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

The prevalence of, and factors associated with, a risk of depression in residential aged care services residents: Findings from the FIRST study

OBJECTIVES

Depression is common amongst Australian residential aged care services (RACS) residents. This study aimed to estimate the risk of depression amongst residents and identify factors associated with this risk. In care settings such as RACS, time-efficient screening tools to identify depression risk may be a preferred tool.

METHODS

The two-item Patient Health Questionnaire (PHQ-2), derived from the nine-item PHQ-9 used commonly in the United States (US), was employed in this study. A resident was identified as being at risk of depression where the score was ≥3. Multivariable logistic regression analysis was used to identify independent factors associated with being at risk of depression.

RESULTS

Residents' mean age was 87.7 (standard deviation: 7.3) years and 73% were female. One-fifth of residents (n = 108 or 20%) were at risk of depression. Age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99); Pain Assessment in Advanced Dementia (PAINAD) score (OR 1.55, 95% CI 1.11-2.16); Epworth Sleepiness Scale (ESS) score (OR 1.08, 95% CI 1.03-1.13); and 38-item Frailty Index (FI) score (OR 1.07, 95% CI 1.03-1.10) were significantly associated with being at risk of depression, whilst sex, urinary incontinence, polypharmacy, Dementia Severity Rating Scale (DSRS) and Nursing Home Life Space Diameter (NHLSD) score were not.

CONCLUSIONS

One in five residents were at risk of depression. Younger age, higher pain, higher daytime sleepiness and higher frailty status were associated with depressive risk. Future studies focusing on interventions targeting these factors may contribute to improved health outcomes.

PsyNBIOsis: Investigating the Association between Maternal Gestational Diabetes, Mental Health, Diet and Childhood Obesity Risk: Protocol for a Prospective, Longitudinal, Observational Study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with poorer maternal mental health (depression and anxiety). Maternal mental health and GDM are likely to influence diet, which in turn impacts the course of GDM. Maternal diet may also be directly or indirectly associated with changes in infant anthropometry. The aims of this study are to (1) examine the associations between maternal GDM, mental health and diet, and (2) evaluate the associations between these maternal factors, breastmilk composition and infant anthropometry.

METHODS

This prospective, observational, longitudinal cohort study compares a cohort of women with and without GDM. Maternal mental health and diet are assessed using validated questionnaires. Breastmilk composition is measured with the Human Milk Analyzer, and infant body composition is measured with air displacement plethysmography.

SIGNIFICANCE AND IMPACT

Once data have been collected, PsyNBIOsis will provide evidence for the associations between maternal mental health, GDM status and diet, and their impact on breastmilk composition and early infant growth. The results may inform the Developmental Origins of Health and Disease framework and provide data on which to build cost-effective interventions to prevent both the development of mental health issues in mothers and adverse growth patterns in infants.

Depression risk among community-dwelling older people is associated with perceived COVID-19 infection risk: effects of news report latency and focusing on number of infected cases

Awareness of COVID-19 infection risk and oscillation patterns ('waves') may affect older people's mental health. Empirical data from populations experiencing multiple waves of community outbreaks can inform guidance for maintaining mental health. This study aims to investigate the effects of COVID-19 infection risk and oscillations on depression among community-dwelling older people in Hong Kong.

A rolling cross-sectional telephone survey method was used. Screening for depression risk was conducted among 8,163 older people (age ≥ 60) using the Patient Health Questionnaire-2 (PHQ-2) from February to August 2020. The relationships between PHQ-2, COVID-19 infection risk proxies - change in newly infected cases and effective reproductive number (R_t), and oscillations - stage of a 'wave' reported in the media, were analysed using correlation and regression.

8.4% of survey respondents screened positive for depression risk. Being female (β = .08), having a pre-existing mental health issue (β = .21), change in newly infected cases (β = .05), and screening during the latency period before the media called out new waves (β = .03), contributed to higher depression risk (R² = .06, all p <.01).

While depression risk does not appear alarming in this sample, our results highlight that older people are sensitive to reporting of infection, particularly among those with existing mental health needs. Future public health communication should balance awareness of infection risks with mental health protection.

Which of the Cornell Scale for Depression in Dementia or the Geriatric Depression Scale is more useful to screen for depression in older adults?

BACKGROUND

Depression in older adults is a major disorder that can be triggering, exacerbating, or co-occurring with dementia symptoms.

AIM

This study compared the diagnostic accuracy of the Cornell Scale for Depression in Dementia (CSDD) and the Geriatric Depression Scale (GDS), a depression screening tool developed for older adults.

METHODS

Electronic searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycINFO databases using the following keywords: dementia, depression, and CSDD.

RESULTS

The pooled sensitivity of the CSDD and the GDS was 0.89 and 0.82, the pooled specificity was 0.88 and 0.85, and the summary receiver operating characteristic (SROC) curve was 0.94 and 0.91, respectively. In the subgroup analysis, the CSDD had the highest accuracy in the pooled sensitivity of 0.91, the pooled specificity of 0.87, and the sROC curve of 0.95 in the dementia group, and the GDS was the best in the non-dementia group at 0.88, 0.82, and 0.93, respectively.

CONCLUSIONS

The CSDD showed high diagnostic accuracy in older adults with dementia, and the GDS in older adults without dementia.

