The association between geriatric treatment and 30-day readmission risk among medical inpatients aged ≥75 years with multimorbidity

Background Readmission to hospital is frequent among older patients and reported as a post-discharge adverse outcome. The effect of treatment in a geriatric ward for acutely admitted older patients on mortality and function is well established, but less is known about the possible influence of such treatment on the risk of readmission, particularly in the oldest and most vulnerable patients. Our aim was to assess the risk for early readmission for multimorbid patients > 75 years treated in a geriatric ward compared to medical wards and to identify risk factors for 30-day readmissions. Methods Prospective cohort study of patients acutely admitted to a medical department at a Norwegian regional hospital. Eligible patients were community-dwelling, multimorbid, receiving home care services, and aged 75+. Patients were consecutively included in the period from 1 April to 31 October 2012. Clinical data were retrieved from the referral letter and medical records. Results We included 227 patients with a mean (SD) age of 86.0 (5.7) years, 134 (59%) were female and 59 (26%) were readmitted within 30 days after discharge. We found no statistically significant difference in readmission rate between patients treated in a geriatric ward versus other medical wards. In adjusted Cox proportional hazards regression analyses, lower age (hazard ratio (95% confidence interval) 0.95 (0.91–0.99) per year), female gender (2.17 (1.15–4.00)) and higher MMSE score (1.03 (1.00–1.06) per point) were significant risk factors for readmission. Conclusions Lower age, female gender and higher cognitive function were the main risk factors for 30-day readmission to hospital among old patients with multimorbidity. We found no impact of geriatric care on the readmission rate.

Download Full-text

Prevalence and Risk of Polypharmacy among Community-Dwelling, Elderly Kuwaiti Patients

Medical Principles and Practice ◽

10.1159/000503298 ◽

2019 ◽

Vol 29 (2) ◽

pp. 166-173 ◽

Cited By ~ 1

Author(s):

Nabil Ahmed Badawy ◽

Shokria Adely Labeeb ◽

Mawaheb Falah Alsamdan ◽

Badria Faleh Alazemi

Keyword(s):

Risk Factors ◽

Hospital Admissions ◽

Antihypertensive Drugs ◽

Female Gender ◽

Community Dwelling ◽

Older Individuals ◽

Cross Sectional ◽

Factors Associated ◽

High Prevalence ◽

Study Population

Objectives: To estimate the prevalence of polypharmacy in community-dwelling, older Kuwaiti patients, describe the number and types of drugs used, and identify risk factors associated with polypharmacy. Subjects and Methods: This was a descriptive cross-sectional questionnaire-based survey in which we interviewed 500 community-dwelling Kuwaiti adults over 65 years of age. The data collection occurred during a 4-month period from March to July 2017. Results: Fifty-two percent (n = 260) of the patients were males, with a mean age of 71.73 ± 5.32 years. The prevalence of polypharmacy (5–8 drugs) and excessive polypharmacy (>8 drugs) was 58.4% (n = 292) and 10.2% (n = 51), respectively. The risk factors associated with an increased number of medicines used were: female gender (p = 0.019), a lower level of education (p = 0.003), a high number of hospital admissions (p = 0.000), clinics visited by the patient (p =0.000), and number of comorbidities (p = 0.000). The most commonly used medications (82.6% of the study population) were blood glucose-lowering agents, excluding insulin. Other commonly used medications were antihypertensive drugs and lipid-modifying agents. Conclusion: A significant sector of the older Kuwaiti patient population has a high prevalence of polypharmacy and is thus exposed to its potential hazards. The current study highlights the need to revise the drug-dispensing policy among community-dwelling, older Kuwaiti people, as well as to initiate educational programs among healthcare practitioners concerning prescribing issues in older individuals.

Download Full-text

Dementia, Alzheimer’s Disease, and Mortality after Hemodialysis Initiation

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.10150917 ◽

2018 ◽

Vol 13 (9) ◽

pp. 1339-1347 ◽

Cited By ~ 23

Author(s):

Mara A. McAdams-DeMarco ◽

Matthew Daubresse ◽

Sunjae Bae ◽

Alden L. Gross ◽

Michelle C. Carlson ◽

...

