The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity study

Prevalence and incidence of delirium in long-term care

OBJECTIVES

(1) To describe the prevalence and 6-month incidence of delirium in long-term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics.

METHODS

A multisite, prospective observational study was conducted in seven LTCFs in the province of Quebec, Canada. Residents of age 65 and over were recruited into two cohorts: Cohort A with a Mini-Mental State Examination (MMSE) score of 10 or more and Cohort B with an MMSE score of less than 10. Baseline resident measurements were obtained from research resident assessments, nurse interviews, and chart review. Weekly resident assessments for up to 24 weeks included the Confusion Assessment Method (CAM).

RESULTS

Two hundred seventy-nine residents were recruited and completed baseline delirium assessments: 204 in Cohort A and 75 in Cohort B. The prevalence of delirium at baseline was 3.4% in Cohort A and 33.3% in Cohort B. The incidence of delirium among those without delirium at baseline (per 100 person-weeks of follow-up) was 1.6 in Cohort A and 6.9 in Cohort B. In multivariate analyses, a diagnosis of dementia, moderate to severe cognitive impairment, and depressive symptoms at baseline were associated with a greater prevalence and incidence of delirium.

CONCLUSION

Delirium is an important clinical problem in LTCF residents, particularly among those with moderate to severe cognitive impairment at baseline.

The effectiveness of music listening in reducing depressive symptoms in adults: a systematic review

OBJECTIVES

We aim to review trials of the effectiveness of music listening in reducing depressive symptoms in adults, and identify areas requiring further study.

BACKGROUND

Little is known about the efficacy of music listening in the mediation of depressive symptoms.

METHODS

We systematically search 9 databases and reviewed 17 studies included randomized controlled and quasi-experimental trails of music listening in reducing depressive symptoms in adults. The Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument was used for quality assessment of included studies.

RESULTS

Music listening over a period of time helps to reduce depressive symptoms in the adult population. Daily intervention does not seem to be superior over weekly intervention and it is recommended that music listening session be conducted repeatedly over a time span of more than 3weeks to allow an accumulative effect to occur.

CONCLUSIONS

All types of music can be used as listening material, depending on the preferences of the listener. So, it is recommended that the listeners are given choices over the kind of music which they listen to. There is a need to conduct more studies, which replicate the designs used in the existing studies that met the inclusion criteria, on the level of efficacy of music listening on the reduction of depressive symptoms for a more accurate meta-analysis of the findings and reflect with greater accuracy the significant effects that music has on the level of depressive symptoms.

The structure and validity of self-reported affect in mild cognitive impairment and mild Alzheimer's disease

BACKGROUND

This study determined the reliability, validity, and factor structure of self-report emotions in persons with mild Alzheimer's disease (AD) and mild cognitive impairment (MCI) relative to controls.

METHODS

Participants (mild AD, n = 73; MCI, n = 159; controls, n = 96) rated current emotions with the Visual Analogue Mood Scales (Stern, 1997).

RESULTS

Internal consistency reliabilities were comparable across groups, as were the factor structures of emotion. Persons with AD reported more negative affect (NA) than persons with MCI and controls. The emotion that most differentiated groups was confusion. NA and PA may be more bipolar in persons with AD than for persons with MCI and controls.

CONCLUSIONS

The underlying structure of affect was similar in persons with mild AD, MCI, and controls. Further, persons with MCI appeared to be "transitional" between cognitive health and dementia with regard to mood and affect. That is, participants with MCI tended to have affect scores that were intermediate between those with AD and controls. Implications for interventions to improve emotional well-being in AD and MCI are discussed.

The Collateral Source version of the Geriatric Depression Scale: evaluation of psychometric properties and discrepancy between collateral sources and patients with dementia in reporting depression

BACKGROUND

Depression is under-diagnosed and under-treated in older adults. The purposes of this study were to (a) evaluate the psychometric properties of the Collateral Source Geriatric Depression Scale (CS-GDS), (b) compare collateral source scores on the CS-GDS with patient scores on the GDS, and (c) examine factors associated with any discrepancies between the CS-GDS and the GDS.

METHODS

This secondary analysis used data from 132 older adults and their collateral sources attending a geriatric assessment program over a 15-month period. Scores on the 30-, 15-, and 5-item CS-GDS were compared to clinician diagnoses of depression using DSM-IV-TR criteria and patient GDS scores.

