Depression in a long-term care facility: clinical features and discordance between nursing assessment and patient interviews

Discrepancies Between Community-Dwelling Individuals with Dementia and Their Proxies in Completing the Cornell Scale for Depression in Dementia: A Secondary Data Analysis

Background

Depressive symptoms are common in people with dementia.

Purpose

This study examined the discrepancies in the ratings of depressive symptoms between people with dementia and their family caregivers, and the extent to which these discrepancies varied according to the functional status of people with dementia.

Participants and Methods

This study is a cross-sectional secondary analysis. Twenty-five people living with dementia (“participants”) and their family caregivers (“proxies”) participated as pairs in the study (participant mean age = 71.36, SD = 8.63; proxy mean age = 67.54, SD = 11.46). Data were collected in Victoria, Australia between May 2018 and May 2019. Participants were administered a semi-structured interview comprising the Cornell Scale for Depression in Dementia (CSDD). Proxies independently completed the CSDD and the Functional Activities Questionnaire (FAQ). A paired sample t-test was used to investigate differences in CSDD scores between participants and proxies. Kendall’s tau-b correlation was used to examine the relationship between FAQ scores and discrepancy scores of CSDD. Participants were then classified into either low or high functional impairment. Mann–Whitney U-test was used to examine whether the discrepancy scores of CSDD were similar between these two groups. Intraclass correlation coefficients were calculated to indicate the level of agreement between participants and proxies in each group.

Results

The CSDD scores of participants were significantly lower than proxies. The size of the discrepancy in CSDD scores was positively correlated with FAQ scores. The “high functional impairment” group had larger discrepancy scores and a lower level of agreement than the “low functional impairment” group.

Conclusion

The findings highlighted that relying on proxy CSDD scores may not reflect estimates of depressive symptoms by people with dementia. Hence, both perspectives need to be taken into account, particularly when the level of functional impairment in dementia is advanced.

Vocally disruptive behaviour in nursing home residents in Ireland: a descriptive study

BACKGROUND

Vocally disruptive behaviour (VDB) is relatively common in nursing home residents but difficult to treat. There is limited study on prevalence and treatment of VDB. We hypothesise that VDB is a result of complex interaction between patient factors and environmental contributors.

METHODS

Residents of nursing homes in south Dublin were the target population for this study. Inclusion criteria were that the residents were 65 years or over and exhibited VDB significant enough for consideration in the resident's care plan. Information on typology and frequency of VDB, Interventions employed and their efficacy, diagnoses, Cohen-Mansfield Agitation Inventory scores, Mini-Mental State Examination scores, and Barthel Index scores were obtained.

RESULTS

Eight percent of nursing home residents were reported to display VDB, most commonly screaming (in 39.4% of vocally disruptive residents). VDB was associated with physical agitation and dementia; together, these two factors accounted for almost two-thirds of the variation in VDB between residents. One-to-one attention, engaging in conversation, redirecting behaviour, and use of psychotropic medication were reported by nurses as the most useful interventions. Analgesics were the medications most commonly used (65.7%) followed by quetiapine (62.9%), and these were reportedly effective in 82.6% and 77.2% of residents respectively.

CONCLUSIONS

VDB is common, challenging, and difficult to manage. The study of VDB is limited by a variety of factors that both contribute to this behaviour and make its treatment challenging. Issues relating to capacity and ethics make it difficult to conduct randomised controlled trials of treatments for VDB in the population affected.

Prevalence and correlates of major depressive disorder, bipolar disorder and schizophrenia among nursing home residents without dementia: systematic review and meta-analysis

BACKGROUND

The elderly population and numbers of nursing homes residents are growing at a rapid pace globally. Uncertainty exists regarding the actual rates of major depressive disorder (MDD), bipolar disorder and schizophrenia as previous evidence documenting high rates relies on suboptimal methodology.

AIMS

To carry out a systematic review and meta-analysis on the prevalence and correlates of MDD, bipolar disorder and schizophrenia spectrum disorder among nursing homes residents without dementia.

METHOD

Major electronic databases were systematically searched from 1980 to July 2017 for original studies reporting on the prevalence and correlates of MDD among nursing homes residents without dementia. The prevalence of MDD in this population was meta-analysed through random-effects modelling and potential sources of heterogeneity were examined through subgroup/meta-regression analyses.

RESULTS

Across 32 observational studies encompassing 13 394 nursing homes residents, 2110 people were diagnosed with MDD, resulting in a pooled prevalence rate of 18.9% (95% CI 14.8-23.8). Heterogeneity was high (I2 = 97%, P≤0.001); no evidence of publication bias was observed. Sensitivity analysis indicated the highest rates of MDD among North American residents (25.4%, 95% CI 18-34.5, P≤0.001). Prevalence of either bipolar disorder or schizophrenia spectrum disorder could not be reliably pooled because of the paucity of data.

CONCLUSIONS

MDD is highly prevalent among nursing homes residents without dementia. Efforts towards prevention, early recognition and management of MDD in this population are warranted.

Development and Validation of a Short Version of the Cornell Scale for Depression in Dementia for Screening Residents in Nursing Homes

OBJECTIVES

To develop and validate a short version of the Cornell Scale for Depression in Dementia (CSDD-19) for routine detection of depression in nursing homes.

