Depression in nursing homes: ensuring adequate treatment

Concordance of self- and informant-rated depressive symptoms in nursing home residents with Dementia: cross-sectional findings

BACKGROUND

Depression is highly prevalent in nursing home residents living with moderate to severe dementia. However, assessing depressive symptoms in residents with dementia can be challenging and may vary by rater perspective. We aimed to investigate the concordance of, and factors associated with self- and informant-rated depressive symptoms in nursing home residents with dementia.

METHODS

Cross-sectional data was collected from N = 162 nursing home residents with dementia (age: 53-100; 74% women). Self-ratings were assessed with the Geriatric Depression Scale, while the depression and anxiety items of the Neuropsychiatric Inventory were used for informant-ratings. Cohen's Kappa was calculated to determine the concordance of both measures and of each with antidepressant medication. Multivariate associations with sociodemographic variables, self- and informant-rated quality of life, dementia stage, neuropsychiatric symptoms, functional status and antidepressant medication were analysed with linear mixed models and generalized estimating equations.

RESULTS

Concordance between self- and single item informant-rated depressive symptoms was minimal (Cohen's Kappa = .22, p = .02). No concordance was found for self-reported depressive symptoms and the combined informant-rated depression-anxiety score. Self-reported depression was negatively associated with self-rated quality of life (β = -.32; 95%CI: -.45 to -.19, p < .001), informant-rated quality of life (β = -.25; 95%CI: -.43 to -.07, p = .005) and functional status (β = -.16; 95%CI: -.32 to -.01, p = .04), whilst single item informant-rated depression revealed negative associations with informant-rated quality of life (β = -.32; 95%CI: -.52 to -.13, p = .001) and dementia stage (β = -.31; 95%CI: -.52 to -.10, p = .004). The combined informant-rated depression-anxiety score showed negative associations with self-rated quality of life (β = -.12; 95%CI: -.22 to -.03, p = .01) and dementia stage (β = -.37; 95%CI: -.67 to -.07, p = .02) and a positive association with neuropsychiatric symptoms (β = .30; 95%CI: .10 to .51, p = .004). No concordance was found with antidepressant medication.

CONCLUSIONS

In line with our expectations, low agreement and unique association patterns were found for both measures. These findings indicate that both instruments address different aspects of depression und underline the need for comprehensive approaches when it comes to detecting signs of clinically relevant depressive symptoms in dementia.

TRIAL REGISTRATION

The trial was registered with the ISRCTN registry (Trial registration number: ISRCTN98947160 ).

The association between specific activity components and depression in nursing home residents: the importance of the social component

OBJECTIVES

To longitudinally explore the association between activities and depressive symptoms of nursing home (NH) residents, taking into account that each activity may contain multiple components (physical, creative, social, cognitive, and musical).

METHOD

Study with a baseline and two follow-ups (four and eight months). Participants were forty physically frail residents of four NHs in the Netherlands. Residents were interviewed about depressive symptoms (CES-D) and activities they conducted over the previous week. Three researchers independently rank ordered each activity on the degree to which it could be regarded as having physical, creative, social, cognitive, and musical components. Accounting for the rank score and the time the resident spent on that activity, residents were categorized per activity component into four levels: absent, low, medium, and high.

RESULTS

Mixed models predicting depressive symptoms from individual activity components showed significant associations for the social and cognitive components. Compared with the lowest activity level, the analyses showed fewer depressive symptoms for all higher levels of the social and cognitive components. However, a mixed model adjusted for all activity components showed no unique effect of the cognitive component or other components, while the effects of the social component remained significant. The analyses did not show differences between the time points.

CONCLUSION

The results suggest that the effects of activities on depressive symptoms might be mainly explained by their social component. It is, thus, important to always stimulate social involvement and interaction when developing and applying depression interventions. However, intervention research is needed to confirm these findings.

The influence of sense of control and cognitive functioning in older cancer patients' depression

OBJECTIVE

This study aimed to evaluate the associations between depression, sense of control, and cognitive functioning, as well as the predictive power of sense of control and cognitive functioning in older cancer patients' depression.

METHODS

Eighty-six cancer patients were referred to a palliative care unit. They completed the 15-item Geriatric Depression Scale, the Cancer Locus of Control, and the Mini Mental State Examination questionnaires.

RESULTS

Higher perceived control over the 'course of illness' was associated with higher levels of depressive symptoms (p < 0.0005), whereas lower perceived control over the 'cause of illness' was associated with higher depressive symptoms. The same results were found for 'cause of illness' between non-depressed and depressed patients (p = 0.001). Multivariate analysis revealed that whereas an external orientation in 'course of illness' increased the likelihood of depression (p = 0.002), an external orientation in 'cause of illness' decreased the likelihood of depression (p = 0.05).