RESULTS

The three forms of the CS-GDS had acceptable internal consistency, sensitivity and specificity with recommended cut-off scores of 18, 9 and 3, respectively. Collateral sources reported more depressive symptoms than patients did themselves. Simple regression analysis showed that caregiver burden significantly influenced the discrepancy between CS-GDS scores and GDS scores (β = 0.147; p = 0.004). Functional limitations and collateral relations to the patient were not associated with these discrepancies.

CONCLUSION

All three collateral versions had acceptable psychometric properties, which supports the use of the CS-GDS to assess depression in older adults. The CS-GDS provides an important alternative for depression screening with older adults who cannot complete screening tools themselves; however, alternative cut-off scores must be used for high sensitivity and specificity.

Factors associated with delirium severity among older persons with dementia

Delirium is a common cause of functional and cognitive decline, morbidity, and mortality among hospitalized elderly individuals. Several studies reveal that the prognosis of delirium is worse among elderly individuals with severe delirium. In light of these findings, it is important to identify which factors are associated with delirium severity: individual (predisposing) or environmental (precipitating) factors. This study wanted to investigate individual and environmental factors associated with delirium severity among older persons with delirium superimposed on dementia. This study is a secondary analysis of a cross-sectional study (N = 71) on delirium carried out in three long-term care facilities and one long-term care unit of a large regional hospital. Of the 29 potential risk factors considered, researchers found 6 to be significantly associated with delirium severity in univariate analysis: marital status (being married), severity of dementia, lower functional autonomy, less medication consumption, presence of behavioral problems, and inadequacy of the physical environment. In multivariate analysis, only marital status (being married) and severity of dementia remained statistically associated with delirium severity. Results of this study provide further evidence that the weakened brain functions of persons with dementia increases not only the risk of delirium but also its severity. Given the poor outcomes associated with delirium severity, nurses need to pay closer attention to the predisposing and precipitating factors of delirium severity.

Act In case of Depression: the evaluation of a care program to improve the detection and treatment of depression in nursing homes. Study Protocol

BACKGROUND

The aim of this study is evaluating the (cost-) effectiveness of a multidisciplinary, evidence based care program to improve the management of depression in nursing home residents of somatic and dementia special care units. The care program is an evidence based standardization of the management of depression, including standardized use of measurement instruments and diagnostical methods, and protocolized psychosocial, psychological and pharmacological treatment.

METHODS/DESIGN

In a 19-month longitudinal controlled study using a stepped wedge design, 14 somatic and 14 dementia special care units will implement the care program. All residents who give informed consent on the participating units will be included. Primary outcomes are the frequency of depression on the units and quality of life of residents on the units. The effect of the care program will be estimated using multilevel regression analysis. Secondary outcomes include accuracy of depression-detection in usual care, prevalence of depression-diagnosis in the intervention group, and response to treatment of depressed residents. An economic evaluation from a health care perspective will also be carried out.

DISCUSSION

The care program is expected to be effective in reducing the frequency of depression and in increasing the quality of life of residents. The study will further provide insight in the cost-effectiveness of the care program.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1477.

Quality of life of residents with dementia in long-term care settings in the Netherlands and Belgium: design of a longitudinal comparative study in traditional nursing homes and small-scale living facilities

BACKGROUND

The increase in the number of people with dementia will lead to greater demand for residential care. Currently, large nursing homes are trying to transform their traditional care for residents with dementia to a more home-like approach, by developing small-scale living facilities. It is often assumed that small-scale living will improve the quality of life of residents with dementia. However, little scientific evidence is currently available to test this. The following research question is addressed in this study: Which (combination of) changes in elements affects (different dimensions of) the quality of life of elderly residents with dementia in long-term care settings over the course of one year?

METHODS/DESIGN

A longitudinal comparative study in traditional and small-scale long-term care settings, which follows a quasi-experimental design, will be carried out in Belgium and the Netherlands. To answer the research question, a model has been developed which incorporates relevant elements influencing quality of life in long-term care settings. Validated instruments will be used to evaluate the role of these elements, divided into environmental characteristics (country, type of ward, group size and nursing staff); basic personal characteristics (age, sex, cognitive decline, weight and activities of daily living); behavioural characteristics (behavioural problems and depression); behavioural interventions (use of restraints and use of psychotropic medication); and social interaction (social engagement and visiting frequency of relatives). The main outcome measure for residents in the model is quality of life. Data are collected at baseline, after six and twelve months, from residents living in either small-scale or traditional care settings.