Keyword(s):

Risk Factors ◽

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Confidence Interval ◽

Competing Risks ◽

Older Patients ◽

Disease Diagnosis ◽

Hazard Ratio ◽

Old Patients ◽

Diagnosis Of Dementia

Background and objectivesOlder patients with ESKD experience rapid declines in executive function after initiating hemodialysis; these impairments might lead to high rates of dementia and Alzheimer’s disease in this population. We estimated incidence, risk factors, and sequelae of diagnosis with dementia and Alzheimer’s disease among older patients with ESKD initiating hemodialysis.Design, setting, participants, & measurementsWe studied 356,668 older (age ≥66 years old) patients on hemodialysis (January 1, 2001 to December 31, 2013) from national registry data (US Renal Data System) linked to Medicare. We estimated the risk (cumulative incidence) of diagnosis of dementia and Alzheimer’s disease and studied factors associated with these disorders using competing risks models to account for death, change in dialysis modality, and kidney transplant. We estimated the risk of subsequent mortality using Cox proportional hazards models.ResultsThe 1- and 5-year risks of diagnosed dementia accounting for competing risks were 4.6% and 16% for women, respectively, and 3.7% and 13% for men, respectively. The corresponding Alzheimer’s disease diagnosis risks were 0.6% and 2.6% for women, respectively, and 0.4% and 2.0% for men, respectively. The strongest independent risk factors for diagnosis of dementia and Alzheimer’s disease were age ≥86 years old (dementia: hazard ratio, 2.11; 95% confidence interval, 2.04 to 2.18; Alzheimer’s disease: hazard ratio, 2.11; 95% confidence interval, 1.97 to 2.25), black race (dementia: hazard ratio, 1.70; 95% confidence interval, 1.67 to 1.73; Alzheimer’s disease: hazard ratio, 1.78; 95% confidence interval, 1.71 to 1.85), women (dementia: hazard ratio, 1.10; 95% confidence interval, 1.08 to 1.12; Alzheimer’s disease: hazard ratio, 1.12; 95% confidence interval, 1.08 to 1.16), and institutionalization (dementia: hazard ratio, 1.36; 95% confidence interval, 1.33 to 1.39; Alzheimer’s disease: hazard ratio, 1.10; 95% confidence interval, 1.05 to 1.15). Older patients on hemodialysis with a diagnosis of dementia were at 2.14-fold (95% confidence interval, 2.07 to 2.22) higher risk of subsequent mortality; those with a diagnosis of Alzheimer’s disease were at 2.01-fold (95% confidence interval, 1.89 to 2.15) higher mortality risk.ConclusionsOlder patients on hemodialysis are at substantial risk of diagnosis with dementia and Alzheimer’s disease, and carrying these diagnoses is associated with a twofold higher mortality.

Download Full-text

Clinical Features and Mortality of Nosocomial Candidemia in Very Old Patients: A Multicentre Italian Study

Gerontology ◽

10.1159/000510638 ◽

2020 ◽

Vol 66 (6) ◽

pp. 532-541

Author(s):

Marta Zatta ◽

Stefano Di Bella ◽

Daniele Roberto Giacobbe ◽

Filippo Del Puente ◽

Maria Merelli ◽

...

Keyword(s):

