The Gerontologist 47:528-534 (2007)
© 2007 The Gerontological Society of America
Mental Health Status of Home Care Elders in Michigan
Lydia W. Li, PhD1 and
Yeates Conwell, PhD2
Correspondence: Address correspondence to Lydia Li, University of Michigan School of Social Work, 1080 S. University Avenue, Ann Arbor, MI 48109-1106. E-mail: lydiali{at}umich.edu
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Abstract
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Purpose: This study describes the mental health status of community-living frail elders in Michigan and identifies subgroups of individuals who are vulnerable to mental health problems. Design and Methods: We analyzed the baseline assessment data collected from older adults who were admitted to two community-based long-term-care programs in Michigan (N = 18,939). Results: Results show that 40.5% of the individuals in the sample have recognized mental disorders, 39.6% use psychotropic medications, 24.5% have probable depression, and 1.4% have self-injury thoughts or attempts. Frail elders who are White, younger, and female—as well as those who experience more pain, disease burden, cognitive impairment, and limitations in instrumental activities of daily living—are more prone to psychological distress. Implications: Mental health care is greatly needed by community-living frail elders.
Key Words: Depression • Psychological distress • Community-based long-term care • Frail elders • MDS-HC
This study has two purposes: (a) to describe the mental health status of frail elders living at home in Michigan, and (b) to identify subgroups of individuals, by sociodemographic and clinical characteristics, who are more likely to experience mental health problems. Community-living frail elders are an understudied population, partly because they are difficult to access and interview. Among the few researchers who have examined mental health in this population, Bruce and colleagues (2002) reported that 13.5% of elders in their home care sample had major depression, a rate twice as high as that in elderly primary care patients. In their study, Ell, Unutzer, Aranda, Sanchez, and Lee (2005) estimated that 10% of elderly home care recipients have clinically significant depression, 8.5% have probable or definite major depression, and 4% have suicidal ideation. These prior studies, however, are limited in that the analyzed samples may be biased because of high refusal rates (e.g., 39% in Bruce et al. and 23% in Ell et al.). Furthermore, they relied on a single measure, such as a clinical diagnosis of depression or self-report of depressive symptoms, to assess mental health. In this study, we use several indicators—including recognized mental disorders, psychotropic drug use, depressive symptoms, and self-injury thoughts and attempts—to depict a broader picture of the mental health status of community-living frail elders.
Sociodemographic characteristics, including age, gender, race, education, and marital status, have been found to be associated with mental health in community-living older adults (Cairney & Krause, 2005; Hybels & Blazer, 2003). Clinical characteristics, such as functional disability, comorbidity, cognitive limitation, and pain, are strong correlates of depression in various elderly populations (Bruce et al., 2002; Lyness, Niculescu, Tu, Reynolds, & Caine, 2006). Because of the correlation between clinical and sociodemographic characteristics, it is necessary to control for each other when examining their associations with mental health.
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Methods
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Data and Sample
Data for this study came from newly admitted elderly participants (65 years of age or older) of two community-based long-term-care programs in Michigan, that is, Medicaid Waiver and Care Management, between 1998 and 2003 (N = 18,939). Both programs aim to help adults who are at risk of nursing home placement to remain in the community by providing them supportive services, such as homemaking, meal delivery, and personal emergency response systems. The Medicaid Waiver program was limited to low-income individuals and the Care Management program was for people aged 60 years or older. The two programs used the same assessment instrument (the standardized Minimum Data Set for Home Care, known as the MDS-HC, plus some questions added by the Michigan Department of Community Health). All eligible applicants to the two programs received a comprehensive in-person assessment, conducted by a nurse and a social worker, using the MDS-HC. We had assessment data sent to a central database by means of scanning.
Variables and Measures
Mental Health Status
We included four sets of measures for mental health status (Table 2): recognized mental disorders, psychotropic medications, depressive symptoms, and self-injury. For recognized mental disorders, the MDS-HC recorded diseases diagnosed by doctors that required treatments or symptom management, including diagnoses of depression, manic depression, anxiety disorder, and schizophrenia. For psychotropic medications, the MDS-HC recorded whether the respondents took antidepressant, antianxiety, or antipsychotic drugs, respectively, in the previous week. We measured depressive symptoms by using an adapted version of the MDS Depression Rating Scale (Burrows, Morris, Simon, Hirdes, & Phillips, 2000). The adapted scale consisted of six items; each was rated from 0, not exhibited in the past 30 days, to 2, exhibited daily (Cronbach's alpha, 
= 0.74). We used a score of 3 or above on the scale to indicate probable depression, as suggested by Burrows and colleagues. We measured self-injury by means of three variables: (a) self-injurious attempts in the past year; (b) suicide attempts in the past year; and (c) self-injury thoughts, defined as considering self-injurious behavior, in the past month. We coded all three variables dichotomously (yes or no).
