Anxiety and Depression during Transition from Hospital to Community in Older Adults: Concepts of a Study to Explain Late Age Onset Depression
Abstract
:1. Introduction
- Assess the time-course of symptoms of anxiety and depression amongst older adults who have been discharged to the community following at least two weeks of hospitalization.
- Identify and understand inter-relationships between factors that may cause older adults to experience symptoms of anxiety and depression during the six months following an extended period of hospitalization.
- Develop a predictive index to identify older adults, at the point of hospital discharge, who are likely to experience clinically significant symptoms of anxiety or depression following discharge to the community.
2. Experimental Section
2.1. Study Design
2.2. Participants and Setting
2.3. Measurements
2.3.1. Prospective Cohort Study Measurements
Domain | Questionnaire Data (Measurement Tool) | Measurement Points | |||||||
---|---|---|---|---|---|---|---|---|---|
R | B | 1 | 2 | 3 | 4 | 5 | 6 | ||
Output feedback loop | Depression symptoms (GDS15, EQ-5D-5L) | X | X | X | X | X | X | X | X |
Anxiety symptoms (GAI, EQ-5D-5L) | X | X | X | X | X | X | X | X | |
Physical capacity and participation (PhoneFITT) | X | X | X | X | X | X | X | X | |
Quality of life (EQ-5D-5L) | X | X | |||||||
Falls | X | X | X | X | X | X | X | ||
Sleepiness and sleep quality (ESS, PSQI) | X | X | X | X | |||||
Perception of death * (DAQ) | X | ||||||||
Exercise program | X | X | X | ||||||
Long-standing vulnerabilities | Gender | X | |||||||
Culturally and Linguistically Diverse (CALD) | X | ||||||||
Marital status | X | ||||||||
Housing situation | X | ||||||||
Financial situation | X | ||||||||
Primary occupation | X | ||||||||
Education level | X | ||||||||
Existing chronic conditions * | X | ||||||||
Religiosity/spirituality (ISS) | X | ||||||||
Perception of death * (DAQ) | X | ||||||||
Pain and stoicism (PAQ-R) | X | ||||||||
Resilience and coping style (BRCS) | X | ||||||||
Personality (TIPI) | X | ||||||||
Stressful life events and loss of social roles | Services received | X | |||||||
Social isolation (LSNS-6, Friendship Scale) | X | X | X | ||||||
Computer use | X | X | X | ||||||
Driving/transport | X | X | X | ||||||
Carer/volunteering | X | ||||||||
Stressful life events | X | X | X | ||||||
Changes in health, physical ability, or cognitive ability | Cognition (COWAT-S, CTT) | X | X | X | |||||
Vision and visual aids | X | ||||||||
BMI | X | ||||||||
Falls history | X | ||||||||
Physical capacity and participation * (PhoneFITT) | X | X | X | X | X | X | X | X | |
Continence (UDI-6) | X | X | X | ||||||
Reason for hospital admission | X | ||||||||
Existing chronic conditions * | X | ||||||||
Nutrition | X | ||||||||
Caffeine intake | X | X | X | ||||||
Alcohol intake | X | X | X | ||||||
Smoking intake | X | X | X | ||||||
Health professional consultations | X | X | X | ||||||
Medication | X | X | X |
2.3.2. Initial Cognitive Screen
2.3.3. Output Feedback Loop Domain
2.3.4. Long-Standing Vulnerabilities Domain
2.3.5. Stressful Life Events and Loss of Social Roles Domain
2.3.6. Changes in Health, Physical Ability, or Cognitive Ability Domain
2.3.7. Qualitative Measurements—Semi Structured Interview
2.4. Procedure
2.5. Analysis
2.5.1. Aim 1. Time Course Symptomology
2.5.2. Aim 2. Factors That Increase Symptoms of Anxiety or Depression
2.5.3. Aim 3: Predictive Index Development
2.5.4. Sample Size
3. Discussion
4. Conclusions
Acknowledgments
Author Contributions
Conflicts of Interest
Appendix
Measure | Reliability/Validity | Sample Item |
---|---|---|
Short Geriatric Depression Scale (GDS15) | The GDS15 has a high level of internal consistency (Cronbach’s α = 0.80) [56] and strong sensitivity (81.3%) and specificity (78.4%) [57]. Additionally, the efficiency (fraction correctly identified) of the GDS15 is significantly higher than the GDS (77.6% vs. 71.2%, Chi² = 24.8, p < 0.0001) and the clinical utility of the GDS15 was rated as “good” for screening (UI—0.75) [57]. | Individuals are asked to choose the best answer for how they have felt over the past week, e.g., “Are you basically satisfied with your life?” |
Geriatric Anxiety Inventory (GAI) | The GAI has well established psychometric properties in various population groups within the older aged [58], with high test-retest reliability (R = 0.91) and inter-rater reliability (R = 0.99) [17] and demonstrated sensitivity (85.7%) and specificity (78.0%) [59]. | Individuals are asked to choose the best answer for how they have felt over the past week, e.g., “I worry a lot of the time”. |