Risk Factors ◽

Venous Catheter ◽

Prognostic Impact ◽

Old Patients ◽

Very Old ◽

Probability Of Survival ◽

Independent Risk Factors ◽

Nosocomial Candidemia ◽

Medical Wards ◽

Few Data

Introduction: Being elderly is a well-known risk factor for candidemia, but few data are available on the prognostic impact of candidemia in the very old (VO) subjects, as defined as people aged ≥75 years. Objective: The aim of this study was to assess risk factors for nosocomial candidemia in two groups of candidemia patients, consisting of VO patients (≥75 years) and adult and old (AO) patients (18–74 years). In addition, risk factors for death (30-day mortality) were analysed separately in the two groups. Methods: We included all consecutive candidemia episodes from January 2011 to December 2013 occurring in six referral hospitals in north-eastern Italy. Results: A total of 683 nosocomial candidemia episodes occurred. Of those, 293 (42.9%) episodes were in VO and 390 (57.1%) in AO patients. Hospitalization in medical wards, chronic renal failure, urinary catheter, and peripheral parenteral nutrition (PPN) were more common in VO than in AO patients. In the former patient group, adequate antifungal therapy (73.2%) and central venous catheter (CVC) removal (67.6%) occurred less frequently than in AO patients (82.5 and 80%, p < 0.002 and p < 0.004, respectively). Thirty-day mortality was higher in VO compared to AO patients (47.8 vs. 23.6%, p < 0.0001). In AO patients, independent risk factors for death were age (OR 1.04, 95% CI 1.00–1.09, p = 0.038), recent history of chemotherapy (OR 22.01, 95% CI 3.12–155.20, p = 0.002), and severity of sepsis (OR 40.68, 95% CI 7.42–223.10, p < 0.001); CVC removal was associated with higher probability of survival (OR 0.10, 95% CI 0.03–0.33, p < 0.001). In VO patients, independent risk factors for death were PPN (OR 3.5, 95% CI 1.17–10.47, p = 0.025) and hospitalization in medical wards (OR 2.58, 95% CI 1.02–6.53, p = 0.046), while CVC removal was associated with improved survival (OR 0.40, 95% CI 0.16–1.00, p = 0.050). Conclusion: Thirty-day mortality was high among VO patients and was associated with inadequate management of candidemia, especially in medical wards.

Download Full-text

Clinical features and tumor mutational profile of younger versus older patients with cholangiocarcinoma (CCA).

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.240 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 240-240

Author(s):

Lipika Goyal ◽

Stephanie Reyes ◽

Apurva Jain ◽

Rachna T. Shroff ◽

Tri Minh Le ◽

...

Keyword(s):

Risk Factors ◽

Older Patients ◽

Tertiary Care ◽

Tumor Biology ◽

Young Patients ◽

Molecular Testing ◽

Extrahepatic Cholangiocarcinoma ◽

Younger Patients ◽

Molecular Features ◽

Significant Difference

240 Background: As seen in lung cancer, young patients with cancer can have different risk factors, presentation, and tumor genotype than older patients with the same disease. The clinical and molecular features of young patients with CCA have yet to be well characterized. Methods: Retrospective chart review was performed on patients with intrahepatic (ICC) or extrahepatic cholangiocarcinoma (ECC) across 5 institutions. Data on demographics, risk factors, treatments, pathology, and overall survival (OS) were collected. Tumor genotyping results from MGH SNaPShot and Foundation Medicine were analyzed. Log-rank tests and Kaplan-Meier survival curves were used for statistical analysis. Results: Of 567 patients analyzed, 134 (23.6%) were < 50 years old (yo) and 455 (80.2%) had ICC. When assessed for risk factors, younger patients ( < 50yo) were more likely to have primary sclerosing cholangitis (PSC) (p < 0.001) and less likely to have diabetes (p = 0.05), compared to older patients ( ≥ 50yo). Surgical resection rates were similar in younger vs older patients (41.9 vs 42.6%, p = 0.890), but younger patients had larger tumors (median size 7.1 vs 5.3cm p = 0.012). Younger patients were also more likely to receive palliative systemic chemotherapy (p < 0.001) and more lines of therapy (median, 2 vs 1 line, p < 0.001). Frequency of treatment with liver directed therapy did not differ between the two groups. Molecular testing was performed on 222/567 (39.1%) patients of which 84/134 (62.7%) were younger patients and 138/433 (31.9%) were older patients. FGFR aberrations were more common in younger patients versus older patients (17.6 vs. 5.7%, p = 0.002). Targeted therapy was given to 15/84 (17.9%) younger and 28/138 (20.3%) older patients based on results of mutational profiling. Finally, no significant difference was seen in OS between younger and older patients (22.9 vs 22.7 months, p = 0.89). Conclusions: Younger patients with CCA may have different risk factors, tumor biology, and tolerance of systemic therapy compared to older patients. Further study is needed as referral patterns to tertiary care centers and motivation of younger patients to seek tertiary care may impact these results.

