supplements are realistic and plausible primary prevention methods. Before these programs could be considered, however, their effectiveness would need to be assessed in a randomised controlled trial. No such trials have yet taken place.
(Received 6 Jun 2002, accepted 16 Aug 2002)

Letters

Pain management programs in residential aged care

Robert H Llewellyn-Jones, Karen A Baikie, Heather E Smithers and Philip D Funnell To the Editor: The articles by Melding1 and McClean and Higginbotham2 highlight the important problem of chronic pain in residential care. We have conducted two studies to investigate factors related to depression in residential care. In our first study, in 1994, we approached a random one-in-two sample of the non-nursing-home population of a Sydney retirement village (n = 1466). We excluded residents who were under 65 years, had severe dementia, were away from the village at the time of the survey, or were too deaf or ill to participate. Of 610 eligible residents, 513 participated (response rate, 84%). Of these, 42.1% lived in hostels and 57.9% in independent living units. In a second, similar study, in 20002001, we surveyed residents of three Sydney aged-care hostels (n = 205). Of 159 eligible residents, 148 (93%) participated. In both studies, residents were asked how often over the previous six months they had experienced recurring pain and asked to rate the severity of pain at its worst (see Box). Using the Geriatric Depression Scale (GDS),3 Study 1 found that residents reporting frequent/constant pain were significantly more likely to be depressed (ie, to have a GDS score 11) than people reporting rare/occasional pain; similarly, people who felt rare/occasional pain were more likely to be depressed than those with no pain (odds ratio, 1.44; 95% CI, 1.131.83). In Study 2, there

was a non-significant association between frequent pain and depression (odds ratio, 1.47; 95% CI, 0.962.24). We implemented pain management programs at each facility. In Study 1, the program was part of a multifaceted intervention for depression,4 but residents could attend whether depressed or not. Based on general practitioner referral, the program provided interdisciplinary assessments by a visiting rehabilitation specialist together with a physiotherapist, occupational therapist and registered nurse from the facility. Consultative psychiatric input was also available. Neuropathic and musculoskeletal pain were the most common reasons for referral. Recommended interventions included drug treatment, exercise and preventive measures. Our impression was that they were well received by residents and GPs. In Study 2, residents with chronic pain were referred to a physiotherapist specialising in pain management and reported that this was beneficial. A clinical psychologist also offered to assist, but residents were reluctant to accept this form of help. Our impression was that psychological assistance would have been better received as part of an interdisciplinary pain management program. Older people in residential care may find it difficult to travel to hospital-based pain management programs. Our experience indicates that it is feasible to conduct pain management programs in residential care. However, improving pain management is not only a matter of pharmacological interventions. If we are serious about achieving adequate standards of pain management in residential-care facilities in Australia, resources should also be devoted to providing accessible interdisciplinary pain management programs and to changing the attitude that pain is an inevitable part of old age. Self-reported pain frequency and severity among residents of aged-care facilities Study 1 (1994) (n = 513) Study 2 (20002001) (n = 148) Pain frequency Not at all Rarely/occasionally Frequently/constantly Pain severity* Minimal/mild Moderate Severe/bad as could be 230 (44.8%) 115 (22.4%) 168 (32.8%) 58 (20.5%) 98 (34.6%) 127 (44.9%) 54 (36.5%) 52 (35.1%) 42 (28.4%) 27 (28.7%) 36 (38.3%) 31 (33.0%)

*Severity rated only for residents experiencing pain.

(Received 26 Jul 2002, accepted 30 Sep 2002)