6-item Cognitive Inventory Test (6-CIT) | It takes less than 5 min to complete (mean 2.5 min) and has demonstrated high correlation (R2 = 0.911) with the Mini-Mental State Examination [60,61,62]. Recent evidence has highlighted the advantages of using the 6-CIT over the MMSE in hospital settings [62]. It has also demonstrated good sensitivity and specificity of 78.57% and 100% (cut-off 7/8) for detecting mild dementia and when compared to the Mini-Mental State Examination (90% and 96%, respectively) [60,62]. It is recognized for being culturally unbiased and has further demonstrated not to be sensitive to educational level, nor require advanced language skills [62]. The 6-CIT has limited validation data available although stable reliability (test-retest immediate: Pearson’s r = 0.68; test-retest delayed: Pearson’s r = 0.74) has been reported [63]. | Individuals are asked to “Count backwards from 20-1”. |
Phone-FITT | Preliminary evidence demonstrates substantial test-retest reliability (95% CI, intra-class correlation coefficients 0.74–0.88; Spearman’s rho = 0.29–0.57), in addition to concurrent, convergent and discriminant validity [19]. | Individuals are asked initially to answer Yes/No as to whether they completed an activity (e.g., Light housework such as tidying, dusting, laundry, or ironing). If the individual answers yes, they are then asked “How many times in the past week did you complete this activity?” Individuals are also asked “About how much time did you spend on each occasion completing this activity?” |
2.3.19. EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) | The EQ-5D-5L was recently developed following revision of the EQ-5D-3L to improve sensitivity and reduce possible ceiling effects previously found in the EQ-5D-3L. [18] Recent research has supported the revised version for sensitivity [64]. | Measures 5 dimensions of health including: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression across a five point scale (0 = “No problems” to 5 = “Extreme problems”) [18]. |
Intrinsic Spirituality Scale (ISS) | The overall measure reports strong internal consistency (Cronbach’s α = 0.96), strong reliability (0.80), and strong construct validity (r = 0.91, p < 0.001) [23]. | The ISS uses a ranking scale from 0 to 10 where 0 = “Plays absolutely no role” to 10 = “Is always the over-riding consideration”. Individuals are asked to rank themselves in response to each item (e.g., “When I am faced with an important decision my spirituality…”). |
Death Anxiety Questionnaire (DAQ) | Initial research suggests discriminative validity of the items, construct and concurrent validity of the scale as a whole, and applicability over a broad age range ranging from 30 to 82 years [22]. Subsequent research has indicated excellent internal consistency (Cronbach’s α = 0.90) and strong factor structure [65]. | Individuals are asked to respond either “not at all”, “somewhat”, or “very much” in relation to each item (e.g., “Do you worry about dying?”) |
Pain Attitudes Questionnaire (Revised) (PAQ-R) | Previous evidence suggests chronic pain sufferers attempt to preserve their self-esteem and maintain acceptance socially by exhibiting stoicism and reduce negative (expected or real) social consequences of disclosure [66,67]. | Individuals are asked to select the best answer for them (e.g., “I do not see any good in complaining when I am in pain”) [39]. |
Brief Resilient Coping Scale (BRCS) | Initial evidence exists relating to adequate reliability of the tool (Cronbach’s α = 0.69; test-retest correlation = 0.68–0.71, p < 0.001) and validity (r = 0.37, p < 0.01), given the brevity of the measure [25,67,68]. Preliminary evidence demonstrates that the BRCS is a reliable and valid measure of resilient coping in non-English speaking elderly populations [69]. | Individuals are asked to select the extent to which they agree to each of the statements (e.g., “I tend to bounce back quickly after hard times”). |
Ten-Item Personality Inventory (TIPI) | Initial evidence reports adequate psychometric levels for the tool. [26] | Individuals are asked to rate how they perceive themselves across various personality traits (e.g., “I see myself as: extraverted/enthusiastic”). |
Lubben Social Network Scale Abbreviated (six items; LSNS-6) | The two factor (family and friends) structure was confirmed across three European community samples and loaded highly on each factor indicating strong construct validity. [70] The LSNS-6 has high levels of internal consistency (Cronbach’s α = 0.83) and correlations with criterion variables. [70] | Individuals are asked to rate, where 0 = None and 5 = Nine or more, “considering the people to whom you are related either by birth or marriage, how many relatives (including spouses, partners, children, etc.) do you see or hear from at least once a month?” |
Friendship Scale | Developed in Australia, the Friendship Scale comprises six of the seven identified dimensions that are believed to contribute to social isolation or social connectedness. [27] While the Friendship Scale has limited related publications at present, initial evidence suggest it has excellent internal structures (CFI = 0.99, RMSEA = 0.02), strong reliability (Cronbach’s α = 0.83), and concurrent discriminant validity suggesting sensitivity to known social isolation correlates. [27] | Individuals are asked to rate, on a 5-point scale from “Almost always” to “Not at all”, over the past 4 weeks “It has been easy to relate to others” |
