Which version of the geriatric depression scale is most useful in medical settings and nursing homes? Diagnostic validity meta-analysis

Clinical update on nursing home medicine: 2013

This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.

Preoperative predictors of pain following total knee arthroplasty

Total knee arthroplasty has provided dramatic improvements in function and pain for the majority of patients with knee arthritis, yet a significant proportion of patients remain dissatisfied with their results. We performed a prospective analysis of 215 patients undergoing TKA who underwent a comprehensive array of evaluations to discover whether any preoperative assessment could predict high pain scores and functional limitations postoperatively. Patients with severe pain with a simple knee range-of-motion test prior to TKA had a 10 times higher likelihood of moderate to severe pain at 6 months. A simple test of pain intensity with active flexion and extension preoperatively was a significant predictor of postoperative pain at 6 months after surgery. Strategies to address this particular patient group may improve satisfaction rates of TKA.

A pilot study of depression among older people in Rawalpindi, Pakistan

BACKGROUND

Depression is common among elderly in developed countries and it is more pronounced in institutional settings. In Pakistan there is a lack of empirical data on depression among this segment of the population particularly with reference to their living arrangements.The objectives of the present study are to report the magnitude of depression among elderly having two different residential arrangements and to examine the association of depression and its established demographic factors.

FINDINGS

Data were collected from 141 respondents. 108 were community residents (m = 57 and f = 51) and 33 were living in the care homes (m = 29 and f = 4).Prevalence of depression as assessed by Geriatric Depression Scale (GDS) among community and Care Homes (CHs) participants was 31.5 percent and 60.6 percent, respectively.On Centre of Epidemiological Studies Depression Scale (CES-D), 42.6 percent of the community and 69.7 percent of the CH respondents were deemed depressed. Before adjusting for any other potential risk factors the odds of being depressed was significantly increased if the study participants were living in CH, relatively older, female, not currently married, had low educational level, had lower Mini Mental State Examination (MMSE) scores, and reported lower perceived emotional and practical support. In a partially adjusted logistic regression model an increased risk of depression was not confounded by any of the above mentioned risk factors.However, the risk associated was not significant when it was adjusted for social support.

CONCLUSIONS

The findings of the current study are consistent with previous research and throws light on the dire need for interventions to address mental health needs of Pakistani elderly.Implications for improving the mental health status of elderly are also presented.

Assessment of the person with late-life depression

This article discusses characteristic factors in the presentation of depressive disorders in persons older than age 65 years. Clinical presentation is discussed along with risk and protective factors. Detailed descriptions of tests useful for screening and diagnosis of depression in the elderly are presented. Each test is reviewed according to time to administer, sensitivity and specificity, outcomes, advantages, and disadvantages. The importance of clinical history and the diagnostic interview, as well as the role of laboratory studies and neuroimaging in the clinical evaluation are discussed.

Detection of suicide among the elderly in a long term care facility

Purpose

The aim of this study was to establish the level of correlation between the suicide item contained within the Core Symptom Index (CSI), and the presence of suicidal thoughts as assessed by the Mini-International Neuropsychiatric Interview (MINI) and the Cornell Scale of Depression in Dementia (CSDD).

Patients and methods

Seventy elderly residents in a long term care facility were included in this study. All of these patients completed a CSI and a geriatric depression scale (GDS), plus were interviewed using CSDD, MINI (suicide module), and MMSE. Test characteristics of item two of the CSI (suicidal thoughts) and MINI were compared. Gwet’s AC1 and Cohen’s Kappa were also used to test the level of agreement between raters, and univariate analysis was used to determine predictors for the severity of any suicidal thoughts present.

Results

There was found to be a significant correlation between suicidal ideation, as assessed by item two of the CSI, and the suicidal ideation score as assessed by MINI and CSDD (r=0.773 and r=0.626, P<0.001, respectively). The level of agreement across all three instruments was good (Gwet’s AC1 =0.907). The CSI yielded a high level of sensitivity (100%) and specificity (90.32%) for suicidal thoughts as measured by MINI, with an area under the curve of 97%. When assessing predictors of the severity of suicidal thoughts, only item two of the CSI predicted severity, while the depression, GDS, and total scores obtained from the CSI did not.

