Depression, isolation, social support and cardiovascular rehabilitation in older adults

Transcription

1 Depression, isolation, social support and cardiovascular rehabilitation in older adults B. Rauch ZAR Ludwigshafen Klinikum EuroPRevent 21 Prague

2 some data to the actual situation

3 Depression increases mortality after myocardial infarction Total mortality Major depression (5; 1779) depressive symptoms (5; 147) Short follow-up (6; 1478) Long follow-up (6; 251) Cardiac mortality Major depression (1; 222) Depressive symptoms (6; 2665) Short follow-up (3; 16) Long follow-up (5; 2116) Risk lower Risk higher Van Melle JP et al., Psychosomatic Medicine 24; 66: ; Metaanalyse

4 About what we all know: disease and symptoms trigger depression BDI 14 (%) BDI < 14 (%) OR (95% - CI) AMI in history ( ) hypercholesterinemia ( ) diabetes ( ) smokers ( ) angina pectoris 12 months follow-up ( ) no dyspnoe 12 months follow-up (.36-.6) dyspnoe NYHA II 12 months follow-up ( ) dyspnoe NYHA III 12 months follow-up ( ) heart failure during 12 mo follow-up ( ) Rauch B, Zimmer R, Schneider S, Senges J for the OMEGA Study Group 21, unpublished results

5 depression more probable HR + 95% CI But living alone also is associated with a higher prevalence of depressive symptoms in older people - in contrast: high social activity may protect 3 2,5 2 1,5 1,5 Isaac V et al., Am J Geriatr Psychiatry 29

6 depression more probable HR + 95% CI The effect of social contact on the development of depression in older people depends on gender and age women men sustained developing low contact low contact frequency frequency sustained small contact diversity developing small contact diversity 7-74 y sustained alone 75 + y sustained alone sustained developing low contact low contact frequency frequency sustained small contact diversity developing small contact diversity 7-74 y sustained alone 75 + sustained alone Lund R et al. Eur J Epidemiol 2

7 lowe - - mortality - - higher Lack of social network and social support increases all-cause mortality in elderly men adequacy of social participation (low/high) availability of emotional support (low/high) adequacy of emotional support (low/high) adequacy of social influence (low/high) marital status (living alone/cohabiting) Analysis of 485 men, born in 1914 in Malmö, Sweden; cross-sectional sample in 1969 and in 1982, Hanson BS et al. Am J Epidemiol 1989

8 isolation depression life style behaviour cardiovascular disease clinical event

9 some aspects to the therapeutic options

10 HR + 95% CI Higher social activity may improve depression in older people 2,5 2 1,5 1,5 Monpellier district France Community residents 65 years randomly seleted between March 1999 Febr 21 n = 1,849 Male = 78 (depressive 21.7%) Female = 1,69 (depressive 37.%) higher social activity and baseline depressive symptomatology high social activity and improvement of depressive symptoms within 2 years Isaac V et al., Am J Geriatr Psychiatry 29

11 Hazard Ration + 95% CI Effects of treating depression and low perceived social support on clinical events after myocardial infarction (ENRICHD) 1,4 1,2 1,8,6,4,2 Effect of intervention Interventions randomized to usual care: Cognitive behaviour therapy at least 6 months as soon as possible after MI Social support interventions + sertraline, if indicated in patients with high depression scores Treatment n=1,243; control n=1,238 Improvement of depression and social isolation No effect on clinical events Writing Committee for the ENRICHD Investigators, JAMA 23; 289: 316

12 percent But cardiac rehabilitation (CR) may reduce not only depression but also mortality before CR after CR control CR + exercise prevalence of depression mortality during follow-up in 139 patients with baseline depression Coronary patients, n = 522, 381 men, 141 woman, age 64 ± 1 years, 2-25 Control group, n = 179 not completing CR Mean follow-up 1,296 ± 551 days Milani RV & Lavie CJ, Am J Med 27

13 Physical exercise following myocardial infarction improves prognosis in patients with depression and/or low social support 2 years of follow-up reduced risk mortality non fatal myocardial infarction,2,4,6,8 1 1,2 Blumenthal JA et al; ENRICHD-Trial; Medicine and Science in Sports and Exercise 24; 36:746

14 HR + 95% CI HR + 95% CI Cardiac rehabilitation (CR) and long-term risks of death and myocardial infarction among elderly 1,2 1,8,6,4,2 Reduced risk 1,9,8,7,6,5,4,3,2,1 Reduced risk 36/24 CR sessions 36/12 sessions 36/1 session 36/24 CR sessions 36/12 CR sessions 36/1 CR session patients with at least 1 CR session between Jan 2 Dec 25; age 7-78; male 63.8%; CR indication: CABG, MI, stable angina, others; follow-up 4 years after index date Hammil BG, Curtis LH, Schulman KA, Whellan DJ, Circulation 21; 121: 63

15 The association of reduced mortality with the attendance to CR also can be demonstrated in old patients Männer male Frauen female reduced risk Diab. diabetes mell. + kein Diab. no diabetes mell. red. EF EF normal EF < 4% EF normal Alter > 7 J Alter < 7 J age > 7 years age < 7 years keine akute Reka akute Reka + no acute revasc. acute revasc.,2,4,6,8 1 Subgroup analysis of the OMEGA-study; observation period 4-12 months after acute MI Rauch B et al. for the OMEGA Study Group 21

16 But, advanced age appears to be an independent predictor not to attend CR in patients after AMI >7 y NSTEMI MI in history coronary bypass in history COPD Diabetes PCI in history Peripheral artery disease Male EF <4,4,6,8 1 1,2 1,4 Bernhard Rauch 21 for the OMEGA Study Group lower probability higher

17 Reduced adherence Moreover, persistent depression reduces adherence to secondary prevention after acute coronary syndromes 1,2 1,8,6,4,2 quitting smoking taking medications exercising attending cardiac rehabilitation N = 492 patients after ACS, 3 months follow-up; Kronish IM et al., J Gen Intern Med 26

18 BCI scale Finally, depressive patients show reduced compliance to CR Non-completers show an elevated BDI-score, if compared to completers completers sessions attended completers noncompleters noncompleters 6 cardiac patients, 7% men, average age 66 years 12-week phase II cardiac rehabilitation Beck Depression Inventory (BDI) Casey et al., J Behav Med 28

19 NOTE THE POSITIVE: Don`t worry, be happy 1-years incidence of coronary events 1,2 1,8,6,4,2 Reduced risk Positive affection depressive symptoms hostility anxiousness Davidson KW, Eur Heart J 29; Canadian Nova Scotia Health Survey, follow-up , 145 CHD events, person years

20 cardiac rehabilitation + physical exercise in the old improve social participation avoid isolation improve satisfaction, happyness avoid depression life style behaviour improved quality of life reduced clinical events despite cardiovascular disease

21 Thank you

22 Depression increases CHD-risk in initially healthy people all studies (n=13) depressive mood (n=1) depression (n=3) risk lower risk higher Rugulies R, Am J Prev Med 22; 23: 51-61