DISCUSSION

The results of this study will provide an insight into the determinants of quality of life for people with dementia living in traditional and small-scale long-term care settings in Belgium and the Netherlands. Possible relevant strengths and weaknesses of the study are discussed in this article.

TRIAL REGISTRATION

ISRCTN: ISRCTN23772945.

Development of a composite pain measure for persons with advanced dementia: exploratory analyses in self-reporting nursing home residents

CONTEXT

Experts agree that pain assessment in noncommunicative persons requires data from sources that do not rely on self-report, including proxy reports, health history, and observation of pain behaviors. However, there is little empirical evidence to guide clinicians in weighting or combining these sources to best approximate the person's experience.

OBJECTIVES

The aim of this exploratory study was to identify a combination of observer-dependent pain indicators that would be significantly more predictive of self-reported pain intensity than any single indicator. Because self-reported pain is usually viewed as the criterion measure for pain, self-reported usual and worst pains were the dependent variables.

METHODS

The sample consisted of 326 residents (mean age: 83.2 years; 69% female) living in one of 24 nursing homes. Independent variables did not rely on self-report: surrogate reports from certified nursing assistants (CNAs) using the Iowa Pain Thermometer (IPT), Checklist of Nonverbal Pain Indicators (CNPI), Cornell Scale for Depression in Dementia (CSDD), Pittsburgh Agitation Scale (PAS), number of painful diagnoses, and Minimum Data Set (MDS) pain variables.

RESULTS

In univariate analyses, the CNA IPT scores were correlated most highly with self-reported pain. The final multivariate model for self-reported usual pain included CNA IPT, CSDD, PAS, and education; this model accounted for only 14% of the variance. The more extensive of the two final models for worst pain included MDS pain frequency, CSDD, CNA IPT, CNPI, and age (R(2)=0.14).

CONCLUSION

Additional research is needed to develop a predictive pain model for nonverbal persons.

Can older adults with dementia accurately report depression using brief forms? Reliability and validity of the Geriatric Depression Scale

The Geriatric Depression Scale (GDS) is a commonly used screening tool, but its use in older adults with cognitive impairment has been controversial. This study compared the short forms of the GDS with clinician diagnosis of depression using standard criteria (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision) in people with and without dementia. Sensitivity and specificity were acceptable for all forms of the GDS. These results build evidence for using the short GDS 5- and 15-item versions in populations that include people with mild to moderate dementia, increasing the ease of depression screening so it can be performed more frequently in clinical settings.

Cognitive impairment and depression among Chinese nonagenarians/centenarians

PURPOSE

In this study, we explored the association between cognitive impairment and depression in the very elderly using a sample aged 90-108 years.

METHODS

A cross-sectional study.

RESULTS

The sample included 682 unrelated Chinese nonagenarians/centenarians (67.25% women, mean age of 93.49 years). The mean depression score (measured with the brief 23-item Geriatrics Depression Scale-Chinese Edition was 8.45 (standard deviation [SD] = 3.30). The mean of cognitive function scores (measured with the 30-item Mini-Mental State Examination) was 15.54 (SD = 5.38). There was no significant difference in cognitive function scores between subjects with and without depression, and there was also no significant difference in depression scores between subjects with and without cognitive impairment. There was also no significant difference in the frequency of depression between subjects with and without cognitive impairment or in the frequency of cognitive impairment between subjects with and without depression. Both the odds ratio (OR) of depression (as a function of increased cognitive impairment) and the OR of cognitive impairment (as a function of increased depression) were found to be insignificant. Pearson Correlation also showed no significant correlation between depression scores and cognitive function scores.

CONCLUSIONS

In summary, we found that depression was not directly correlated with cognitive impairment in Chinese nonagenarians and centenarians.