GERIATRICS

Say it again?
Elderly people with hearing loss have a greater chance of developing dementia, a risk that increases as their deafness worsens, according to a new report. The research studied 639 individuals between the ages of 36 and 90 without dementia, who were given cognitive and hearing testing between 1990 and 1994. The test subjects were followed for the development of dementia and Alzheimer disease through May 2008, according to the study published in the February issue of Archives of Neurology. Of the participants, 125 had mild hearing loss (25 to 40 decibels), 53 had moderate hearing loss (41 to 70 decibels) and six had severe hearing loss (more than 70 decibels). During a follow-up midway through the study, after about 12 years of research, 58 individuals were diagnosed with dementia, including 37 who had Alzheimer disease. The study found that the risk of dementia was higher among those with hearing loss of greater than 25 decibels, with further increases in risk observed among those with moderate or severe hearing loss as compared with mild hearing loss. Hearing loss may be causally related to dementia, possibly through exhaustion of cognitive reserve, social isolation, environmental deafferentation (elimination of sensory nerve fibers) or a combination of these pathways, wrote the researchers, who are affiliated with the Johns Hopkins University in Baltimore, Maryland. With the increasing number of people with hearing loss, research into the mechanistic pathways linking hearing loss with dementia and the potential of rehabilitative strategies to moderate this association are critically needed. The researchers said that by the year 2050, an estimated 100 million people or nearly one in 85 individuals worldwide will be affected by dementia. Interventions that could delay the onset of dementia by even one year could lead to a more than 10-percent decrease in the prevalence of dementia in 2050, the authors wrote, but added that at present, unfortunately, there are no known interventions that currently have such effectiveness.

Helping Elderly Leave Nursing Homes for a Home

Jessica Kourkounis for The New York Times

Walter Brown was moved into public housing after having spent two years in a nursing home.
By JOHN LELAND Published: September 18, 2009

PHILADELPHIA Walter Brown never wanted to live in a nursing home, but when he had a stroke two years ago, he saw little choice. Mr. Brown, 72, could not walk, use his left arm or transfer himself into his wheelchair. It was like being in jail, Mr. Brown said on a recent afternoon. In the nursing home youve got to do what they say when they say it, go to bed when they tell you, eat what they want you to eat. The food was terrible. But recently state workers helped Mr. Brown find a two-bedroom apartment in public housing here, which he shares with his daughter. It just makes me more relaxed, more confident in myself, he said, speaking with some difficulty, but with a broad smile. More confident in the future. A growing number of states are reaching out to people like Mr. Brown, who have been in nursing homes for more than six months, aiming to disprove the notion that once people have settled into a nursing home, they will be there forever. Since 2007, Medicaid has teamed up with

29 states to finance such programs, enabling the low-income elderly and people with disabilities to receive many services in their own homes. The program in Pennsylvania provides up to $4,000 in moving expenses, including a furniture allowance and modifications to the apartment, and Mr. Brown has a home health aide every morning and a care manager to arrange for services like physical therapy. The new programs, financed largely by $1.75 billion from Medicaid, are a sharp departure from past practices, where Medicaid practically steered people into nursing homes. Medicaid has had an institutional bias in favor of nursing homes, even for people who do not need them, said Gene Coffey, a staff lawyer at the nonprofit National Senior Citizens Law Center. Federal law requires states to provide nursing home services. They dont have to provide home or community-based services. For Mr. Brown, the transition to his own home has changed his life, he said. Now, with his motorized wheelchair, he travels the city on public buses, visiting friends in other neighborhoods. Its a great feeling, he said. In the nursing home I got up at 5 oclock in the morning, then the rest of the day was just watching the TV or my VCR. I wanted to be able to get out and see people, see the world. I didnt want to be confined. Now I go where I want to go. States and the federal government hope to save money, though research about cost savings has so far been inconclusive. A recent study by researchers at the University of California, San Francisco, found that home care costs taxpayers $44,000 a year less than a nursing home stay though this number cannot be used to estimate total savings, because often home-based services replace family care, not nursing home care. About 1.5 million Americans are living in nursing homes. Its amazing how quickly people can end up in a nursing home, said Jean Janik, the director of community living options at the nonprofit Philadelphia Corporation for Aging. Say youre a single man and have a stroke, and need to go into a nursing home to rehab. Youre elderly so you dont quite bounce back quickly. After 60 days, Medicare doesnt pay any longer, so you need a Medicaid grant to stay in the nursing home. Then your Social Security will go to the nursing home. Many lose their apartments and regular support from family members, Ms. Janik said. We meet people who say, I went to the hospital and next thing I know, here I am. I dont know what happened to my apartment. Ms. Janik added, We go and check, and its not in their name. Especially if they dont have a strong family support system in place. A lot of people just think, Uncle Joe fell and broke his hip and now hes in a nursing home, so be it, thats where hell be. People dont realize they can get services in their home.

