Accepted Manuscript

Title: Depression and Functional Impairment: a Pernicious Pairing in Older

Adults

Author: Eric J. Lenze, Peggy P. Barco, Marghuretta D. Bland

PII: S1064-7481(17)30491-8
DOI: https://doi.org/doi:10.1016/j.jagp.2017.09.028
Reference: AMGP 944

To appear in: The American Journal of Geriatric Psychiatry

Received date: 27-9-2017

Accepted date: 29-9-2017

Please cite this article as: Eric J. Lenze, Peggy P. Barco, Marghuretta D. Bland, Depression and
Functional Impairment: a Pernicious Pairing in Older Adults, The American Journal of Geriatric
Psychiatry (2017), https://doi.org/doi:10.1016/j.jagp.2017.09.028.

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Depression and functional impairment: a pernicious pairing in older adults

Eric J Lenze, M.D., Peggy P. Barco, OTD, OTR/L, FAOTA, Marghuretta D. Bland, PT, DPT

Author affiliations: Washington University, St Louis, Missouri (Department of Psychiatry, 660 S. Euclid Box

8134, St Louis, MO 63110: Dr. Lenze.

Corresponding author: Eric Lenze, M.D., Department of Psychiatry, Washington University School of

Medicine, 660 S. Euclid, Box 8134, St Louis, MO 63110, phone 314-362-1671, fax 314-362-4260, email

lenzee@wustl.edu.

Submitted on September 27, 2017

990 words; 7 references. No tables or figures.

Financial Disclosure

Dr. Lenze has received research support from NIH, FDA, McKnight Brain Research Foundation, Taylor Family

Institute for Innovative Psychiatric Research, Center for Brain Research in Mood Disorders, Barnes Jewish

Foundation, Takeda, Lundbeck, Janssen, and Alkermes.

Dr. Barco has received research support from NIH and Missouri Department of Transportation.

Dr. Bland has received research support from NIH.

Acknowledgements

This publication was supported by funding from the National Institutes of Health (MH099011) and the Taylor

Family Institute for Innovative Psychiatric Research and Center for Brain Research in Mood Disorders (at

Washington University) to Dr. Lenze. The funding source(s) had no role in the preparation, review, or approval

of the manuscript.

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In older adults, function is the most important public health issue.

When we assess an older adult for depression, our inclination is to first ask “how do you feel?” but maybe the

most important question should be “how do you function?” The strong bidirectional relationship between late-

life depression (LLD) and functional impairment means that disability is a risk factor for depression (major

depression or clinically significant depressive symptoms), and depression is a risk factor for disability (1).

For a concrete example of this bidirectional relationship, imagine an older woman who is frail but is living

independently, until one day she falls and suffers a hip fracture. The surgical repair is effective, but afterwards

she has depressive symptoms; she participates poorly in physical and occupational therapy at a nursing home

due to her apathy, anergia, and low confidence. Therapy stops, she is now a long-term nursing home resident

and as a result she is persistently depressed.

Consider the public health impact of her unfortunate case multiplied by 2 billion – the number of adults aged

60+ worldwide by 2050. Functional impairment is a common and expensive part of aging (2). Functional

impairment is also our greatest fear in aging: staying functional gives purpose in life, while being dependent on

others, and living in a nursing home is high on our “undesirable” list (3).

This is where the new study by Bingham and colleagues looms large. Their question is quite simple – how

good are we at measuring functional impairment in depression studies with older adults? This question is

important because scientific progress is possible only when we can conduct accurate measurements. Bingham’s

finding is sobering: simply stated, we are very limited in how we measure function in LLD. Bingham’s

systematic review examined all LLD studies that focused on two aspects of function – instrumental activities of

daily living (IADLs; for example, the ability to perform household and community activities of daily living

such as cooking, shopping, financial and medication management) and social functioning (how health and

emotions limit social activities and interactions such as going out and visiting friends, working, and other social

roles). They found only two measures formally validated in late-life depression – the Performance Assessment

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of Self-care Skills (PASS) and the Medical Outcome Survey 36-item short form (SF-36). Even this definition

of “validated” is liberal –researchers would like to think that “validated” means “this measure captures the

essence of the variable of interest, and it consistently does so reliably.” Yet as Bingham and colleagues discuss,

it’s not that easy: depression may cloud an older adult’s understanding of their function, and it is innately

challenging for anyone to self-identify what aspect of function is most impacted by depression (e.g.,

participation levels or independence levels). For these reasons, it is concerning that our measures continue to be

mainly based on self-report and only one of the 21 assessments identified and reviewed by Bingham (e.g., the

PASS) was based on a measure of actual performance.

