Changes of Aging Influencing Medication Use

Journal Articles (a 2 paragraph summary ) from any Nursing journal in the library.

First journal:

Use of Central Nervous System Medications Among Elderly Home Health Clients

Cheryl Dellasega and Mary Lou Stricklin

Older persons consume a disproportionate share of all medications dispensed in the United States. In particular, medications acting upon the central nervous system (CNS) have been overprescribed for elderly persons, both in and out of the institutional setting. Although researchers have studied drug use by elders who live in the community, little is known about the use of CNS medications by ill older persons who live at home. This descriptive study examined the use of CNS medications in a group of elderly persons (N = 141) admitted to a visiting nurse association for skilled care. Subjects resided in the community of a large midwestern city. Approximately half of the subjects used some type of CNS drug. Sedative/hypnotic and narcotic and opoid analgesics, two categories of medications with the potential for serious side effects, were most frequently prescribed. Nurses in community and institutional settings are in an ideal position to screen and monitor the use of CNS medications by homebound ill elders,

p ERSONS MORE than 65 years of age take one third of all pharmaceuticals consumed in the United States (Delafuente, 1991) and account for 25% of total medication costs in developed coun- tries (Williams & Lowenthal, 1992). Because of the many changes in the body resulting from aging (Table 1) that influence absorption, metabolism, and excretion of medications, older persons also are at greater risk for serious and possibly fatal drug

reactions (Brown & Castleden, 1990).

In particular, medications acting on the central

nervous system (CNS) are prescribed significantly more often for older persons (Shorr, Bauwens, & Landefeld, 1990) and cause more adverse side effects. Closser (1991, p. 40) noted that undesired CNS medication side effects, such as psychomotor and cognitive impairment, occur more frequently in the elderly, “who can least afford these risks.”

Clinical trials confirm that the aged are more vulnerable to undesired effects of medications than

From the School of Nursing, Pennsylvania State University, University Park, PA; and the Visiting Nurses’ Association of Cleveland, Cleveland, OH.

Cheryl Dellasega, PhD, RN, GNP: Assistant Professor, School of Nursing, Pennsylvania State University, University Park, PA; and Mary Lou Stricldin: Chief Executive Officer, Visiting Nurses ‘Association of Cleveland, Cleveland, OH.

Address reprint requests to Cheryl Dellasega, PhD, RN, GNP, Assistant Professor, School of Nursing, Pennsylvania State University, University Park, PA 16801.

their younger counterparts. Greenblatt, Harmatz, Shapiro, et al. (1991) administered a single dose of triazolam to 26 younger and 21 older adults and found that the elders experienced a greater degree of both sedation and impaired psychomotor func- tion. Nikaido, Ellinwood, Heatherly, and Gupta (1990) reported similar findings in their compara- tive study of benzodiazepene use across age groups. Benzodiazepenes remain the most widely pre- scribed class of sedative/antianxiety drug for older adults (Greenblatt, Harmatz, & Shader, 1991).

Traditionally, it has been thought that misuse of CNS medications was much more of a problem in the institutional setting. Studies conducted in nurs- ing homes or other long-term care facilities re- vealed that between half and two thirds of residents received one of these medications, even if there was no clear evidence that they were needed (Avorn, Dreyer, Connelly, & Soumerai, 1989). These findings, in part, prompted reform that led to the Omnibus Reconciliation ACt (OBRA) regula- tions of 1987, which mandated that physicians caring for nursing-home residents “strive to order medications judiciously, and observe for untoward side effects and complications, especially regarding psychotropic medications” (Levenson, 1990, p. 5).

Although efforts have been made to address the problem of CNS medication misuse in long-term care facilities, only 5% of those more than the age of 65 years reside in such a setting on any given day (Koff, 1988). The majority of elders live in the

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CNS MEDICATIONS AND ELDERLYHOME HEALTH

131

Table 1. Changes of Aging Influencing Medication Use

Their brief stays in the acute care setting often undermine the efforts of nurses to make sure that the elder understands the reason for and proper administration of prescription medications. It is common for older patients to be discharged quickly from the hospital with prescriptions for several new medications that they know nothing about in addi- tion to previous medications (Burns, Sneddon, Lovell, McLean, & Martin, 1992).

The problem of patient education and discharge planning in the hospital setting is further compli- cated by the existence of delirium, which can affect up to half of all hospitalized older patients and may persist beyond discharge (Murray et al., 1993). Delirium is a temporary impairment of cognition that can inhibit an elder’s ability to take in and process information, such as that related to teach- ing about a medication regimen.