Each participating state has designed its own program, called Money Follows the Person. The federal government, which shares Medicaid costs, provides extra financing for the first year. Some experts worry that the programs will end up transferring some of the expenses of caring for the elderly or the disabled to their family members. Carol Irvin, a senior researcher at Mathematica Policy Research has been contracted by Medicare and Medicaid Services to study the costs of the program in its first five years. It could be shifting costs onto a persons relatives, Ms. Irvin said. But even if its not saving money, a lot of people believe living in the community is the right thing for individuals. Elizabeth Kamara, 72, spent 18 months in a nursing home after having her left foot amputated because of diabetes. Mrs. Kamara can get around using a walker, but in the nursing home she spent whole days in a wheelchair. I just let people do things for me, she said. They say, If you fall, well get in trouble. Please sit down. Mrs. Kamara has moved into a independent living facility, where she cooks dishes from her native Sierra Leone and navigates the hallways on her own. She gives herself insulin injections and gets a friend to drive her to doctors appointments. An aide comes twice a week to help clean. This is my home; Im free, she said. In the nursing home it was two persons in one room. Here I have my privacy. I can get my hair done, my nails done. Susan C. Reinhard, a senior vice president of the AARP Public Policy Institute, said of Money Follows the Person: Its gotten Congresss attention, and shown that people can leave a nursing home. That is a wake-up. For Esther Pinckney, 88, who ended up in a nursing home after a stroke, moving out has been literally a breath of fresh air. Ms. Pinckney now lives in a bright subsidized apartment where home aides visit twice a day. What didnt I like about the nursing home? she asked recently. What would you like about smell, smell, smell, morning, noon and night? Because Ms. Pinckney lost her apartment and furniture while she was in the nursing home, the Philadelphia Corporation for Aging bought her new furniture and a microwave oven. Before, she said, her Social Security check went to the nursing home; now she pays 30 percent of her check for her rent. I couldnt even buy a soda, Ms. Pinckney said. You want to be independent, dont you? Thats what I wanted. Life on her own has not been perfect, she admitted. Aides often fail to show up or spend their time talking on the telephone.

But her pastor takes her to church four times a week, and she can go to stores near her building. If her health should fail again, she said, she did not like to think about going back into a nursing home. Dont mention it, she said, her face tightening. I dont want to do that.

Moving Elderly Parents: Convincing Mom and Dad When They Don't Want To
In 2001, Gail Heimberg says she had to make one of the most difficult decisions of her life. Her 88-year-old mothera sharp, independent woman who had lived alone in Brooklyn, New York, for most of the latter part of her lifewas quickly growing frail. While she used to walk from her home to the neighborhood bakery with ease, navigating the stairs of her circa-1920 apartment building had become a daily battle. She couldnt walk very well, remembers Heimberg. And her emphysema had worsened. Heimberg knew the discussion she needed to have with her mother, yet like many adult children who were thinking of moving elderly parents, the three words assisted living facility seemed foreign, cold, and impossible to utter. A few months passed, and Heimberg got a disturbing call. Her mother had suffered a mild heart attack and had been taken to the hospital. Heimberg used the opportunity to share her concerns with her mother. Im sure she now understands that she has to move someplace where she can be taken care of, thought Heimberg. But when the subject came to moving her mother away from her home, she was met with sharp resistance. No, said her mother firmly. Im not moving. Those can be the most difficult words a concerned child may hear their elderly parent say. So how does a worried family member convince a recalcitrant parent that moving to a long-term care facility is in their best interest? Having the Conversation When it comes to moving elderly parents and broaching the nursing home or assisted living conversation, experts like Stella Henry, R.N., author of The Eldercare Handbook (HarperCollins, 2006) say this is probably one of the hardest decisions a child will ever have to make. Henry, an eldercare specialist who has been featured in Time, The New York Times, and The Wall Street Journal, says many seniors unrealistically believe they can take care of themselves for the rest of their lives. And thats where their children or other family members can be instrumental in identifying the problem and instigating change. No matter what the age of your parent, Henry and other experts say now is the time to begin communicating about the future. If you open the lines of communication early on, she says, words like nursing home lose their sting later on. Thats important, considering that most of Henrys clients approach her with little communication groundwork laid. Ninety-five percent of my clients come to me in crisis situations, says Henry. The result? Confused elders, disorganized yet well-meaning children, and a family in chaos.

