Published: Feb. 1, 2006
Updated: Feb. 2, 2006
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By Duke Medicine News and Communications
DURHAM, N.C. -- Poor emotional health, such as symptoms of depression and anxiety, may significantly reduce the likelihood that elderly patients will receive preventive health services, according to a study led by a Duke University Medical Center School of Nursing researcher. The researchers said their findings lead them to recommend that physicians actively screen older patients to determine if they might be experiencing symptoms of psychological distress.
The study showed people age 65 and older are up to 30 percent less likely to receive preventive services that are generally recommended for older adults, including influenza vaccinations, dental check-ups or clinical breast exams, said Joshua Thorpe, Ph.D., MPH, assistant research professor in the School of Nursing and senior fellow in the Duke University Center for Aging. Receiving these services may help control the costs of health care by preventing the need for more expensive health care services, Thorpe said.
"We must screen for and treat psychological distress because it can translate into better physical health," Thorpe said. "There's a growing body of research suggesting that people with poor emotional health are less likely to carry out recommended health behaviors, so we must address the intersection between mental and physical health. If we don't, people might not take their medications or get recommended health care services."
The researchers published their findings in the February 2006 issue of Medical Care, a journal associated with the American Public Health Association. Funding for the study was provided by a National Research Service Award from the Agency for Healthcare Research and Quality and the American Foundation for Pharmaceutical Education.
The researchers said their study was one of few studies to focus on the effect that psychological distress -- clinically defined as a condition including symptoms of depression and anxiety -- has on the use of preventive services. The study was also unusual in that it was the first to use a sample nationally representative of all older adults living in the community, and not just older adults polled in a doctor's office.
According to Thorpe, individuals who are bereaved, lonely, coping with chronic pain or other illnesses common to older adults or who are primary caregivers for loved ones with chronic or terminal illnesses are at risk for not receiving proper preventive care due to psychological distress.
The study included an analysis of survey data from approximately 3,700 elderly individuals – a group that represented 33.8 million community-dwelling elderly living in the U.S. Results showed that distressed elderly were 30 percent less likely to receive an influenza vaccine, 23 percent less likely to receive an annual dental check-up, and distressed women were 27 percent less likely to undergo a clinical breast examination. The researchers controlled for many outside factors that could affect patient behavior, including age, sex, race/ethnicity, marital status and education.
"A flu shot is cheap and effective and it prevents the need for secondary care. Without it, pneumonia is a bigger possibility," Thorpe said. "Patients who don't receive regular dental check-ups are also prone to suffer from periodontitis and other dental diseases."
Psychologically distressed women are also less likely to receive mammograms. For this preventive service, the study focused on women ages 65 to 69. Of that group, women under distress were 32 percent less likely to receive the test. Because the respondent population for mammograms was smaller than for other services in the study, Thorpe said, while somewhat significant, the relationship between mammography and distress should be studied in greater depth.
The prevalence of depression among the elderly ranges from 10 percent to 50 percent, depending on their health, activity level and living situation, according to the Hartford Institute for Geriatric Nursing. However, physicians screen for psychological distress in only 14 percent of elderly primary care visits, according to previous research published in Medical Care. According to that previous research, physicians used a formal screening tool in only three out of 389 encounters. Primary care physicians can use tools such as the Geriatric Depression Scale (GDS), a self-administered questionnaire, to assess the level of psychological distress in an elderly patient. This test involves answering questions about feelings of helplessness, restlessness and energy level. Any patient scoring above a certain level is deemed at risk for depression and requires further evaluation.
The new study analyzed data from individuals over age 65 in the 2001 Medical Expenditure Panel Survey, a longitudinal survey collected by the federal government that consists of responses to health care inquiries from nearly 34,000 individuals. Participants are interviewed in their homes rather than in a doctor's office, creating an accurate sampling of individuals who both do and do not receive adequate health care, said the researchers.
The researchers pointed out several limitations in their study. For example, they said, medical information about psychological distress was based on patient self-reports. In addition, researchers could not determine from the data set whether patients received instructions from a physician to undergo these services and ignored the direction or whether the physician did not tell the patient to seek out these services because they were focused on treating other conditions.
In addition to Thorpe, who conducted much of the research at the University of North Carolina at Chapel Hill, other co-authors were Carolyn Kalinowski, MPH, University of North Carolina at Chapel Hill School of Public Health, Mark Patterson, MPH, University of North Carolina at Chapel Hill School of Pharmacy, and Betsy Sleath, Ph.D. University of North Carolina at Chapel Hill School of Pharmacy.