A second reason for examining the use of CNS medications in elderly home health clients is that the use of home health care has increased in the postdiagnostic-related groups era (Rogers, 1989). The elderly are the most frequent users of home health care services (Barkauskas, 1990); many older persons receive levels of care at home that would have previously been provided in institu- tions. The expectation is that persons who receive health care at home must often take responsibility for administering their own medications. Although supervision by a professional home health nurse may be available for an elderly person or an informal caregiver, this supervision is more epi- sodic and may not be available at critical times.

A third reason this study is important is that adverse effects of medications are a leading cause for hospitalization of the elderly (Beard, 1992). In particular, CNS medications are known to cause many untoward effects. Inappropriate use of CNS medications could increase the risk of falls, hip frac- ture, and confusion (Greenblatt, Harmatz, & Shader, 1991; Ray, Griffin, & Malcolm, 1991), which would place elderly home health clients at risk for either short- or long-term institutionalization.

The goal of this descriptive study was to exam- ine the use of CNS medications in elderly persons newly admitted to a large, urban home health agency. The following specific questions were addressed:

1. Are prescribing patterns of CNS medica- tions for elderly home health care clients

Change

Absorption

Change in amount and

acidity of hydrochloric

acid in stomach Decreasedperistalsis

Decreased gastrointestinal blood flow

Distribution

Less body water

More body fat

Decreasedserum albumin

Metabolism

Less efficient liver function

Excretion

Decreased renal function

Consequence

Difficulty breaking down and absorbing certain medica- tions

Slower movement of drugs through gastrointestinal system

Slower absorption of drugs

Higher concentration of medi- cations in blood and tissue Risk of toxicity from accumula-

tion of fat-soluble drugs Less binding of drugs to

albumin

Slower breakdown and excre- tion of some medications

Decreased renal excretion of some drugs; potential for retention of drug metabo- lites

Note. From Clinical Pharmacology and Nursing Manage- ment (pp. 1179-1187), by R, Spencer, L. Nicols, G. Lipkin, H. Sabo, and E West, 1989, Philadelphia: Lippincott. Copyright 1989 byJ. B. Lippincott. Reprinted with permission.

community where patterns of drug use are less understood or monitored.

Studies on CNS medication use in the commu- nity focused primarily on “well” groups and re- vealed that a serious problem may exist. Potempa and Folta (1992) estimated that although 75% of community-dwelling elders take at least one pre- scribed drug, an average of 12 to 15 drugs are consumed daily, including over-the-counter (OTC) medications. The Johnson and Moore (1988) inves- tigation of 100 elderly men and women showed that 70% took OTC drugs without advice from a health care professional before use. Furthermore, these researchers found that 19% of their subjects reported an adverse side effect related to their medication use, but none sought help when this occurred.

It is important to investigate patterns of CNS medication use in elderly recipients of home health care. Examining this issue is relevant for several reasons. First, elderly persons currently enter and leave the hospital more quickly as a consequence of the prospective payment system (Rogers, 1989).

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DELLASEGA AND STRICKLIN

similar to those of elderly persons in institu- tions, such as nursing home and hospitals?

2. What particular categories of CNS medica- tions, that is, sedatives, psychotropics, are used by elderly home health clients?

3. Is there a relationship between the clients’ diagnostic category and the type of prescribed medications?

METHODS

Sample

To evaluate CNS medication use, a chart review was conducted on a convenience sample of all persons older than the age of 65 years who were admitted to the skilled care component of the participating agency. Persons admitted to hospice or other agency branches were excluded because their medication use was believed to be atypical. Approximately 25% (n = 35) of elderly admissions fell into the later categories.

Over a 1-month time period, a total of 141 charts were reviewed, which represented 82% (n = 171) of all eligible admissions. The 18% (n = 30) of charts not reviewed were excluded because the chart could not be located during the data collection period or because the client had been readmitted to the hospital or otherwise relocated.

Procedures

Permission was received from the agency to collect the data; thereafter, the principal investiga- tor reviewed all admission charts of persons com- ing into the agency during a 1-month period using the following procedures. First, the principal inves- tigator would obtain a list of all pending admissions to the agency. Then the investigator would contact the appropriate nursing supervisor and confirm that the new admission was indeed being admitted on that day and was appropriate for the study. The investigator would wait until the staff nurse who had completed the admission assessment submitted the standardized chart forms to agency secretaries for processing. At this point, the chart would be retrieved by the investigator and relevant informa- tion recorded.

