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Classification of emergency departments according to their services for community-dwelling seniors.

https://arctichealth.org/en/permalink/ahliterature124306
Source
Acad Emerg Med. 2012 May;19(5):552-61
Publication Type
Article
Date
May-2012
Author
Roxane Borges Da Silva
Jane McCusker
Danièle Roberge
Antonio Ciampi
Alain Vadeboncoeur
Jean-Frédéric Lévesque
Eric Belzile
Author Affiliation
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada. roxane.borgesdasilva@mail.mcgill.ca
Source
Acad Emerg Med. 2012 May;19(5):552-61
Date
May-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Community Health Services - organization & administration
Emergency Service, Hospital - classification - organization & administration
Female
Health Services for the Aged - classification - organization & administration
Humans
Male
Quality of Health Care - classification
Quebec
Questionnaires
Abstract
The goal was to develop a classification of emergency departments (EDs) based on their organization of services for seniors discharged to the community.
This was a secondary analysis of data collected in a survey of key informants (chief physicians and head nurses) in EDs in Quebec on the organization of services for community-dwelling seniors discharged to the community. Organizational characteristics were classified a priori in the following three categories: 1) availability of human resources, 2) care processes, and 3) links to community services. A multifactorial analysis (MFA) was used to analyze the variables by category and globally, thus investigating not only the relationships between variables within each category, but also the relationships between different categories. The authors then proceeded to classify EDs using Ward's method (hierarchical ascendant classification) applied to reduced data dimensions.
The sample consisted of 103 EDs. Analyses were carried out on data from the 68 (66%) of these EDs that supplied complete data. These 68 EDs did not differ in terms of their size or geographical location from the 35 other departments that supplied incomplete or no data. We identified three groups of EDs: most specialized (with regard to internal staff and care processes) and less community-oriented (n = 12), moderately specialized and less community-oriented (n = 28), and least specialized and more community-oriented (n = 28).
This classification of EDs with respect to their organization of services for community-dwelling seniors may be helpful to those planning services, to decision-makers, and to researchers. The three groups of EDs identified in this study represent three types of organizations with differing assets and limitations. The generalizability of these groups to other settings and the implications for patient outcomes should be investigated.
PubMed ID
22594359 View in PubMed
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Classification of patterns of delirium severity scores over time in an elderly population.

https://arctichealth.org/en/permalink/ahliterature169571
Source
Int Psychogeriatr. 2006 Dec;18(4):667-80
Publication Type
Article
Date
Dec-2006
Author
Marie-Pierre Sylvestre
Jane McCusker
Martin Cole
Armelle Regeasse
Eric Belzile
Michal Abrahamowicz
Author Affiliation
Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada.
Source
Int Psychogeriatr. 2006 Dec;18(4):667-80
Date
Dec-2006
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Cluster analysis
Combined Modality Therapy
Comorbidity
Delirium - classification - diagnosis - mortality - therapy
Dementia - classification - diagnosis - mortality - therapy
Female
Follow-Up Studies
Hospitals, University
Humans
Male
Mental Status Schedule - statistics & numerical data
Neuropsychological Tests - statistics & numerical data
Prognosis
Proportional Hazards Models
Quebec
Survival Analysis
Abstract
To describe and classify individual trajectories of 15-day changes in delirium severity.
A longitudinal hospital-based study was carried out with 230 medical inpatients aged 65 and over admitted to St Mary's Hospital in Montreal, Canada, between 1996 and 1999, diagnosed with delirium at enrollment, and who had at least four measurements of delirium severity during the next 15 days. Delirium severity was assessed using the Delirium Index (DI). To classify patients' individual trajectories, we applied a new method that relies on principal factor analysis and cluster analysis. We used multiple linear regression to investigate if clusters were associated with DI scores measured at an 8-week follow-up. Multivariable Cox's proportional hazards regression was used to assess whether the clusters were associated with survival over the next 12 months.
Individual patterns were classified into five clusters: Steady (n = 89, 38.9%), Fluctuating (n = 36, 15.7%), Worsening (n = 15, 6.6%), Fast Improve-ment (n = 26, 11.3%), and Slow Improvement (n = 63, 27.5%). The Fast Improvement cluster had much lower prevalence of dementia (38.5% vs. 55.6% to 77.8% in other clusters, p = 0.003). Subjects whose 2-week patterns were classified as Fast or Slow Improvement had a significantly lower DI at 8 weeks than those in the Steady or Fluctuating clusters. The Worsening cluster had the largest percentage of deaths. The Fast Improvement and Worsening clusters initially had a high risk of death in the first 2 weeks (adjusted relative risks of approximately 3 and 6, respectively) but that risk decreased rapidly thereafter.
Two-week trajectories of delirium severity were associated with short-term mortality and delirium severity at 8-week follow-up.
PubMed ID
16640798 View in PubMed
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Comorbidity information in older patients at an emergency visit: self-report vs. administrative data had poor agreement but similar predictive validity.

