Community-based Rehabilitation Management for Patients With Remitted Geriatric Depression

Study Overview
=================
Brief Summary
-----------------
This study intends to take patients with RGD as objects. Further construct a community-based rehabilitation management (CBRM) program with drug treatment, rehabilitation measures of education, psychology and exercise as its core content on the basis of evidence-based practice approach. Based on the cost-utility analysis of health economics, the health and economic benefits of the CBRM program will be evaluated, and a theoretical reference will be provided for community health institutions to carry out whole-course rehabilitation management practice and health policy formulation.

Detailed Description
-----------------
Based on the background of population aging, the prevalence of Late life depression tends to increase, and the recurrence rate after antidepressants treatment is still as high as 35%-57%, and the disease course tends to be chronic. Therefore, the formulation and implementation of prevention and control programs have become a significant part of the government's work plan. Physical frailty symptoms such as loss of daily activities and weakness are common in patients with remitted geriatric depression (RGD), and cognitive impairment is also considered to be an independent persistent symptom of RGD patients, which are related to the fluctuation and recurrence of depressive symptoms in elderly patients. Physical cognitive decline syndrome (PCDS) can comprehensively assess the physical frailty symptoms and the degree of cognitive impairment of the elderly, and effectively predict the course of the disease and the trend of healthy development. However, studies applied to the field of emotional disorder have not been retrieved. Therefore, this study intends to take patients with RGD as objects to investigate the prevalence of PCDS, build a risk prediction model and reveal it is warning mechanisms. That is, after determinning the basis of risk factors affecting the occurence of PCDS in RGD patients, we will carry out the formulation, implementation and evaluation of the follow-up CBRM program.

Official Title
-----------------
Construction and Evaluation of Risk Early Warning Mechanism of Physical Cognitive Decline Syndrome and Community-based Rehabilitation Management Program for Patients With Remitted Geriatric Depression

Conditions
-----------------
Geriatric Depression

Intervention / Treatment
-----------------
* Combination Product: CBRM (community-based rehabilitation management)
* Combination Product: TAR(treatment as routine)


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: aged 60 years old or above at the time of enrollment; meet the diagnostic criteria for MDD without psychotic features according to DSM-5, and depressive symptoms have been improved and remained stable for at least 2 months after treatment with SSRIs; the total score of HAMD-17 is less than 7 at the time of enrollment; meet the diagnostic criteria for physio-cognitive decline: 1) the total score of ADL and IADL was less than 26; 2)cognitve decline: first, subjects with severe impairment of cognitive function will be excluded (years of education ≥ 6, MMSE scores <24；years of education <6 years, MMSE total score <14). After completing a neuropsychological task, cogintive declined will be confirmed when any aspects of cognitve function is 1.5 standard deviations lower than that of normal elderly; 3) the grip strength is weakened, and the domaint hand grip strength is < 28kg for males or <18kg for females; 4)slow step speed, that is, in a space of length >10 meters, the subjects walks 6 meters from the starting point at a normal and uniform pace, and the pace is <1m/s. comprehension, reading and writing skills to complete the measurements or complete them with assistance of the researchers with obstacles; voluntary participation and signed informed consent. Exclusion Criteria: meet the diagnostic of schizophrenia, bipolar disorder, dementia; comorbidity of physical diseases, such ascardiovascular and cerebrovascular diseases, rheumatoid arthritis, stroke and malignant tumors; history of alcohol or drug dependence; severe deformity of spine and limbs; complete or partial dependence on caregivers for daily life, such as long-term bedridden, wheelchair assisted; have received physical therapy or psychological treatment in the past three months; currently participating in other clinical research.