Instruments

Data from the agency’s standard chart forms were used for the study. In addition to medication use, demographic information, diagnosis, func- tional impairments (i.e., difficulty with activities of

daily living), and the presence of a caregiver were noted. These data were all initially gathered by the agency staff nurses during their admission assess- ments of new clients. The data were considered to be both current and accurate.

An accepted classification format was needed to categorize medications as CNS medications. An extensive review of the literature revealed that such a classification format was not readily available, with many terms used interchangeably to describe the same categories of medications. The labels psychoactive, psychotherapeutic, and psychotropic were used frequently and interchangeably to describe the same medications (antipsychotics, neuroleptics, sedative-hypnotics, antipsychotics, and anxiolitics). In some studies, antidepressants were categorized as a psychoactive medication, whereas in others they were not. Analgesics also were inconsistently included or excluded.

To use a standardized criteria that was likely to be readily accepted and understood by nurses, the investigator decided that the Nurses Drug Hand- book (Springhouse, 1990) classification system of medications that act on the CNS would be used to categorize the medications. The 11 categories of CNS medications consisted of: nonnarcotic analge- sics and antipyretics; nonsteroidal anti-inflamma- tory drugs; narcotic and opoid analgesics; sedative- hypnotics; anticonvulsants; antidepressants; antianxiety agents; antipsychotics; miscellaneous psychotherapeu- tics; cerebral stimulants; and respiratory stimulants.

FINDINGS AND DISCUSSION

Table 2 contains the characteristics of clients whose charts were reviewed for the study. This group was typical of home health clients described by Barkauskas (1990). The mean age of the sample was 78 years and approximately half (n = 71; 54%) used CNS medication.

Approximately half of elderly persons (n = 71) newly admitted to home health used at least one CNS medication. Sedative-hypnotics and narcotic and opoid analgesics, both categories with serious potential for adverse effects, were the most fre- quent types prescribed (Table 3). Over half of those receiving CNS drugs took more than one prescrip- tion in this category. Use or nonuse of different types of CNS medications also did not seem to be related to the client’s diagnostic category. Persons with a diagnosis of cancer or endocrine disorders (primarily diabetes) were nearly three times more

CNS MEDICATIONS AND ELDERLY HOME HEALTH

133

Table 2. Demographic Characteristics

Table 3. Types of CNS Medications Most Frequently Used

Sex Male

Female Marital status

Married Widowed Other

Residence before admission to home health agency

Hospital

Own home Nursing home

Primary medical diagnosis~ Cardiac

Endocrine Genitourinary Respiratory Cancer

Caregiver Yes

Prescription medications

Average

Range

Use of CNS drugs

Yes

Use of more than one CNS drug

Yes

Use of more than two CNS drugs

Yes

No Race

White Black Other

Note. Mean age = 78.

Narcotic and opoid analgesics

Sedative hypnotics

Nonnarcotic analgesics and antipyretics

Nonsteroidal anti-inflammatory drugs Anticonvulsants 8 Antianxiety agents 8 Antidepressants 8 Antipsychotics 5 Miscellaneous psychotherapeutics 1

Note. Total number of CNS prescriptions = 92.

Results of this study reveal that CNS medica- tions, a group of drugs that potentially pose serious problems for the frail elderly, were prescribed for elderly home health clients at least as often as for institutionalized elderly persons. Particularly trou- bling was the frequency of prescriptions for narcoid and opoid analgesics and’ sedative hypnotics, medi- cation categories that are strictly regulated and monitored in hospital and nursing-home settings. For the 23% of subjects who lived alone and did not have a caregiver, ingestion of these drugs on a regular basis has the potential for serious, adverse consequences. In this study, it was also notable that there seemed to be little relationship between diagnosis and the type of medication used. For example, few persons with the diagnosis of cancer received any type of analgesic, which might be expected, whereas people with genitourinary prob- lems were the most frequent users of sedative- hypnotics, a group of drugs known to exacerbate urinary problems, such as incontinence (Urinary Incontinence Guideline Panel, 1992).

IMPLICATIONS

Because most of the clients whose charts were reviewed for this study had been discharged from the hospital setting within the last 24 hours, these

Table 4. Use of CNS Medications by Diagnosis

a37 cases unaccounted for included integument, neurologi- cal, gastrointestinal, vascular, trauma, musculoskeletal, and other diagnoses.

likely to get a CNS medication than their counter- parts with other disorders (see Table 4).