Conclusion

CSI item two has the ability to detect suicidal ideation, regardless of whether the patient has cognitive impairment and/or depression or not, and is currently the best predictor of its presence. Therefore, it shows promise as a measure for screening the presence of suicidal thoughts among the elderly in long term care facilities.

Self- and proxy report for the assessment of pain in patients with and without cognitive impairment: experiences gained in a geriatric hospital

BACKGROUND

Pain assessment is a complex procedure in patients with different degrees of cognitive impairment. The challenge is to determine whether self-reporting tools are adequate and to identify the cases in which proxy ratings are necessary.

PATIENTS AND METHODS

As part of an open, prospective observational study, 178 patients underwent a comprehensive pain assessment consisting of the Numeric Rating Scale (NRS), the Verbal Rating Scale with four and five items (VRS4 and VRS5) and the Pain Assessment in Advanced Dementia Scale (PAINAD).

RESULTS

Even without prior knowledge of a patient's cognitive impairment, this toolkit can be used to reliably identify cases where self-rating is appropriate and where proxy rating becomes necessary. Inter-rater reliability: "good" agreement [Cohen's κ = 74.2% (p < 0.001) (95%CI, 54.6-93.8%)], test-retest reliability: "moderate" agreement [κ = 55.3% (p < 0.001) (95%CI, 28.5-82.1%)]. Furthermore, movement resulted in a higher correlation between the selected assessments. Self-report assessments are appropriate up to a mini-mental state examination (MMSE) value greater than ten. In comparison to NRS, VRS4 and VRS5 remain more stable as the degree of cognitive impairment increases.

CONCLUSIONS

In the majority of the cases, our approach enables reliable appropriate pain assessment without the strict prerequisite of an upstream cognitive assessment.

Beside the Geriatric Depression Scale: the WHO-Five Well-being Index as a valid screening tool for depression in nursing homes

OBJECTIVE

The aim of the study was to compare criterion validities of the WHO-Five Well-being Index (WHO-5) and the Geriatric Depression Scale 15-item version (GDS-15) and 4-item version (GDS-4) as screening instruments for depression in nursing home residents.

METHODS

Data from 92 residents aged 65-97 years without severe cognitive impairment (Mini Mental State Examination ≥15) were analysed. Criterion validities of the WHO-5, the GDS-15 and the GDS-4 were assessed against diagnoses of major and minor depression provided by the Structured Clinical Interview for DSM-IV. Subanalyses were performed for major and minor depression. Areas under the receiver operating curve (AUCs) as well as sensitivities and specificities at optimal cut-off points were computed.

RESULTS

Prevalence of depressive disorder was 28.3%. The AUC value of the WHO-5 (0.90) was similar to that of the GDS-15 (0.82). Sensitivity of the WHO-5 (0.92) at its optimal cut-off of ≤12 was significantly higher than that of the GDS-15 (0.69) at its optimal cut-off of ≥7. The WHO-5 was equally sensitive for the subgroups of major and minor depression (0.92), whereas the GDS-15 was sensitive only for major depression (0.85), but not for minor depression (0.54). For specificity, there was no significant difference between WHO-5 (0.79) and GDS-15 (0.88), but both instruments outperformed the GDS-4 (0.53).

CONCLUSIONS

The WHO-5 demonstrated high sensitivity for major and minor depression. Being shorter than the GDS-15 and superior to the GDS-4, the WHO-5 is a promising screening tool that could help physicians improve low recognition rates of depression in nursing home residents.

Higher serum dehydroepiandrosterone sulfate levels are protectively associated with depressive symptoms in men, but not in women: a community-based cohort study of older Japanese

OBJECTIVE

Dehydroepiandrosterone sulfate (DHEAS) appears to have a protective effect against depression, but evidence from prospective cohort studies is sparse. Therefore, we examined the association between serum DHEAS levels and depressive symptoms in older community-dwelling Japanese.

