Hospitalization, depression and dementia in community-dwelling older Americans: findings from the National Health and Aging Trends Study

doi:10.1016/j.genhosppsych.2013.11.008

General Hospital Psychiatry

Volume 36, Issue 2, March–April 2014, Pages 135-141

https://doi.org/10.1016/j.genhosppsych.2013.11.008 Get rights and content

Abstract

Objective

The objective was to estimate the prevalence of both dementia and depression among community-dwelling older Americans and to determine if hospitalization is independently associated with dementia or depression in this population.

Method

This cross-sectional study utilized data from a nationally representative, population-based sample of 7197 community-dwelling adults ≥ 65 years old interviewed in 2011 as part of the National Health and Aging Trends Study. Information on hospitalizations was obtained from self- or proxy-report. Possible and probable dementia was assessed according to a validated algorithm. Depressive symptoms were assessed with the Patient Health Questionnaire-2.

Results

An estimated 3.1 million community-dwelling older Americans may have dementia, and approximately 5.3 million may have substantial depressive symptoms. After adjusting for demographic and social characteristics, medical diagnoses, smoking history, serious falls and pain symptoms, being hospitalized in the previous year was independently associated with greater odds of probable dementia (odds ratio [OR]: 1.42, 95% confidence interval [95% CI]: 1.16–1.73) and substantial depressive symptoms (OR: 1.60, 95% CI: 1.29–1.99).

Conclusions

Dementia and depression are common in community-dwelling older Americans, and hospitalization is associated with these conditions. Additional research increasing understanding of the bidirectional relationship between hospitalizations, dementia and depression, along with targeted interventions to reduce hospitalizations, is needed.

Introduction

As the population ages and the burdens of chronic illnesses such as coronary artery disease and diabetes increase [1], [2], hospitalizations among older adults are of growing concern to health care providers and health care systems. Hospitalizations among older adults are costly to the American health care system [3], and the Centers for Medicare and Medicaid Services are actively incentivizing efforts to reduce rehospitalizations among older adults in order to reduce costs and improve quality of care [4].

In addition to financial strain on the health care system, an emerging body of literature has identified that hospitalizations for a wide range of medical illnesses among older adults may increase the risks of dementia and depression [5], [6], [7], [8]. The potential for these outcomes following hospitalizations for older adults is an important public health problem since both dementia and depression are substantial contributors to disability and are both independently associated with increased health care costs and early mortality [9], [10], [11], [12], [13], [14].

Despite the adverse outcomes associated with dementia and depression among older adults, these disorders remain underrecognized [15], [16]. In addition, recent prevalence estimates of dementia and depression in older Americans have included residents of skilled nursing and assisted-living facilities, populations known to have extremely high rates of these disorders [17]. Recognition of dementia and depression in community-dwelling older adults is especially important in order to preserve functional independence, particularly in light of existing evidence-based interventions [18], [19]. Furthermore, although hospitalizations among older adults may be associated with increased risks of cognitive impairment and depression, it remains unclear if these risks are independent of chronic medical comorbidity or other associated factors such as falls [20], [21], [22], [23], a potential indication of overall frailty [24].

The present investigation utilizes data from a new, nationally representative cohort of Americans 65 and older, the National Health and Aging Trends Study (NHATS), to estimate the prevalence of dementia and depression among community-dwelling older Americans, as well as to examine if hospitalization among community-dwelling older adults is independently associated with dementia or depression after adjusting for demographic and social characteristics, medical comorbidity, pain and falls.

Section snippets

Participants

The present investigation is a cross-sectional study comprised of community-dwelling participants in the first wave of the NHATS, Beta Release 1.0. The NHATS is the successor to the National Long Term Care Survey and is a panel study of Medicare beneficiaries ages 65 and older [25]. The NHATS used a stratified three-stage sample design with sampling based on U.S. county and residential zip code as well as age [26], [27], and the final sample included participants from every state except Alaska,

Results

A total of 7197 community-dwelling Medicare recipients ages 65 or older participated in the first wave of the NHATS (Fig. 1). Table 1 describes the demographic, social and clinical characteristics of the entire cohort as well as by possible dementia, probable dementia, and substantial depressive symptom status. Over half of the cohort was female and nearly one-third was composed of racial/ethnic minorities. The most prevalent medical diagnoses among the entire cohort of community-dwelling NHATS

Discussion

In this nationally representative sample, we have identified that dementia and depression are alarmingly common among community-dwelling older Americans. Our results suggest that nearly 1 in 12 community-dwelling Americans 65 years or older may have dementia and that nearly 1 in 7 may have substantial depressive symptoms. The prevalence of probable dementia and substantial depressive symptoms among community-dwelling Americans 65 years or older presented here is similar to previous studies of

Acknowledgments

We appreciate the expert programming of Laetitia Shapiro, A.M., University of Michigan; Vicki A. Freedman, Ph.D., University of Michigan, for assistance with the use of the NHATS sampling weights; and Judith D. Kasper, Ph.D., Johns Hopkins University, for assistance with the NHATS dementia classifications.