Predictive validity of the Cornell Scale for depression in dementia among older adults with and without dementia: A systematic review and meta-analysis

This review analyzes the predictive validity of the Cornell Scale for Depression in Dementia (CSDD), considering cognitive function. Electronic searches were performed using MEDLINE, EMBASE, CINAHL, and PsycINFO databases. Overall, 20 studies were reviewed, including 3,499 older adults, with and without dementia, who satisfied the selection criteria. Participants were stratified into the dementia, non-dementia, and mixed groups, and the diagnostic performance of the CSDD was assessed using receiver operating characteristic (ROC) curves. In the dementia and non-dementia groups, the area under the curve was ≥ 0.9, confirming high accuracy of the test. The pooled sensitivity was the highest in the dementia group (0.87), followed by the mixed group (0.84) and non-dementia group (0.82). In the subgroup analysis based on the Mini-Mental State Examination (MMSE), the ROC curve was 0.90 for older adults with MMSE scores < 15 and 0.87 for those with an MMSE score ≥ 15. Therefore, the CSDD can be considered excellent tool for assessing depression in all older adults, although its predictive ability is better for older adults with dementia compared to that in those without dementia. It can be used as a first-line screening tool for depression, regardless of cognitive function.

Detecting depression in persons living in long-term care: a systematic review and meta-analysis of diagnostic test accuracy studies

OBJECTIVE

Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings.

METHODS

We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias.

RESULTS

We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%-76.5%), specificity was 76.5% (95% CI 62.9%-86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%-90.0%) for persons in LTC living with dementia.

CONCLUSIONS

There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses.

Mental health and its associations with weight in women with gestational diabetes mellitus. A prospective clinical cohort study

OBJECTIVE

Despite the prevalence of depression in women with gestational diabetes mellitus (GDM) and the relationship between mental health (depression and well-being) and metabolic health, little is known about mental health or its metabolic impact in GDM pregnancy. This prospective clinical cohort study aimed to investigate associations between 1) well-being and depression, and 2) mental health and weight/weight gain in women with GDM.

METHODS

We included 334 pregnant women with GDM treated at a Swiss University Hospital between January 2016 and December 2018. They completed two self-report questionnaires: The World Health Organization well-being index (WHO-5) at the first (29 weeks of gestation) and last (36 weeks of gestation) GDM visits during pregnancy and the Edinburgh Postnatal Depression Scale (EPDS) at the first GDM visit. A cut-off of ≥11 was selected for this questionnaire to indicate the presence of elevated depression scores.

RESULTS

There was an inverse association between the well-being and depression total scores at the first GDM visit during pregnancy (r = -0.55; p < 0.0001). Elevated depression scores at the first GDM visit were associated with subsequent weight gain in GDM pregnancy (β = 1.249; p = 0.019).

CONCLUSION

In women with GDM, elevated depression scores during pregnancy are prospectively associated with weight gain. Depression symptoms should therefore be screened for and treated in women with GDM to reduce the risks associated with excessive weight gain during pregnancy.

Performance of the Geriatric Depression Scale-15 with Older Adults Aged over 65 Years: An Updated Review 2000-2019

OBJECTIVES

This up-to-date systematic review and meta-analysis aimed to examine the predictive validity of the Geriatric Depression Scale-15 (GDS-15) for screening depression in older adults aged over 65 years.

METHODS

Electronic searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycINFO database using the following keywords: depression, depressive disorder, major, geriatric depression scale, and geriatric depression scale short. The Quality Assessment of Diagnostic Accuracy Studies-2 was applied to assess the risk of bias in diagnostic studies.

RESULTS

Thirty-one studies that included 8,897 older adults were analyzed. The pooled sensitivity of the GDS-15 was 0.80 (95% CI:0.78 to 0.82), its pooled specificity was 0.79 (95% CI:0.78 to 0.80), the area under the curve (AUC) was 0.89 (SE = 0.01) and the Q* value was 0.82 (SE = 0.01). The subgroup analysis revealed that the pooled sensitivity and specificity of the GDS-15 were higher in older adults with normal cognitive function than in those with cognitive impairment.

CONCLUSIONS

These finding suggest that the GDS-15 may be more accurate for screening depression in older adults with normal cognitive function.

CLINICAL IMPLICATIONS

The utility the GDS-15 may be restricted because its diagnostic accuracy is slightly lower among older adults with cognitive impairment.

Mental health and its associations with glucose-lowering medication in women with gestational diabetes mellitus. A prospective clinical cohort study

AIMS

Mental health symptoms are frequent in women with gestational diabetes mellitus (GDM) and may influence glycemic control. We therefore investigated if mental health symptoms (high depression and low well-being scores) predicted a need for glucose-lowering medication and if this use of medication influenced the trajectory of mental health during pregnancy and in the postpartum period.

METHODS

We included 341 pregnant women from a cohort of GDM women in a Swiss University Hospital. The World Health Organization Well-being Index-Five was collected at the first and last GDM and at the postpartum clinical visits and the Edinburgh Postnatal Depression Scale at the first GDM and the postpartum clinical visits. Medication intake was extracted from participants' medical records. We conducted linear and logistic regressions with depression as an interaction factor.

RESULTS

Mental health symptoms did not predict a need for medication (all p ≥ 0.29). Mental health improved over time (both p ≤ 0.001) and use of medication did not predict this change (all p ≥ 0.40). In women with symptoms of depression, medication was associated with less improvement in well-being at the postpartum clinical visit (p for interaction=0.013).