Ages Eligible for Study
-----------------
Minimum Age: 60 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: case group,<br>Patients in case group will be treated with CBRM program | Combination Product: CBRM (community-based rehabilitation management)<br>* The case group patients will undergo drug treatment (Selective Serotonin Reuptake Inhibitors), health education, cognitive-motor dual task training, cognitive-training.<br>|
| Other: control group<br>the control group patients will be treated routinely as usual. | Combination Product: TAR(treatment as routine)<br>* Patients in control group will be treated rountinely which includes drug treatment (SSRIs) and traditional health education.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| depressive symptoms | The Hamilton Depressive Scale (HAMD-17) which consists of 17 items will be employed to screen for depressive symptoms and evaluate the mental status and severity of depressive symptoms. Scores were calculated by totaling the responses, which can be divided into four types (Health): normal/not depressed (0-7 points), mild/subthreshold (8-13), moderate/mild (14-18), severe/moderate (19-22), and severe/very severe (>23). | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| cognitive and intellectual function | Mini-mental State Examination (MMSE), as a simple screening tool for cognitive and intellectual function decline in the elderly with a total score of 30. The results of this test is closely related to the level of education, and the normal cutoff is defined as, illiterates >17 points, primary schools >20 points, and middle schools and above >24 points. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| changes of the handgrip strength | The grip strength of a man's dominant hand < 28kg or a woman < 18kg is considered to have weak grip strength. The grip strength increased compared with the baseline period, that is, the subjects' physiological function tended to recover; Instead, physiological function tends to decline. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| changes of the gait speed | The time it takes for the subject to walk 6 meters at normal pace from the starting point without slowing down, with a threshold for gait deceleration set to < 1m/s. The gait speed increased compared with the baseline period, that is, the subjects' physiological function tended to recover; Instead, physiological function tends to decline. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| quality of life of the elderly | The WHO Quality of Life Scale (WHOQOL-BREF Chinese version) includes four dimensions, such as physiological, psychological, social relations and environment, covering 26 items related to quality of life. This scale is widely used in patients with cancer, chronic diseases and the elderly. Each item is scored according to Likert 1-5. The higher the total score, the better the quality of life. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| sleep quality | The Pittsburgh Sleep Quality Index (PSQI) will be used to measure the subjects' sleep treatment. The total score range is 0-21 points. It is generally believed that the total score of PSQI ≤7 indicates that the sleep quality is fair, while the total score of > 7 indicates poor sleep quality, and the higher the total score of PSQI scale, the worse the sleep quality of the subjects. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| the balance ability of the elderly | The Short Physical Performance Battery test (SPPB) will be used to assess the balance ability of the elderly, including: (1) Sit-stand test for 5 times. The shorter the time, the better the balance ability. (2) Timing test of 2.44m short distance walking. The shorter the time, the better the balance ability. (3) Balance function test, the longer the time, the better the balance ability. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| activity of daily living | Activity of Daily Living (ADL) whose total score is ranging from 14 to 56. Total score ≤26, basically normal; > 26 indicates different degree of functional decline; Score of 2 or more individual scores > 3 points, significant dysfunction. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| the word memory function | Chinese Version Verbal Learning Test (CVVLT) will be used to evaluate the word memory function of the elderly. Researchers repeated 9 words at a rate of one word per second for four times in a fixed sequence. The elderly will be asked to recall the words 30 seconds later and again 10 minutes later. In this study, only the results of the delayed free memory test at the 10th minute will be included in the later statistics. The more vocabularies remembered, the better the cognitive function. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| language functions | Boston Naming Test (BNT-30) will be used to evaluate language functions of the elderly. During the test, if the subject could make a spontaneous naming error within 20 seconds, the semantic cue will be used to prompt the subject; if the subject could not answer within 20 seconds, the subject will be given a recognition choice including three choices. The evaluation indexes include spontaneous correct naming number, prompt correct naming percentage and selection of correct naming percentage. The higher the score, the better the cognitive function. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| verbal functions | Verbal Fluency Test (VFT) will be used to assess the verbal functions of the elderly. Subjects are required to say as many animal names as possible within one minute. The test involves multiple cognitive functions such as memory, language and execution, which is the most important tool for testing subjects' language fluency. The more words they can say, the better their cognitive function. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| visuospatial structure ability and visual memory of the elderly | Rey-Osterrieth Complex Figure Test (ROCFT) will be used to asses the visuospatial structure ability and visual memory of the elderly. During the test, the elderly will be asked to copy complex images. Researchers record the copying time and remove the cards immediately after the copying completed. After 3 minutes and 30 minutes, the subjects will be asked to re-draw according to the recall, and the researchers record the duration of the instantaneous recall. Each drawing should take no more than 10 minutes. Reference standards will used to score the images of copying, instantaneous meeting and delayed recall respectively, with a total score of 36 points. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| working memory portion of the executive function | Digital Backward (DB) will be used to evaluate the working memory portion of the executive function. The elderly will be asked to read a sequence of numbers at a rate of one number per second and asked to immediately repeat the sequence in reverse order. The number of numbers in the last sequence that the subject can recite correctly is the score of the DB test. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 
| the executive ability and the visuospatial ability | Clock Drawing Test (CDT) will be used to evaluate the executive ability and the visuospatial ability. Subjects will be asked to draw the face of a clock and write all the numbers. The hour and minute hands point to 11:10. The clock face is complete (0-2 points), the number is complete and sequence (0-4 points), and the pointer is complete and position (0-4 points). The higher the total score is, the better the cognitive function is. | This variable will be measured at 0 (baseline) and after 3, 6 months post-intervention. | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Remitted geriatric depression, Physio-cognitive decline syndrome, risk early warning mechanism, community-based rehabilitation management