Sociodemographic Characteristics
Sociodemographic characteristics included gender, race, age, education, marital status, type of community long-term-care programs, and health insurance (Table 1). We coded gender dichotomously. We used three categories for race: White, Black, and other. We measured age in chronological years. Education had four categories: completed Grade 8 or below, completed Grades 9–11, graduated high school, and completed bachelor's degree or more. Marital status also had four categories: married, widowed, separated or divorced, and never married. The type of program referred to whether the respondent was admitted to the Medicaid Waiver or the Care Management program, which can be used as a proxy of income. Almost all respondents (99%) had Medicare. We used Medicaid and private insurance, both of which we coded as receiving versus not, to indicate health insurance.
Clinical Characteristics
Clinical characteristics included functional disability, disease burden, cognitive impairment, and pain (Table 1). We measured functional disability in terms of limitations in activities of daily living (ADLs, such as having mobility in bed, transferring, having locomotion in the home, dressing, eating, using the toilet, and conducting personal hygiene) and limitations in instrumental activities of daily living (IADLs, such as preparing meals, housekeeping, managing finances, managing medications, using the phone, shopping, and using transportation). We indicated disease burden by a count of out of a possible 29 chronic conditions (excluding mental disorders). We assessed cognitive impairment and pain by means of the Cognitive Performance Scale and the pain scale for MDS, respectively (Fries, Simon, Morris, Flodstrom, & Bookstein, 2001; Morris, Fries, Mehr, Hawes, & Phillips, 1994).
Data Analysis
We used descriptive statistics to assess prevalence of recognized mental disorders, psychotropic use, depressive symptoms, and self-injury in the sample of participants. Then we conducted multivariate logistic regression to identify the sociodemographic and clinical correlates of the mental health measures. Most study variables had missing data. We undertook multiple imputation by using the NORM program (Schafer, 1999). We analyzed three imputed data sets separately. We calculated the final estimates and standard errors by using formulas that combine results from the three analyses (Schafer & Olsen, 1998).
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Results
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Sociodemographic and Clinical Characteristics
About 70.6% of the study participants were female (Table 1). Whites were the largest ethnic category (81.2%), followed by Blacks (18.0%). Participants were, on average, 79 years old. Most were educated at below the high school level (52.9%). A majority of the participants were widowed (53.2%), and about one third of the participants were married (32.3%). About 39.3% lived alone; the others lived with spouses (30.1%), children (20.4%), or others (10.2%). More than half (53.8%) were admitted to the Care Management program. About 35.7% of the participants had Medicaid; a minority (13.4%) had private insurance from employers, unions, or self-purchase.
The participants had relatively severe disability, with three ADL and six IADL limitations on average. The majority of participants (56.9%) were cognitively intact; approximately one third (34.1%) had mild to moderate cognitive impairment. On average, participants had 5.3 chronic conditions. The majority of respondents (68.8%) reported experiencing pain, with 25.1% having intense pain daily.
Mental Health Status
Approximately 40.5% of the participants had recognized mental disorders, with depression (32.9%) being the most prevalent, followed by anxiety disorder (18.8%), manic depression (0.8%), and schizophrenia (0.6%; see Table 2). About 39.6% of the participants used psychotropic medications; of those individuals, most took antidepressants (26.9%), followed by antianxiety medications (17.4%) and antipsychotic drugs (5.8%).
The mean score on the adapted MDS Depression Rating Scale was 1.55. Using a score of 3 on the scale as the cutoff point (Burrows et al., 2000), we classified 24.5% of the participants as having probable depression. Overall, about 1.4% of the participants had self-injurious thoughts or attempts—0.4% had self-injurious attempts and 0.3% had suicide attempts in the past year; 1.2% of the participants had considered injuring themselves in the previous month.
Sociodemographic and Clinical Correlates of Mental Health Status
In the multivariate logistic regression analyses, we examined the predictors of recognized depression and anxiety disorders, each of the three types of psychotropic drugs, probable depression as measured by the adapted MDS Depression Rating Scale, and any self-injury thoughts or attempts (Table 3).
