Poor Emotional Health is Barrier to Preventive Care in Elderly
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
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.