CONCLUSIONS

Mental health and glucose-lowering medication did not influence each other in an unfavourable way in this cohort of women with GDM.

High vision-related quality of life indices reduce the odds of depressive symptoms in aged care facilities

Objective: To examine the association between vision-related quality of life (VRQoL) and depressive symptoms in residents with vision impairment (VI) in aged care facilities.Methods: In this cross-sectional study using baseline data from a cluster-randomized controlled trial (ACTRN12615000587505) assessing the effectiveness of a novel eye care model, 186 English-speaking residents (mean age 84 years, SD[standard deviation] = 8.7; 33.9% male) with VI and moderate cognitive functioning or better were recruited from 38 facilities across Victoria, Australia. VRQoL was measured using Rasch-transformed scores from the 'Reading'; 'Mobility', and 'Emotional' scales of the Impact of Vision Impairment for Residential Care (IVI-RC) questionnaire. Outcomes were presence of depressive symptoms (binary score: Cornell Scale for Depression in Dementia [CSDD] > 0 vs. CSDD = 0) and severity of depressive symptoms (continuous CSDD score; sample range 1-21). Independent associations with presence and severity of depressive symptoms were examined using zero-inflated logistic and linear multivariable models, respectively.Results: Of the 186 participants, n = 79 (42.5%), n = 94 (50.5%) and n = 13 (7%) reported no, mild (scores 1-7), and clinically significant depressive symptoms (score ≥8), respectively. Better vision-related Mobility (OR = 0.64; 95% CI: 0.44, 0.95, p = 0.02) was associated with reduced odds of depressive symptoms. With every unit improvement in vision-related Reading (β=-0.48; 95% CI: -0.94, -0.01, p = 0.04) and Emotional (β=-0.56; 95% CI: -1.09, -0.02, p = 0.04), severity of depressive symptoms reduced, independent of sociodemographic and medical issues.Conclusion: Better VRQoL was independently associated with reduced depressive symptoms. Supporting older people in aged care to maintain optimal levels of vision-specific functioning, independence, and emotional well-being may protect their mental health.

Barriers to the Recognition of Geriatric Depression in Residential Care Facilities in Alberta

This study explored the barriers that regulated nurse professionals encountered in recognizing and assessing geriatric depression in residential care facilities in the Canadian province of Alberta. The study used a convergent parallel mixed methods design, including a cross-sectional survey (N = 635) and qualitative interviews (N = 14) with regulated nurse professionals. Findings revealed six major barriers to the recognition of geriatric depression in Alberta, including 1) insufficient clinical knowledge and training in geriatric depression; 2) misconceived beliefs about geriatric depression; 3) limited access to resources; 4) unclear depression assessment protocol and procedures in facilities; 5) characteristics of models of care and organizational culture in facilities; and 6) communication difficulties among all stakeholders in the process. Socio-cultural values and beliefs about geriatric depression played a key role in the complex interaction of the various structural and agential barriers to the effective recognition and assessment of depression in residential care facilities in Alberta.

How Do Regulated Nurse Professionals in Alberta Assess Geriatric Depression in Residential Care Facilities?

Although geriatric depression is a prevalent, serious, and under-recognized mental health condition in residential care facilities, there is a dearth of related research in Canada. This exploratory mixed methods study examines the perspectives and practices of regulated nurse professionals on assessment of geriatric depression in residential care facilities in Alberta. Findings from the quantitative surveys (n = 635) and qualitative interviews (n = 14) suggest that geriatric depression is not systematically assessed in these care settings due to multiple challenges, including confusing assessment protocol, inconsistent use and contested clinical utility of current assessment methods in facilities, limited availability of mental health professionals in facilities, and the varied views of regulated nurse professionals on who is responsible for depression assessment in facilities. Implications and future research directions are discussed.

Depressive symptoms in long term care facilities in Western Canada: a cross sectional study

BACKGROUND

The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC.

METHODS

11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80-120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers.

RESULTS

Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management.

CONCLUSIONS

Depressive symptoms are common in LTC residents -particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.

Measurement validity of the Patient-Health Questionnaire-9 in US nursing home residents

OBJECTIVES

The objective of this study was to assess the measurement properties of the self-reported Patient Health Questionnaire-9 (PHQ-9) and its 10-item observer version (PHQ-10OV) among nursing home residents.

METHODS

We conducted a retrospective study of Minimum Data Set 3.0 assessments for national cohorts of Medicare Fee-for-Service beneficiaries who were newly admitted or incident long-stay residents in 2014-2015 at US nursing homes (NHs) certified by the Center for Medicare and Medicaid Services. Statistical analyses included examining internal reliability with McDonald's omega, structural validity with confirmatory factor analysis, and hypothesis testing for expected gender differences and criterion validity with descriptive statistics. The Chronic Condition Warehouse depression diagnoses were used as an administrative reference standard.

RESULTS

Both the PHQ-9 and PHQ-10OV had good internal reliability with omega values above 0.85. The self-reported scale yielded good model fit for a one-factor solution, while the PHQ-10OV had slightly poorer fit and a lower standardized factor loading on the additional irritability item. Both scales appear sufficiently one-dimensional given that somatic items had higher factor loading on a general depression factor than on a somatic subfactor. We were unable to obtain expected gender differences on the PHQ-10OV scale. The PHQ-9 and PHQ-10OV were both highly specific but had poor sensitivity compared with an administrative reference standard.

