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Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up
- Authors:
- LICHT E., et al
- Journal article citation:
- British Medical Journal, 21.2.09, 2009, pp.463-466.
- Publisher:
- British Medical Association
This study aimed to investigate the duration of depression, recovery over time, and predictors of prognosis in an older cohort (55 years) in 32 general practices in West Friesland, the Netherlands. Participants were 234 patients aged 55 years or more with a prevalent major depressive disorder. Main outcome measures were depression at baseline and every six months using structured diagnostic interviews (primary care evaluation of mental disorders according to diagnoses in Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and a measure of severity of symptoms (Montgomery Åsberg depression rating scale). The main outcome measures were time to recovery and the likelihood of recovery at different time points. Multivariable analyses were used to identify variables predicting prognosis. The median duration of a major depressive episode was 18.0 months (95% confidence interval 12.8 to 23.1). 35% of depressed patients recovered within one year, 60% within two years, and 68% within three years. A poor outcome was associated with severity of depression at baseline, a family history of depression, and poorer physical functioning. During follow-up functional status remained limited in patients with chronic depression but not in those who had recovered. Depression among patients aged 55 years or more in primary care has a poor prognosis. Using readily available prognostic factors (for example, severity of the index episode, a family history of depression, and functional decline) could help direct treatment to those at highest risk of a poor prognosis.
An in-home geriatric programme for vulnerable community-dwelling older people improves the detection of dementia in primary care
- Authors:
- PERRY M., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 23(12), December 2008, pp.1312-1319.
- Publisher:
- Wiley
Dementia is under-diagnosed in primary care. This study investigated whether an in-home geriatric assessment and management programme could improve the identification of patients with dementia in primary care. A secondary analysis was performed, using data of a randomised controlled trial that studied the effects of an in-home geriatric evaluation and management programme compared with usual care. In this trial, 151 vulnerable community-dwelling patients, aged 70 years and older, living in the Netherlands participated: 86 in the intervention group and 66 in the control group. The effect of the programme on the dementia detection rate was determined by comparing the number of new dementia diagnoses in both study arms at 6 months follow-up. Of all 151 participants, 38 (25%) had a registered dementia diagnosis at baseline. During follow-up, 23 of 113 patients without a registered dementia diagnosis at baseline were identified as suffering from dementia. The difference between the numbers of new dementia diagnoses in the intervention group (19 of 66 patients) and the control group (4 of 47 patients) was significant. (p = 0.02). An in-home geriatric assessment and management programme for vulnerable older patients improves the detection of dementia and can therefore contribute to overcoming of under-diagnosis of dementia.
Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis
- Authors:
- BLOM J.W., et al
- Journal article citation:
- Age and Ageing, 47(5), 2018, pp.705-714.
- Publisher:
- Oxford University Press
Purpose: To support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care. Methods design: Individual patient data (IPD) meta-analysis of eight clinically controlled trials. Setting: Primary care sector. Interventions: Combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified. Main: Outcome activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up. Secondary outcomes: Quality of life (visual analogue scale 0–10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness. Analysis: Intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics. Results: Included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was −0.01 (95% confidence interval −0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%. Conclusion: Compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective. (Publisher abstract)
Development and preliminary validation of an Observation List for detecting mental disorders and social Problems in the elderly in primary and home care (OLP)
- Authors:
- TAK Erwin C.P.M., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 31(7), 2016, pp.755-764.