Color Trails Test (CTT) | Research has been conducted comparing the utility of the CTT to three other tests for assessing executive functioning in older adults and was found to be the highest loading for the executive function domain (factor loading = 0.57). [71] Further evidence also suggests that the CTT is appropriate for cross-cultural and clinical assessment of mental processing speed, sequencing, and visual scanning in non-English-speaking adults and adults with limited education. [72] | N/A |
Urogenital Distress Inventory (UDI-6) | Research has demonstrated that the UDI-6 has strong psychometric properties (Cronbach’s α = 0.93) and is considered more useful in clinical and research settings. [31] High internal consistency (Cronbach’s α = 0.74) and test-retest reliability (Spearman’s rho = 0.99, p <0.001) was demonstrated with a sample of 302 Turkish speaking women with urinary issues. [73] Furthermore, while predominantly utilized with women, the UDI-6 has been used in studies with both males and females and identified high levels of distress relating to urinary issues in males that had not previously been detected. [74] | Individuals are asked whether they currently experience: “Urine leakage related to the feeling of urgency” (Yes or No). |
Epworth Sleepiness Scale (ESS) | The ESS has high internal consistency (Cronbach’s α = 0.88) and test-retest reliability (r = 0.82) [20,35,74,75,76]. | Individuals are asked to choose the most appropriate response, on a 4 point scale where 1 = would NEVER doze or sleep to 4 = HIGH chance of dozing or sleeping, for various situations (e.g., “Sitting and reading”). |
Pittsburgh Sleep Quality Index (PSQI) | Initial development of the PSQI was conducted with patients with major depression and patients with a sleep disorder. [21] It has subsequently become a widely used, recognized and validated tool for assessing sleep quality with participants presenting with a variety of medical diagnoses. [77,78] More recently, the PSQI has been further validated for use with community-dwelling older men and older women. [79,80] Adequate internal consistency was reported for total PSQI scores (Cronbach’s α = 0.69). Previous research also demonstrated good internal consistency (Cronbach’s α = 0.78) for the PSQI in both black (n = 306) and white (n = 2662) community-dwelling women aged 70 years and over. [79] Adequate test-retest reliability (0.85), strong criterion validity, and responsiveness to have also been established for the PSQI. [21,81] The global score has a strong diagnostic sensitivity (89.6%) and specificity (86.5%). [82] | Individuals are asked to answer various items relating to their usual sleep habits during the past month. (e.g., “During the PAST month, what time have you usually gone to bed at night?”) |
Area/Construct | Potential Questions |
---|---|
Build rapport with the participant |
|
Establish participant’s expectation for the interview |
|
Narrative—establish the participants experience |
|
Functional Decline/Falls Experience of the participant and how this relates to their symptoms of depression or anxiety |
|
Establish the Health Care Resources that the participant has sought/engaged with to assist with their symptoms | The following section is split depending on whether the participant answers Yes or No to accessing services
|
Establish what advice/changes the participant would recommend | Now that you’ve experienced what you have over the past 6 months what is some advice that you would give someone currently in hospital? |
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Lalor, A.F.; Brown, T.; Robins, L.; Lee, D.-C.A.; O'Connor, D.; Russell, G.; Stolwyk, R.; McDermott, F.; Johnson, C.; Haines, T.P. Anxiety and Depression during Transition from Hospital to Community in Older Adults: Concepts of a Study to Explain Late Age Onset Depression. Healthcare 2015, 3, 478-502. https://doi.org/10.3390/healthcare3030478
Lalor AF, Brown T, Robins L, Lee D-CA, O'Connor D, Russell G, Stolwyk R, McDermott F, Johnson C, Haines TP. Anxiety and Depression during Transition from Hospital to Community in Older Adults: Concepts of a Study to Explain Late Age Onset Depression. Healthcare. 2015; 3(3):478-502. https://doi.org/10.3390/healthcare3030478
Chicago/Turabian StyleLalor, Aislinn F., Ted Brown, Lauren Robins, Den-Ching Angel Lee, Daniel O'Connor, Grant Russell, Rene Stolwyk, Fiona McDermott, Christina Johnson, and Terry P. Haines. 2015. "Anxiety and Depression during Transition from Hospital to Community in Older Adults: Concepts of a Study to Explain Late Age Onset Depression" Healthcare 3, no. 3: 478-502. https://doi.org/10.3390/healthcare3030478