CONCLUSIONS

The PHQ-9 appears to be a valid and promising measurement instrument for research about depression among NH residents, while the validity of the PHQ-10OV should be examined further with a structured psychiatric interview as a stronger criterion standard.

Development of a caregiver-reported measure to support systematic assessment of people with dementia in long-term care: The Integrated Palliative care Outcome Scale for Dementia

BACKGROUND

Symptom burden is common for long-term care residents with dementia which if untreated compromises quality of life. Measurement tools can support assessment of symptoms and problems but are not widely used in long-term care settings. We developed the Integrated Palliative care Outcome Scale for Dementia derived from the Palliative care Outcome Scale, Palliative care Outcome Scale-Symptom and Integrated Palliative care Outcome Scale.

AIM

To examine the content validity, acceptability and comprehension of Integrated Palliative care Outcome Scale for Dementia for routine use in long-term care settings for people with dementia and to refine Integrated Palliative care Outcome Scale for Dementia.

DESIGN

A multi-method qualitative study consisting of focus groups, semi-structured interviews and cognitive interviews.

SETTING/PARTICIPANTS

Three residential long-term care settings in London, UK. Focus group and semi-structured interview participants included caregiver staff, family, general practitioners and district nurses. Caregiver staff were sampled purposively for cognitive interviews.

RESULTS

A total of 26 respondents participated in the focus groups ( n = 21) or semi-structured interviews ( n = 5) and 10 caregiver staff completed cognitive interviews. Additional symptoms and problems included agitation, wandering, sleep problems, communication problems and diarrhoea. Refinements or lay terms were required to improve comprehension and consistency of item response for nausea, drowsiness, delusions/hallucinations, agitation, loss of interest, communication problems and interaction. A video presentation was required to support comprehension of instructions and assessment of verbally compromised residents.

CONCLUSION

Integrated Palliative care Outcome Scale for Dementia is a comprehensive and acceptable caregiver-reported measure to detect symptoms and problems in dementia. It is suitable for caregiver staff without professional training as it has been refined and tailored to maximise caregiver expertise, ready for further psychometric testing.

Factors that Influence Physical Activity among Residents in Assisted Living

The purpose of this study was to examine factors that influence physical activity among residents in assisted living. This was a secondary data analysis using baseline data from a function-focused care intervention study including 171 residents from 4 assisted living facilities. Using structural equation modeling, we found that mood, satisfaction with staff and activities, and social support for exercise were directly associated with time spent in physical activity. Gender, cognition, depression, and comorbidities were indirectly associated with physical activity and accounted for 13% of the total variance in physical activity. Implications for future research and social work practice are presented.

[Instruments developed for the management and care of the elderly in long-stay care institutions: a systematic review]

The demand for long-stay care institutions for the elderly (ILPIs) is increasing and it is relevant for public health systems to discuss the process of assessing the health status of its residents. The study aimed to identify measurement tools built specifically for the management and care of elderly residents in long-stay care facilities. A systematic review was conducted following PRISMA recommendations in Medline and CINAHL databases since their creation to May 2013 using the Medical Subject Headings terms suitable for the search. A total of 1858 articles were located, of which 30 were selected and 28 instruments were identified in the studies. The United States was the country that created most instruments geared to this population and the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) was the one most used in the studies of this review. The variables most frequently evaluated by the instruments were depression, cognition and functional capacity. The reformulation of public policies that ensure a standardized assessment system for residents in ILPIs in Brazil is urgently needed and the challenge is to ensure that the instruments developed are disseminated and effectively implemented in the daily tasks of the professionals working in these institutions.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale

AIMS

Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS.

METHODS

The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment.

RESULTS

The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( r_s = 0.30, 95% CI = 0.09-0.48, P = .006).

CONCLUSION

This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

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.

Identifying depression with the PHQ-2: A diagnostic meta-analysis

BACKGROUND

There is interest in the use of very brief instruments to identify depression because of the advantages they offer in busy clinical settings. The PHQ-2, consisting of two questions relating to core symptoms of depression (low mood and loss of interest or pleasure), is one such instrument.

METHOD

A systematic review was conducted to identify studies that had assessed the diagnostic performance of the PHQ-2 to detect major depression. Embase, MEDLINE, PsychINFO and grey literature databases were searched. Reference lists of included studies and previous relevant reviews were also examined. Studies were included that used the standard scoring system of the PHQ-2, assessed its performance against a gold-standard diagnostic interview and reported data on its performance at the recommended (≥3) or an alternative cut-off point (≥2). After assessing heterogeneity, where appropriate, data from studies were combined using bivariate diagnostic meta-analysis to derive sensitivity, specificity, likelihood ratios and diagnostic odds ratios.

RESULTS

21 studies met inclusion criteria totalling N=11,175 people out of which 1529 had major depressive disorder according to a gold standard. 19 of the 21 included studies reported data for a cut-off point of ≥3. Pooled sensitivity was 0.76 (95% CI =0.68-0.82), pooled specificity was 0.87 (95% CI =0.82-0.90). However there was substantial heterogeneity at this cut-off (I(2)=81.8%). 17 studies reported data on the performance of the measure at cut-off point ≥2. Heterogeneity was I(2)=43.2% pooled sensitivity at this cut-off point was 0.91 (95% CI =0.85-0.94), and pooled specificity was 0.70 (95% CI =0.64-0.76).