https://arctichealth.org/en/permalink/ahliterature157859
Source
J Clin Epidemiol. 2008 May;61(5):511-5
Publication Type
Article
Date
May-2008
Author
Stephanie R Susser
Jane McCusker
Eric Belzile
Author Affiliation
Faculty of Medicine, McGill University, Canada.
Source
J Clin Epidemiol. 2008 May;61(5):511-5
Date
May-2008
Language
English
Publication Type
Article
Keywords
Aged
Comorbidity
Educational Status
Emergency Service, Hospital
Female
Geriatric Assessment
Health Services - utilization
Health Status Indicators
Hospitalization - statistics & numerical data
Humans
Male
Medical Records - statistics & numerical data
Quebec - epidemiology
Reproducibility of Results
Self Disclosure
Abstract
The objectives of this study were (1) to ascertain the level of agreement between the Charlson Comorbidity Index (CCI) based on self-report vs. administrative records, and factors affecting agreement and (2) to compare the predictive validity of the two indices in a sample of older emergency department (ED) patients.
The study was a secondary analysis of data from a randomized trial of an ED-based intervention. The self-report and administrative CCI were compared using the intraclass correlation coefficient (ICC). Factors examined for effect on agreement included health service utilization, age, and sex. The predictive validity of the indices was compared using subsequent health services utilization and functional decline as outcomes. Participants (n=520) were recruited at four university-affiliated Montreal hospitals. Eligibility criteria included 65 years of age or older, able to speak English or French, and discharged to the community.
Agreement between the two sources was poor to fair (overall weighted ICC 0.43 [95% confidence interval [CI]: 0.40, 0.47]). The predictive validity was similar for the two indices (area under the receiver-operating characteristic curve 0.51-0.66, depending on the outcomes).
Agreement between self-report and administrative comorbidity data is only poor to fair but both have comparable predictive validity.
PubMed ID
18394546 View in PubMed
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Comparing the validity of different sources of information on emergency department visits: a latent class analysis.

https://arctichealth.org/en/permalink/ahliterature176075
Source
Med Care. 2005 Mar;43(3):266-75
Publication Type
Article
Date
Mar-2005
Author
Nandini Dendukuri
Jane McCusker
François Bellavance
Sylvie Cardin
Josée Verdon
Igor Karp
Eric Belzile
Author Affiliation
Technology Assessment Unit, McGill University Health Center, Montreal, Canada. nandini.dendukuri@mcgill.ca
Source
Med Care. 2005 Mar;43(3):266-75
Date
Mar-2005
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Data Collection - methods
Emergency Service, Hospital - utilization
Female
Frail Elderly - statistics & numerical data
Hospitals, University - utilization
Humans
Insurance Claim Review
Male
Medical Records
Quebec - epidemiology
Research Design
Self Disclosure
Utilization Review - statistics & numerical data
Abstract
Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard.
We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect.
Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal.
The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database.
Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization.
The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall.
The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.
PubMed ID
15725983 View in PubMed
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The course of delirium in older long-term care residents.

https://arctichealth.org/en/permalink/ahliterature125088
Source
Int J Geriatr Psychiatry. 2012 Dec;27(12):1291-7
Publication Type
Article
Date
Dec-2012
Author
Martin G Cole
Jane McCusker
Philippe Voyer
Johanne Monette
Nathalie Champoux
Antonio Ciampi
Minh Vu
Eric Belzile
Author Affiliation
Department of Psychiatry, St Mary's Hospital Center and McGill University, Montreal, Quebec, Canada. martin.cole@ssss.gouv.qc.ca
Source
Int J Geriatr Psychiatry. 2012 Dec;27(12):1291-7
Date
Dec-2012
Language
English
Publication Type
Article
Keywords
Aged, 80 and over
Canada - epidemiology
Delirium - epidemiology - physiopathology
Disease Progression
Female
Humans
Incidence
Long-Term Care - statistics & numerical data
Male
Prospective Studies
Regression Analysis
Abstract
The purpose of this study was to determine the course of delirium in older long-term care (LTC) residents.
A prospective cohort study of 279 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. The Mini Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. Information on medical problems and medication was abstracted from resident charts. Data were analyzed using descriptive statistics, Cox proportional hazard regression, and logistic regression.
Of the 279 residents, 41 (14.7%) had 61 CAM-defined incident episodes of delirium: 28 (10%) had one episode and 13 (4.7%) had two or more episodes. Episode duration was 7-63 days, mean, 11.3 (SD, 10.1) days. The mean episode DI score was 11.5 (SD, 3.5). Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2% 77.1%, and 80.3%, respectively. Most episodes were preceded or followed by one or more CAM core symptoms of delirium, sometimes lasting many weeks.
Confusion Assessment Method-defined incident episodes of delirium in older LTC residents appear to last longer than episodes in acute care hospital patients, but rates of recovery at 4 and 24 weeks are similar. Notably, most episodes were preceded or followed by one or more CAM core symptoms of delirium. These findings have implications for clinical practice and research in LTC settings.
PubMed ID
22517219 View in PubMed
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The course of delirium in older medical inpatients: a prospective study.