- Publisher:
- Wiley
Objective: Even though the prevalence of mental disorders and social problems is high among elderly patients, it is difficult to detect these in a primary (home) care setting. Goal was the development and preliminary validation of a short observation list to detect six problem areas: anxiety, depression, cognition, suspicion, loneliness, and somatisation. Methods: A draft list of indicators identified from a short review of the literature and the opinions of 22 experts was evaluated by general practitioners (GPs) and home care organisations for feasibility. It was then used by GPs and home care personnel to observe patients, who also completed validated tests for psychological disorders (General Health Questionnaire 12 item version (GHQ-12)), depression (Geriatric Depression Scale 15-item version (GDS-15)), anxiety and suspicion (Symptom Checklist-90 (SCL-90)), loneliness (University of California, Los Angeles (UCLA)), somatisation (Illness Attitude Scale (IAS)), and cognition (Mini-Mental State Examination (MMSE)). Results: GPs and home care personnel observed 180 patients (mean age 78.4 years; 66% female) and evaluated the draft list during a regular visit. Cronbach's α was 0.87 for the draft list and ≥0.80 for the draft problem areas (loneliness and suspicion excepted). Principal component analysis identified six components (cognition, depression + loneliness, somatisation, anxiety + suspicion, depression (other signs), and an ambiguous component). Convergent validity was shown for the indicators list as a whole (using the GHQ-12), and the subscales of depression, anxiety, loneliness, cognition, and somatisation. Using pre-set agreed criteria, the list was reduced to 14 final indicators divided over five problem areas. Conclusion: The Observation List for mental disorders and social Problems (OLP) proved to be preliminarily valid, reliable, and feasible for use in primary and home care settings. (Publisher abstract)
Home visits for frail older people: a qualitative study on the needs and preferences of frail older people and their informal caregivers
- Authors:
- KEMPEN Janneke A. L. van, et al
- Journal article citation:
- British Journal of General Practice, 62(601), August 2012, pp.417-418.
- Publisher:
- Royal College of General Practitioners
Despite continuing interest from professionals in home visits for older people, reports on older people's needs and preferences for such visits are scarce. This qualitative study investigated the views and needs of 11 community-dwelling older people living in the area of Nijmegen, the Netherlands, concerning home visits. Most participants felt home visits would give older people the personal attention they used to receive from GPs. Most stated that this would give them more trust in GPs. Participants stated that trust was one of the most important factors in a good patient-professional relationship. Further, participants preferred home visits to focus on the psychosocial context of the patient. They stated that more knowledge of the psychosocial context and a good patient-professional relationship would enable the professional to provide better and more patient-centred care. The authors concluded that future studies on home visits should involve patients in the development of home visiting programmes.
Can we make sense of multidisciplinary co-operation in primary care by considering routines and rules?
- Authors:
- ELISSEN Arianne M.J., RAAK Arno J.A. Van, PAULUS Aggie T.G.
- Journal article citation:
- Health and Social Care in the Community, 19(1), January 2011, pp.33-42.
- Publisher:
- Wiley
The complex health problems of chronically ill older people require care provision across professional boundaries. However, achieving multidisciplinary co-operation in primary care can be problematic. In this paper the authors developed an explanation for this based of the concepts of routines and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. Interviews were conducted with providers from six primary care professions in the Dutch region of Limburg. Findings suggest that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current shape of multidisciplinary co-operation to expand. The authors suggest that further research should attempt to validate this explanation by utilising a larger research population.
Co-occurrence of depression and anxiety in elderly subjects aged 90 years and its relationship with functional status, quality of life and mortality
- Authors:
- VAN DER WEELE Gerda M., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 24(6), June 2009, pp.595-601.
- Publisher:
- Wiley
This study aimed to examine the prevalence of concurrent depression and anxiety and its relationship with functional status, quality of life and mortality in individuals at age 90. In the Leiden 85-plus Study, a population based cohort study, depression (15-item Geriatric Depression Scale 5 points) and anxiety (Anxiety Screening Questionnaire 1 positive answer) were assessed in all 90-year old subjects with 19 points on the Mini Mental State Examination (MMSE). Functional status included: cognitive function (MMSE) and disability in activities of daily living (Groningen Activity Restriction Scale). Quality of life included: loneliness (Loneliness Scale of De Jong-Gierveld) and life satisfaction (Cantril's ladder). For all subjects mortality data were available up to a maximum age of 95.3 years. Findings were that of the subjects aged 90 years with MMSE 19 points (56 men, 145 women), 50 subjects experienced depression and 25 subjects anxiety; of them 34 (17%) experienced depression only, 9 (4%) anxiety only, and 16 (8%) both depression and anxiety. Presence of depression was associated with an overall decreased functional status and quality of life and with increased mortality. Within the depressed group, subjects with anxiety did not differ from subjects without anxiety, except for higher loneliness scores. The authors conclude that among individuals aged 90 years, depression and anxiety and their co-occurrence are highly prevalent. Anxiety does not add to poor functional status and increased mortality beyond that associated with depression, and is probably part of the phenomenology of depression in old age.