CONCLUSION

The generally lower sensitivity of the PHQ-2 at cut-off ≥3 than the original validation study (0.83) suggests that ≥2 may be preferable if clinicians want to ensure that few cases of depression are missed. However, in situations in which the prevalence of depression is low, this may result in an unacceptably high false-positive rate because of the associated modest specificity. These results, however, need to be interpreted with caution given the possibility of selectively reported cut-offs.

Using a theoretical approach to identify factors influencing adherence to an exercise programme for adults with venous leg ulcers

This study assessed the relationships between self-efficacy, outcome expectations, fear-avoidance beliefs and adherence to an exercise for a home-based exercise programme for adults with venous leg ulcers. Patients ( n=63) were randomised to receive either an intervention or usual care group. Of those in the exercise intervention group, 59per cent adhered to the exercise protocol more than 75per cent of the time. There was a significant relationship between self-efficacy and outcome expectations, and both of these constructs were significantly related to adherence to the leg exercise programme. Adherence significantly correlated with wound healing indicating a possible pathway to healing.

Measures to assess commonly experienced symptoms for people with dementia in long-term care settings: a systematic review

BACKGROUND

High symptom burden is common in long-term care residents with dementia and results in distress and behavioral challenges if undetected. Physicians may have limited time to regularly examine all residents, particularly those unable to self-report, and may rely on reports from caregivers who are frequently in a good position to detect symptoms quickly. We aimed to identify proxy-completed assessment measures of symptoms experienced by people with dementia, and critically appraise the psychometric properties and applicability for use in long-term care settings by caregivers.

METHODS

We searched Medline, EMBASE, PsycINFO, CINAHL and ASSIA from inception to 23 June 2015, supplemented by citation and reference searches. The search strategy used a combination of terms: dementia OR long-term care AND assessment AND symptoms (e.g. pain). Studies were included if they evaluated psychometric properties of proxy-completed symptom assessment measures for people with dementia in any setting or those of mixed cognitive abilities residing in long-term care settings. Measures were included if they did not require clinical training, and used proxy-observed behaviors to support assessment in verbally compromised people with dementia. Data were extracted on study setting and sample, measurement properties and psychometric properties. Measures were independently evaluated by two investigators using quality criteria for measurement properties, and evaluated for clinical applicability in long-term settings.

RESULTS

Of the 19,942 studies identified, 40 studies evaluating 32 measures assessing pain (n = 12), oral health (n = 2), multiple neuropsychiatric symptoms (n = 2), depression (n = 8), anxiety (n = 2), psychological wellbeing (n = 4), and discomfort (n = 2) were included. The majority of studies (31/40) were conducted in long-term care settings although none of the neuropsychiatric or anxiety measures were validated in this setting. The pain assessments, PAINAD and PACSLAC had the strongest psychometric evidence. The oral health, discomfort, and three psychological wellbeing measures were validated in this setting but require further psychometric evaluation. Depression measures were poor at detecting depression in this population. All measures require further investigation into agreement, responsiveness and interpretability.

CONCLUSIONS

Measures for pain are best developed for this population and setting. All other measures require further validation. A multi-symptom measure to support comprehensive assessment and monitoring in this population is required.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes

BACKGROUND

Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting.

METHODS

Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves.

RESULTS

Among residents without dementia, both the self-rated (AUC = 0.75-0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively.

CONCLUSIONS

The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

One-year trajectories of depression and anxiety symptoms in older patients presenting in general practice with musculoskeletal pain: A latent class growth analysis

OBJECTIVE

Distinguishing transient from persistent anxiety and depression symptoms in older people presenting to general practice with musculoskeletal pain is potentially important for effective management. This study sought to identify distinct post-consultation depression and anxiety symptom trajectories in adults aged over 50years consulting general practice for non-inflammatory musculoskeletal pain.

METHODS

Self-completion questionnaires, containing measures of anxiety and depressive symptoms, age, gender, pain status, coping and social status were mailed within 1week of the consultation and at 3, 6 and 12months. Latent class growth analysis was used to identify anxiety and depression symptoms trajectories, which were ascertained with cut-off score ≥8 on Hospital Anxiety and Depression Scale subscales. Associations between baseline characteristics and cluster membership were examined using multivariate multinomial logistic regression analysis (the 3-step approach).

RESULTS

Latent class growth analyses determined a 3-cluster anxiety model (n=499) and a 3-cluster depression model (n=501). Clusters identified were: no anxiety problem (44.1%), persistent anxiety problem (33.9%) and transient anxiety symptoms (22.2%); no depression problem (74.1%), persistent depression problem (22.0%) and gradual depression symptom recovery (4.0%). Widespread pain, interference with valued activities, coping by increased behavioral activities, catastrophizing, perceived lack of instrumental support, age ≥70years, being female, and performing manual/routine work were associated with anxiety and/or depression clusters.

CONCLUSIONS

Older people with non-inflammatory musculoskeletal pain are at high risk of persistent anxiety and/or depression problems. Biopsychosocial factors, such as pain status, coping strategies, instrumental support, performing manual/routine work, being female and age ≥70years, may help identify patients with persistent anxiety and/or depression.

The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes

OBJECTIVE

To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes.

SETTING

14 nursing homes in Sydney and Brisbane, Australia.

PARTICIPANTS

92 residents with a mean age of 85 years.

MEASUREMENTS

Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves.

RESULTS

The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia.