https://arctichealth.org/en/permalink/ahliterature183829
Source
J Gen Intern Med. 2003 Sep;18(9):696-704
Publication Type
Article
Date
Sep-2003
Author
Jane McCusker
Martin Cole
Nandini Dendukuri
Ling Han
Eric Belzile
Author Affiliation
Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, McGill University, 3830 Lacombe Avenue, Montreal, Quebec H3T 1M5, Canada. jane.mccusker@mcgill.ca
Source
J Gen Intern Med. 2003 Sep;18(9):696-704
Date
Sep-2003
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Aged
Aged, 80 and over
Delirium - diagnosis - physiopathology - therapy
Dementia - diagnosis - physiopathology - therapy
Female
Health Status Indicators
Hospitalization
Hospitals, Teaching
Humans
Length of Stay
Male
Multivariate Analysis
Outcome and Process Assessment (Health Care)
Patient Discharge
Prospective Studies
Quebec
Abstract
To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium.
Prospective cohort study.
Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal.
Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital.
Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the in-hospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality.
Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.
Notes
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Comment In: J Gen Intern Med. 2003 Sep;18(9):770-112950488
PubMed ID
12950477 View in PubMed
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Detection of delirium and its symptoms by nurses working in a long term care facility.

https://arctichealth.org/en/permalink/ahliterature135768
Source
J Am Med Dir Assoc. 2012 Mar;13(3):264-71
Publication Type
Article
Date
Mar-2012
Author
Philippe Voyer
Sylvie Richard
Jane McCusker
Martin G Cole
Johanne Monette
Nathalie Champoux
Antonio Ciampi
Eric Belzile
Author Affiliation
Faculty of Nursing Sciences, Laval University, Quebec City, Canada. philippe.voyer@fsi.ulaval.ca
Source
J Am Med Dir Assoc. 2012 Mar;13(3):264-71
Date
Mar-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Clinical Competence
Delirium - diagnosis - physiopathology
Female
Humans
Male
Nurse's Role
Nursing Homes
Prospective Studies
Quebec
Abstract
To investigate the ability of nurses to recognize delirium and its symptoms and to investigate the factors associated with undetected delirium.
A prospective, observational study with repeated measurements over a 6-month period.
Seven long term care settings in Montreal and Quebec City, Canada.
Residents aged 65 and older, with or without dementia, admitted to long term care (not respite care) and able to communicate in English or French.
Delirium and its symptoms were assessed using the Confusion Assessment Method. Ratings of delirium by nurses based on their observations during routine care were compared with delirium ratings by trained research assistants based on a one-time formal structured evaluation (Confusion Assessment Method and Mini Mental State Examination). This procedure was repeated for 10 delirium symptoms. Sensitivity, specificity, and positive and negative predictive values were calculated. The method of generalized estimating equations was used to identify factors associated with undetected delirium.
Research assistants identified delirium in 43 (21.3%) of the 202 residents. Nurses identified delirium in 51% of the cases identified by the research assistants. However, for cases without delirium according to the research assistants, nurses identified 90% of them correctly. Detection rates for delirium symptoms ranged from 25% to 66.7%. Undetected delirium was associated with lower number of depressive symptoms manifested by the resident.
Detection of delirium is a major issue for nurses. Strategies to improve nurse recognition of delirium could well reduce adverse outcomes for this vulnerable population.
PubMed ID
21450220 View in PubMed
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Development of a delirium risk screening tool for long-term care facilities.