Download Full-text

Type 2 diabetes in older patients: an analysis of the DPV and DIVE databases

Therapeutic Advances in Endocrinology and Metabolism ◽

10.1177/2042018820958296 ◽

2020 ◽

Vol 11 ◽

pp. 204201882095829

Author(s):

Gesine van Mark ◽

Sascha R. Tittel ◽

Stefan Sziegoleit ◽

Franz Josef Putz ◽

Mesut Durmaz ◽

...

Keyword(s):

Risk Factors ◽

Type 2 Diabetes ◽

Older Patients ◽

Microvascular Complications ◽

Oldest Old ◽

Age Groups ◽

Young Patients ◽

Severe Hypoglycemia ◽

Old Patients

Background: The clinical profile differs between old and young patients with type 2 diabetes mellitus (T2DM). We explored, based on a large real-world database, patient and disease characteristics and actual treatment patterns by age. Methods: The analysis was based on the DIVE and DPV registries of patients with T2DM. Patients were analyzed by age groups 50–59 (middle-young), 60–69 (young-old), 70–79 (middle-old), 80–89 (old), and 90 years or more (oldest-old). Results: A total of 396,719 patients were analyzed, of which 17.7% were 50–59 years, 27.7% 60–69 years, 34.3% 70–79 years, 18.3% 80–89 years and 2.0% at least 90 years. We found that (a) T2DM in old and oldest-old patients was characterized much less by the presence of metabolic risk factors such as hypertension, obesity, dyslipidemia and smoking than in younger patients; (b) the HbA1c was much lower in oldest-old than in middle-young patients (7.2 ± 1.6% versus 8.0 ± 2.2%; p < 0.001), but it was associated with higher proportions of patients with severe hypoglycemia (7.0 versus 1.6%; p < 0.001); (c) this was potentially associated with the higher and increasing rates of insulin use in older patients (from 17.6% to 37.6%, p < 0.001) and the particular comorbidity profile of these patients, for example, chronic kidney disease (CKD); (d) patients with late diabetes onset had lower HbA1c values, lower bodyweight and less cardiovascular risk factors; (e) patients with a longer diabetes duration had a considerable increase in macrovascular and even more microvascular complications. Conclusion: In very old patients there is a need for frequent careful routine assessment and a tailored pharmacotherapy in which patient safety is much more important than blood-glucose-lowering efficacy.

Download Full-text

The International Classification of Functioning, Disabilities, and Health Categories Necessary for Care Planning for Older Patients with Heart Failure: A Survey of Care Managers in Japan

10.21203/rs.3.rs-653779/v1 ◽

2021 ◽

Author(s):

Shigehito Shiota ◽

Toshiro Kitagawa ◽

Takayuki Hidaka ◽

Naoya Goto ◽

Naoki Mio ◽

...

Keyword(s):

