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Relation between Symptoms of Depression and Health Status Outcomes in Acutely Ill Hospitalized Older Persons

Kenneth E. Covinsky, MD, MPH; Richard H. Fortinsky, PhD; Robert M. Palmer, MD, MPH; Denise M. Kresevic, MSN; and C. Seth Landefeld, MD
[+] Article and Author Information

For author affiliations and current author addresses, see end of text. Grant Support: By the John A. Hartford Foundation (88277-3G) and the National Institute on Aging (AG-10418-03). Dr. Covinsky was supported in part by a clinical investigator award from the National Institute on Aging (1K08AG00714-01) and by career development and pilot project awards from the Claude D. Pepper Older Americans Independence Center at Case Western Reserve University. Dr. Landefeld is a senior research associate at the Health Services Research and Development Service of the Department of Veterans Affairs. Requests for Reprints: Kenneth Covinsky, MD, MPH, Division of General Internal Medicine and Health Care Research, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106. Current Author Addresses: Drs. Covinsky and Fortinsky: Division of General Internal Medicine and Health Care Research, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;126(6):417-425. doi:10.7326/0003-4819-126-6-199703150-00001
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Background: Older patients often have poor health status outcomes after hospitalization. Symptoms of depression are common in hospitalized older persons and may be a risk factor for these poor outcomes.

Objective: To determine whether symptoms of depression predict worse health status outcomes in acutely ill, older medical patients, independent of health status and severity of illness at hospital admission.

Design: Prospective cohort study.

Setting: Medical service of a teaching hospital.

Patients: 572 hospitalized medical patients older than 70 years of age.

Measurements: 15 symptoms of depression, health status, and severity of illness were measured at admission. The main outcome was dependence in basic activities of daily living at discharge and 30 and 90 days after discharge. Other outcome measures were dependence in instrumental activities of daily living, fair or poor global health status, and poor global satisfaction with life.

Results: The median number of symptoms of depression on admission was 4. Patients with 6 or more symptoms on admission (n = 196) were more likely than patients with 0 to 2 symptoms (n = 181) to be dependent in basic activities of daily living (odds ratio, 2.47 [95% CI, 1.58 to 3.86]) after controlling for demographic characteristics and severity of illness. At each subsequent time point, patients with more symptoms of depression on admission were more likely to be dependent in basic activities of daily living. This association persisted after adjustment for dependence in basic activities of daily living, severity of illness, and demographic characteristics on admission. The odds ratios comparing patients who had 6 or more symptoms with those who had 0 to 2 symptoms were 3.23 (CI, 1.76 to 5.95) at discharge, 3.45 (CI, 1.81 to 6.60) 30 days after discharge, and 2.15 (CI, 1.15 to 4.03) 90 days after discharge. At each time point, patients with 6 or more symptoms of depression were more likely to have more dependence in instrumental activities of daily living, worse global health status, and less satisfaction with life.

Conclusions: Symptoms of depression identified a vulnerable group of hospitalized older persons. The health status of patients with more symptoms of depression was more likely to deteriorate and less likely to improve during and after hospitalization. This association was not attributable to health status or severity of illness on admission. The temporal sequence and magnitude of this association, its consistency over time with different measures, and its independence from the severity of the somatic illness strongly support a relation between symptoms of depression on admission and subsequent health status outcomes.

Figures

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Figure 1.
Frequency distribution of the total number of symptoms of depression on hospital admission.

Patients were divided into tertiles on the basis of the frequency distribution.

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Figure 2.
Frequency of dependence in one or more basic activities of daily living at discharge and 30 and 90 days after discharge, according to the number of symptoms of depression on admission.Top.Bottom.P

To reduce confounding between dependence in basic activities of daily living on admission and subsequent dependence, patients were stratified by whether they were dependent in one or more basic activities of daily living on admission. Of the 503 patients who survived for 90 days, the 36 patients for whom data on dependence in basic activities of daily living were not available for all three time points were excluded from this analysis. Frequency of dependence in one or more basic activities of daily living in 248 patients who were not dependent in any activity on admission. Frequency of dependence in one or more basic activities of daily living in 219 patients who were dependent in at least one basic activity of daily living on admission. At each of the three time points, the association between symptoms of depression on admission and dependence in basic activities of daily living was significant in stratified analyses that controlled for dependence in basic activity of daily living on admission ( < 0.01).

Grahic Jump Location
Grahic Jump Location
Figure 3.
Frequency of dependence in instrumental activities of daily living at discharge and 30 and 90 days after discharge, according to the number of symptoms of depression on admission.Top.Bottom.P

To reduce confounding between dependence in instrumental activities of daily living on admission and subsequent dependence, patients were stratified by whether they were dependent in three or more activities on admission. Of the 359 eligible patients who survived for 90 days, the 23 patients for whom data on dependence in instrumental activities of daily living were not available for all three time points were excluded from this analysis. The eligible sample size is smaller for this analysis than for the analysis of basic activities of daily living because data on the former at admission were collected only during the latter part of the study period. Frequency of dependence in three or more instrumental activities of daily living in 116 patients who were dependent in fewer than three activities on admission. Frequency of dependence in three or more instrumental activities of daily living in 220 patients who were dependent in at least three activities on admission. At each of the three time points, the association between symptoms of depression on admission and dependence in instrumental activities of daily living was significant in stratified analyses that controlled for dependence on admission ( < 0.01).

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