Depression Predicts Functional Outcome in Geriatric Inpatient Rehabilitation

  • Author Footnotes
    ∗ Shahab and Nicolici contributed equally to this work.
    Saba Shahab
    ∗ Shahab and Nicolici contributed equally to this work.
    Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
    Search for articles by this author
  • Author Footnotes
    ∗ Shahab and Nicolici contributed equally to this work.
    Diana-Felicia Nicolici
    ∗ Shahab and Nicolici contributed equally to this work.
    Division of Geriatric Psychiatry, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
    Search for articles by this author
  • Alva Tang
    Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Paul Katz
    Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, United States
    Search for articles by this author
  • Linda Mah
    Corresponding author Linda Mah, MD, MHS, FRCPC, Rotman Research Institute, Baycrest Division of Geriatric Psychiatry, University of Toronto Faculty of Medicine, BHC 738, 3560 Bathurst St., Toronto, ON M6A 2E1, Canada.
    Division of Geriatric Psychiatry, Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Rotman Research Institute, Baycrest, Toronto, ON, Canada

    Baycrest Health Sciences Centre, Toronto, ON, Canada
    Search for articles by this author
  • Author Footnotes
    ∗ Shahab and Nicolici contributed equally to this work.
Published:August 13, 2016DOI:



      To evaluate the effect of depression on functional recovery in geriatric patients who have completed an inpatient rehabilitation program.


      Prospective cohort study.


      Inpatient rehabilitation unit of a university-affiliated geriatric hospital.


      Convenience sample of patients (N=65; mean age, 81.6y; 25 men) admitted to rehabilitation over a 10-month period. Patients >60 years of age who were proficient in English and capable of providing informed consent were eligible to participate in the study.


      Depression was assessed using both the Geriatric Depression Scale-short form (GDS-15) and the Patient Health Questionnaire (9-item screen for depression) (PHQ-9). Measures of well-established predictors of rehabilitation outcome, which may interact with depression, were also obtained, and multiple regression linear modeling was used to evaluate the relation between depression and functional outcome over and above the contribution of these other factors.

      Main Outcome Measure

      FIM (Functional Independence Measure) at discharge from the rehabilitation program.


      Depression, as assessed by the GDS-15, but not the PHQ-9, was predictive of functional outcome (standardized beta=−.151, P=.030) after controlling for other significant predictors, which included baseline disability, pain, cognition, and educational level. Participation in recreational, but not physio- or occupational, therapy additionally contributed to a small amount of variance in the functional outcome.


      Our findings suggest that self-report of depression is an independent predictor of functional outcome in high-tolerance, short-duration geriatric rehabilitation. Routine assessment of depressive symptoms in older adults using an instrument (eg, GDS-15) may help identify those at risk for poorer outcomes in rehabilitation.


      List of abbreviations:

