Presented by: William D. Cabin, PhD, JD, MSW, MA

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Eyes Wide Open The Relationship Between Sensory
Limitations Elderly Depression

• Presented by William D. Cabin, PhD, JD, MSW, MA
• Vision Aging Session 3401.0, Abstract 296092,
• Monday, November 17, 2014, 230-4o0PM
• American Public Health Association, New Orleans,
  LA

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I. The Sociological Framework

• Social Construction of Reality orients creation
  of constructs of depression (Berger
  Luckmann,1967 Bolton, 2008Szasz,1984, 2010)
• Stigmatization of normal sorrow may occur
  (Horwitz,Wakefield, Spitzer, 2007) (DSM revision
  in progress)
• MedicalizationOver-reliance on pharmacology to
  prevent, treat, and cure may occur (Conrad, 2007
  Szasz, 2007)
• On to the reality

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II. The Problem Elderly Depression-Constructs
and Nature Prevalence

• Major Depression 16.2 (33MM) have experienced
  in their lifetime in U.S., across all ages
• Hospital outpatient visits for depression
  increased by 48 between 1995-2005
• American adults depressive disorders estimated
  to generate 36 billion in salary-equivalent lost
  productivity potential for psychological,
  emotional, and physical impacts
• Associated with other chronic conditions asthma,
  arthritis, cancer, cardiovascular disease,
  diabetes, obesity myocardial infraction,
  sensory impairment (based on literature review)

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Elderly Depression

• Elderly persons 65 years of age or older
• Wide variation in estimate types of depression
• 1-5 all community dwelling elderly have
  clinically defined major depression
• 7-36 of elderly medical outpatients have
  clinically defined major depression
• 11.5-40 among hospitalized elderly are
  depressed
• 13.5 of elderly receiving formal home care are
  depressed
• 50 of elderly in long-term care facilities are
  depressed
• Often under-diagnosed under-treated

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• Estimates increase when add
• Elderly with sub-syndromal depression (i.e. less
  than full DSM-IV definition of major depression)
  adds another 8-20 community-dwelling elderly)
• Late-life depression among community dwelling
  elderly (8-20)
• Geriatric primary care patients (37 have either
  clinically or symptom-assessed depression)
• NYC estimate 14 of elderly depressed, with 50
  living alone (NYCDFTA, 2010)
• 90 US NYC elderly are community-dwelling
• Major risk factor for functional disability
• Relationship to co-morbidities (often two-way)

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III. Literature Review

• Why Necessary?
• Professional belief that individual-level
  explanations of depression are insufficient
• Interest in social inequalities and disparities
  in health mental health
• Interest in the nature consequences of the
  aging population, including depression and
• Need for increased knowledge to guide policy,
  practice and research decisions.

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Literature Review

• Found two major review articles an updated
  search
• One (Mair, Diez Roux, Galea, 2008) based on
  PubMed (79 articles) Psych Info (168) search
  covering 1/90-8/07, focusing on depression across
  all ages. 45 articles reviewed. Built on work of
  Truong Ma (2006) systematic review of 29
  articles on relationship of neighborhood and
  mental health.
• Second (Kim, 2008) based on PubMed (1966-4/1/08)
  Social Services Citation Index (1956-4/1/08).
  Found only 28 articles meeting his criteria (13
  were not in Mair, et al. review). Depression
  across all ages.

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• Cabin update- used same keywords in NYU Bobst
  Library Bobcat database for 1/07-5/31/14. Total
  of 1,940 articles, only 2 relevant not in other
  two reviews (Beard, Tracy, Vlahov Galea, 2008
  and Beard, Cerda, Blaney Ahern, Vlahou Galea,
  2009)
• Cabin literature review on association of
  depression with other physical mental health
  conditions

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Major Limitations of Existing Research/Areas of
Research Improvements

• Most on adults limited number on children and
  elderly (10 on elderly, but age definitions
  varied not all in US).
• Mainly cross-sectional
• Over-reliance on self-report
• Limited use of external validating data sources f
  neighborhood variables
• Variation in definition of many variables
• Variation in instruments used to measure
  depression
• Variations in neighborhood definitions
• Limited number of studies on neighborhood level
  variables (vs. individual), especially built
  environment

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Major Substantive Findings

• Mair, et al. (2008)
• 82 of studies (37 of 45) had at least one
  neighborhood characteristic associated with
  depression/depressive symptoms, after controlling
  for individual-level characteristics, usually a
  combination of age, gender, race/ethnicity,
  marital status, and income
• 52 of the different structural characteristics
  (i.e. neighborhood socioeconomic racial/ethnic
  composition residential stability built
  environment service environment) examined were
  significantly associated with depression/depressiv
  e symptoms

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• Built environment measures were more consistently
  associated with depression/depressive symptoms
  than socioeconomic composition, racial/ethnic
  composition, or residential stability.
• 68 of the social processes (neighborhood
  disorder, social cohesiveness and ties with
  neighborhood, and perceived exposure to crime,
  violence, drug use graffiti) examined were
  significantly associated with depression/depressiv
  e symptom.