Examination of the multifactorial model of delirium among long-term care residents with dementia

The multifactorial model of delirium was developed to explain the interrelationship between predisposing and precipitating factors for delirium. Although validated among hospitalized patients, this model has never been tested among long-term care residents with dementia. We undertook this secondary data analysis to investigate the combined effect of predisposing and precipitating factors on the likelihood of having delirium among this population. Delirium was defined as meeting the Confusion Assessment Method criteria for definite or probable delirium. Risk factors considered in the study were those found significantly associated with delirium in the original study. Participants (N=155) were classified into risk groups. Prevalence of delirium for the low, moderate, and high predisposing risk groups were 32%, 78.4%, and 98.1%, respectively, and 37.9%, 67.2%, and 86.8% for the precipitating factors risk groups. When both variables were included in the same model, only predisposing factors remained statistically associated with delirium. Predisposing factors play a key role in the likelihood of having delirium among this population. Increased awareness of these factors among nurses could improve the care of these residents by targeting modifiable risk factors.

A systematic review on the effectiveness of music listening in reducing depressive symptoms in adults

BACKGROUND

The use of pharmacotherapy in the treatment of depressive symptoms has its disadvantages, therefore various complementary treatments have been sought and included to reduce depressive symptoms. The use of music as a healing intervention has been well documented throughout history. Even though there are many benefits to the use of music as a potential intervention, little is known about the efficacy of music listening in the mediation of depressive symptoms.

OBJECTIVES

The objective of this review was to determine the effectiveness of music listening in reducing depressive symptoms in adults.

INCLUSION CRITERIA

Types of participants This review included studies on adult men and women (aged 18 years and above) with depression or depressive symptoms.Types of intervention The review focused on studies that investigated music listening as an intervention for depressive symptoms.Types of outcomes The primary outcome measures examined were changes in depressive symptoms as quantified via validated depression scale scores.Types of studies Randomised controlled trials, quasi-experimental studies, interrupted time series (ITSs) and controlled before and after designs were included.

SEARCH STRATEGY

A literature search ranging from the 1989 to January 2010, was conducted using major electronic databases. A three-stage search strategy was utilized in the process of the search to ensure that all studies that met the inclusion criteria were included.

METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers using the critical appraisal checklists for experimental studies from the JBI-MAStARI (Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument).

DATA EXTRACTION/DATA SYNTHESIS

Data were extracted from included papers using the standardized extraction tool from the JBI -MAStARI. Quantitative data were grouped together and combined into a meta-analysis for the assessment of the overall efficacy of an intervention were appropriate. Narrative formats were used when meta-analysis was not appropriate.

CONCLUSIONS

From the overall results, the evidence offers some support that music listening over a period of time helps to reduce depressive symptoms in the adult population.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR RESEARCH: There is a need to conduct more studies, which replicate the designs used in the existing studies that met the inclusion criteria, on the level of efficacy of music listening on the reduction of depressive symptoms for a more accurate meta-analysis of the findings and reflect with greater accuracy the significant effects that music has on the level of depressive symptoms.

Assessing depression outcome in patients with moderate dementia: sensitivity of the HoNOS65+ scale

To date, there is no widely accepted clinical scale to monitor the evolution of depressive symptoms in demented patients. We assessed the sensitivity to treatment of a validated French version of the Health of the Nation Outcome Scale (HoNOS) 65+ compared to five routinely used scales. Thirty elderly inpatients with ICD-10 diagnosis of dementia and depression were evaluated at admission and discharge using paired t-test. Using the Brief Psychiatric Rating Scale (BPRS) "depressive mood" item as gold standard, a receiver operating characteristic curve (ROC) analysis assessed the validity of HoNOS65+F "depressive symptoms" item score changes. Unlike Geriatric Depression Scale, Mini Mental State Examination and Activities of Daily Living scores, BPRS scores decreased and Global Assessment Functioning Scale score increased significantly from admission to discharge. Amongst HoNOS65+F items, "behavioural disturbance", "depressive symptoms", "activities of daily life" and "drug management" items showed highly significant changes between the first and last day of hospitalization. The ROC analysis revealed that changes in the HoNOS65+F "depressive symptoms" item correctly classified 93% of the cases with good sensitivity (0.95) and specificity (0.88) values. These data suggest that the HoNOS65+F "depressive symptoms" item may provide a valid assessment of the evolution of depressive symptoms in demented patients.