      GDS-15 (Geriatric Depression Scale-short form), MoCA (Montreal Cognitive Assessment), OT (occupational therapy), PHQ-9 (Patient Health Questionnaire (9-item screen for depression)), PT (physiotherapy), RT (recreational therapy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Herrmann N.
        • Black S.E.
        • Lawrence J.
        • Szekely C.
        • Szalai J.P.
        The Sunnybrook Stroke Study: a prospective study of depressive symptoms and functional outcome.
        Stroke. 1998; 29: 618-624
        • Holmes J.
        • House A.
        Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study.
        Psychol Med. 2000; 30: 921-929
        • Arinzon Z.
        • Shabat S.
        • Peisakh A.
        • Gepstein R.
        • Berner Y.N.
        Gender differences influence the outcome of geriatric rehabilitation following hip fracture.
        Arch Gerontol Geriatr. 2010; 50: 86-91
        • Morghen S.
        • Bellelli G.
        • Manuele S.
        • Guerini F.
        • Frisoni G.B.
        • Trabucchi M.
        Moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture.
        Int J Geriatr Psychiatry. 2011; 26: 1136-1143
        • Nanna M.J.
        • Lichtenberg P.A.
        • Buda-Abela M.
        • Barth J.T.
        The role of cognition and depression in predicting functional outcome in geriatric medical rehabilitation patients.
        J Appl Gerontol. 1997; 16: 120-132
        • MacNeill S.E.
        • Lichtenberg P.A.
        Predictors for functional outcome in older rehabilitation patients.
        Rehabil Psychol. 1998; 43: 246-257
        • Lenze E.J.
        • Munin M.C.
        • Dew M.A.
        • et al.
        Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.
        Int J Geriatr Psychiatry. 2004; 19: 472-478
        • Gillen R.
        • Tennen H.
        • McKee T.E.
        • Gernert-Dott P.
        • Affleck G.
        Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients.
        Arch Phys Med Rehabil. 2001; 82: 1645-1649
        • Mast B.T.
        • Azar A.R.
        • MacNeill S.E.
        • Lichtenberg P.A.
        Depression and activities of daily living predict rehospitalization within 6 months of discharge from geriatric rehabilitation.
        Rehabil Psychol. 2004; 49: 219-223
        • Patrick L.
        Depressive symptoms and treatment outcome in geriatric rehabilitation: a three-point perspective.
        Top Geriatr Rehabil. 1997; 13: 42-49
        • Cully J.A.
        • Gfeller J.D.
        • Heise R.A.
        • Ross M.J.
        • Teal C.R.
        • Kunik M.E.
        Geriatric depression, medical diagnosis, and functional recovery during acute rehabilitation.
        Arch Phys Med Rehabil. 2005; 86: 2256-2260
        • Patrick L.
        • Knoefel F.
        • Gaskowski P.
        • Rexroth D.
        Medical comorbidity and rehabilitation efficiency in geriatric inpatients.
        J Am Geriatr Soc. 2001; 49: 1471-1477
        • Lieberman D.
        • Friger M.
        • Lieberman D.
        Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients.
        Arch Phys Med Rehabil. 2006; 87: 167-171
        • Hama S.
        • Yamashita H.
        • Shigenobu M.
        • et al.
        Depression or apathy and functional recovery after stroke.
        Int J Geriatr Psychiatry. 2007; 22: 1046-1051
        • Paolucci S.
        • Antonucci G.
        • Pratesi L.
        • Traballesi M.
        • Grasso M.G.
        • Lubich S.
        Poststroke depression and its role in rehabilitation of inpatients.
        Arch Phys Med Rehabil. 1999; 80: 985-990
        • Resnick B.
        • Daly M.P.
        Predictors of functional ability in geriatric rehabilitation patients.
        Rehabil Nurs. 1998; 23: 21-29
        • Seematter-Bagnoud L.
        • Lecureux E.
        • Rochat S.
        • Monod S.
        • Lenoble-Hoskovec C.
        • Bula C.J.
        Predictors of functional recovery in patients admitted to geriatric postacute rehabilitation.
        Arch Phys Med Rehabil. 2013; 94: 2373-2380
        • Denkinger M.D.
        • Igl W.
        • Lukas A.
        • et al.
        Relationship between fear of falling and outcomes of an inpatient geriatric rehabilitation population–fear of the fear of falling.
        J Am Geriatr Soc. 2010; 58: 664-673
        • Gluyas C.
        • Lum C.
        • Chong S.Y.
        • Borg C.
        • Haines T.P.
        Prevalence and influence of psychiatric comorbidity on rehabilitation outcome for older hospital inpatients.
        Int Psychogeriatr. 2011; 23: 1502-1514
        • Torpilliesi T.
        • Bellelli G.
        • Morghen S.
        • et al.
        Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery.
        J Am Med Dir Assoc. 2012; 13: 81.e1-81.e5
        • Hershkovitz A.
        • Kalandariov Z.
        • Hermush V.
        • Weiss R.
        • Brill S.
        Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture.
        Arch Phys Med Rehabil. 2007; 88: 916-921
        • Yochim B.P.
        • Lequerica A.
        • MacNeill S.E.
        • Lichtenberg P.A.
        Cognitive initiation and depression as predictors of future instrumental activities of daily living among older medical rehabilitation patients.