SETTING

Australian nursing homes.

METHODS

A series of cross-sectional studies were conducted involving: 1) descriptive analysis of pooled data from five nursing home studies that used the CSDD-19 (N = 671) to identify patterns of responses and missing data on individual CSDD items; 2) analysis of four of the five studies (N = 556) to assess CSDD-19 for unidimensionality, item fit, and differential item functioning using Rasch modeling to develop a shorter version, the CSDD-4; 3) validation of the CSDD-4 against the DSM-IV using the fifth study of 115 residents and through expert consultations; and 4) evaluation of the clinical utility of CSDD-4 using an independent cohort of 92 nursing home residents.

RESULTS

Four items from the original CSDD-19 were found to be most suitable for depression screening: anxiety, sadness, lack of reactivity to pleasant events, and irritability. The CSDD-4 highly correlated with the original scale (N = 474, r = 0.831, p < 0.001), with acceptable internal consistency (Cronbach's alpha = 0.70). At the cutoff score of less than 2, sensitivity and specificity of CSDD-4 were 81% and 51%, respectively, for the independent cohort (N = 92), of whom 50% had dementia. The CSDD-4 had an area under the curve (AUC) of 0.73 (z = 3.47, p < 0.001), which was compatible with the CSDD-19 (AUC = 0.69, z = 2.89, p < 0.01).

CONCLUSIONS

The CSDD-4 is valid for routine screening of depression in nursing homes. Its adoption is feasible and practical for nursing home staff, and may facilitate more comprehensive assessment and management of depression in nursing home residents.

Health-related quality-of-life and service utilization in Alzheimer's disease: A cross-sectional study

The objective of this study was to explore the relationships between the severity of Alzheimer's disease (AD) in different care settings, health-related quality-of-life (HQoL), service utilization, and caregiver time and burden.

Data were from a 1996 cross-sectional study of 679 AD patient/caregiver pairs. Patients met NINCDS/ADRDA criteria for probable Alzheimer's, were staged with the Clinical Dementia Rating Scale, and recruited from managed care plans, academic medical centers, nursing homes, and assisted living facilities. Patient data included: demographics, MMSE, co-morbidities, health-related quality-of-life, health status, and service utilization. Family caregiver data included demographics, caregiver time and burden.

Significant findings included: patient HQoL scores were better for community patients, but worsened with disease severity; regardless of setting, patient SF-36 scores showed worse physical functioning and better mental health scores as disease severity increased; inpatient stays and ER visits were rare regardless of severity or setting, and for community patients, day care and in-home services use increased with AD severity. Family caregivers spent 18 hours per month on ADLs and 32 hours on IADLs. Hours increased for community patients and those with greater disease severity. Caregiver burden levels were higher for those serving community patients and increased with disease severity. Burden was lowest for mild and moderate patients in assisted living.

Greater patient AD severity was related to increased morbidity, poorer health status, lower health-related quality-of-life, greater family caregiver time and burden, and greater service use regardless of setting. Findings reinforce the need for an AD continuum of care.

Discrepancies in Cornell Scale for Depression in Dementia (CSDD) items between residents and caregivers, and the CSDD's factor structure

Purpose

This validation study aims to examine Cornell Scale for Depression in Dementia (CSDD) items in terms of the agreement found between residents and caregivers, and also to compare alternative models of the Thai version of the CSDD.

Patients and methods

A cross-sectional study was conducted of 84 elderly residents (46 women, 38 men, age range 60–94 years) in a long-term residential home setting in Thailand between March and June 2011. The selected residents went through a comprehensive geriatric assessment that included use of the Mini-Mental State Examination, Mini-International Neuropsychiatric Interview, and CSDD instruments. Intraclass correlation (ICC) was calculated in order to establish the level of agreement between the residents and caregivers, in light of the residents’ cognitive status. Confirmatory factor analysis (CFA) was adopted to evaluate the alternative CSDD models.

Results

The CSDD yielded a high internal consistency (Cronbach’s alpha = 0.87) and moderate agreement between residents and caregivers (ICC = 0.55); however, it was stronger in cognitively impaired subjects (ICC = 0.71). CFA revealed that there was no difference between the four-factor model, in which factors A (mood-related signs) and E (ideational disturbance) were collapsed into a single factor, and the five-factor model as per the original theoretical construct. Both models were found to be similar, and displayed a poor fit.

Conclusion

The CSDD demonstrated a moderate level of interrater agreement between residents and caregivers, and was more reliable when used with cognitively impaired residents. CFA indicated a poorly fitting model in this sample.

Benefit of an integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of psychogeriatric patients and caregiver burden after six months of follow-up: a re-analysis of a randomized controlled trial

BACKGROUND

In this paper, we aim to test the long-term benefit of an integrative reactivation and rehabilitation (IRR) program compared to usual care in terms of improved psychogeriatric patients on multiple psychiatric symptoms (MPS) and of caregivers on burden and competence. Improvement was defined as >30% improvement (≥ a half standard deviation) compared to baseline.