CONCLUSION

When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

Development of the psychometric property of a Minimum Data-Set-Based Depression Rating Scale for use in long-term care facilities in Taiwan

OBJECTIVES

Our aim is to develop the psychometric property of the Minimum Data-Set-Based Depression Rating Scale (MDS-DRS) to ensure its use to assess service needs and guide care plans for institutionalized residents.

METHODS

378 residents were recruited from the Haoran Senior Citizen Home in northern Taiwan. The MDS-DRS and GDS-SF were used to identify observable features of depression symptoms in the elderly residents.

RESULTS

A total of 378 residents participated in this study. The receiver operating characteristic (ROC) curve indicated that the MDS-DRS has a 43.3% sensitivity and a 90.6% specificity when screening for depression symptoms. The total variance, explained by the two factors 'sadness' and 'distress,' was 58.1% based on the factor analysis.

CONCLUSIONS

Reliable assessment tools for nurses are important because they allow the early detection of depression symptoms. The MDS-DRS items perform as well as the GDS-SF items in detecting depression symptoms. Furthermore, the MDS-DRS has the advantage of providing information to staff about care process implementation, which can facilitate the identification of areas that need improvement. Further research is needed to validate the use of the MDS-DRS in long-term care facilities.

Screening for geriatric depression in residential care facilities: a systematic narrative review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.

Racial and ethnic variation in home healthcare nurse depression assessment of older minority patients

OBJECTIVE

The objective of this study is to determine the racial/ethnic effect of depression symptom recognition by home healthcare nurses.

METHODS

This is a secondary analysis of administrative data from a large urban home healthcare agency. Patients' age were 65 years and older with a valid depression screen, identified as Caucasian, African American, or Hispanic and admitted to homecare in 2010 (N = 3711). All demographic and clinical information were obtained from the electronic medical record.

RESULTS

Subjects were 29.34% Caucasian, 37.81% African American, and 32.85% Hispanic. About 6.52% had a formal chart diagnosis of depression, and 13.39% received antidepressant therapy. The rates of positive depression screens by nurses were higher in Caucasians than that of in African Americans or Hispanics (13.41% vs. 9.27% vs. 10.99%; χ(2)  = 10.70, df [degrees of freedom] = 2; p < 0.01). Depression screening rates were then stratified by the number of clinical indicators from the chart (depression diagnosis or antidepressant on medication list). The proportion of positive screen increased for minorities with an increase in the number of indicators. African Americans had significantly greater positive screens with two indicators compared with that of the Caucasians and Hispanics (50.00% vs. 23.81% vs. 35.59%; χ(2)  = 6.65, df = 2; p = 0.04).

CONCLUSIONS

These findings show a wide range of variation in screening for depression among ethnic groups. The rates increase for minorities with the presence of increased clinical indicators, suggesting that nurses may screen higher in minorities when there is higher clinical suspicion. Future research in home healthcare should be aimed at training nurses to conduct culturally tailored depression screening to improve management of depression in older minorities.

Validation of a causal model of agitation among institutionalized residents with dementia in Taiwan

The aim of this study was to test a causal model of the predictors of agitation among 405 nursing home residents in Taiwan with varying degrees of cognitive impairment. Chart review and behavioral observations were used to assess residents' physical and psychosocial condition. The final version of the model had a good fit. Cognitive function and depression had direct effects on agitation, and pain and functional ability had indirect effects on agitation via depression. Additionally, cognitive function and pain influenced functional ability directly, which in turn influenced depression and ultimately influenced agitation. The results suggest that effective management of agitation in demented residents requires identifying the needs underlying the behavior rather than directly treating the behavior itself.

Cornell scale for depression in dementia: study of residents in a northern thai long-term care home

OBJECTIVE

This study aimed to analyse the validity of the Thai version of the Cornell Scale for Depression in Dementia (CSDD) when using DSM-IV criteria.

METHODS

A cross-sectional study was carried out of 84 elderly residents in a residential care home setting in Thailand. The participants went through a comprehensive geriatric assessment which included a Mini-Mental State Examination, a Mini-International Neuropsychiatric Interview (MINI) and use of the CSDD tool. A ROC analysis was performed in order to test the validity of the CSDD as against the DSM-IV when used by the MINI.

RESULTS

ROC analysis revealed a better score for those areas found under the curve for the CSDD-as against the DSM-IV criteria (0.96). With a cut-off score of >6, the CSDD yielded the highest sensitivity score (100%), plus produced a specificity of 81% and a negative predictive value of 100%. It also had a positive predictive value of 69%. The validity of the CSDD was found to be better for the group experiencing cognitive impairment than with the non-cognitive impairment group in terms of the agreement of CSDD items between patients and caregivers. The CSDD yielded a high internal consistency (Cronbach's alpha=0.87).

CONCLUSION

CSDD is a valid tool to use for identifying depressive disorders among Thai LTC home residents - those experiencing and those not experiencing cognitive impairment.

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.

12-month incidence, prevalence, persistence, and treatment of mental disorders among individuals recently admitted to assisted living facilities in Maryland

BACKGROUND

To estimate the 12-month incidence, prevalence, and persistence of mental disorders among recently admitted assisted living (AL) residents and to describe the recognition and treatment of these disorders.

METHODS

Two hundred recently admitted AL residents in 21 randomly selected AL facilities in Maryland received comprehensive physician-based cognitive and neuropsychiatric evaluations at baseline and 12 months later. An expert consensus panel adjudicated psychiatric diagnoses (using DSM-IV-TR criteria) and completeness of workup and treatment. Incidence, prevalence, and persistence were derived from the panel's assessment. Family and direct care staff recognition of mental disorders was also assessed.