The majority of older persons who were home health clients had been recently discharged from the hospital and were likely to still be recovering from the very condition that precipitated their stay in the acute care facility. The remainder of elderly home health clients were suffering from an ongoing illness serious enough to warrant home health care services. For either group, the inappropriate use of CNS medications may place them at risk for further declines in their health and even may jeopardize their capacity for continued independent existence.

Diagnosis

Cardiac Endocrine Genitourinary Respiratory

Cancer

% Users/ Nonusers

65/35 76/24 38/63 53/47

75/25

Most Prescribed Category(% Receiving)

Narcotic & opoid analgesics (23) Antidepressants (31) Sedative-hypnotic (33) Sedative-hypnotic (38) Antianxiety (38) Sedative-hypnotic (50)

52 89

49 59 33

36.9 63.1

34.8 41.8 23.4

18 18 14 12

n (%)

76.6 3 21.3

48 34 17 12 16 11

108

30 2.1

8 5.7

168 77 32 23

5.16

0-17 —

71 50,4 70 49.6

67 48.0

46 33.0 94 67.0

53 38 22 16

—

52.0

Category

Number of Prescriptions

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DELLASEGAAND STRICKLIN

findings have implications for nurses employed in both acute care and home health settings. During discharge planning, hospital nurses need to take the responsibility for carefully reviewing the medica- tions of those persons who are returning home to detemaine the number and type of medications pre- scribed and the reason why. In particular, ongoing prescriptions for CNS medications should be scruti- nized and the rationale for use confirmed with the primary physician. If appropriate, education of the patient and his or her caregiver about the use of CNS medications and potential interactions or side effects should be stressed. Documentation and communica- tion of current prescriptions should then be for- warded to the visiting nurse at the time of discharge because, most often, the client’s recall will be the sole source of information if records are missing.

Use of prescribed medications in the community setting is regulated almost completely by the client or his or her caregiver. Regulations related to the use of medications and, in particular, to the screen- ing for inappropriate prescription of CNS drugs are lacking. Therefore, home health nurses must take the responsibility for coordinating the many differ- ent prescriptions elderly persons are likely to be given. The awareness that CNS medication use is as prevalent in the community as in institutions should alert nurses to screen specifically for these drugs. For each CNS or non-CNS medication the client takes, a clear reason for the prescription should be evident. Review of the record with the client and/or caregiver and the physician should be an integral part of the admission visit and thereafter as needed. Education that has ideally been started in the hospital or physician’s office should also be reinforced continuously by the home health nurse.

LIMITATIONS

Although use of all types of medications was high (M = 5.16), this study did not examine use of non-CNS medications, which have the potential to interact adversely with each other and/or CNS drugs. These potential interactions are another concern that the home health nurse must monitor. The research described here did not examine actual side effects experienced by the subjects because the chart data available for review was not specifically focused on medication behaviors. This topic would be an interesting study for the future, as would a longitudinal investigation of client outcomes in users and nonusers of CNS drugs.

CONCLUSIONS

Health care providers have come to recognize the risk of administering particular medications to older patients. In particular, CNS medications have been identified as a group of drugs requiring special caution. In long-term care institutions and hospi- tals, prescription of these medications for elderly persons is carefully regulated (Smith, 1990). How- ever, in the home setting, this practice is largely unmonitored.

Nurses in institutional settings must take an active role in screening medications that are or- dered on discharge for elderly clients, and home health nurses must continue this surveillance in the home. Proactive intervention on the part of nurses may not only prevent adverse consequences, but may prevent unnecessary institutionalizations and preserve quality of life for elderly home health clients.

Avorn, J., Dreyer, R, Connelly, K., & Soumerai, S. (1989). Useofpsychoactivemedicationandthequalityofcareinrest homes: Findings and policy implications of a statewide study. New England Journal of Medicine, 321, 54-55.

Barkauskas, V. (1990). Home health care: Responding to need, growth, and cost containment. In N. Chaska (Ed.), The nursing profession: Turning points (pp. 394-405). St. Louis: Mosby.

Beard, K. (1992). Adverse reactions as a cause of hospital admissionin the aged.Drugs andAging. 2, 356-367.

Brown, L., & Castleden, C. (1990). Adverse drug reactions: Anoverviewofspecialconsiderationsinthemanagementofthe elderlypatient.Drug Safety, 5, 421-435.

Burns, J., Sneddon, I., LoveU,M., McLean, A,, & Martin, B. (1992).Elderlypatientsandtheirmedication:Apost-discharge follow-upstudy.Age and Aging, 21, 178-181.