METHODS

We used the following outcome variables: difference in the number of improved patients on MPS (Neuropsychiatric Inventory, NPI) and improved caregivers on burden (Caregiver Burden, CB) and competence (Caregiver Competence List, CCL). Assessments were taken after intake (T1) and after six months of follow-up (T3). Risk ratios (RR), number needed to treat (NNT), and odds ratios (ORs) were calculated.

RESULTS

IRR had a significant positive effect on NPI-cluster hyperactivity (RR 2.64; 95% CI: 1.26-5.53; NNT 4.07). In the complete cases analysis, IRR showed significant ORs of 2.80 on the number of NPI symptoms and 3.46 on the NPI-sum-severity; up to 76% improved patients. For caregivers, competence was a significant beneficiary in IRR (RR 2.23; 95% CI: 1.07-4.62; NNT 5.07). In the complete cases analysis, the ORs were significantly in favor of IRR on general burden and competence (ORs range: 2.40-4.18), with up to 71% improved caregivers.

CONCLUSION

IRR showed a significantly higher probability of improvement with a small NNT of four on multiple psychiatric symptoms in psychogeriatric patients. The same applies to the higher probability to improve general burden and competence of the caregiver with an NNT of five. The results were even more pronounced for those who fully completed the IRR program. (Inter)national psychogeriatric nursing home care and ambulant care programs have to incorporate integrative psychotherapeutic interventions.

Deinstitutionalization? Where have all the people gone?

Although there is broad consensus that the state psychiatric hospital population drastically declined over the past five decades, the destination and well-being of people with serious mental illness (SMI) have been in greater doubt. In this article, we examine the aftermath of the deinstitutionalization movement. We begin with a brief historical overview of the move away from state hospitals, followed by an examination of where people with SMI currently reside and receive treatment. Next, we review recent trends reflecting access to treatment and level of community integration among this population. Evidence suggests the current decentralized mental health care system has generally benefited middle-class individuals with less severe disorders; those with serious and persistent mental illness, with the greatest need, often fare the worst. We conclude with several questions warranting further attention, including how deinstitutionalization can be defined and how barriers to community integration may be addressed.

Evaluating the Cornell Scale for Depression in Dementia as a proxy measure in nursing home residents with and without dementia

OBJECTIVES

We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents' self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores?

METHODS

Residents and nurse proxy pairs (n=395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores.

RESULTS

On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r=0.16). The mean discrepancy score was -2.03 (SD=5.28, p<0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents' cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD.

CONCLUSION

These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.

Identifying elderly depression using the Depression Rating Scale as part of comprehensive standardised care assessment in nursing homes

OBJECTIVES

This study used data from the SHELTER (Services and Health for Elderly in Long TERm care) project to explore the benefits of using the Depression Rating Scale (DRS) as part of a standardised needs assessment in UK nursing homes, including a statistical method of effectively identifying characteristics linking to residents' depression.

METHOD

About 499 residents in nine nursing homes in south-east England were assessed with interRAI Long Term Care Facilities (interRAI LTCF), a standardised assessment tool containing the validated DRS residents who scored 3 or more on the DRS were considered 'might suffer from depression'. A list of characteristics associated with depression was then examined using bivariate analysis and logistic regression.

RESULTS

Among the 499 residents assessed, 67.5% were not depressed (DRS < 3) and 32.3% might suffer from depression (DRS ≥ 3). The final logistic model showed 'never married' (p = 0.019), 'diagnosis of COPD' (COPD, chronic obstructive pulmonary disease) (p = 0.015), 'feelings of pain' (p = 0.015) and 'trouble sleeping' (p < 0.001) were significantly associated with reporting of DRS score of 3 and more.

CONCLUSION

The article argued that DRS has distinctive advantages for using in UK nursing homes where a preponderance of residents is cognitively impaired, the procedure of screening depression is not regulated and resources to treat depression is relatively scarce. This article also demonstrated how using the DRS as part of a comprehensive standardised needs assessment facilitates analysis of characteristics linking to depression, which has significant policy implications in improving care quality and management.

Depression in older people living in residential homes

There is a large body of published research relating to depression in residential homes for older people (also called long-term-care homes, and including both nursing homes and hostels) (Ames 1990; 1993; Seitzet al., 2010; Snowdon and Purandare, 2010; Snowdon, 2010). However, despite increased detection and more frequent treatment in recent years, depression remains a significant problem for many older people living in such settings. This guest editorial summarizes current knowledge about prevalence, etiology, detection and screening, treatment and outcomes of depression in residential homes and concludes with a summary of key issues requiring urgent future action.

Integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of cognitively impaired patients and caregiver burden: randomized controlled trial

OBJECTIVE

To test the effectiveness of an integrative psychotherapeutic nursing home program (integrative reactivation and rehabilitation [IRR]) to reduce multiple neuropsychiatry symptoms (MNPS) of cognitively impaired patients and caregiver burden (CB).

DESIGN

Randomized controlled trial.

SETTING

Psychiatric-skilled nursing home (IRR) and usual care (UC), consisting of different types of nursing home care at home or in an institution.