https://arctichealth.org/en/permalink/ahliterature126672
Source
Int J Geriatr Psychiatry. 2012 Oct;27(10):999-1007
Publication Type
Article
Date
Oct-2012
Author
Jane McCusker
Martin G Cole
Philippe Voyer
Antonio Ciampi
Johanne Monette
Nathalie Champoux
Minh Vu
Eric Belzile
Author Affiliation
St Mary's Research Centre, St Mary's Hospital, Montreal, Quebec, Canada. jane.mccusker@mcgill.ca
Source
Int J Geriatr Psychiatry. 2012 Oct;27(10):999-1007
Date
Oct-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Cohort Studies
Delirium - diagnosis
Female
Humans
Long-Term Care
Male
Mass Screening - methods
Quebec
Risk factors
Abstract
The aim of this study is to develop a delirium risk screening tool for use in long-term care (LTC) facilities.
The sample comprised residents aged 65?years and over of seven LTC facilities in Montreal and Quebec City, Canada, admitted for LTC. Primary analyses were conducted among residents without delirium at baseline. Incident delirium was diagnosed using multiple data sources during the 6-month follow-up. Risk factors, all measured at or prior to baseline, included the following six groups: sociodemographic, medical, cognitive status, physical function, agitated behavior, and symptoms of depression. Variables were analyzed individually and by group using Cox regression models. Clinical judgment was used to select the most feasible among similarly performing factors.
The cohort comprised 206 residents without delirium at baseline; 69 cases of incident delirium were observed (rate 7.6 per 100 person weeks). The best-performing screening tool comprised five items, with an overall area under the curve of 0.82 (95% CI 0.76, 0.88). These items included brief measures of cognitive status, physical function, behavioral, and emotional problems. Using cut-points of 2 (or 3) over 5, the scale has a sensitivity of 90% (63%), specificity of 59% (85%), and positive predictive value of 52% (66%).
This brief screening tool allows nurses to identify LTC residents at increased risk for delirium. These residents can be targeted for closer monitoring and preventive interventions.
PubMed ID
22367973 View in PubMed
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Source
J Am Geriatr Soc. 2003 Nov;51(11):1539-46
Publication Type
Article
Date
Nov-2003
Author
Jane McCusker
Martin G Cole
Nandini Dendukuri
Eric Belzile
Author Affiliation
Departments of Clinical Epidemiology and Community Studies Psychiatry, St Mary's Hospital, Montreal, Quebec. jane.mccusker@mcgill.ca
Source
J Am Geriatr Soc. 2003 Nov;51(11):1539-46
Date
Nov-2003
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Cohort Studies
Delirium - diagnosis - epidemiology
Female
Geriatric Assessment
Humans
Length of Stay - statistics & numerical data
Linear Models
Male
Prospective Studies
Quebec - epidemiology
Severity of Illness Index
Abstract
To determine the effects of prevalent and incident delirium on length of hospital stay.
Prospective cohort study, comparing (1). length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2). length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis.
The medical services of a primary, acute care hospital.
Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled.
Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score.
The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay.
In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.
PubMed ID
14687382 View in PubMed
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Does depression in older medical inpatients predict mortality?

https://arctichealth.org/en/permalink/ahliterature167603
Source
J Gerontol A Biol Sci Med Sci. 2006 Sep;61(9):975-81
Publication Type
Article
Date
Sep-2006
Author
Jane McCusker
Martin Cole
Antonio Ciampi
Eric Latimer
Sylvia Windholz
Eric Belzile
Author Affiliation
Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, 3830 Lacombe, Montreal (Quebec), Canada. jane.mccusker@mcgill.ca
Source
J Gerontol A Biol Sci Med Sci. 2006 Sep;61(9):975-81
Date
Sep-2006
Language
English
Publication Type
Article
Keywords
Age Distribution
Aged
Antidepressive Agents - therapeutic use
Cognition Disorders - epidemiology
Cohort Studies
Depression - drug therapy - mortality
Depressive Disorder - drug therapy - mortality
Drug Utilization - statistics & numerical data
Female
Hospitalization
Humans
Male
Multivariate Analysis
Psychiatric Status Rating Scales
Quebec - epidemiology
Severity of Illness Index
Abstract
Previous studies of the effect of depression on mortality among older medical inpatients have yielded inconsistent results. We examined the effects on mortality of both a diagnosis of depression at hospital admission and a history of previous depression, taking into account potential sources of bias (sample selection and confounding).
Medical inpatients aged 65+ with at most mild cognitive impairment were recruited at two Montreal hospitals and were screened for depression. All those with a diagnosis of major or minor depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] criteria) and a random sample of nondepressed patients were invited to participate. Baseline data included: history of previous depression, severity of physical illness, comorbidity, and health services utilization. Cox proportional hazards methods were used to analyze survival during the 16- to 52-month follow-up period.
Five hundred patients were enrolled; 116 (23.2%) had a history of previous depression. After adjustment for demographic factors, physical illness, cognitive impairment, and prior service utilization, the only depression group with significantly different mortality was patients with both current major depression and a history of depression, who had lower mortality than all other patient groups (hazard ratio 0.42; 95% confidence interval: 0.25, 0.70).
Among patients with no history of depression, a diagnosis of depression was not associated with mortality after adjustment for confounding by physical illness and other factors. Coincident major depression and history of depression was associated with decreased mortality.
Notes
Comment In: J Gerontol A Biol Sci Med Sci. 2007 Jul;62(7):796-7; author reply 79817634330
PubMed ID
16960030 View in PubMed
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30 records – page 1 of 3.