Closser, M. (1991). Benzodiazepenes and the elderly: A reviewofpotentialproblems.Journal ofSubstanceAbuseand Treatment, 8(1-2), 35-41.

Delafuente, J. (1991). Perspectives on geriatric pharmaco- therapy. Pharmacotherapy, 11, 222-224.

Greenblatt, D., Harmatz, J., & Shader, R. (1991). Clinical pharmacokinetics of anxiolytics and hypnotics in the elderly: Therapeutic considerations(part 1). Clinical Psychopharmaco- kinetics, 21, 165-177.

Greenblatt, D., Harmatz, J., Shapiro, L., Engelherdt, N., Gouthro, T., & Shader, R. (1991). Sensitivityto triazolamin the elderly.NewEngland Journal ofMedicine, 324, 1691-1698.

Johnson,J., &Moore,J. (1988).Thedrug-takingpracticesof the rural elderly.Applied Nursing Research, 1, 128-131.

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REFERENCES

2nd journal:

Applied Nursing Research 22 (2009) 133–137 Research Brief

www.elsevier.com/locate/apnr

All you have to do is call; a pilot study to improve the outcomes of patients with coronary artery disease

Abstract

Colleen M. Norris, RN, BScN, MN, PhDa,⁎,1, Lauren Patterson, BScNa, Diane Galbraith, BN, MN b, Kathleen M. Hegadoren, RN, BScN, MSc, PhDa,2

aFaculty of Nursing, University of Alberta, Edmonton, Alberta, Canada T6G2G3 bDepartment of Community Health Medicine, University of Calgary, Calgary, Alberta, Canada T2N 1N4 Received 7 June 2007; accepted 14 June 2007

Background: Studies have identified prevalence rates of major depression in patients with cardiovascular disease to range from 16% to 23%, whereas 65% of patients report some symptoms after a myocardial event. Depression has been shown to be strongly related to overall poorer outcomes in patients with coronary artery disease.

Purpose: The purpose of this pilot study was to assess the potential benefit of providing follow-up information regarding mental health resources to patients who had undergone cardiac catheterization and had reported significant levels of depression symptoms. Two methods of providing this follow-up information (personal telephone interaction and mailed-out written information) were compared.

Methods: As part of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry, patients completed baseline questionnaires, including the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. Patients reporting a score of 10 or higher were randomly assigned to one of three groups. Group A patients were contacted by mail, whereas Group B patients were contacted through a telephone follow-up call by a nurse. Both groups received information regarding community- and hospital-based mental health resources. Six weeks after the initial contact, patients in Groups A and B and those in a third control group (Group C) were called and asked to complete a repeat CES-D via telephone interview. Logistic regression modeling was used to determine the influence of the intervention on the change in depression scores from baseline to 6 weeks.

Results: Ninety-eight respondents had both baseline and 6-week CES-D scores. The mean age of the respondents was 64.9 years, and women constituted 27% of the sample. There was no statistically significant clinical difference between the three groups. Regression analysis demonstrated that patients who were contacted by either telephone or mail were significantly more likely to report improvement in the CES-D scores (odds ratio = 3.03, p = .03) as compared with the control group. Furthermore, respondents who were phoned reported the highest percentage of improved CES-D scores as compared with the mailed and control groups.

Conclusions: This pilot study demonstrated that early recognition strategies and referral protocols that address mental health needs are effective in decreasing the reported depressive symptomatology of this high-risk population. Proactively addressing mental health issues as an integral part of the

⁎ Corresponding author. Tel.: +1 780 492 0644; fax: +1 780 492 1219.

E-mail addresses: colleen.norris@ualberta.ca (C.M. Norris), diane.galbraith@ucalgary.ca (D. Galbraith), kathleen.hegadoren@ualberta.ca (K.M. Hegadoren).

1 Dr. Norris is an Alberta Heritage Foundation for Medical Research Population Health Investigator, a Canadian Institute for Health Research New Investigator, and a Canadian Cardiovascular Outcomes Research Team; CCORT (a pan-Canadian cardiac outcomes research team supported by the Canadian Institute for Health Research and the Heart and Stroke Foundation) Investigator.

2 Dr. Hegadoren holds a Canada Research Chairs Program chairpersonship in stress disorders in women.

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C.M. Norris et al. / Applied Nursing Research 22 (2009) 133–137

overall treatment with patients with coronary artery disease could potentially improve the health outcomes in this population.