PARTICIPANTS

N = 168 (81 IRR and 87 UC). Patients had to meet classification of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for dementia, amnestic disorders, or other cognitive disorders. Further inclusion criteria: Neuropsychiatric Inventory (NPI) ≥3; Mini-Mental State Examination ≥18 and ≤27; and Barthel Index (BI) ≥5 and ≤19.

INTERVENTION

IRR consisted of a person-oriented integrative psychotherapeutic nursing home program to reduce MNPS of the patient and CB. UC consisted of different types of nursing home care at home or in an institution, mostly emotion oriented.

MEASUREMENTS

Primary outcome variable was MNPS (number and sum-severity of NPI). Furthermore, burden and competence of caregiver were also measured.

ASSESSMENTS

T1 (inclusion), T2 (end of treatment), T3 (after 6 months of follow-up). Cohen's d (Cd) was calculated for mean differences (intention to treat). For confounding, repeated measurement modeling (random regression modeling [RRM]) was applied.

RESULTS

In the short term from the perspective of the caregiver, IRR showed up to 34% surplus effects on MNPS of the patients; NPI symptoms: 1.31 lower (Cd, -0.53); and NPI sum- severity: 11.16 lower (Cd, -0.53). In follow-up, the effects were sustained. However, from the perspective of the nursing team, these effects were insignificant, although the trend was in the same direction and correlated significantly with the caregiver results over time (at T3: r = 0.48). In addition, IRR showed surplus effects (up to 36%) on burden and competence of caregiver: NPI emotional distress: 3.78 (Cd, -0.44); CB: 17.69 (Cd, -0.63) lower; and Competence: 6.26 (Cd, 0.61) higher. In follow-up, the effects increased up to 50%. RRM demonstrated that the effects were stable.

CONCLUSION

From the perspective of the caregiver, IRR was significantly more effective than UC to reduce MNPS in cognitively impaired patients and CB. In follow-up, the effect on CB even increased. However, from the perspective of the nursing team, the effects on MNPS were statistically insignificant. Nevertheless, the trend was in the same direction and correlated significantly with the caregiver results over time. Further research is needed, preferably using a blinded randomized controlled trial.

Australia's use of the Cornell scale to screen for depression in nursing homes

AIM

To examine the utility of the Cornell scale for depression in dementia (CSDD), following its introduction as a routine measure in nursing homes.

METHODS

The CSDD is administered in Australian nursing homes as section 10 of the Aged Care Funding Instrument. CSDD, cognitive and behavioural ratings, and medication use, recorded in three Sydney nursing homes in 2008-2009 were reviewed. Staff discussed what actions were taken if CSDD scores indicated depression.

RESULTS

Of 223 residents, 23% scored >12 on the CSDD, indicating probable depression. Another 21% were possibly depressed and 29% not depressed. The CSDD had not been completed for 27%, commonly because preliminary screening indicated no depression, but sometimes because severe cognitive impairment made various CSDD items impossible to rate. Second CSDD assessments had usually not been made.

CONCLUSION

Nursing homes need to document policies that will ensure best use is made of CSDD findings.

Trends in mental health admissions to nursing homes, 1999-2005

OBJECTIVE

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics.

METHODS

The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received.

RESULTS

The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community.

CONCLUSIONS

Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

Practical depression screening in residential care/assisted living: five methods compared with gold standard diagnoses

OBJECTIVE

To test the accuracy of five practical depression screening strategies in older adults residing in residential care/assisted living (RC/AL).

DESIGN

Cross-sectional screening study.

SETTING

Four RC/AL communities in North Carolina.

PARTICIPANTS

A total of 112 residents aged > or =65 and 27 staff members involved in their care.

MEASUREMENTS

Direct care staff was trained in and completed the Cornell Scale for Depression in Dementia, modified for use by long-term care staff (CSDD-M-LTCS). They additionally responded to a one-item question "Do you believe the resident is often sad or depressed?" and the Minimum Data Set Depression Rating Scale (DRS). Residents responded directly to the Geriatric Depression Scale (15-item version; GDS-15) and the Patient Health Questionnaire, 2-item version (PHQ-2). A geriatric psychiatrist performed gold standard diagnostic interviews using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Sensitivities and specificities were calculated for all instruments at predetermined cutpoints.

RESULTS

Gold standard diagnoses yielded 14% prevalence of major or minor depression. The CSDD-M-LTCS and one-item screen completed by caregivers failed to significantly discriminate depressed cases. The DRS yielded high specificity (0.85) but low sensitivity (0.47). For the two resident reported measures, the PHQ-2 had a sensitivity of 0.80 and specificity of 0.71, and the GDS-15, 0.60 and 0.75, respectively.

CONCLUSION

Measures completed by caregivers failed to adequately detect depression. Of the measures completed directly by residents, the PHQ-2 seems to have the best mix of brevity, sensitivity, and ease of administration.

Effectiveness of a training program for carers to recognize depression among older people

OBJECTIVE

Depression is a mental disorder that is frequently not detected among older people. The current study was designed to evaluate the effectiveness of a training program to assist carers to better recognize depression among older people in both community and residential care settings.

METHODS

In total, 52 professional carers (26 in community care, 26 in residential care) across a range of occupations completed a four session (for personal care attendants) or six session (for registered nurses or managers) training program. The program provided training for staff to identify and respond appropriately to signs of depression. In addition, nurses and managers were trained on the use of screening tools and referral processes. Outcomes were evaluated at post-test, and 6-month follow-up.