Validity of the Cornell scale for depression in dementia in Parkinson's disease with and without cognitive impairment

Valid tools are needed to assess depression across the spectrum of cognitive impairment in Parkinson's disease (PD). The validity of the Cornell scale for depression in dementia (CSDD) was tested in a PD sample with a range of cognitive impairment. Psychiatric diagnoses were established according to DSM-IV-TR. Receiver operating characteristic curves tested the discriminant validity of the CSDD compared to the clinical diagnoses of major and minor depression. The curve for symptomatic depression had an area under the curve of 0.82. For the cut-off score >or= 6, sensitivity was 0.83 and specificity was 0.73; for the cut-off score >or= 8, sensitivity was 0.75 and specificity was 0.82. There was no evidence for differential measurement with respect to cognitive impairment or any other demographic or clinical variables. This study suggests that the CSDD is a valid tool for identifying depressive disorders in patients with PD across a spectrum of cognitive impairment.

Predisposing factors associated with delirium among demented long-term care residents

This was a cross-sectional study to investigate predisposing factors associated with delirium among demented long-term-care residents and to assess the cumulative effect of these factors on the likelihood of having delirium. Of the 155 participants, 109 (70.3%) were found delirious according to the confusion assessment method. Among these individuals, age (OR = 1.07; 95% CI = 1.05-1.10) and severity of dementia (OR = 1.05; 95% CI = 1.03-1.07) were the most associated factors of delirium. The likelihood of being in delirium increased with the number of associated predisposing factors present (OR = 1.67; 95% CI = 1.11-2.51). Associated factors identified were level of functional autonomy, pain, depression, behavioral disturbances, number of medications, dehydration, fever, and malnutrition. Identification of predisposing factors will help nurses in detecting those residents in long-term care settings who are at high-risk for delirium, as well as in designing preventive intervention strategies for delirium, based on these factors.

Is the geriatric depression scale a reliable screening tool for depressive symptoms in elderly patients with cognitive impairment?

OBJECTIVE

To determine the reliability of the 30-item Geriatric Depression Scale (GDS-30) for the screening of depressive symptoms in dementia and mild cognitive impairment (MCI) using the Cornell Scale for Depression in Dementia (CSDD) as the 'gold standard'.

METHODS

Diagnosed according to strictly applied clinical diagnostic criteria, patients with MCI (n = 156) and probable Alzheimer's disease (AD) (n = 247) were included. GDS-30, CSDD, Mini Mental State Examination (MMSE) and Global Deterioration Scale were assessed in all patients at inclusion. The AD group was divided in three subgroups: mild AD (MMSE>or=18) (n = 117), moderate AD (MMSE< 18 and >or=10) (n = 89) and severe AD (MMSE<10) (n = 38).

RESULTS

In MCI patients, moderate but highly significant correlations were found between GDS-30 and CSDD scores (Pearson: r = 0.565; p < 0.001). In mildly (r = 0.294; p = 0.001), moderately (r = 0.273; p = 0.010) and severely (r = 0.348; p = 0.032) affected AD patients, only weak correlations between GDS-30 and CSDD scores were calculated. ROC curve analysis showed that sensitivity and specificity values of respectively 95% and 67% were achieved when a GDS-30 cut-off score of 8 was applied in MCI patients. In AD patients, too low sensitivity and specificity values did not allow selecting an optimal cut-off score by means of ROC curve analysis.

CONCLUSION

Using the CSDD as 'gold standard', we demonstrated that the GDS-30 is a reliable screening tool for depressive symptoms in MCI but not in AD patients.

Psychotropic medication use and cognition in institutionalized older adults with mild to moderate dementia

BACKGROUND

Most studies examining psychotropic medication use on cognition in older persons with dementia include measures of global cognitive function. The present study examined the relationship between different types of psychotropic medication and specific cognitive functions in older people with dementia.

METHODS

Two hundred and six institutionalized older adults with dementia (180 women, mean age 85 years) were administered neuropsychological tests. Psychotropic medication use was extracted from their medical status and categorized as: sedatives, antidepressants and antipsychotics.

RESULTS

Analysis of covariance revealed that psychotropic consumers, and particularly those who used antipsychotics, performed worse on neuropsychological tests of executive/attentional functioning than non-consumers. There were no differences between consumers of other classes of psychotropic drugs and non-consumers. The number of psychotropic drugs used was inversely related to executive/attentional functioning.

CONCLUSIONS

These findings show that in institutionalized older adults with dementia, specific impairment of cognitive function, i.e. executive/attentional impairments, are associated with antipsychotic medication use. Future longitudinal studies are recommended.