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Others have estimated that 11% of U.S. adults over 65 are living with Alzheimer disease or other dementias.4 Based on community-dwelling older adults in the National Health and Aging Trends Study (NHATS), it has been estimated that 11.2% of Americans over age 65 have probable dementia and 10.6% have possible dementia.5 Although Langa et al.6 observed a significant decline in dementia prevalence between 2000 and 2012, owing to demographic factors such as population growth and aging, the number of cases of dementia is expected to increase by the year 2050.3,4
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The present study examines the association between subjective age and risk of incident dementia in a large longitudinal sample of older adults. Participants were adults aged 65 years and older from the National Health and Aging Trends Study (NHATS). Subjective age, covariates, and cognitive status were assessed in 2011 and cognitive status was again assessed in 2012, 2013, 2014 and 2015. Incident dementia was determined based on answers from self and proxy respondents. The analyses included 4262 participants without dementia at baseline. Adjusting for demographic factors and baseline cognition, an older subjective age was related to higher likelihood of incident dementia. This association was partly accounted by depressive symptoms. Beyond the effect of chronological age, feeling older is associated with the risk of incident dementia.
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^☆: This work was supported by grants KL2 TR000421 and U01 AG032947 from the National Institutes of Health. The National Health and Aging Trends Study is performed at the Johns Hopkins University School of Public Health.

^☆☆: Sponsor’s role: The sponsor had no role in the design, methods, subject recruitment, data collection, analysis or preparation of the manuscript.

^★: Potential conflicts of interest: The authors have no relevant potential conflicts of interest to disclose.

^★★: Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Institutes of Health, or the US government.

View full text

Psychiatric–Medical ComorbidityHospitalization, depression and dementia in community-dwelling older Americans: findings from the National Health and Aging Trends Study☆,☆☆,★,★★

Abstract

Objective

Method

Results

Conclusions

Introduction

Section snippets

Participants

Results

Discussion

Acknowledgments

Med Clin North Am

Lancet

Biol Psychiatry

Lancet Neurol

Am J Geriatr Psychiatry

Neurochem Int

Am J Geriatr Psychiatry

Psychosomatics

Chest

Aging, diabetes, and the public health system in the United States

Am J Public Health

Rehospitalizations among patients in the Medicare fee-for-service program

N Engl J Med

Hospital readmissions and the Affordable Care Act: paying for coordinated quality care

JAMA

Association between acute care and critical illness hospitalization and cognitive function in older adults

JAMA

Long-term cognitive impairment and functional disability among survivors of severe sepsis

JAMA

Cognitive decline after hospitalization in a community population of older persons

Neurology

Functional disability, cognitive impairment, and depression after hospitalization for pneumonia

Am J Med

The state of U.S. health, 1990–2010: burden of diseases, injuries, and risk factors

JAMA

Increased mortality risk in women with depression and diabetes mellitus

Arch Gen Psychiatry

Survival after initial diagnosis of Alzheimer disease

Ann Intern Med

Increased medical costs of a population-based sample of depressed elderly patients

Arch Gen Psychiatry

Monetary costs of dementia in the United States

N Engl J Med

Survival of people with clinical diagnosis of dementia in primary care: cohort study

BMJ

Recognition of depression by non-psychiatric physicians—a systematic literature review and meta-analysis

J Gen Intern Med

Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review

Int Psychogeriatr

Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial

JAMA

Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial

JAMA

Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study

J Am Geriatr Soc

Cognition and the risk of hospitalization for serious falls in the elderly: results from the Cardiovascular Health Study

J Gerontol A Biol Sci Med Sci

Frailty in older adults: evidence of a phenotype

J Gerontol A Biol Sci Med Sci

Validation of new measures of disability and functioning in the National Health and Aging Trends Study

J Gerontol A Biol Sci Med Sci

Psychiatric–Medical Comorbidity
Hospitalization, depression and dementia in community-dwelling older Americans: findings from the National Health and Aging Trends Study☆,☆☆,★,★★