RESULTS

The results demonstrated that for all groups training was effective in increasing carers' knowledge of depression and self-efficacy in detecting depression, as well as reducing the barriers to care at both post-test and 6-month follow-up.

CONCLUSIONS

The training program evaluated in the current study was effective in increasing the level of skills necessary for care staff to better detect depression among older people in both community and residential care settings. Further research is needed to determine if these improved skills are sustained over time, and if they actually improve the level of recognition of depression among older people.

Developing an intervention for depressed, chronically medically ill elders: a model from COPD

BACKGROUND

Geriatric depression preferentially afflicts individuals with chronic medical illnesses. Disability, hopelessness, lack of acceptance of antidepressant treatment, and limited problem-solving skills contribute to poor treatment adherence, compromised outcomes, and chronically experienced adversity.

METHODS

This paper uses depression comorbid with chronic obstructive pulmonary disease (COPD) as a model entity to develop an approach for integrating treatment components essential for improving treatment adherence and outcomes.

RESULTS

The behavioral inertia of depression and its coexisting cognitive problems reduce adherence to the sustained and complex demands of the COPD rehabilitation regimen and antidepressant treatment. An intervention identifying reasons for poor treatment adherence and offering direct instructions for addressing them can be combined with problem-solving therapy to target treatment adherence, depressive symptoms, and disability.

CONCLUSIONS

An intervention focusing on treatment adherence and problem-solving skills development may serve as the platform for administering specific treatments to address the interacting problems of depressed medically ill patients.

Correlates of knowledge and beliefs about depression among long-term care staff

CONTEXT

Despite the high prevalence of depression in long-term care (LTC), it often is unrecognized and inadequately treated. Thus, the goals of the present study were to evaluate LTC staff characteristics that are associated with knowledge and beliefs about depression.

METHODS

A cross sectional study of 371 LTC staff members completed a knowledge and beliefs about depression questionnaire, a short demographic questionnaire, a burden measure, and a questionnaire about attitudes associated with working with depressed residents.

RESULTS

Relative to nurses, social workers, and activity staff, paraprofessional caregivers had a lower score on the depression measure and a higher score on the burden measure. Paraprofessional caregivers were more likely to view depression as a normal phenomenon, held less accurate beliefs about signs and symptoms of depression, and were less familiar with the effectiveness of specific treatments of depression.

CONCLUSIONS

Educational interventions about depression should be specifically geared to meet the needs of paraprofessional caregivers who provide the majority of care to LTC residents, yet possess less knowledge about depression and its treatments.

Recognising depression in residential facilities: an Australian challenge

BACKGROUND

Depression in aged care facilities (ACFs) is reportedly under-recognised and under-treated. Observer-rated and self-rated depression rating scales can help identify cases of depression, and could be used to estimate the prevalence of depression in ACFs.

METHOD

Direct care staff in 168 ACFs used a survey form and administered the Cornell Scale for Depression in Dementia (CSDD) and (in those able to be tested) the 15-item Geriatric Depression Scale (GDS-15) to every fourth resident. In seven facilities the same subjects were clinically assessed and (where appropriate) diagnosed by a psychiatrist.

RESULTS

Survey forms and CSDD ratings were completed by staff concerning 91.6% of the one-in-four selected subjects. Their mean age was 82.1 years. CSDD scores of 8 or more, indicating depression, were recorded for 34.7% of the ACF residents, comprising 40.5% of the 1,084 high care (nursing home level) residents, and 25.4% of the 674 low care residents. Of 1,250 residents tested with the GDS-15, 41.1% scored 6 or more, indicating depression. The correlation between GDS-15 and CSDD scores was 0.6. Use of the survey tool allowed staff to identify which factors were most strongly associated with depression, the strongest being grief over loss of abilities and opportunities to participate in valued activities.

CONCLUSIONS

The CSDD (and the GDS-15 in those without severe cognitive impairment) proved useful in identifying residents who were depressed. Survey questions helped draw attention to factors of importance in development or persistence of these depressions, and hence to strategies for intervention.

Prevalence of Pain in Nursing Home Residents With Different Cognitive and Communicative Abilities

OBJECTIVES

To determine the prevalence of pain and its impact among nursing homes residents with different cognitive and communication abilities.

DESIGN

Cross-sectional study.

SETTING

Three nursing homes in Singapore.

PARTICIPANTS

Residents aged 65 years and above, without a recent change in their cognitive status.

MEASUREMENTS

Self-reports were obtained whenever possible. Pain severity was measured with the Pain Assessment in Advanced Dementia scale (categorized version) among the uncommunicative. Residents were also assessed with the short-form version of the Geriatric Depression Scale, the Cornell Scale for Depression in Dementia, the state portion of the Spielberger State-Trait Anxiety Inventory, and the Human Activities Profile.