Heart Failure ◽

Medical Care ◽

Information Sharing ◽

Older Patients ◽

Community Dwelling ◽

Medical Professionals ◽

Care Planning ◽

Care Plans ◽

Care Managers ◽

Significant Difference

Abstract Background: Establishing an information-sharing system between medical professionals and welfare/care professionals may help prevent heart failure (HF) in community-dwelling older adults. Therefore, we aimed to identify the ICF categories necessary for care managers to develop care plans for older patients with HF. Methods: A questionnaire was administered to 695 care managers in Hiroshima, Japan, on ICF items necessary for care planning. We compared the care managers according to their specialties (medical and welfare). Furthermore, we created a co-occurrence network using text mining, regarding the elements necessary for collaboration between medical and care professionals. Results: There were 520 valid responses (74.8%). Forty-nine ICF items, including 18 for body functions, one for body structure, 21 for activities and participation, and nine for environmental factors, were classified as "necessary" for making care plans for older people with HF. Medical professionals more frequently answered "necessary" than care professionals regarding the 11 items for body functions and structure and three items for activities and participation (p<0.05). Medical–welfare/care collaboration requires (1) information sharing with related organisations; (2) emergency response; (3) a system of cooperation between medical care and non-medical care; (4) consultation and support for individuals and families with life concerns, (5) management of nutrition, exercise, blood pressure and other factors, (6) guidelines for consultation and hospitalisation when physical conditions worsen.Conclusions: Our findings showed that 49 ICF categories were required by care managers for care planning, and there was a significant difference in perception between medical and welfare/care professionals.

Download Full-text

The International Classification of Functioning, Disabilities, and Health categories rated as necessary for care planning for older patients with heart failure: a survey of care managers in Japan

BMC Geriatrics ◽

10.1186/s12877-021-02647-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Shigehito Shiota ◽

Toshiro Kitagawa ◽

Takayuki Hidaka ◽

Naoya Goto ◽

Naoki Mio ◽

...

Keyword(s):

Heart Failure ◽

Medical Care ◽

Information Sharing ◽

Older Patients ◽

Community Dwelling ◽

Medical Professionals ◽

Care Planning ◽

Care Plans ◽

Care Managers ◽

Significant Difference

Abstract Background Establishing an information-sharing system between medical professionals and welfare/care professionals may help prevent heart failure (HF) exacerbations in community-dwelling older adults. Therefore, we aimed to identify the ICF categories necessary for care managers to develop care plans for older patients with HF. Methods A questionnaire was administered to 695 care managers in Hiroshima, Japan, on ICF items necessary for care planning. We compared the care managers according to their specialties (medical qualifications and welfare or care qualifications). Furthermore, we created a co-occurrence network using text mining, regarding the elements necessary for collaboration between medical and care professionals. Results There were 520 valid responses (74.8%). Forty-nine ICF items, including 18 for body functions, one for body structure, 21 for activities and participation, and nine for environmental factors, were classified as “necessary” for making care plans for older people with HF. Medical professionals more frequently answered “necessary” than care professionals regarding the 11 items for body functions and structure and three items for activities and participation (p < 0.05). Medical–welfare/care collaboration requires (1) information sharing with related organisations; (2) emergency response; (3) a system of cooperation between medical care and non-medical care; (4) consultation and support for individuals and families with life concerns, (5) management of nutrition, exercise, blood pressure and other factors, (6) guidelines for consultation and hospitalisation when physical conditions worsen. Conclusions Our findings showed that 49 ICF categories were required by care managers for care planning, and there was a significant difference in perception between medical and welfare or care qualifications qualifications.

Download Full-text

Is ESR Important for Predicting Post-ERCP Pancreatitis?

Clinical Medicine Insights Gastroenterology ◽

10.4137/cgast.s18938 ◽

2015 ◽

Vol 8 ◽

pp. CGast.S18938

Author(s):

Amir Houshang Mohammad Alizadeh ◽

Esmaeil Shamsi Afzali ◽

Catherine Behzad ◽

Mirhadi Mousavi ◽

Dariush Mirsattari ◽

...

Keyword(s):

Risk Factors ◽

Risk Model ◽

Significant Risk ◽

Female Gender ◽

The Elderly ◽

Tertiary Center ◽

Significant Difference ◽

Close Observation ◽

Potential Risk Factors ◽

History Of

Background Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP). Aim To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population. Materials and Methods Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria. Results Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method. Conclusions Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.