Avoid these unnecessary results by having regular conversations with your parent about what the future holds. Make it your problem instead of your parents problem, adds Henry. If you say you have to do this, or do that, youll lose them. Instead say something like, Mom, Im concerned about you; it makes me worried to see you like this. Thats the approach Heimberg ended up taking with her mother. After sharing her serious concerns about her mothers health and safety, the elderly woman slowly came around. She finally said yes, says Heimberg. Nine out of ten parents, says Henry, dont want to burden their children, and they will often respond to this sort of honest communication. Parents sometimes hide things from their adult children because they dont want to scare them, she says. Yet, if you show them that you are trying to be their advocate, adds Henry, and that you are genuinely concerned about their wellbeing, it can make all the difference. The Resistant Parent Barry Jacobs, PsyD, a psychologist who has counseled many people in the situation of moving elderly parents, knows how difficult it can be when a parent in need of aging parent care refuses to leave his or her home. While hes quick to say there are no magic strategies or tricks for persuading an elder to move, he suggests that adult children ask their parent to indulge them by visiting an assisted living facility. Most of us are more likely to change our position and lifestyle if such a transformation is of our own choosing, writes Jacobs in his book The Emotional Survival Guide for Caregivers (Guilford Press, 2006). Placed under duress to change, we typically resist, regardless of the soundness of the other persons arguments. And when a parent continually refuses to entertain the idea of moving? The child needs to back off for the time being, advises Jacobs. But dont give up, he adds, seek other openings to raise the issue again. What I tell adult children is that, unfortunately, sometimes things have to get worse to get better, he says. It may take the parent falling or being spooked by burglars or having the electricity turned off because he forgot to pay the bills for the realization to dawn that the parent can no longer safely reside in the home. Even then, it may take the strong urgings of health care providers and extended family members for the parent to accept the inevitable. If the parent begins to show signs of warming up to the topic, the child needs to emphasize the parents right of self-determination but also urge action, adds Jacobs. He suggests structuring the conversation in the following way: Tell your parent: I cant make decisions about how you should run your life. It would make me feel better, though, if we could go together to look at some possible assisted living facilities so that youre better informed about what choices are available. Would you be willing to humor me in that way? If there is a willingness on the parents part to visit a senior housing facility, says Jacobs, the child should proceed post-haste to set up visits at local facilities and point out that most of these

facilities will allow an aged individual to try living in them for a week or a month before the person has to decide whether to sell his house and stay in the facility or return home. Experts say that can be the extra bit of comfort that can make the difference for many hesitant seniors. Forming a Caregiving Team Caregiving is a family affair, says Henry. Thats even more reason to gather your brothers, sisters, children, and uncles and aunts together to address an ailing loved ones needs. Have a meeting and discuss the problem, without the parent present, says Henry. Important items to address include financial issues and who will act as the elders durable power of attorney for health care (someone who is in charge of making medical decisions for a loved one when he or she is incapacitated). One of the most important things is to decide who will make the critical decisions, says Henry. Though she recommends a family approach to aging parent care, she recommends that one capable person be appointed as the elders primary advocate. This person, whether a son or daughter or adult grandchild, should be in charge of financial decisions and act as the elders durable power of attorney for health care. When it comes to approaching a parent about making a move, Jacobs says its vital that all siblings and family members are on the same page. Its crucial that all the adult siblings are giving their parent the same general message, he says. It often only takes one disgruntled child who urges the parent to stay in his home to make placement nearly impossible. When families get together, there can sometimes be personal luggage brought to the table, Henry cautions. She says its best to avoid unnecessary confrontation or sensitive family subjects, for the good of the parent. These can be emotionally charged issues, she says. But remember, its not about your issue, its about whats best for your parent.