RESULTS

Pain prevalence did not differ between the communicative resident with normal cognition (48.7%), mildly impaired cognition (46.5%), or severely impaired cognition (42.9%). However, the latter 2 groups reported more acute pain than those with normal cognition (7.9% to 14.1% vs. 2.5%). Those with impaired cognition reported constant pain more often, reported fewer total sites of pain, and had more frequent and more severe pain. Regardless of cognitive status, 73.3% to 100% of residents had significant scores on depression or anxiety measures when they reported pain-related mood disturbance. Pain-related reduction in activity was associated with a lower Human Activities Profile score. Sixteen of 36 uncommunicative residents had pain on the Pain Assessment in Advanced Dementia and at least 12 of them had significant mood disturbance.

CONCLUSIONS

Cognitive status does not affect pain prevalence; however, it affects the chronicity and characteristics of reported pain. Self-report of pain-related mood involvement is associated with significant mood scores.

Does Organisational Culture Influence Prescribing in Care Homes for Older People?

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.

Mirtazapine orally disintegrating tablets in depressed nursing home residents 85 years of age and older

INTRODUCTION

Treatment studies of depression in the very oldest patients are infrequent. For these reasons, this study of mirtazapine orally disintegrating tablets was carried out in nursing home residents>or=85 years old with physician-diagnosed depression. The naturalistic conditions of the study allowed us to include patients with cognitive impairment, concomitant medications and comorbid illness.

METHODS

This was a subgroup analysis of nursing home residents>or=85 years old who took part in a larger 12-week open-label trial. Patients were eligible if they had physician-diagnosed depression, and a Mini-Mental State Exam score>or=10. The physician or nurse coordinator obtained data from healthcare professionals in daily contact with the patient to complete the Clinical Global Impression (CGI) scale, a modified 16-item Hamilton Depression Scale (HAM-D), and the Cornell Scale for Depression in Dementia (CSDD). Treatment-emergent adverse events were recorded.

RESULTS

Of the 50 patients enrolled at 23 sites, 72% completed the 12-week trial. The mean age of the participants was 89.3 years. The mean HAM-D score declined from 16.9 at baseline to 7.3 at endpoint (ITT, LOCF analysis) For the CSDD, the mean score declined from 15.1 to 7.1. The percentage of responders on the CGI-Improvement (CGI-I) scale increased at each assessment reaching 55% at endpoint. Only 10% of the patients discontinued treatment because of adverse events. There was a mean increase in weight of 1.32 lbs (0.6 kg) at day 84.

CONCLUSION

Although lacking a placebo control, this naturalistic study suggests that mirtazapine orally disintegrating tablets were effective and well tolerated in this sample of depressed nursing home residents>or=85 years of age.

Assessment of Adult Psychopathology: Meta-Analyses and Implications of Cross-Informant Correlations

Assessment of adult psychopathology relies heavily on self-reports. To determine how well self-reports agree with reports by "informants" who know the person being assessed, the authors examined 51,000 articles published over 10 years in 52 peer-reviewed journals for correlations between self-reports and "informants" reports. Qualifying correlations were found in 108 (0.2%) of the articles. When self-reports and informant reports were obtained with parallel instruments, mean cross-informant correlations were .681 for substance use, .428 for internalizing, and .438 for externalizing problems. When based on different instruments, the mean cross-informant correlation was .304. The moderate sizes of the correlations argue for systematically obtaining multi-informant data. National survey findings were used to illustrate practical ways to obtain and use such data.

Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes?

BACKGROUND

There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes.

OBJECTIVE

This study evaluated the relation between organizational characteristics and management of depression using antidepressants.

RESEARCH DESIGN

This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000.

SUBJECTS

We studied 87,907 residents with depression in 2,128 facilities.

MEASURES

Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations.

RESULTS

Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents.

CONCLUSIONS

Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing.

Effect of Medical Comorbidity on Response to Fluoxetine Augmentation or Dose Increase in Outpatients With Treatment-Resistant Depression

This study assessed the effect of general medical comorbidity on response to next-step antidepressant treatments among subjects with major depressive disorder whose depression failed to respond to an 8-week open trial of 20 mg/day of fluoxetine. Of the 386 outpatients in the open trial, 101 who remained depressed were randomly assigned to double-blind treatment with either an increased dose of fluoxetine or lithium or desipramine augmentation for 4 weeks. The Cumulative Illness Rating Scale (CIRS) was used to assess baseline general medical comorbidity, and the Hamilton Depression Rating Scale was used to assess depressive symptoms. Logistic regression analysis showed that CIRS score was not associated with likelihood of remission or premature study discontinuation. Medical comorbidity thus does not appear to be associated with significantly poorer outcome among patients whose major depressive disorder failed initially to respond to an initial trial of 20 mg/day of fluoxetine.

Open-label study of mirtazapine orally disintegrating tablets in depressed patients in the nursing home

OBJECTIVE

To evaluate the efficacy and tolerability of mirtazapine orally disintegrating tablets in depressed, elderly nursing home residents, under naturalistic study conditions.