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Table 3. Multivariate Logistic Regression Analyses of Sociodemographic and Clinical Correlates of Mental Health Status (N = 18,939).
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Being White (vs Black) and younger increased the odds of having mental health problems as indicated by all measures. Being female and married (vs never married) increased the likelihood of having recognized depression and anxiety, taking antidepressant and antianxiety medications, and having probable depression. However, women were less likely than men to have self-injury attempts or thoughts; widowed elders were less likely than those who were married to use antidepressant and antipsychotic medications. Education increased the likelihood of having recognized depression and taking antidepressant and antipsychotic medications, but college degree holders were less likely than the least educated individuals to have recognized anxiety. Medicaid recipients were more likely to have recognized anxiety, but they were less likely to have probable depression. Older adults with private insurance were more likely to use antianxiety drugs. Those admitted to the Care Management program were more likely than Medicaid Waiver enrollees to use antidepressant and antipsychotic medications.
Higher levels of cognitive impairment, disease burden, and pain were associated with a greater likelihood of having recognized depression and anxiety, using antidepressant and antianxiety drugs, and having probable depression. Cognitive impairment increased the odds of taking antipsychotic medication; pain increased the odds of having self-injury thoughts or attempts. IADL limitations increased the likelihood of having recognized depression, taking antidepressant and antipsychotic drugs, and having probable depression. However, ADL limitations decreased the odds of having recognized anxiety.
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Discussion
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Given the dearth of information about the mental health of community-living frail elders, this study makes an important contribution by revealing their vulnerability to mental health problems. The high rates of recognized mental disorders (40.5%) and psychotropic medication use (39.6%) in the sample warrant heightened attention. These figures very clearly indicate the great need for mental health care by community-living frail elders. Prior research has suggested that physical health and mental health are closely related, and that depression is related to more health service use among older adults (Katz, 1996; Unutzer et al., 1997). It seems imperative that mental health interventions be a component of community-based long-term-care programs, which may also be cost effective.
Our findings about sociodemographic and clinical correlates of frail elders' mental health, for the most part, corroborate previous research (Bruce et al., 2002; Ell et al., 2005; Hybels & Blazer, 2003; Lyness et al., 2006). Cognitive impairment, pain, IADL limitations, and disease burden are strong correlates of mental health. These findings suggest that, if resources are limited and mental health services have to target those individuals who are most in need, then the most vulnerable segment of the frail elderly population should be given a top priority. Frail elders who are younger, White, and female should also be given more attention in relation to their mental health. The findings concerning race, however, should be interpreted cautiously. Although they suggest that Blacks may be more resilient than Whites to stress in later life (Kubzansky, Berkman, & Seeman, 2000), it is possible that the measures in the MDS-HC are inadequate in assessing the mental health of Black elders (Neighbors, Jackson, Campbell, & Williams, 1989). In addition, the relative mental health advantages of never-married elders may be due to selection effect, in that a frail elder with poor mental health is less likely to remain in the community when he or she has neither spouse nor children.
Methodological strengths of this study include a large sample size and multiple measures to assess the mental health of frail elders. The prevalence rates of mental health problems from the imputed sample are similar to those using valid data, suggesting that the missing-data mechanism might be random (Little & Rubin, 2002). The study's limitations include its sample and measures. Our sample of frail elders does not represent those who do not seek publicly funded services, and it does not represent elders who receive home care in other states. Our assessment of mental health is based on measures available in the MDS-HC (Michigan version). However, the use of multiple measures of mental health in this study has helped to compensate for the potential shortcomings of any single measure.
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Footnotes
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Dr. Li received support for this study from the University of Michigan Claude D. Pepper Older Americans Independence Center (under Grant AG024824). Dr. Conwell was supported in part by the National Institutes of Mental Health under Grants R25 MH68564-01 (Eric Caine, Principal Investigator) and R24 MH07164 (Yeates Conwell, Principal Investigator). We thank the Michigan Department of Community Health for making the data available, as well as Mary James, MA, Brant Fries, PhD, and Kristina Szafara, PhD for their assistance in accessing and extracting the data. 
1 University of Michigan School of Social Work, Ann Arbor.
2 University of Rochester Medical Center, Rochester, NY.
Decision Editor: Linda S. Noelker, PhD
Received for publication December 29, 2006.
Accepted for publication March 27, 2007.
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References
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Abstract
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