1. Introduction

The health effects of heart disease and depression are immense. Depression is estimated to be the leading cause of disability worldwide (Murray & Lopez, 1996), and heart disease is the leading cause of death and disability in Canada (Tu, Ghali, Pilote, & Brien, 2006). Over the past two decades, research studies have shown that depression and heart disease are common companions and that, more importantly, each is an independent risk factor of the other. Studies have identified the prevalence of major depression in patients with cardiovascular disease to be between 16% and 23% (Carney, Rich, Freedland, & Saini, 1988; Frasure- Smith, Lesperance, & Talajic, 1993; Gonzalez et al., 1996; Schleifer et al., 1989), whereas 65% of patients manifest symptoms of major or minor depression after myocardial infarction (MI; Carney, Freedland, Sheline, & Weiss, 1997). Depression after episodes of acute coronary syndrome is associated with major cardiac events (Lesperance, Frasure- Smith, Juneau, & Theroux, 2000), a 2.5-fold increase in the risk for a heart attack (Kirbey, 2004), and a 3- to 4-fold increase in cardiac mortality (Barefoot et al., 1996; Carney et al., 1988; Denollet & Brutsaert, 1998; Frasure-Smith et al., 2000; Frasure-Smith, Lesperance, Juneau, Talajic, & Bour- assa, 1999; Frasure-Smith, Lesperance, & Talajic, 1995). As well, depression predicts slow recovery and poor quality of life (QoL; Lane, Carroll, Ring, Beevers, & Lip, 2001; Lesperance & Frasure-Smith, 1999). These statistics led the investigators of the Sertraline Anti-Depressant Heart Attack Randomized Trial to comment that “depression that recurs or persists in ACS [acute coronary syndrome] should be identified and treated because it is a serious illness that is both painful to patients and impedes their medical care” (Glassman et al., 2002). The purpose of this pilot study was to assess the potential benefit of providing follow-up information regarding mental health resources to patients who had undergone cardiac catheterization and had reported significant levels of depressive symptomatology.

2. Background

It is well known that depression is a common response to a significant stressor or traumatic life event (Kendler, Kessler, Neale, Heath, & Eaves, 1993) and that depressive symptoms and major depressive disorders are common in patients with coronary artery disease (CAD). The pre- valence rate of major depression in patients with CAD is approximately three-fold higher than that in age-matched community-based samples (Grace et al., 2002). The exact

mechanisms that increase vulnerability in those with chronic health problems have not been elucidated; how- ever, evidence suggests that multiple biological and psychosocial factors contribute to the emergence of depressive symptoms.

Depression has been associated with poor health out- comes in a variety of medical conditions, including cardiovascular events (Ai et al., 1997; Frasure-Smith et al., 1993; Grace et al., 2002; Lesperance et al., 2000; Rutledge et al., 2001; Welin, Lappas, & Wilhelmsen, 1997). Grace et al. noted that “Accordingly, there has been recent interest in the literature in specific depressive symptoms and their relation to cardiac outcome.” A pilot study (a Canadian Cardiovascular Outcomes Research Team summer student- ship award) was undertaken (Norris, Patterson, Galbraith, & Hegadoren, 2006) to assess the potential benefit of providing follow-up information regarding mental health resources to patients who had undergone cardiac catheterization in an effort to address this concern. Other objectives included obtaining descriptive data on the preferred contact method and its relationship to accessing resources and any sex difference in our data set.

3. Methods

This study was conducted using a prospective cohort design and the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry. The APPROACH project began data collection in 1995 and has been previously described (Ghali & Knudtson, 2000). Briefly, the APPROACH registry provides a database to study provincial outcomes of care and facilitate quality assurance/quality improvement for individuals with CAD. The APPROACH database contains detailed clinical infor- mation on adults with known or suspected CAD and is merged biannually with mortality data from the Vital Statistics Registry. Individuals in the APPROACH registry consent to be followed longitudinally after cardiac catheter- ization, thus allowing for assessment of subsequent proce- dures (i.e., percutaneous coronary intervention or coronary artery bypass graft surgery) and outcomes (e.g., mortality and QoL).

3.1. Study population

Eligible participants included all Alberta residents older than 18 years with at least one-vessel CAD (Duke Coronary Index between 3 and 13 [Smith et al., 1991]), without a previous cardiac catheterization, and who had undergone cardiac catheterization between May 1 and 31, 2006, who

consent to be enrolled in the APPROACH cohort. Patients were approached for consent at catheterization.