Reducing disability in community-dwelling frail older people: cost-effectiveness study alongside a cluster randomised controlled trial
- Authors:
- METZELTHIN Silke F., et al
- Journal article citation:
- Age and Ageing, 44(3), 2015, pp.390-396.
- Publisher:
- Oxford University Press
Background: Although proactive primary care, including early detection and treatment of community-dwelling frail older people, is a part of the national healthcare policy in several countries, little is known about its cost-effectiveness. Objective: To evaluate the cost-effectiveness of a proactive primary care approach in community-dwelling frail older people. Design and setting: Embedded in a cluster randomised trial among 12 Dutch general practitioner practices, an economic evaluation was performed from a societal perspective with a time horizon of 24 months. Method: Frail older people in the intervention group received an in-home assessment and interdisciplinary care based on a tailor-made treatment plan and regular evaluation and follow-up. Practices in the control group delivered usual care. The primary outcome for the cost-effectiveness and cost-utility analysis was disability and health-related quality of life, respectively. Results: Multilevel analyses among 346 frail older people showed no significant differences between the groups regarding disability and health-related quality of life at 24 months. People in the intervention group used, as expected, more primary care services, but there was no decline in more expensive hospital and long-term care. Total costs over 24 months tended to be higher in the intervention group than in the control group (€26,503 versus €20,550, P = 0.08). Conclusions: The intervention under study led to an increase in healthcare utilisation and related costs without providing any beneficial effects. This study adds to the scarce amount of evidence of the cost-effectiveness of proactive primary care in community-dwelling frail older people. (Edited publisher abstract)
Primary care management of major depression in patients aged ≥55 years: outcome of a randomised clinical trial
- Authors:
- van MARWIJK Harm W.J., et al
- Journal article citation:
- British Journal of General Practice, 58(555), October 2008, pp.680-687.
- Publisher:
- Royal College of General Practitioners
Late-life depression is associated with chronic illness, disability, and a poor prognosis. Primary care management may be in need of improvement. This study compares the effects of an intervention programme that aims to improve the identification, diagnosis, and treatment of depression in patients aged ≥55 years with the effects of usual care. A cluster randomised controlled trial in general practices in the Netherlands was used. Trained GPs performed the intervention and their practice assistants conducted the screenings. Patients were screened with the 15-item Geriatric Depression Scale (GDS-15) and given a consultation with the GP who diagnosed depression with the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Antidepressant treatment was proposed. Primary outcomes were measured with the Montgomery Åsberg Depression Rating Scale (MÅDRS). Trained independent research assistants performed independent evaluations in both arms. Eighteen practices (23 GPs) were allocated to the intervention and 16 practices (20 GPs) to usual care. From June 2000 to September 2002, 3937 patients were screened; 579 patients had a positive score on the GDS-15, 178 had major depression, of whom 145 participated in the trial. MÅDRS scores for the intervention group dropped from 21.66 at baseline to 9.23 at 6 months, and the usual care group from 20.94 at baseline to 11.45 at 6 months. MÅDRS scores decreased during the year in both arms. For the intervention group, these scores increased between 6 and 12 months. The programme resulted in lower MÅDRS scores in the intervention group than in the usual care group, but only at the end of the intervention, at 6 months after baseline.
Social policy review 10
- Editors:
- BRUNSDON Edward, HARTLEY Dean, WOODS Roberta
- Publisher:
- Social Policy Association
- Publication year:
- 1998
- Pagination:
- 304.,bibliogs.
- Place of publication:
- London
Collection of essays on social policy divided into two sections: developments in British welfare under New Labour; and international developments.