RESULTS

At baseline, three-quarters suffered from a cognitive disorder (56% dementia, 19% Cognitive Disorders Not Otherwise Specified) and 15% from an active non-cognitive mental disorder. Twelve-month incidence rates for dementia and non-cognitive psychiatric disorders were 17% and 3% respectively, and persistence rates were 89% and 41% respectively. Staff recognition rates for persistent dementias increased over the 12-month period but 25% of cases were still unrecognized at 12 months. Treatment was complete at 12 months for 71% of persistent dementia cases and 43% of persistent non-cognitive psychiatric disorder cases.

CONCLUSIONS

Individuals recently admitted to AL are at high risk for having or developing mental disorders and a high proportion of cases, both persistent and incident, go unrecognized or untreated. Routine dementia and psychiatric screening and reassessment should be considered a standard care practice. Further study is needed to determine the longitudinal impact of psychiatric care on resident outcomes and use of facility resources.

Apathy and weight loss in nursing home residents: longitudinal study

OBJECTIVES

Determine which behavioral syndromes of dementia are independently related to weight loss.

DESIGN

Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments. Characteristics obtained in one period were related to weight loss observed in the next period.

SETTING

Eight nursing homes in the Netherlands.

PARTICIPANTS

The initial population was 2031 nursing home residents with four quarterly MDS assessments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the time of the first assessment and who were not comatose.

MEASUREMENTS

Information about the presence of four behavioral syndromes (depression, apathy, agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time that residents were involved in activities were obtained from MDS 2.0.

RESULTS

Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were involved in activities. Multivariable binary logistic regression with these factors showed that the only behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivariable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss.

CONCLUSION

These results suggest that of all behavioral factors we have assessed, apathy had the strongest association with weight loss in nursing home residents even when adjusted for the degree of cognitive impairment.

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.

The assessment of generalized anxiety disorder: psychometric validation of the Spanish version of the self-administered GAD-2 scale in daily medical practice

AIM

To psychometrically validate the Spanish version of the self-administered 2-item GAD-2 scale for screening probable patients with generalised anxiety disorder (GAD).

METHODS

The GAD-2 was self-administered by patients diagnosed with GAD according to DSM-IV criteria and by age- and sex-matched controls who were recruited at random in mental health and primary care centres. Criteria validity was explored using ROC curve analysis, and sensitivity, specificity and positive and negative predictive values were determined for different cut-off values. Concurrent validity was also established using the HAM-A, HADS, and WHODAS II scales.

RESULTS

The study sample consisted of 212 subjects (106 patients with GAD) with a mean age of 50.38 years (SD = 16.76). No items of the scale were left blank. Floor and ceiling effects were negligible. No patients with GAD had to be assisted to complete the questionnaire. Reliability (internal consistency) was high; Cronbach's α = 0.875. A cut-off point of 3 showed adequate sensitivity (91.5%) and specificity (85.8%), with a statistically significant area under the curve (AUC = 0.937, p < 0.001), to distinguish GAD patients from controls. Concurrent validity was also high and significant with HAM-A (0.806, p < 0.001), HADS (anxiety domain, 0.825, p < 0.001) and WHO-DAS II (0.642, p < 0.001) scales.

CONCLUSION

The Spanish version of the GAD-2 scale has been shown to have appropriate psychometric properties to rapidly detect probable cases of GAD in the Spanish cultural context under routine clinical practice conditions.

Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0

OBJECTIVES

To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.

METHODS

The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ≥30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and Schizophrenia (m-SADS) was measured with weighted kappas (κ). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.

RESULTS

The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted κ = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted κ = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.

DISCUSSION

Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.

Relationship between symptoms of depression and agitation in nursing home residents with dementia

OBJECTIVE

The aim of this study is to analyze modifiable factors related to agitation of nursing home residents with dementia.

METHODS

Relationship of agitation with three modifiable factors (depression, psychosis, and pain) was explored using longitudinal Minimum Data Set (MDS) information from 2032 residents of Dutch nursing homes. Presence of agitation and depression was ascertained using validated scales based on MDS information. Presence of psychosis and pain was ascertained from the individual MDS items.

RESULTS

There was a significant correlation between MDS depression and agitation scores. Depression scores increased in residents whose agitation worsened and decreased in residents whose agitation improved. Psychosis scores (combination of delusions and hallucinations) also correlated with MDS depression scores, and psychosis scores increased in residents whose agitation worsened. Pain scores correlated with agitation scores, but the pain scores did not change with changes in agitation. Depression symptoms were present in 51% of residents, while psychotic symptoms were present only in 15% of residents, and two-thirds of these residents were also depressed.

CONCLUSION

These results indicate that depression may be the most common factor associated with agitation in nursing home residents with dementia.

A comparison of the validity of the Cornell Scale and the MADRS in detecting depression among memory clinic patients

BACKGROUND

The aim of the study was to compare the validity of the Cornell Scale for Depression in Dementia (CSDD) and the Montgomery-Aasberg Depression Rating Scale (MADRS) among memory clinic patients.

METHODS

The scales were independently completed for 125 patients. The diagnosis of depression was made by psychiatrists blinded to the depression scores.