No matter how smoothly the process goes, children often retain guilt about moving elderly parents to a long-term care facility. Jacobs cautions against that. What I point out to adult children is that, regardless of whether they promised to never put a parent in a nursing home, the decision about placement must be based on whats best for the parent at a given time, he says. Often, putting a parent in a nursing home is the most loving act that a child can do because it improves the quality of the parents life from medical and social perspectives, Jacobs continues. Nursing homes vary in quality but are not snake pits. Parents often thrive in them, to their great surprise. While Heimberg admits she had moments when she questioned her decision, she eventually felt peace about her mothers move, knowing it was the right decision. After two and a half years in the facility, her mother passed away at the age of 91. She credits the residence for making her mothers final years the best they could be. I felt like it extended her life, she remembers. She was cared for and watched over. Finding the right facility is so important, and we were lucky. Article | August 01, 2002 Major Depression in Elderly Home Health Care Patients

Martha L. Bruce, Ph.D., M.P.H.; Gail J. McAvay, Ph.D., M.S.; Patrick J. Raue, Ph.D.; Ellen L. Brown, Ed.D., M.S., R.N.; Barnett S. Meyers, M.D.; Denis J. Keohane, M.D., M.S.; David R. Jagoda, M.A., C.C.C., S.L.P.; Carol Weber, R.N., M.S. Am J Psychiatry 2002;159:1367-1374. 10.1176/appi.ajp.159.8.1367 Abstract OBJECTIVE: Despite the growth of geriatric home health services, little is known about the mental health needs of geriatric patients seen in their homes. The authors report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems. METHOD: Geriatric patients newly admitted to a large, traditional visiting nurse agency were sampled on a weekly basis over a period of 2 years. The 539 patients ranged in age from 65 to 102 years; 351 (65%) were women, and 81 (15%) were nonwhite. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to interview patients and informants. The authors reviewed the results of these interviews plus the patients medical charts to generate a best-estimate DSM-IV psychiatric diagnosis. RESULTS: The patients had substantial medical burden and disability. According to DSM-IV criteria, 73 (13.5%) of the 539 patients were diagnosed with major depression. Most of these patients (N=52, 71%) were experiencing their first episode of depression, and the episode had lasted for more than 2 months in most patients (N=57, 78%). Major depression was significantly associated with medical morbidity, instrumental activities of daily living disability, reported pain, and a past history of depression but not with cognitive function or sociodemographic factors. Only 16 (22%) of the depressed patients were receiving antidepressant treatment, and none was receiving psychotherapy. Five (31%) of the 16 patients receiving antidepressants were prescribed subtherapeutic doses, and two (18%) of the 11 who were prescribed appropriate doses reported not complying with their antidepressant treatment. CONCLUSIONS: Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients. Home care has grown into a vital source of health care, especially for older adults, who represent 72% of recipients (1). Little is known about the mental health needs of these patients. In this article we report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems. Because major depression is associated in more healthy populations with significant risk for mortality, morbidity, institutionalization, and functional decline (28), investigating the extent to which depression affects home health care recipients represents an important step toward improving the clinical care and outcomes of this medically and functionally compromised patient population. Home care services for patients confined to their homes by illness and disability is an important component of the overall health care system. Home care agencies typically offer a range of services, including skilled nursing care, occupational therapy, physical therapy, and home assistance. The great majority of home care patients (85%) are referred for medical or surgical diagnoses for which they receive skilled nursing care (9, 10). In the past two decades, use of home care services and the sector itself have grown rapidly. Between 1987 and 1997, Medicares spending for home care rose at an annual rate of 21%, and home cares share of total Medicare expenditures increased from 2% to 9% (11). During this