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• 2. Kim (2008)
• Social disorder (crime, violence, safety, illicit
  drug access) higher the level, the higher the
  odds of depression (6 studies)
• Physical conditions/built environment (housing,
  streets, walking surfaces) the worse the built
  environment, the higher the level/odds of
  depression (3 studies)
• Neighborhood SES limited evidence of protective
  factor for depression.

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• Beard, et al. (2008)
• Longitudinal (baseline 6-18-30 months f/up)
• NYC-based used telephone surveys adults
• Primarily individual-level variables
• Poor physical health, low income, prior family
  history, high life stressors, being separated and
  low social support (neighborhood-level variable)
  are predictors of greater risk for late-life
  depression.

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• 4. Beard, et al. (2009)
• Longitudinal NYC-based persons 50 or older
• Began 2005 from existing database 2007 follow-up
• Neighborhood effects Neighborhood affluence can
  be protective factor against worsening
  depression, adjusting for all other individual
  and neighborhood factors. Neither ethnicity nor
  residential stability associated with depressive
  symptoms.
• Individual effects high neuroticism high
  initial stressor score increased post-baseline
  stressor score (i.e., worsening stress level)
  being African American a lower baseline
  frequency of contact with social networks were
  predictors of worsening depression

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IV. Using the Brookdale Demonstration Initiative
in Health Urban Aging (BDI)

• Why?
• To explore research gap regarding elderly
  depression and individual and neighborhood-level
  predicators
• Literature reviews indicate only 5 studies on
  depression for persons 65 or older in the United
  States
• What is BDI?
• Conducted in 2008
• 1,870 Respondents from more than 50 NYC senior
  centers
• 24-page survey
• Administered by interviewers in 6 different
  languages
• Done by Brookdale Center on Healthy Aging and
  Longevity with NYC Department for the Aging
  (DFTA) funding.

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• Three Step Process
• The Sample Profile
• Mean Age 70
• Depression Measure (On 0-27 score range from Phq
  9)
• Mean 3.6
• None 72 (0-4) Mild 18 (5-9) Moderate
  7 (10-14)
• Moderately severe 2 (15-19) Severe 1
  (20-27)
• 2.Statistical significance of Selected Variables
  (based on Literature Review) to Depression (PHQ-9
  based)
• - 48 variables identified in BDI database
  related to variables in literature review (11
  neighborhood 20 demographic/activity 17
  physical health/comorbidity).
• - 40 of 48 had a statistically significant
  relationship to depression (p.05)
• 3. Stepwise Regression Analysis conducted using
  the 40 variables.

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• Results
• Eight Variables together are most predictive of
  elderly depression, explaining 18 of variance in
  response (r square .18).
• Eight Variables visual impairment (p.000)
  frequent falling (p.000) lower income (p.000)
  little leisure-time physical activity (p.000)
  low neighborhood satisfaction (p.000) trouble
  hearing (p.000) arthritis/rheumatoid arthritis
  (p.001) being disabled (p.005)

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• Implications
• Research Practice
• New Emphasis on potential relationships between
  physical activity, falls, and sensory impairment.
• Focus future mining of BDI database by
  consolidating multiple variables into key factors
  to analyze based on conceptual model for mental
  health and old Americans (see Fahs, Gallo, and
  Cabin, 2010 unpublished).
• Increased mental health professional focus on
  early identification of sensory impairment.

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Implications (continued)

• Policy
• Medicare Medicaid on eligibility, coverage, and
  reimbursement for sensory impairment diagnosis
  and treatment, including necessary
  equipment/devices in home and community-based
  settings. Particularly important with ACA focus
  on ACOs, health homes, Medicaid expansion,
  clinical evidence-based practice, and mental
  health and substance abuse equity coverage and
  inclusion in standard benefit plans.
• Role of Senior Centers (see also NYAM Report,
  2010)
• Senior Center- Health/Mental Health/Home Care
  Provider Collaborations (link to NORCs)
• Increased Case for Preventive Gerontology in
  policy, building on Goldman, et al. (2009).

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Presenter Disclosures

• The following personal financial relationships
  with commercial interests relevant to this
  presentation existed during the past 12 months
• No relationships to disclose