RESULTS

The mean score of the Mini-Mental State Examination was 25.5 (SD: 4.6), of the CSDD 6.8 (SD: 4.9), and of the MADRS 8.5 (SD: 6.8). In receiver operation characteristics (ROC) analyses, the AUC for the CSDD was 0.73 (95% CI: 0.63-0.82) using the International Classification of Diseases-10 (ICD-10) criteria for depression, and 0.68 (95% CI: 0.57-0.79) using the DSM-IV criteria. The AUC was 0.88 (95% CI: 0.81-0.95) for the MADRS using the ICD-10 criteria, and 0.84 (95% CI: 0.76-0.92) using the DSM-IV criteria.

CONCLUSION

Both scales are suitable as screening tools. According to the ROC analyses, the MADRS seems better at distinguishing depressed from nondepressed patients.

An evaluation of a national program to implement the Cornell Scale for Depression in Dementia into routine practice in aged care facilities

BACKGROUND

Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression.

METHODS

A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facility managers took part in an interview to determine barriers to the effective implementation of the instrument.

RESULTS

The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9-13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change.

CONCLUSIONS

The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.

Measuring symptoms of depression: comparing the Cornell Scale for Depression in Dementia and the Patient Health Questionnaire-9-Observation Version

The purpose of this study was to extend available psychometric data on the Patient Health Questionnaire-9-Observation Version (PHQ-9-OV) by comparing it with the Cornell Scale for Depression in Dementia (CSDD) in a new sample of long-term care residents. Data were collected post intervention in a quasi-experimental storytelling study across six communities. The sample (N = 54) was 87% women with mean age of 84.5, mean CSDD score of 3.96, and mean PHQ-9-OV score of 4.22. Prevalence of depressive symptoms by CSDD criteria was 20.4% and by PHQ-9-OV criteria was 40.7%. The CSDD and PHQ-9-OV were well correlated (r(s) = 0.78, p < 0.0001). Neither scale was significantly correlated with depression diagnosis nor antidepressant agent use. Both measures demonstrated adequate reliability. The PHQ-9-OV item scoring and established cut-off points designate a lower threshold than the CSDD to detect clinically significant depressive symptoms. Further study is needed to determine the sensitivity of the PHQ-9-OV in identifying treatment effects.

How do the PHQ-2, the PHQ-9 perform in aging services clients with cognitive impairment?

OBJECTIVE

To examine the performance of the Patient Health Questionnaire-2 (PHQ-2) and the PHQ-9 in detecting current major depressive episode (MDE) in aging services care management clients who screen positive for cognitive impairment (CI).

METHODS

Cross-sectional observational study of 236 care management clients ages ≥60 years recruited from an Upstate NY aging services agency. The test characteristics of the PHQ-2 and PHQ-9 to screen for depression were calculated using the Structured Clinical Interview for DSM-IV (SCID) to identify MDE (gold standard). CI was identified with the Six-Item Screen (SIS).

RESULTS

Participants had a mean age of 77 years, 68% female, 16% non-white, and 26% had less than a high school education. 16% of participants had CI identified by ≥2 errors on SIS. Of these, 41% had positive PHQ-2 (scores ≥3), 43% had positive PHQ-9 (scores ≥10), while 24% met criteria for MDE. In the sample with CI, the PHQ-2, using a cutoff of 3, had sensitivity = 0.78, specificity = 0.71, and receiver operating characteristic (ROC) area under the curve (AUC) = 0.81, compared with 0.79, 0.82, and 0.88, respectively, for those without CI. In the sample with CI, the PHQ-9, using a cutoff of 10, had sensitivity = 0.89, specificity = 0.71, and AUC = 0.85, compared with 0.85, 0.89, and 0.91, respectively, for those without CI.

CONCLUSIONS

Cognitive status should be considered when using the PHQ as a depression screener due to poorer specificity in seniors with CI.

Depression and the health care experiences of Medicare beneficiaries

OBJECTIVES

To compare health care experiences of Medicare beneficiaries with and without symptoms of depression and investigate the role of patient confidence in shaping these experiences.

DATA SOURCES

Data came from the 2009 CAHPS Medicare 4.0 Fee-for-Service (FFS) Survey, which was fielded to a national probability sample of 298,492 FFS Medicare beneficiaries.

STUDY DESIGN

Linear regression was used to model associations of depression with four global ratings and three composite measures of health care and to test whether beneficiaries' confidence in their ability to recognize the need for care mediates these associations.

PRINCIPAL FINDINGS

Beneficiaries with depressive symptoms reported worse experiences with care across the full range of patient experience covered by the CAHPS survey. Depressive symptoms were associated with decreased patient confidence and decreased confidence was in turn associated with poorer reports of care.

CONCLUSIONS

Our study highlights depressive symptoms as a risk factor for poorer experiences of health care and highlights depressed patients' confidence in recognizing their need for care and for designing programs to improve the health care of this population.

The role of the gerontological social worker in assisted living

This qualitative study reports on thirteen assisted living (AL) administrators' perspectives of the role and the importance of the AL social worker in addressing the unmet needs of older adults as they move and transition into AL. Participant interviews were analyzed using the constant comparative method. Administrators described 5 AL social work roles: (a) decision-making and adjustment coordinator; (b) resident advocate; (c) mental health assessor and counselor; (d) family social worker; and (e) care planner. Implications include directly examining AL social workers' views, analyzing costs and benefits of employing AL social workers, and developing social work practicum sites within AL.