        J Clin Exp Neuropsychol. 2008; 30: 236-244
        • Landi F.
        • Bernabei R.
        • Russo A.
        • et al.
        Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital.
        J Am Geriatr Soc. 2002; 50: 679-684
        • Colombo M.
        • Guaita A.
        • Cottino M.
        • Previderé G.
        • Ferrari D.
        • Vitali S.
        The impact of cognitive impairment on the rehabilitation process in geriatrics.
        Arch Gerontol Geriatr Suppl. 2004; : 85-92
        • Toglia J.
        • Fitzgerald K.A.
        • O'Dell M.W.
        • Mastrogiovanni A.R.
        • Lin C.D.
        The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome.
        Arch Phys Med Rehabil. 2011; 92: 792-798
        • LaBuda J.
        • Lichtenberg P.
        The role of cognition, depression, and awareness of deficit in predicting geriatric rehabilitation patients' IADL performance.
        Clin Neuropsychol. 1999; 13: 258-267
        • Luk J.K.
        • Chiu P.K.
        • Chu L.W.
        Rehabilitation of older Chinese patients with different cognitive functions: how do they differ in outcome?.
        Arch Phys Med Rehabil. 2008; 89: 1714-1719
        • Alexopoulos G.S.
        • Meyers B.S.
        • Young R.C.
        • et al.
        Executive dysfunction and long-term outcomes of geriatric depression.
        Arch Gen Psychiatry. 2000; 57: 285-290
        • Skidmore E.R.
        • Whyte E.M.
        • Holm M.B.
        • et al.
        Cognitive and affective predictors of rehabilitation participation after stroke.
        Arch Phys Med Rehabil. 2010; 91: 203-207
        • Williams C.S.
        • Tinetti M.E.
        • Kasl S.V.
        • Peduzzi P.N.
        The role of pain in the recovery of instrumental and social functioning after hip fracture.
        J Aging Health. 2006; 18: 743-762
        • Morrison R.S.
        • Magaziner J.
        • McLaughlin M.A.
        • et al.
        The impact of post-operative pain on outcomes following hip fracture.
        Pain. 2003; 103: 303-311
        • Denti L.
        • Agosti M.
        • Franceschini M.
        Outcome predictors of rehabilitation for first stroke in the elderly.
        Eur J Phys Rehabil Med. 2008; 44: 3-11
        • Glass T.A.
        • Maddox G.L.
        The quality and quantity of social support: stroke recovery as psycho-social transition.
        Soc Sci Med. 1992; 34: 1249-1261
        • Colantonio A.
        • Kasl S.V.
        • Ostfeld A.M.
        • Berkman L.F.
        Psychosocial predictors of stroke outcomes in an elderly population.
        J Gerontol. 1993; 48: S261-S268
        • Petrella R.J.
        • Payne M.
        • Myers A.
        • Overend T.
        • Chesworth B.
        Physical function and fear of falling after hip fracture rehabilitation in the elderly.
        Am J Phys Med Rehabil. 2000; 79: 154-160
        • GTA REHAB Network
        Inpatient geriatric rehab triage guideline.
        2008 (Available at: Accessed May 24, 2016)
        • Linacre J.M.
        • Heinemann A.W.
        • Wright B.D.
        • Granger C.V.
        • Hamilton B.B.
        The structure and stability of the Functional Independence Measure.
        Arch Phys Med Rehabil. 1994; 75: 127-132
        • Miller E.L.
        • Murray L.
        • Richards L.
        • et al.
        Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association.
        Stroke. 2010; 41: 2402-2448
        • Duncan P.W.
        • Zorowitz R.
        • Bates B.
        • et al.
        Management of adult stroke rehabilitation care: a clinical practice guideline.
        Stroke. 2005; 36: e100-e143
        • Dawson A.
        • Knox J.
        • McClure A.
        • Foley N.
        • Teasell R.
        Stroke rehabilitation.
        in: Lindsay M.P. Gubitz G. Bayley M. Canadian best practice recommendations for stroke care. 4th ed. Heart & Stroke Foundation, Ottawa (Canada)2013
        • Lenze E.J.
        • Munin M.C.
        • Quear T.
        • et al.
        The Pittsburgh Rehabilitation Participation Scale: reliability and validity of a clinician-rated measure of participation in acute rehabilitation.
        Arch Phys Med Rehabil. 2004; 85: 380-384
        • Yesavage J.A.
        • Brink T.L.
        • Rose T.L.
        • et al.
        Development and validation of a Geriatric Depression Screening Scale: a preliminary report.
        J Psychiatr Res. 1983; 17: 37-49
        • Yang S.Y.
        • Kong K.H.
        Level and predictors of participation in patients with stroke undergoing inpatient rehabilitation.
        Singapore Med J. 2013; 54: 564-568
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Meader N.
        • Moe-Byrne T.
        • Llewellyn A.
        • Mitchell A.J.
        Screening for poststroke major depression: a meta-analysis of diagnostic validity studies.
        J Neurol Neurosurg Psychiatry. 2014; 85: 198-206
        • Williams L.S.
        • Brizendine E.J.
        • Plue L.
        • et al.
        Performance of the PHQ-9 as a screening tool for depression after stroke.
        Stroke. 2005; 36: 635-638
        • Marin R.S.
        • Biedrzycki R.C.
        • Firinciogullari S.
