Older adults in North America use emergency departments (EDs) at a higher rate than younger adults [1–6]. Previous studies also found that a significant proportion of older adults released from an ED make return visits and return frequently [7, 8]. Common diagnoses among older ED patients included injuries caused by falls; acute cerebrovascular accidents; infections (including pneumonia, bronchitis, and urinary tract infections), abdominal disorders, and dehydration [1, 3]. Chronic illnesses—especially cardiac, respiratory, and diabetic diseases—and high levels of comorbidities, including cognitive impairment and depression, and disabilities are significant predictors of ED visits among older adults [1–4, 7–13]. In addition to these clinical characteristics, being Black, having a low income and Medicaid coverage, being uninsured, and/or not having a primary care physician (PCP) were associated with a higher level of ED visits [4, 14]. However, compared to younger ones, older ED patients more often had a PCP and were referred to the ED by their PCP .
Compared to their nondepressed peers, depressed older adults tend to use both ambulatory and inpatient healthcare services at a significantly higher rate even after adjusting for chronic medical illness, and their high rates of ED visits and return visits have been well documented [7, 9, 11, 15–18]. Depression in older adults especially with chronic medical conditions can result in increased numbers of ED visits because depression (1) tends to amplify both symptoms of the physical illness and physical symptoms, including pain and discomfort, associated with other body organ systems; (2) has been shown to adversely impact self-management/self-care of chronic illness by its adverse effect on memory, energy, sense of self-efficacy, and adherence to medication, diet, and exercise regimens; and (3) adversely affects satisfaction with care and may add a degree of urgency to the pursuit of help [19, 20]. Increased severity of medical illness could also lead to increased symptoms of depression, and untreated depression or worsening depressive symptoms may mimic or exacerbate the somatic symptoms associated with other chronic medical conditions . Conversely, treated depression or reduced depressive symptoms may contribute to positive health perceptions and a decrease in ED visits.
Despite the high volume of extant research on depressed older adults’ ED visits, few studies examined the longitudinal relationship between depressive symptoms and the frequency of ED visits. The primary aim of the present study was to examine (1) whether depressive symptom severity was associated with the frequency of ED visits at two different points of time among low-income, depressed homebound older adults aged 50 years and older; and (2) whether changes in depressive symptom severity overtime was associated with the changes in the frequency of ED visits and return visits. The older adults’ self-reported reasons for their ED visits were also presented. The study subjects were residents of central Texas in the United States who participated in a randomized controlled trial (RCT) of a short-term psychotherapy—telehealth-delivered or in-person problem-solving therapy (PST) compared to telephone support call—for low-income homebound older adults with moderately severe or severe depressive symptoms at baseline. The longitudinal data on the changes, or lack thereof, in the study subjects’ depressive symptoms and ED visits during the study period offered a great opportunity to examine longitudinal relationship between depressive symptoms and the frequency of ED visits among these older adults who were largely underrepresented in previous research on older adults’ ED use.
According to the 2011 United States census data, of 40 million non-institutionalized adults age 65 years and older, 23.5% (9.2 million) had ambulatory disability/activity limitation and about 10% were considered homebound [21–23]. The rates of major depression and clinically significant depressive symptoms have been found to be twice as high in homebound older adults as in their age peers without mobility impairment [24–27]. Homebound older adults, often suffering from multiple chronic illnesses and depression, are frequent users of intensive and costly healthcare services including rapidly increasing home healthcare services in the United States [23, 28]. Low-income, depressed homebound older adults are especially likely to be frequent users of EDs, given their precarious physical and functional health conditions comorbid with depression and other multiple life stressors associated with lack of financial resources. These older adults tend to be socially isolated and have difficulty managing their physical and mental health conditions due to many other competing life demands (e.g., housing issues, financial worries, family relationship issues) and, oftentimes, lack of information and knowledge needed for treatment adherence and self-management of their chronic diseases [29, 30].
Employing Andersen’s behavioral model of health services use  as the conceptual framework, the study hypotheses were as follows: (H1) higher depressive symptoms at baseline would be associated with a higher frequency of ED visits during the six months prior to baseline; (H2) higher depressive symptoms at 24-week follow-up would be associated with a higher frequency of ED visits during the 24 weeks after baseline; and (H3) reduced depressive symptoms 24 weeks after baseline would be significantly associated with a lower frequency of ED visits during that period, controlling for baseline number of ED visits and predisposing, enabling, and other need factors.