Data on the patients’ sociodemographic, clinical, and comorbid conditions as well as coronary anatomy were collected through the APPROACH registry. Data collected at cardiac catheterization included the following: sociodemo- graphic characteristics (sex, age, address with postal code); presence or absence of comorbidities (renal insufficiency, hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, smoking status, pulmonary disease, liver/gastrointestinal disease, malig- nancy); disease-specific variables (congestive heart failure, prior MI, prior thrombolytic therapy, Canadian Cardiovas- cular Society Angina class, results of noninvasive tests); and coronary angiography results (coronary anatomy, extent of coronary stenosis, left ventricular ejection fraction).

Patients were provided with two options for completing the baseline questionnaires mailed within 1 week of their index cardiac catheterization. They may complete the questionnaires and mail them back in a stamped addressed envelope or may call a toll-free line and respond to a verbally administered questionnaire, with their responses being recorded and transcribed daily. The questionnaire set included a questionnaire on sociodemographic variables; the baseline Seattle Angina Questionnaire (measuring health-related [HR] QoL before the cardiac catheterization), a 19-item disease-specific HRQoL instrument; the EuroQoL 5D, a 5-item generic HRQoL instrument; and the Center for Epidemiologic Studies Depression (CES-D) Scale.

3.2. Measurement

The CES-D is a 10-item self-report measure of depressive symptoms. Each item provides a statement representing a symptom characteristic of depression followed by a 4-point Likert-type response scale with options ranging from rarely or none of the time (b1 day) to most or all of the time (5–7 days). Respondents are instructed to check the response to each statement that best describes how often they felt or behaved in a particular way during the past week. The CES- D was developed to be used in epidemiologic studies of depression in the general population. It is therefore designed to measure the current level of depressive symptomatology. The CES-D is scored by summing all the highest ratings for each of the 20 items. Scores range from 0 to 40. Higher scores indicate a higher frequency of current depressive symptoms experienced during the past week. Investigators have designated a cutoff score of 10 as a suitable indicator to differentiate clinically depressed from nondepressed patients (Irwin, Artin, & Oxman, 1999; Practitioner’s Guide to Empirically Based Measures of Depression, 2000).

The patients reporting total scores indicating significant depressive symptomatology were randomly assigned to one of three groups using SPSS 14 statistical software (SPSS, Chicago, IL). Patients in Groups A and B received written information regarding community- and hospital-based men-

tal health resources. However, those in Group A were also contacted via telephone by a nurse to discuss the written information. Patients in Group C (control group) underwent usual care (follow-up questionnaire). Six weeks after the initial contact, patients in Groups A, B, and C were called and asked to complete a repeat CES-D via telephone interview by the same nurse involved with Group A.

3.3. Statistical analysis

All three groups were compared using t test and/or chi- square statistics. Baseline and 6-week CES-D scores were calculated, and a change score was created. Patients were given “1” if their depression score decreased between baseline and 6 weeks (i.e., improvement) or “0” if their depression score stayed the same or increased (i.e., became worse). Logistic regression modeling was used to determine the influence of the intervention on the change in depression scores from baseline to 6 weeks. SPSS version 14 was used for all the analyses.

4. Results

Ninety-eight respondents were randomized (using SPSS random selection) into the three groups and had complete baseline and 6-week CES-D scores. The mean age of the respondents was 64.9 years, and women constituted 27% of the sample. Aside from hyperlipidemia in the mailed-only group (Group B), reporting fewer current smokers, there was no statistically significant clinical difference between the three groups, suggesting that the randomization was successful (Table 1). Table 2 presents the results of the logistic regression analyses and demonstrates that patients who were contacted by telephone were significantly more likely to report improvement in the CES-D scores (odds ratio = 5.25, p = .007) as compared with the control group after controlling for age and sex. Furthermore, respondents who were simply mailed the information on mental health resources were significantly more likely to report improved CES-D scores (odds ratio = 3.75, p = .035) as compared with the control group. Finally, the respondents who were phoned were more likely to report improved CES-D scores as compared with the respondents who were mailed informa- tion, although this relationship was nonsignificant (odds ratio = 1.47, p = .20).

5. Discussion

There have been a number of studies that examined strategies to reduce psychological distress and their impact on cardiac prognosis; however, the results have been equivocal. The conclusion drawn in a systematic review by Wenger et al. (1995) was that psychosocial treatment including multifactorial programs (education, counseling, and psychosocial interventions conducted

C.M. Norris et al. / Applied Nursing Research 22 (2009) 133–137 135

136 C.M. Norris et al. / Applied Nursing Research 22 (2009) 133–137

Table 1

Baseline demographic characteristics by randomized treatment group

hospital readmissions. The results of this study demon- strated that interventions that reduce psychological distress have the potential to improve long-term prognosis and psychological status for both men and women.