DESIGN

A community-based cohort study.

SETTING

Kurabuchi Town, Gunma Prefecture, Japan.

PARTICIPANTS

A total of 554 residents (248 men and 306 women) age 65 years or older without depressive symptoms at baseline.

MEASUREMENTS

We performed a baseline examination of the subjects between 2005 and 2006 to determine serum DHEAS levels. The subjects were categorized into three groups based on age strata- and sex-specific tertiles of DHEAS. Depressive symptoms were assessed with the Geriatric Depression Scale 15-item version (GDS-15) in face-to-face home visit interviews carried out once in 2007 and once in 2008. The association of DHEAS with depressive symptoms (GDS-15 ≥ 6) was analyzed with the use of logistic regression models.

RESULTS

The incidence of depressive symptoms was 12.1% in men and 19.6% in women. In men, the multiadjusted odds ratio of depressive symptoms was 0.24 (95% confidence interval: 0.06-0.94, Wald χ2 = 4.20, degrees of freedom = 1, p = 0.04) for the highest tertile compared with the lowest. The association observed for the highest versus the lowest remained significant even after adjustment for physical performance and cognitive function. In women, DHEAS was not associated with depressive symptoms.

CONCLUSIONS

In this study, higher serum DHEAS levels were found to be protectively and independently associated with the risk of developing depressive symptoms in men, but not in women.

The Use of GDS-15 in Detecting MDD: A Comparison Between Residents in a Thai Long-Term Care Home and Geriatric Outpatients

Background

To assess the psychometric properties of the Thai version of the 15-item Geriatric Depression Scale (TGDS-15) when screening for major depression (MDD) among geriatric outpatients (GOs) and long-term care (LTC) home residents in Thailand.

Methods

This was a cross-sectional study of 156 geriatric outpatients and 81 LTC home residents. All 237 participants were given a Mini-Mental State Examination, a MDD diagnosis according to the Mini-International Neuropsychiatric Interview, and completed a TGDS-15 questionnaire. Sensitivity, specificity, overall accuracy, and positive and negative predictive values were calculated. A comparison between the two groups was carried out. Differential Item Functioning (DIF) using logistic regression and factor analytic study were also applied.

Results

Overall, 38.4% of the participants were found to have MDD. The TGDS-15 was found to perform better when used with the GOs than with the LTC home residents, revealing a sensitivity of 0.92 and a specificity of 0.87 in the GOs (cut-off score of ≥ 5), but a sensitivity of 100% and a specificity of 49% with the LTC home group (cut-off score of ≥ 8), when comparing only cognitively intact subjects. The negative predictive value (NPV) was very good for both groups, but the positive predictive value (PPV) for the GO group was much better than for those in the LTC group (83.3% vs. 31.2%). Seven uniform DIF items were found - 2 by gender and 4 by age. Cronbach’s alpha was higher for the GO group than for the LTC home residents. Factor analysis supported a two-factor solution, using the ‘depressed mood’ and ‘positive mood’ factors, which accounted for 46.55% of the total variance.

Conclusions

The TGDS-15 scale was effective at screening for MDD in elderly cognitively intact Thais, those in both GO and LTC settings, as the sensitivity and NPV were shown to be very good in both groups. However, in the LTC setting, the low specificity and PPV found leads to the need for a further assessment to be carried among the potentially depressed individuals, based on the GDS results. Taking the factor analytic study into account, a more suitable version of the GDS should be developed.

Validation of the Spanish Center for Epidemiological Studies Depression and Zung Self-Rating Depression Scales: a comparative validation study

BACKGROUND

Depressive disorders are leading contributors to burden of disease in developing countries. Research aiming to improve their diagnosis and treatment is fundamental in these settings, and psychometric tools are widely used instruments to support mental health research. Our aim is to validate and compare the psychometric properties of the Spanish versions of the Center for Epidemiological Studies Depression Scale (CES-D) and the Zung Self-Rating Depression Scale (ZSDS).

