Depression and Increased Health Services Utilization Among Elderly Primary Care Patients
Depression and Increased Health Services Utilization Among Elderly Primary Care Patients
The increase in life expectancy in the 21st century has resulted in a major growth in the
 prevalence of age-related diseases and conditions. Depression has been found to be the most
 prevalent among the various mental disorders in later life. It was emphasized that depression
 in the elderly is a persistent or recurrent disorder resulting from psychosocial stress or
 physiologic effects of disease and can lead to disability, cognitive impairments, intensified
 symptoms of other medical conditions and increased utilization of health care services. Due
 to the rapidly aging population, depression is a serious public health concern that has a
 great impact on quality of life and may lay a considerable burden on the health care systems.
 However depression among the elderly may prove to be hard to diagnose since in aged persons
 depressive symptoms are often masked by somatic complaints or by cognitive impairments.
 Consequently depression is often under diagnosed and the patients continue to visit
 constantly the nurse or the physician without getting an adequate answer to their problem.
 For that reason over utilization of health care services may be an indicator to the presence
 of undiagnosed depression. The purpose of this study is to examine the relationships between
 socio-demographic variables, high primary care utilization and depressive symptomatology
 among aged patients.
Introduction The number of Israel's elderly (65 plus) has increased from just 85,200 (4.8% of
 the population) in 1955 to approximately 670,000 people (about 10%) in 2003 (Brodsky et al.,
 2005). According to the most conservative of three projections offered by the Israeli Central
 Bureau of Statistics (CBS), the number of seniors is expected to be approximately 676,500
 (9.8% of the population) in 2005, to rise to 722,500 people (10.7% of the population) by 2010
 and increase to 1,025,800 (almost 12% of the population) by the year 2020.

 The increase in life expectancy in the 20th century has resulted in a major growth in the
 prevalence of age-related diseases and conditions. Depression has been found to be the most
 prevalent among various mental disorders in later life and is the third most common reason
 for consultation in primary care (Shah, 1992). Research shows that 10-15% of the persons over
 65 years of age suffer from various levels of depressive symptoms (Jacob& Palmer, 1998).

 Sadock & Sadock (2003) state that depression among elderly may reach up to 15 percent and
 among these suffering from dementia from 25- 50 percent. Israeli studies show similar rates
 of depressive symptomatology as performed in other Western countries. A prevalence of 21.5
 percent of depressive symptomatology was found among a random sample of 937 Israeli adults.
 (Iancu et al., 2003).

 Depression represents a heterogeneous set of disorders, usually characterized by sad mood and
 inability to experience pleasure. Among the elderly it often may present itself atypically,
 with somatic symptoms dominating the clinical picture (Jacob & Palmer, 1998). Common physical
 complaints, start with the most common features as loss of energy or fatigue, unexplained
 pain, gastrointestinal symptoms, headache, dizziness, palpitations, heartburn, numbness, loss
 of appetite, insomnia specifically early morning awakening. In general, the more unexplained
 somatic complaints and physical symptoms a patient have, the higher the likelihood of
 depression (Glass 2003). Elderly depression impairs significantly the quality of life by
 leading to disability, cognitive impairments, intensified symptoms from medical conditions
 and increases utilization of health care services and the direct and indirect medical costs
 (Luber et al., 2001).

 Herrman et al.,( 2002) argue that health care utilization among depressed patients is higher
 then among those without depression. Elderly with depressive symptoms found to be at least as
 twice as likely to use emergency department and medical inpatient hospital services compared
 to patients without depressive symptomatology ( Himelhoch et al., 2002). Simon & Ormel(1995)
 as well as Katon et al. (2003) stated that patients with depressive symptoms account for
 43-52% higher health care costs than patients without depressive symptoms.

 The increase in costs associated with depressive symptoms was noted even after adjusting for
 the severity of chronic medical illness (Glass, 2003). According to the WHO the significance
 of illness burden attributable to depression increases with age and thus will grow further by
 the year 2020 based upon projected demographic shifts towards an older population (Peveler et
 al., 2002).

 This trend was showed in Israel by Brodsky et al.( 2005). They reported an elderly average of
 11.5 visits at the FP per year while, in the USA, only 25% of the elderly population visited
 any physician 10 or more times annually - including visits to the ER and home visits (Health,
 United States,2003).

 Consequently detecting and treating elderly patients with depressive symptoms in Israel, may
 be cost-effective and produce improvement in health and well-being for the money spent in the
 care of these older adults.

 However depression in the aged patient may be atypical in nature and more difficult to
 diagnose from that in the general population. Therefore it is often under-diagnosed and
 under-treated (Jacob & Palmer, 1998). In contrast to younger depressed patients, elderly
 patients often avoid reporting or showing that their mood level and tend to hide their state
 of disease or, worse, they lack the consciousness of the disease and think that enjoying life
 less than before is an inevitable consequence of aging. Moreover, elderly sometimes attribute
 their depressive symptoms to general medical conditions. Other factors that may hinder
 distinguishing depression from other conditions are also concomitant diseases, especially
 dementia, polypharmacy and drug reactions (Glass, 2003). Furthermore Hybels et al. (2001)
 compared in their study the demographic and risk factor profiles of elderly individuals with
 less and more severe depression. The obtained results indicated the need to recognize that
 elderly adults who do not meet the Diagnostic and Statistical Manual of Mental Disorders
 (DSM) criteria for depression, and those who fall below the threshold on instruments such as
 the Center for Epidemiologic Studies-Depression scale (CES-D), may still experience
 depressive symptomatology that warrant attention.

 The current scales used today measure physical deterioration as part of the depressive state,
 while among the older people these are part of the aging process and may confuse the
 therapist. The Geriatric Depression Scale (GDS) is a more specific tool for the measurement
 in this age group. It was developed during the 80's (Brink et al., 1982) proven valid and
 reliable at 1986 and was translated to many languages including Hebrew. (Zalsman et al.,
 1998). Today it is one of the most widely used instruments for the screening of depression
 among the elderly population.

 To simplify the screening process a Yale Task Force on Geriatric Assessment has recommended
 the use of a single question, "Do you often feel sad or depressed?" (Lachs et al., 1990).
 Mahoney et al.( 1994 ) found this question as a valid and reliable short-form alternative.

 In conclusion depression is a prevalent mental disorder in later life and a considerable
 impending public health problem since it may lay unnecessary cost burden on one hand and is
 difficult to diagnose on the other. Consequently, there is a need to find the most effective
 ways for early detection of this condition. This study will examine the question whether high
 health care services utilization and/ or sociodemographic background may predict the presence
 of depression among aged patients.

 Objectives:

 The purposes of this study is to examine the relationships between socio-demographic
 variables, comorbidity, depressive symptomatology and high primary care utilization.

 METHOD:

 Participants:

 The study will be conducted in 10 primary health care clinics in urban communities of
 Beersheva, Israel. According to the average health care utilization, 11.5 visits to the FP
 per year (Brodsky et al., 2005)) among elderly in Israel, we classify two groups: "low care
 utilizers" with ≤ 6 visits per year and "high care utilizers" with ≥ 16 visits. Primary lists
 of "high and low care utilizer" will be obtained by query to "Clicks" electronic medical
 chart system ( Roshtov Soft wear industry ltd.) .
Inclusion Criteria:-

 -  Age 65 or older,

 -  Clalit health organization client

 -  Outpatient

 -  Hebrew or English or Russian speaker

 -  Living in Beer Sheva

 Exclusion Criteria:

 -  Known diagnosis of depression, major depression, bipolar disorder, psychosis, dementia
 or substance abuse

 -  Current acute illness