METHODS

In this open-label 12-week study, mirtazapine orally disintegrating tablets (15-45 mg/day) were administered to patients > or =70 years old with physician-diagnosed depression and a Mini-Mental State Examination (MMSE) score > or =10. Patients with medical comorbidities, cognitive impairment and/or concomitant medications were enrolled if they met study inclusion criteria and had illnesses and/or medication dosages that were considered stable. Assessments were performed at baseline by physicians and at days 14, 28, 56, and 84 (or early termination) by physicians or nurse coordinators using the Clinical Global Impression (CGI) scale, the 16-item Hamilton Rating Scale for depression (Ham-D-16 (the standard 17-item scale minus item 14)), and the Cornell Scale for Depression in Dementia (CSDD). Tolerability was evaluated based on treatment-emergent adverse events.

RESULTS

A total of 119 patients in the intent-to-treat (ITT) group were treated with mirtazapine orally disintegrating tablets (mean daily dose: 19.4 mg) and evaluated for efficacy. At endpoint, 54% of patients in the ITT group showed CGI-I response (defined as a CGI-I score of 1 or 2 ('very much' or 'much' improved) and 47% were Ham-D-16 responders (defined as decrease from baseline of at least 50% in Ham-D-16 total score). CSDD mean scores and Ham-D-16 mean total scores demonstrated a progressive decrease from baseline to trial completion. The decrease in Ham-D scores from baseline to day 84 was statistically significant (p < 0.0001). Mean changes from baseline to day 84 were -6.6 +/- 6.9 (CSDD score) and -7.9 +/- 7.4 (Ham-D-16 total score). Ham-D Factor I, Factor VI and item 1 scores also decreased. Fourteen of 124 patients in the all-subjects-treated (AST) group (11.3%) discontinued prematurely due to adverse events. The most frequently occurring adverse events were urinary tract infection (19%), accidental injury (18%), fall (18%), somnolence (12%), and upper respiratory infection (12%). Mean body weight increased by 0.7 +/- 2.25 kg (1.54 +/- 5 lb) from baseline to day 28, and by 1.3 +/- 3.36 kg (2.86 +/- 7.4 lb) from baseline to day 84.

CONCLUSIONS

The results suggest that mirtazapine orally disintegrating tablets provide antidepressant efficacy and are a relatively well-tolerated treatment for depression in this patient population of elderly nursing home residents with medical and cognitive comorbidities.

Needs of the dying in nursing homes

OBJECTIVE

To describe the palliative care needs of dying nursing home residents during the last 3 months of life.

METHODS

Nurses, aides, and family members completed structured interviews after all deaths of residents in two nursing homes during a 1-year study period. For each resident who died, family and staff caregivers answered parallel questions on the presence of physical and emotional symptoms, unmet needs for treatment of these symptoms, and the quality of the dying experience.

RESULTS

Of 259 eligible respondents 176 completed interviews (68%). Decedents' average age was 82, and 90% died in the nursing home rather than in a hospital. Most deaths were preceded by orders to withhold resuscitation (79%) and other treatments (39%). The most common physical symptoms were pain (86%), problems with personal cleanliness (81%), dyspnea (75%), incontinence (59%), and fatigue (52%). Depressed mood (44%), anxiety (31%), and loneliness (21%) were common emotional symptoms. Respondents believed residents needed more treatment than they received for emotional symptoms (30%), personal cleanliness (23%) and pain (19%). Fifty-eight percent of respondents believed the resident experienced a "good death," as they would have wanted it to be.

CONCLUSIONS

Dying nursing home residents need improved emotional and spiritual care, help with personal cleanliness, and treatment for pain. Efforts to improve end-of-life care in nursing homes should combine traditional palliative care services with increased attention to emotional symptoms and personal care services.

Comorbidity of late life depression: an opportunity for research on mechanisms and treatment

Late life depression principally affects individuals with other medical and psychosocial problems, including cognitive dysfunction, disability, medical illnesses, and social isolation. The clinical associations of late life depression have guided the development of hypotheses on mechanisms predisposing, initiating, and perpetuating specific mood syndromes. Comorbidity studies have demonstrated a relationship between frontostriatal impairment and late life depression. Further research has the potential to identify dysfunctions of specific frontostriatal systems critical for antidepressant response and to lead to novel pharmacological treatments and targeted psychosocial interventions. The reciprocal interactions of depression with disability, medical illnesses, treatment adherence, and other psychosocial factors complicate the care of depressed older adults. Growing knowledge of the clinical complexity introduced by the comorbidity of late life depression can guide the development of comprehensive treatment models. Targeting the interacting clinical characteristics associated with poor outcomes has the potential to interrupt the spiral of deterioration of depressed elderly patients. Treatment models can be most effective if they focus on amelioration of depressive symptoms, but also on treatment adherence, prevention of relapse and recurrence, reduction of medical burden and disability, and improvement of the quality of life of patients and their families.

A randomized, placebo-controlled trial of paroxetine in nursing home residents with non-major depression

Depression is common across a broad spectrum of severity among nursing home residents. Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression, but it is not known whether antidepressants are helpful in residents with less severe forms of depression. We conducted a randomized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression. The main outcome measure was the primary nurse's Clinical Impression of Change (CGI-C). Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale (HDRS) and Cornell Scale for Depression (CS) scores. Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial. Placebo response was high, and when all subjects were considered, there were no differences in improvement between the paroxetine and placebo groups. Two subjects that received paroxetine developed delirium, and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores (P =.03). There were no differences in serum anticholinergic activity between groups. In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores, there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures (P =.06). Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression, and there is a risk of adverse cognitive effects. Because of the high placebo response and the trend towards improvement in the more severely ill patients, it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo. The study also illustrates the discordance between patient and caregiver ratings, and the difficulties in studying very elderly patients with mood disorders.