Where do we go from here? Bingham and colleagues provide guidance to researchers and practitioners in the

measurement of function in their projects or assessment batteries. Along with the measures they recommend,

we would push for more widespread use of the NIH Toolbox batteries (www.nihtoolbox.org), which include

assessments of physical performance and some aspects of social function. But we should not be satisfied with

these measures. For example, the PASS is recommended as a validated measure of IADL function in LLD, but

Bingham and colleagues demonstrate that this measure falls short in many critical ways – such as a lack of data

to demonstrate sensitivity to change, so we aren’t sure it could be used in a clinical trial to capture functional

improvement related to an intervention. A more fundamental problem is that the PASS only measures a

person’s capacity to complete functional tasks in a laboratory setting, not their real environment. In short, while

the PASS can measure “can do” function in the lab, we lack real-world measures of how an individual actually

does activities in their real environment; this is particularly important in depression, where motivation, energy,

and cognitions sap the ability to do activities in daily life. Of note, one recent study carrying out the PASS in

older depressed participants’ homes did find it was sensitive to change (i.e., improved more in the intervention

arm than the control arm).(4) Similarly, the SF-36 is validated to assess social functioning in LLD but its

purpose is to measure overall quality of life, not to capture (for example) improvements in social functioning

from an intervention. Like all self-report function assessments the SF-36 suffers major reliability issues due to

its retrospective self-assessment nature; in fact, function can fluctuate from day to day and is very context-

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dependent. In summary: none of these measures is a true “gold standard” for assessing LLD-related function;

no such gold standard exists.

We need to innovate. Brief self-reports and in-office assessments have innate limitations; so e-technology –

particularly smartphone-based and sensor-based assessments – will be the source of this innovation. It is now

possible to measure many aspects of depression with e-technology (5). Smartphone-based self-reports,

actigraphy (6), GPS/GIS, and electronic acoustic monitoring can assess function in real-time and the real-world

environment. These measures have the potential to be more reliable and valid assessments of function,

objectively determining how often and how independently older adults are functioning in their IADLs and

social activities. Such techniques need to be validated in older adults, and one concern arises from their use in

more physically or cognitively impaired older adult populations, who may not be able to use e-technology or

provide accurate self-reports; moreover, standard actigraphy may not be able to accurately discern different

movements in highly debilitated individuals (7). Yet these are precisely the types of patients in whom the

depression-disability relationship is strongest and of greatest public health importance (8).

Research to advance methods in functional assessment is not easy; and it is not as exciting as a new

neuroimaging or biomarker study – but it is important. Scientific advances depend on measurement advances –

we can’t move our field forward unless we can accurately and robustly measure the functional impact of late-

life depression.

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References

1. Lenze EJ, Rogers JC, Martire LM, et al: The association of late-life depression and anxiety with
physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry 2001;
9:113-135
2. Greysen SR, Stijacic Cenzer I, Boscardin WJ, et al: Functional Impairment: An Unmeasured Marker of
Medicare Costs for Postacute Care of Older Adults. Journal of the American Geriatrics Society 2017; 65:1996-
2002
3. Salkeld G, Cameron ID, Cumming RG, et al: Quality of life related to fear of falling and hip fracture in
older women: a time trade off study. BMJ 2000; 320:341-346
4. Reynolds CF, 3rd, Butters MA, Lopez O, et al: Maintenance Treatment of Depression in Old Age: A
Randomized, Double-blind, Placebo-Controlled Evaluation of the Efficacy and Safety of Donepezil Combined
With Antidepressant Pharmacotherapy. Arch Gen Psychiatry 2011; 68:51-60
5. Ben-Zeev D, Scherer EA, Wang R, et al: Next-generation psychiatric assessment: Using smartphone
sensors to monitor behavior and mental health. Psychiatr Rehabil J 2015; 38:218-226
6. Lang CE, Waddell KJ, Klaesner JW, et al: A Method for Quantifying Upper Limb Performance in Daily
Life Using Accelerometers. J Vis Exp 2017;
7. Talkowski JB, Lenze EJ, Munin MC, et al: Patient participation and physical activity during
rehabilitation and future functional outcomes in patients after hip fracture. Arch Phys Med Rehabil 2009;
90:618-622
8. Gansler DA, Suvak M, Arean P, et al: Role of Executive Dysfunction and Dysexecutive Behavior in
Late-Life Depression and Disability. The American journal of geriatric psychiatry : official journal of the
American Association for Geriatric Psychiatry 2015; 23:1038-1045

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