Although these results demonstrate the benefit of screening and intervening with patients reporting high levels of depressive symptomatology after MI, the resources used to produce these results were substantial. Frasure-Smith et al. (1997) reported that patients in the M- HART treatment group received an average of 6 to 7 hours of nursing care with a mean number of five to six visits over 7 to 8 months. As well, monthly monitoring calls independent of the visits were performed during the year of the study, requiring a total of 12 nurses. In fact, Frasure- Smith et al. speculated that the psychosocial and psy- chotherapeutic treatments may have caused the transitory and sustained adverse psychological effects reported in the M-HART. The monthly telephone screening for psycholo- gical distress and the interventions in the home may have reminded patients of their MI and increased distress by leading to perceptions of poor prognosis. It is interesting to note that the results of our study demonstrated significant improvements in depressive symptomatology, albeit short- term changes with a single event referral protocol. Furthermore, this study established that the CES-D can be used successfully as a population-based screening tool for patients who are catheterized for CAD.

6. Conclusions

The results of our pilot study demonstrated that a single event referral protocol, which included contact with a professional offering mental health resources, was very effective in decreasing the reported depressive symptoma- tology of this high-risk population. It is now imperative to determine if this simple protocol is effective in maintaining the decrease in depressive symptomatology over the year after the cardiac event and more importantly in improving reported QoL at 1 year. Future studies can also investigate the potential of decreasing the risk of developing depressive symptoms or attenuating the severity of symptoms by providing educational materials and mental health resources in the community.

Table 2

Changes in depression symptomatology by single event referral protocol

Variable Control Mailed-only

group group group

(n= 42) (n= Sex (% female) 26.5 23.1

Age (years, M) 64.8 63.1 Pulmonary disease 11.8 7.7

(%)

Cerebrovascular 4.4 3.8

disease (%)

Congestive heart 10.3 7.7

failure (%)

Dialysis (%) 2.9 0.0 Hypertension (%) 67.6 69.2 Hyperlipidemia (%) 88.2 65.4 Liver/ 1.5 0.0

Gastrointestinal

disease (%)

Malignancy (%) 4.4 3.8 Prior MI (%) 14.7 23.1 Peripheral vascular 10.3 15.4

disease (%)

Diabetes mellitus (%) 23.5 26.8 Smoking status

Never smoked 22.1 3.8 Current smoker 25.0 38.5 Former smoker 41.2 53.8 Missing data 11.8 3.8

Coronary anatomy (%)

One-vessel disease 83.6 76.9 Two-vessel 7.5 3.8

disease

Three-vessel 9.0 19.2

disease

Prior coronary artery 2.9 7.7

bypass graft surgery

Prior percutaneous 5.9 11.5

coronary

26)

intervention

CES-D score at 8.93 9.35

baseline (M)

Phoned p (n= 27)

33.3 .69 67.0 .46 14.8 .72

3.7 .98

3.7 .57

0.0 .45 59.3 .69 88.9 .02

3.7 .56

0.0 .55

7.4 .28 11.1 .79

29.6 .82

37.0 .06 10.0

40.7

11.1

88.9 .55 0.0

11.1

0.0 .28 3.7 .48

9.67 .69

between 1968 and 1992) provided benefit over standard care. In contrast, two subsequent large clinical trials, including the Montreal Heart Attack Readjustment Trial (M-HART; Frasure-Smith et al., 1997; Jones & West, 1996), failed to demonstrate a significant impact of psychosocial intervention on survival. One of the possible reasons for the disparity in the results of these studies was examined by Cossette, Frasure-Smith, and Lesperance (2001) in a further analysis of the M-HART data. They postulated that the intervention (patients were phoned and visited by a trained nurse) within the M-HART program (Frasure-Smith et al., 1997) both decreased and increased the psychological distress in patients, thereby negating the impact on psychological symptoms in the overall sample. This secondary analysis examined the relationship between short-term individual changes in psychological distress, midterm improvement in distress, and 1-year outcomes, including depression, anxiety, mortality, and

Odds ratio (improvement)

5.25 3.75 1.47

95% lower confidence limit

95% upper p confidence

limit

Phoned versus control group

Mailed versus control group

Phoned versus mailed group

17.4 .007 12.8 .035

1.58

1.10

0.32 6.8 .200

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