Download Full-text

Biological Therapy Survivability in Children with Psoriasis: Cohort Study

Вопросы современной педиатрии ◽

10.15690/vsp.v20i5.2323 ◽

2021 ◽

Vol 20 (5) ◽

pp. 451-458

Author(s):

Roman A. Ivanov ◽

Nikolay N. Murashkin

Keyword(s):

Risk Factors ◽

Biological Therapy ◽

Practical Importance ◽

Significant Risk ◽

High Body Mass Index ◽

Genetically Engineered ◽

Rank Test ◽

Old Patients ◽

Adalimumab Therapy ◽

Significant Difference

Background. There is a need to study genetically engineered biological therapy (GEBT) survivability and identify any significant risk factors for its ineffectiveness due to the increasing prevalence of psoriasis among children and the spreading GEBT administration. Such information has practical importance, it can be used to predict treatment outcomes and to develop individual therapeutic approaches. Objective. Our aim was to study biological therapy survivability and to identify risk factors for its ineffectiveness in children with moderate and severe forms of psoriasis. Methods. The study included data from 4-17 years old patients with moderate and severe forms of psoriasis vulgaris. Groups were formed according to the biological medication used. Statistical analyses were performed via SPSS Statistics. Biologic therapy survivability was determined via Kaplan-Meier method with the assessment of differences significance using log-rank test. Significant factors affecting cumulative risk growth were determined by Cox multiple regression method. Results. The study analysed data from the medical records of 105 patients. The average survivability of ustekinumab was 28.7 months, etanercept — 23.1, and adalimumab — 18.4. In the group of bio-naive patients, the survivability was higher: 30.8 months for ustekinumab and 24.4 months for ethanercept, while in the group of patients administrated previously with biological medication the survivability was 24.2 and 8.3 months, respectively. No statistically significant difference was revealed for adalimumab therapy. Significant risk factors for therapy ineffectiveness were the following: high body mass index (BMI) at the time of GEBT onset, aggravated family history, and prior use of one or several subsequent GEBT lines. Conclusion. The therapy survivability is inevitably declining over time. The best results were noted in bio-naive patients treated with ustekinumab that allows us to recommend it as the first-line drug in children with severe and moderate forms of psoriasis.

Download Full-text

Epidemiological characteristics of subsyndromal depression in late life

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867419879242 ◽

2019 ◽

Vol 54 (2) ◽

pp. 150-158

Author(s):

Dae Jong Oh ◽

Ji Won Han ◽

Tae Hui Kim ◽

Kyung Phil Kwak ◽

Bong Jo Kim ◽

...

Keyword(s):

Risk Factors ◽

Confidence Interval ◽

Low Socioeconomic Status ◽

Depressive Disorders ◽

Late Life ◽

Female Gender ◽

Community Dwelling ◽

Poor Sleep ◽

Subsyndromal Depression ◽

Epidemiological Characteristics

Objectives: Subsyndromal depression is prevalent and associated with poor outcomes in late life, but its epidemiological characteristics have barely been investigated. The aim of this prospective cohort study is to compare the prevalence, incidence and risk factors of subsyndromal depression with those of syndromal depression including major and minor depressive disorders in community-dwelling elderly individuals. Methods: In a nationwide community-based study of randomly sampled Korean elderly population aged 60 years or older ( N = 6640), depression was assessed with standardized diagnostic interviews. At baseline and at 2-year and 4-year follow-ups, the authors diagnosed subsyndromal depression by the operational criteria and syndromal depression by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria. Multivariate logistic regression analyses were conducted to identify the risk factors for incident depression. Results: The age- and gender-adjusted prevalence rate of subsyndromal depression was 9.24% (95% confidence interval = [8.54, 9.93]), which was 2.4-fold higher than that of syndromal depression. The incidence rate of subsyndromal depression was 21.70 per 1000 person-years (95% confidence interval = [19.29, 24.12]), which was fivefold higher than that of syndromal depression. The prevalence to incidence ratio of subsyndromal depression was about half that of syndromal depression. The risk for subsyndromal depression was associated with female gender, low socioeconomic status, poor social support and poor sleep quality, while that of syndromal depression was associated with old age and less exercise. Conclusion: Subsyndromal depression should be validated as a clinical diagnostic entity, at least in late life, since it has epidemiological characteristics different from those of syndromal depression.

Download Full-text