        Reliability and validity of the Apathy Evaluation Scale.
        Psychiatry Res. 1991; 38: 143-162
        • Spielberger C.D.
        • Gorsuch R.L.
        • Lushene R.E.
        State-trait anxiety inventory.
        Consulting Psychologists Press, Palo Alto1970
        • Tinetti M.E.
        • Richman D.
        • Powell L.
        Falls efficacy as a measure of fear of falling.
        J Gerontol. 1990; 45: P239-P243
        • Nasreddine Z.S.
        • Phillips N.A.
        • Bedirian V.
        • et al.
        The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
        J Am Geriatr Soc. 2005; 53: 695-699
        • Sweet L.
        • Van Adel M.
        • Metcalf V.
        • et al.
        The Montreal Cognitive Assessment (MoCA) in geriatric rehabilitation: psychometric properties and association with rehabilitation outcomes.
        Int Psychogeriatr. 2011; 23: 1582-1591
        • Parmelee P.A.
        • Thuras P.D.
        • Katz I.R.
        • Lawton M.P.
        Validation of the Cumulative Illness Rating Scale in a geriatric residential population.
        J Am Geriatr Soc. 1995; 43: 130-137
        • Ferreira-Valente M.A.
        • Pais-Ribeiro J.L.
        • Jensen M.P.
        Validity of four pain intensity rating scales.
        Pain. 2011; 152: 2399-2404
        • Fillenbaum G.G.
        Multidimensional functional assessment of older adults: the Duke Older Americans Resources and Services procedures.
        Psychology Press, Hillsdale2013
        • Johnson M.F.
        • Kramer A.M.
        • Lin M.K.
        • Kowalsky J.C.
        • Steiner J.F.
        Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke.
        J Am Geriatr Soc. 2000; 48: 1389-1397
        • Vittinghoff E.
        • Glidden D.V.
        • Shiboski S.C.
        • McCulloch C.E.
        Regression methods in biostatistics: linear, logistic, survival, and repeated measures models.
        2nd ed. Springer Science & Business Media, New York2011
        • Lenze E.J.
        • Munin M.C.
        • Quear T.
        • et al.
        Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay.
        Arch Phys Med Rehabil. 2004; 85: 1599-1601
        • Stiles P.G.
        • McGarrahan J.F.
        The Geriatric Depression Scale: a comprehensive review.
        Journal of Clinical Geropsychology. 1998; 4: 89-110
        • Lenze E.J.
        • Rogers J.C.
        • Martire L.M.
        • et al.
        The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research.
        Am J Geriatr Psychiatry. 2001; 9: 113-135
        • Williamson G.M.
        • Schulz R.
        Pain, activity restriction, and symptoms of depression among community-residing elderly adults.
        J Gerontol. 1992; 47: P367-P372
        • Raskin J.
        • Wiltse C.G.
        • Siegal A.
        • et al.
        Efficacy of duloxetine on cognition, depression, and pain in elderly patients with major depressive disorder: an 8-week, double-blind, placebo-controlled trial.
        Am J Psychiatry. 2007; 164: 900-909
        • Montgomery S.
        • Chatamra K.
        • Pauer L.
        • Whalen E.
        • Baldinetti F.
        Efficacy and safety of pregabalin in elderly people with generalised anxiety disorder.
        Br J Psychiatry. 2008; 193: 389-394
        • Hayes A.F.
        Introduction to mediation, moderation, and conditional process analysis: a regression-based approach.
        Guilford Press, New York2013
        • Williams R.
        • Barrett J.
        • Vercoe H.
        • Maahs-Fladung C.
        • Loy D.
        • Skalko T.
        Effects of recreational therapy on functional independence of people recovering from stroke.
        Therapeutic Recreation Journal. 2007; 41: 326-332
        • Cahow C.
        • Gassaway J.
        • Rider C.
        • et al.
        Relationship of therapeutic recreation inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.
        J Spinal Cord Med. 2012; 35: 547-564
        • Lee Y.
        • Yang H.
        A review of therapeutic recreation outcomes in physical medicine and rehabilitation between 1991-2000.
        Annual in Therapeutic Recreation. 2000; 9: 21-34
        • Johnson C.D.
        Therapeutic recreation treats depression in the elderly.
        Home Health Care Serv Q. 2000; 18: 79-90
        • Eskes G.
        • Salter K.
        Mood and cognition in stroke.
        in: Lindsay M.P. Gubitz G. Bayley M. Canadian best practice recommendations for stroke care. 4th ed. Heart & Stroke Foundation, Ottawa (Canada)2013
        • Almeida O.P.
        • Almeida S.A.
        Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV.
        Int J Geriatr Psychiatry. 1999; 14: 858-865
        • Van Marwijk H.
        • Wallace P.
        • de Bock G.H.
        • Hermans J.
        • Kaptein A.A.
        • Mulder J.D.
        Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale.
        Br J Gen Pract. 1995; 45: 195-199
        • Mitchell A.J.
        • Bird V.
        • Rizzo M.
        • Meader N.
        Diagnostic validity and added value of the Geriatric Depression Scale for depression in primary care: a meta-analysis of GDS30 and GDS15.
        J Affect Disord. 2010; 125: 10-17