Applications of Preference Assessment Procedures in Depression and Agitation Management in Elders with Dementia

Low levels of engagement with leisure activities are commonly seen in older adults with dementia and may lead to decreased social contact, depressed affect, and agitated behaviors. Adults with dementia often have difficulty choosing activities when asked directly about preferences due to cognitive decline, which makes it more difficult to increase their engagement levels. However, simply presenting leisure items without prior knowledge of preferences may be inefficient and may not yield desired results. Long-term care staff need more structured and efficient ways to determine individual preferences and preference assessments (structured choice making opportunities) may offer a solution. Preference assessments have been used to identify effective reinforcers for both individuals with developmental disabilities and older adults with dementia and can provide staff with a brief method for identifying enjoyable activities. This study examined the utility of using stimuli (identified from preference assessments) in behavioral management protocols with 11 elders (mean age = 85.6 years) with dementia in a long-term care setting. Behavioral outcomes of depression and agitation were evaluated at baseline and throughout the intervention. Results indicated positive improvement in behavioral symptoms in 8 of 11 participants. The utility of using preferred items in behavioral management protocols was supported for reducing agitated behaviors but was only partially supported for decreasing depressive symptoms in individuals with dementia.

Dissociations in visual attention deficits among persons with mild cognitive impairment

Impairments in visual attention and visual information processing have been identified as part of the neuropsychological features of Alzheimer's disease (AD), even in its earliest stages. There is increasing recognition that these deficits may be selective rather than global, with some attentional subtypes being more vulnerable than others. The few studies that have investigated attentional deficits in mild cognitive impairment (MCI), a putatively prodromal phase of AD, have not satisfactorily addressed the possible selectivity in attentional deficits in MCI. This study examined potential dissociations in visual attention deficits in MCI using a measure that assesses simple, divided, and selective attention. The results indicated a hierarchy of attentional impairments, with divided attention being the most affected and simple attention the least. Among participants with MCI, 53% showed evidence of impairment in divided attention compared to 19% of controls (OR = 4.81, p < .001). Poorer visual attention was also associated with poorer overall cognitive status. The implications of these findings for early identification of MCI, prevention of functional decline in MCI, and delay/reversal of cognitive degradation in MCI are discussed.

Diagnosing depression in Alzheimer disease with the national institute of mental health provisional criteria

OBJECTIVE

To compare the rates of depression in Alzheimer Disease (AD) determined using National Institute of Mental Health (NIMH) provisional criteria for depression in AD (NIMH-dAD) to those determined using other established depression assessment tools.

DESIGN

Descriptive longitudinal cohort study.

SETTING

The Alzheimer's Disease Research Centers of California.

PARTICIPANTS

A cohort of 101 patients meeting NINDS-ADRDA criteria for possible/probable AD, intentionally selected to increase the frequency of depression at baseline.

MEASUREMENTS

Depression was diagnosed at baseline and after 3 months using NIMH-dAD criteria and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders. Depressive symptoms also were assessed with the Cornell Scale for Depression in Dementia (CSDD), the Geriatric Depression Scale (GDS), and the Neuropsychiatric Inventory Questionnaire.

RESULTS

The baseline frequency of depression using NIMH-dAD criteria (44%) was higher than that obtained using DSM-IV criteria for major depression (14%; Z = -5.50, df = 101, p <0.001) and major or minor depression (36%; Z = -2.86, df = 101, p = 0.021) or using established cut-offs for the CSDD (30%; Z = -2.86, df = 101, p = 0.004) or GDS (33%; Z = -2.04, df = 101, p = 0.041). The NIMH-dAD criteria correctly identified all patients meeting DSM-IV criteria for major depression, and correlated well with DSM-IV criteria for major or minor depression (kappa = 0.753, p <0.001), exhibiting 94% sensitivity and 85% specificity. The higher rates of depression found with NIMH-dAD criteria derived primarily from its less stringent requirements for the frequency and duration of symptoms. Remission rates at 3 months were similar across instruments.

CONCLUSIONS

The NIMH-dAD criteria identify a greater proportion of AD patients as depressed than several other established tools.

Differential item functioning of the Geriatric Depression Scale in an Asian population

BACKGROUND

The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore.

METHODS

The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF.