METHODOLOGY/PRINCIPAL FINDINGS

A Spanish version of the CES-D was revised by 5 native Spanish speaking psychiatrists using as reference the English version. A locally standardized Spanish version of the ZSDS was used. These Spanish versions were administered to 70 patients with a clinical diagnosis of DSM-IV Major Depressive Episode (MDE), 63 without major depression but with clinical diagnosis of other psychiatric disorders (OPD), and 61 with no evidence of psychiatric disorders (NEP). For both scales, Cronbach's alpha (C-α) and Hierarchical McDonald Omega for polychoric variables (MD-Ω) were estimated; and receiver operating characteristics (ROC) analysis performed. For the CES-D and ZSDS scales, C-α was 0.93 and 0.89 respectively, while MD-Ω was 0.90 and 0.75 respectively. The area under the ROC curve in MDE+OPD was 0.83 for CES-D and 0.84 for ZSDS; and in MDE+NEP was 0.98 for CES-D and 0.96 for ZSDS. Cut-off scores (co) for the highest proportions of correctly classified (cc) individuals among MDE+OPD were ≥29 for CES-D (sensitivity (ss) = 77.1/specificity (sp) = 79.4%/(cc) = 78.2%) and ≥47 for ZSDS (ss = 85.7%/sp = 71.4%/cc = 78.9%). In the MDE+NEP, co were ≥24 for the CES-D (ss = 91.4%/sp = 96.7%/cc = 93.9%) and ≥45 for the ZSDS (ss = 91.4%/sp = 91.8%/cc = 91.6%).

CONCLUSION

Spanish versions of the CES-D and ZSDS are valid instruments to detect depression in clinical settings and could be useful for both epidemiological research and primary clinical settings in settings similar as those of public hospitals in Lima, Peru.

Prevalence and correlates of suicidal thought and self-destructive behavior among an elderly hospital population in Iran

BACKGROUND

Few studies have examined suicidal ideation and behavior in hospitalized physically ill elderly patients, a group potentially at high risk. Our aim was to investigate the prevalence and risk factors for suicide ideation, and direct and indirect self-destructive behaviors among a sample of elderly inpatients.

METHODS

A cross-sectional study was conducted in 2009; 650 inpatients aged 60 years and over were screened from various medical services in teaching hospitals affiliated to Shiraz University of Medical Sciences in Iran. Suicidal ideation and behavior were measured with the Beck Scale for Suicidal Ideation (BSSI) and the Harmful Behavior Scale (HBS). Depression was measured with the Geriatric Depression Scale (GDS), medical burden with the geriatric version of the Cumulative Illness Rating Scale (CIRS-G), life events with the Paykel Life Event Scale, and social support with the Perceived Social Support Scale.

RESULT

Of the 650 patients screened with a mean age of 70.5 years (SD ± 7.5), 570 met inclusion criteria and of these 123 (21.6%) reported suicidal ideation on the BSSI and 80 (14.4%) had at least one self-destructive behavior included in the HBS. There was a significant correlation between suicide ideation and harmful behaviors (r = 0.503, p = 0.001). In a regression analysis, depressive symptoms, increased burden of medical conditions, marital status, history of substance use, history of traumatic life events, lack of perceived social support, and poor education were associated with both suicide ideation and harmful behavior. From demographic variables, living without a spouse and unemployment were predictors of suicidal ideation and behavior.

CONCLUSION

Hospitalized, physically ill elderly patients have high rates of suicidal ideation and self-destructive behavior and these vary according to psychosocial and clinical factors. The general hospital is therefore a potential site for the recognition of suicidal individuals and implementation of proximal suicide prevention strategies.