time, the number of agencies certified by Medicare and the number of patients served annually doubled. In 1997, home health care cost Medicare $16.7 billion and served approximately 4 million Medicare enrollees, most of whom (85%) received skilled nursing care (911). Federal projections through 2008 estimate that the cost of home health care services will rise at a faster rate than the economy (12). Factors fueling this rapid growth include increased size and longevity of the elderly population, shorter hospital stays, expansion of Medicare eligibility, and technological advances allowing delivery of more complex care in the home (11). This study is the first, to our knowledge, to investigate major depression among elderly recipients of home care nursing in the United States. Several investigators have reported high prevalence rates of depressive syndromes in elderly recipients of home-based health and social services in other countries (1317). U.S. investigations have generally relied on convenience samples (1820), chart diagnoses (21), or symptom screens (19, 20), which limit their utility for determining treatment needs (2, 3). High prevalence rates of current major depression have been reported in other medically ill or disabled elderly populations, including medical inpatients (11.5%13.2%) (22, 23) and nursing home residents (9.7%12.6%) (2426). These rates exceed those in elderly community samples (0.7%1.4%) (2729) and primary care patients (6.5%9.0%) (30, 31). On the basis of these data we expected that major depression would be highly common in home care patients and associated with greater medical morbidity, disability, and pain. We also hypothesized that major depression in these patients would be largely undetected and untreated. Efficacious treatments for depression are available and can be effectively used in medically ill elderly patients (3). In elderly primary care patients, however, depression goes undiagnosed more often than not, and, when diagnosed, is often inadequately treated (32).

Conclusions
This studys primary finding is that 13.5% of newly admitted, geriatric home health care patients suffered from major depression. The majority of depressed patients (78%) were not receiving treatment for depression. Of those treated, a third had not been prescribed an appropriate dose according to accepted treatment guidelines. In assessing major depression in elderly home care patients, the study hoped to determine the treatment needs of this large and growing patient population. Intensive diagnostic procedures were chosen to address the difficulties of accurately diagnosing depression in the elderly and medically ill. On the one hand, depression can be underestimated because many older adults minimize psychological symptoms and attribute sleep disturbances, fatigue, and other somatic symptoms of depression to physical health causes (51, 52). On the other hand, the prevalence of major depression can be inflated in medically ill populations by misattributing symptoms of medical illness, medication side effects, or treatment sequelae to depression. Because we chose methods designed to minimize both potential sources of diagnostic measurement error, we believe that the estimated prevalence of major depression has clinical significance in this sample. Is 13.5% a high rate of major depression? Research demonstrates that depression is both prevalent throughout the life span and costly in terms of individual suffering, negative sequelae, and health care utilization (3). Embedded in this literature are debates on whether depression is better conceptualized and measured as a diagnosis or spectrum of symptoms (53, 54) and whether diagnoses are more validly or reliability assessed by clinical judgment or self-report (5557). We chose what might be considered the most conservative approach, using clinical judgment to make a strict DSM-IV diagnosis. Using similar criteria and procedures, Lyness et al.