Assessment of psychological distress in prospective bone marrow transplant patients

Patient psychological distress is associated with many aspects of the bone marrow transplantation (BMT) process and has been linked with poor treatment outcomes. We assessed psychological distress in potential BMT candidates, and compared patient and nurse coordinator ratings of emotional distress at the time of initial BMT consultation. Fifty patients self-reported psychological distress using both the NCCN Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). Coordinators rated patient emotional distress using the DT and Coordinator Rating Scales that measure anxiety and depression. Fifty and 51% of patients self-reported clinically significant levels of emotional distress and anxiety, respectively, but only 20% self-reported clinically significant levels of depression. There was good correlation between ratings using the brief DT and the more comprehensive HADS. There was significant but only moderate agreement between patient and coordinator ratings of emotional distress and anxiety, with coordinators underestimating the number of patients with high levels of emotional distress. In addition, coordinator ratings of patient emotional distress primarily reflected anxiety, whereas anxiety and depression together only minimally accounted for patient self-reports of psychological distress. These findings suggest that: (1) the DT can be a useful screening device; (2) approximately half of patients at the time of initial consultation for BMT already experience significant levels of psychological distress; and (3) coordinators observe emotional distress primarily as anxiety, but patients experience psychological distress as something more than anxiety and depression.

Factors associated with antidepressant treatment in residential care: changes between 1990 and 1997

BACKGROUND

Depression is common among older people living in residential and nursing homes. Detection and treatment of late life depression may be sub-optimal in these settings.

AIM

To report the changes in, and factors associated with, antidepressant use among residents in care homes in 1990 and 1997.

METHOD

Censuses of those aged 65 years and over in any type of residential care in the county of Leicestershire, UK, on 27 November 1990 and 30 November 1997. Care staff were asked to complete an assessment form for each resident which included a rating of depression and use of antidepressants.

RESULTS

The use of antidepressants increased from 11% (484/4415) in 1990 to 18.9% (777/4111) in 1997. Severity of depression as assessed by care staff, gender, younger age, better cognitive functioning, and use of other medications were consistently associated with antidepressant treatment. Antidepressant use was associated with better physical functioning (p = 0.001) in 1990 and frequency of falls in 1997 (p = 0.044).

CONCLUSIONS

Increased use of antidepressants appears to be due to the wider range of antidepressant drugs available since 1990. However there is a need for better methods for care staff to detect depression in residents, and for appropriate action to be taken by those responsible for their medical management.

Value-added outcomes: the use of advanced practice nurses in long-term care facilities

The purpose of this study was to determine the effect on clinical outcomes for newly admitted nursing home residents when advanced practice gerontological nurses (APNs) worked with staff to implement scientifically based protocols for incontinence, pressure ulcers, depression, and aggressive behavior. Use of APNs in this manner differs from the usual way APNs have been used in nursing homes, in which their primary focus has been to augment the physician's role. The APN treatment was randomly assigned to two nursing homes and usual care was assigned to a third. Trajectories from admission to 6 months revealed that residents with APN input into their care (n = 86) experienced significantly greater improvement or less decline in incontinence, pressure ulcers, and aggressive behavior, and they had higher mean composite trajectory scores compared with residents receiving usual care (n = 111). Significantly less deterioration in affect was noted in cognitively impaired residents in the treatment group. Findings suggest that APNs can be effective links between current scientific knowledge about clinical problems and nursing home staff.

Depression among nursing home elders: testing an intervention strategy

This study focused on the assessment of depression among nursing home elders, and on determining the efficacy of an intervention strategy for depression using a geropsychiatric nurse in conjunction with trained older adult volunteers in the role of mental health paraprofessionals. Nursing home residents (n = 139) were assessed for depression using the Geriatric Depression Scale (GDS); 94 (68%) were found to have depressive symptomatology. Among those receiving the intervention, depressive symptomatology was significantly reduced, but no significant decline was evident in the control group. The ability of the minimum data set (MDS) to detect depression as compared to the GDS was evaluated. Relationships between depression and health status, life satisfaction, and social support were also examined.

Assessment of depression in a population at risk ... newly admitted nursing home residents

Depression in newly admitted nursing home residents is a frequently overlooked area of nursing concern. Educating staff to systematically use a standardized depression assessment protocol with all newly admitted residents would facilitate efforts to enhance the quality of residents' lives by identifying depression so that prompt treatment is possible. Other previously admitted residents who appear to be particularly vulnerable to depression would also benefit from this assessment. The use of this protocol for the assessment of depression offers the possibility of providing more accurate and more comprehensive information regarding mood states than that currently being documented in the Minimum Data Set.

The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set

OBJECTIVES

To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population.

DESIGN

Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS.

SETTING

270 Medicaid-certified nursing homes in 10 states.

PARTICIPANTS

A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size.

MEASUREMENTS

Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints).

RESULTS

Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04).

CONCLUSIONS

Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.