Predictors of postoperative movement and resting pain following total knee replacement

This study determined preoperative predictors of movement and resting pain following total knee replacement (TKR). We hypothesized that younger patients with higher preoperative pain intensity, pain sensitivity, trait anxiety, pain catastrophizing, and depression would be more likely to experience higher postoperative movement pain than older patients with lower scores on these variables prior to surgery, and that predictors would be similar for resting pain. Demographics, analgesic intake, anxiety, depression, pain catastrophizing, resting pain, movement pain (ie, during active knee range of motion), and quantitative sensory tests were performed preoperatively on 215 participants scheduled for a unilateral TKR. On postoperative day 2, analgesic intake, resting pain, and movement pain were again assessed. Significant predictors of moderate or severe movement pain were higher preoperative movement pain, von Frey pain intensity, and heat pain threshold. People with severe movement pain preoperatively were 20 times more likely to have severe movement pain postoperatively. When the influence of preoperative movement pain was removed, depression became a predictor. Significant predictors of moderate to severe resting pain were higher preoperative resting pain, depression, and younger age. These results suggest that patients with higher preoperative pain and depression are more likely to have higher pain following TKR, and younger patients may have higher resting pain. Cutaneous pain sensitivity predicted movement pain but not resting pain, suggesting that mechanisms underlying movement pain are different from resting pain. Aggressive management of preoperative pain, pain sensitivity, and depression prior to surgery may facilitate postoperative recovery.

Depressive symptoms and gait dysfunction in the elderly

OBJECTIVE

Assess the association between depressive symptoms (not meeting the criteria for major depression) and gait dysfunction in older adults.

DESIGN

Cross-sectional study.

SETTING

Einstein Aging Study, a community-based longitudinal aging study.

PARTICIPANTS

Six hundred ten nondemented and nondepressed community-residing adults age 70 and older.

MEASUREMENTS

Depressive symptoms measured using the 15-item Geriatric Depression Scale. To obtain a comprehensive assessment of gait, eight individual quantitative gait parameters were assessed: velocity (cm/s), stride length (cm), cadence (steps/min), swing phase (seconds), stance phase (seconds), double support phase (seconds), stride length variability (SD of stride length), and swing time variability (SD of swing time). Multiple linear regression analysis was applied to study the association of depressive symptoms with gait, adjusting for potential confounders including demographic variables, medical illnesses, and clinical gait abnormalities.

RESULTS

Increased level of depressive symptoms was associated with worse velocity, stride, and swing time variability. The relationship of the remaining five gait variables with depressive symptoms was not significant in the fully adjusted models.

CONCLUSIONS

Higher levels of depressive symptoms are associated with worse performance in specific quantitative gait variables in community-residing older adults.

Prevalence of major depressive disorders and suicide in long-term care facilities: a report from northern Thailand

BACKGROUND

Depression is a common mental illness among elderly Thais, but little is known about the occurrence of major depressive disorders (MDD) in long-term care (LTC) facilities. This study investigated the prevalence of MDD and suicide risk among residents in an LTC facility in northern Thailand.

METHODS

For this cross-sectional study, a care team conducted a screening program for MDD and suicide risk among LTC residents in 2011. The screening process used the Mini International Neuropsychiatric Interview, the Geriatric Depression Scale-15, the patient and caregiver versions of the Cornell Scale for Depression in Dementia, the Core Symptom Index and the Mini Mental State Examination.

RESULTS

In total, 81 (of 113) residents participated in the study. The mean age was 76.96 ± 7.17 years old (range, 63-94), and 55.6% of participants were women. With the Mini Mental State Examination, 40.7% were found to have cognitive impairment, and with the Mini International Neuropsychiatric Interview, 23.5% met the criteria for current major depressive episodes. Though the majority was in the low-risk group, 26 residents (32.1%) were reported as being at risk of suicide. The patient and caregiver versions of the Cornell Scale for Depression in Dementia, the Geriatric Depression Scale-15 and the Core Symptom Index proved useful for predicting major depressive episodes among the residents (P < 0.001, P = 0.004, P = 0.001 and P < 0.001, respectively), including those with cognitive impairment (P = 0.006, P = 0.020, P = 0.049 and P = 0.012, respectively).

CONCLUSIONS

Nearly one-quarter of LTC facility residents were found to suffer from MDD, and a suicide risk was reported for one-third, though most of the cases were in the low-risk category. Further studies with a larger sample size are recommended to make these findings more precise and universally applicable.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.