RESULTS

We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless.

LIMITATIONS

The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses.

CONCLUSIONS

In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

Depression in long-term care

OBJECTIVES

To review the diagnosis and treatment of depressive disorders in long-term care settings.

METHODS

A review of the literature on the diagnosis and treatment of depression in long-term care.

RESULTS

Up to 35% of residents in long-term care facilities may experience either major depression or clinically significant depressive symptoms. These symptoms are often not recognized for at least 2 reasons: depression is not the focus of physicians and nursing personnel and depression is frequently comorbid with other problems that are common in long-term care, such as cognitive impairment, medical illness, and functional impairment. Nevertheless, depression, once diagnosed, can be treated effectively in the nursing home setting. The foundation of treatment is pharmacotherapy, yet other therapeutic approaches, such as exercise and psychological therapies may be of value.

CONCLUSION

Depression, although often unrecognized in long-term care, is a treatable condition and deserves the attention of the entire medical and nursing staff.

Detection of delirium by nurses among long-term care residents with dementia

Background

Delirium is a prevalent problem in long-term care (LTC) facilities where advanced age and cognitive impairment represent two important risk factors for this condition. Delirium is associated with numerous negative outcomes including increased morbidity and mortality. Despite its clinical importance, delirium often goes unrecognized by nurses. Although rates of nurse-detected delirium have been studied among hospitalized older patients, this issue has been largely neglected among demented older residents in LTC settings. The goals of this study were to determine detection rates of delirium and delirium symptoms by nurses among elderly residents with dementia and to identify factors associated with undetected cases of delirium.

Methods

In this prospective study (N = 156), nurse ratings of delirium were compared to researcher ratings of delirium. This procedure was repeated for 6 delirium symptoms. Sensitivity, specificity, positive and negative predictive values were computed. Logistic regressions were conducted to identify factors associated with delirium that is undetected by nurses.

Results

Despite a high prevalence of delirium in this cohort (71.5%), nurses were able to detect the delirium in only a minority of cases (13%). Of the 134 residents not identified by nurses as having delirium, only 29.9% of them were correctly classified. Detection rates for the 6 delirium symptoms varied between 39.1% and 58.1%, indicating an overall under-recognition of symptoms of delirium. Only the age of the residents (≥ 85 yrs) was associated with undetected delirium (OR: 4.1; 90% CI: [1.5–11.0]).

Conclusion

Detection of delirium is a major issue for nurses that clearly needs to be addressed. Strategies to improve recognition of delirium could result in a reduction of adverse outcomes for this very vulnerable population.

Melatonin for cognitive impairment

BACKGROUND

There are a number of studies that suggest a relationship between decline of melatonin function and the symptoms of dementia.

OBJECTIVES

The review assessed the evidence of clinical efficacy and safety of melatonin in the treatment of manifestations of dementia or cognitive impairment (CI).

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched for trials involving melatonin on 5 October 2005. The search terms used were MELATONIN, and N-ACETYL-5-METHOXYTRYPTAMINE. This Register contains records from all major health care databases as well as many ongoing trials databases and is updated regularly.

SELECTION CRITERIA

All relevant, randomized controlled trials in which orally administered melatonin in any dosage was compared with a control group for the effect on managing cognitive, behavioural (excluding sleep), and/or affective disturbances of people with dementia of any degree of severity.

DATA COLLECTION AND ANALYSIS

Two to three reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected studies. Statistically significant differences in changes in outcomes from baseline to end of treatment between the melatonin and control groups were examined. Each study was summarized using a measure of effect (e.g. mean difference) and meta-analyses were conducted when appropriate.

MAIN RESULTS

Three studies met the inclusion criteria. This review revealed non-significant effects from the pooled estimates of MMSE cognitive, and ADAS-cognitive change scores. Individual study estimates for treatment effect demonstrated a significant improvement for melatonin compared with placebo in behavioural and affective symptoms as measured by the ADAS non-cognitive scale in a study of 20 patients, and the Neuropsychiatric Inventory (NPI) following treatment with 2.5 mg/day (SR) melatonin, but not with 10mg/day (IR) melatonin in a larger study of 157 patients. The remainder of the treatment effects for affect, behaviour and activities of daily living were non-significant.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the effectiveness of melatonin in managing the cognitive and non-cognitive sequelae of dementia.