(30) reported a prevalence of 6.5% in a representative sample of older primary care patients. The difference between that rate and the rate of 13.5% in our sample suggests that depression is twice as common in elderly home care patients. In these patients, depression was usually first-onset, persistent, and associated with medical comorbidity, disability, and reported pain. These correlates have been implicated in both the risk and outcome of late life depression (58, 59). These findings suggest that these complex and difficult-to-disentangle relationships persist even among patients suffering severe medical burden and disability. The specific associations with myocardial infarction, peripheral vascular disease, and diabetes are consistent with theories of vascular depression (60). The sustained episodes suggest that depression was often more than a brief reaction to the events precipitating home care and may be associated with long-term declines in medical and functional status. Factors that potentially limit the generalizability of these findings are sampling from a single agency and the 39% refusal rate. The agency is similar to visiting nurse services agencies throughout the United States, however, and the sample characteristics are similar to national norms (9). The refusal rate reflects the challenges of conducting research with medically ill, frail patients in nonacademic settings and is consistent with other recent U.S. studies conducted in the homes of medically ill older adults (6163). Patients who refused were surprisingly similar to participants. Any attempt to characterize the needs of home care patients is challenged by the volatile home care environment. The Balanced Budget Act of 1997 restricted Medicare reimbursement for home health care in an effort to curb rising Medicare costs. Our sample was accrued during this period of constriction in Medicare spending. How these changes, as well as Medicares recently implemented home care prospective payment system, affect the needs and treatment options for older patients is not yet known. Because major depression can be successfully treated in older patients (3), our finding that depression is not only prevalent but mostly untreated in home health care patients is important for clinical practice. The complex configuration of home care presents a challenge to identifying depression in these patients. Physicians have little opportunity for directly assessing their home health care patients, unlike the patients they see in primary care. The visiting nurse generally serves as the eyes and ears of the physician, thereby playing a key role in establishing the presence of depression and potential need for treatment. Depressive symptoms are an accepted component of a comprehensive geriatric assessment (64, 65), and nurses are now expected to assess depressive symptoms as part of the Health Care Financing Administrations mandatory use, collection, encoding, and transmission of outcome and assessment set (66). However, home health nurses typically are not trained in the assessment of depression or in diagnostic criteria (67), limiting the usefulness of their observations for making treatment decisions (68). This study found that over 40% of the depressed patients receiving antidepressant therapy received inadequate treatment either because the prescribed dose was below recommended guidelines or the patient was noncompliant. Accordingly, home care strategies are needed to improve treatment initiation and management as well as case identification. The challenge is to improve depression care in the context of the complex organization of the nurse-physician-patient triad, the increasing time and financial pressures faced by both home care agencies and physicians, and patient frailty. Effective strategies will likely draw from three areas of research. First are primary care interventions to improve treatment of geriatric depression through the use of structured treatment guidelines and care managers (32, 69). Second are comprehensive home-based interventions that

target the full range of nursing and psychosocial needs in geriatric patients (62, 63, 70). Third are "telemedicine" strategies to facilitate clinical care for hard-to-reach populations, such as the rural and homebound (71). The immediate goal of any depression intervention in home health care is recovery from depression and reduction of depressive symptoms. Data from other populations suggest that treating depression may reduce the risk of negative functional outcomes as well. Functional outcomes are especially important in home health care, both because good functional status is critical in allowing older adults to remain in their own homes and because Medicares prospective payment system bases reimbursement on functional outcomes. Despite the availability of efficacious treatments for depression, however, only nine (12%) of our depressed home care patients received adequate antidepressant treatment. This magnitude of untreated major depression underscores the critical need for effective strategies to reduce the burden of depression in older home health care patients.
Depression and Suicide in Older Adults Resource Guide

Introduction
Depression and suicide are significant public health issues for older adults. Depression is one of the most common mental disorders experienced by elders, but fortunately is treatable by a variety of means. Current cohorts of older adults in the United States evidence lower rates of major depression than younger cohorts, but experience minor depression or significant subsnydromal depressive symptoms at rates equal to or greater than younger groups. Adults soon to enter later adulthood, most notably the so-called Baby Boom cohort, seem to be evidencing depressive disorders at significantly higher rates than previous groups; this trend towards greater incidence of depression in subsequent cohorts seems steady. The reasons for these changes are the subject of much debate and not clearly understood. Because depression tends to be a recurrent disorder, this means that many older adults will have experienced previous bouts of depression and will be at increased risk. Depression is not only a prevalent disorder but is also a pervasive problem. Depressed older adults, like younger persons, tend to use health services at high rates, engage in poorer health behaviors, and evidence what is known as "excess disability." Depression is also associated with suicide. Older adults have the highest rates of suicide of any age group, and this is particularly pronounced among men. Several efficacious treatments are available for geriatric depression but seem to be underused. Pharmacotherapy and several versions of psychotherapy, including interpersonal, brief psychodynamic, problem-solving, and cognitive-behavioral, significantly reduce depressive symptoms. Interestingly, when given thorough descriptions of these treatments, older adults state a preference for receiving psychologically based treatments rather than medication. Geriatric depression will continue to be a topic worthy of much scientific and applied interest in the years to come. This resource guide provides some current information we hope will be useful as you learn more about this important health issue.

Forrest Scogin, PhD Department of Psychology University of Alabama at Tuscaloosa Updated: September 2009