CONCLUSIONS

Older cancer patients' sense of control orientation over the course of illness and the cause of illness predicted the levels of depressive symptomatology.

Aging leads to prolonged duration of inflammation-induced depression-like behavior caused by Bacillus Calmette-Guérin

Geriatric depression is a costly health issue, but little is known about its physiological underpinnings. Systemic inflammation sensitizes the innate immune system of aged animals and humans, but it is unknown if chronic, low-grade infections affect the duration of depressive-like behaviors. In this report, we infected adult (4-6 months) and aged (20-24 months) Balb/c mice with an attenuated strain of Mycobacterium bovis, Bacillus Calmette-Guérin (BCG), to induce a chronic infection. We then measured depression-like behaviors that have construct, face and predictive validity for human inflammation-associated clinical depression. Exposure to BCG caused acute sickness responses in both adult and aged mice. However, sickness behavior was prolonged in aged mice, as assessed by both locomotor and rearing activity. Two measures of depression-like behavior, which were tests involving sucrose preference and tail suspension, both showed that adult mice displayed depression-like behaviors at one day and seven days after exposure to BCG. However, aged mice continued to express both of these depression-like behaviors at three weeks following infection. Infection with BCG caused an increase in tryptophan catabolism, as evidenced by a significant rise in the plasma kynurenine/tryptophan ratio that peaked at 7 days post-infection. In aged mice, greater tryptophan catabolism persisted longer and remained elevated at 21 days post-infection. This finding is consistent with the prolonged duration of depression-like behaviors in aged mice. These are the first data using a chronic infection model to establish that recovery from inflammation-induced depression-like behavior and tryptophan catabolism are prolonged in aged animals.

Antidepressant prescribing patterns in the nursing home: second-generation issues revisited

INTRODUCTION

The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.

DESIGN

Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.

SETTING

Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).

PARTICIPANTS

Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).

MEASUREMENTS

Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.

RESULTS

Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.

CONCLUSION

Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

Depression in older people living in residential homes

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

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.

Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications

BACKGROUND

Few studies have examined factors associated with antidepressant prescribing in older nursing home residents.

OBJECTIVE

The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort.

DESIGN

Longitudinal.

SETTINGS

Settings were 12,556 US nursing homes in 1996 and 2006.

DATA SOURCES

Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF).

MEASUREMENTS

Increasing prescribing of antidepressants analyzed using multivariable multinomial generalized estimating equations (GEE).

RESULTS

Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95% CI 0.53-0.69 and AOR 0.62; 95% CI 0.54-0.71, respectively), or coprescribing of antianxiety or antipsychotic agents (AOR 0.70; 95% CI 0.68-0.72 and AOR 0.74; 95% CI 0.72-0.77, respectively).

CONCLUSIONS

Prescribing of antidepressants has increased dramatically in the past decade in older nursing home residents and seems to be associated with certain staffing characteristics and the coprescribing of psychotropic medications. Further research is needed to determine if antidepressants are appropriately prescribed, and if overuse is determined, develop interventions to improve the quality of prescribing of these medications in older nursing home residents.

Racial differences in medication use among older, long-stay Veterans Affairs nursing home care unit patients

OBJECTIVE

To examine racial differences in medication use by older long-stay Veterans Affairs Nursing Home Care Unit (NHCU) patients.

DESIGN

Longitudinal study.

SETTINGS

133 Veterans Affairs NHCUs.

PARTICIPANTS

Three thousand four hundred eighty veterans 65 years of age or older admitted between January 1, 2004, and June 30, 2005, for 90 days or more.

MAIN OUTCOMES MEASURES

Prevalence of those taking nine or more medications (i.e., polypharmacy) and medications from specific therapeutic medication classes. Racial differences were determined using 0.05 level chi-squared tests.

RESULTS

The sample consisted of 14.3% who were black. Blacks compared with whites (all comparisons P < 0.05 except where noted) were younger (13.6% vs. 17.4%, older than 85 years of age), had less depression (22.24 vs. 29.79%), less allergies (9.82% vs. 20.36%), and a similar rate of moderate-to severe pain (22.65% vs. 24.05; P = 0.49). The percent of polypharmacy was similar by race (blacks 74.35% vs. whites 71.18%; P = 0.62), as was the prevalence of medication class use with the exceptions that blacks were less likely than whites to take central nervous system (CNS) medications (75.75% vs. 80.14%; P = 0.02) and antihistamines (13.03% vs. 16.8%; P = 0.04). Specifically, blacks were less likely than whites to receive a selective serotonin-reuptake inhibitor (SSRI) antidepressant (20.84% vs. 27.17%; P < 0.01) or a second-generation antihistamine (3.41% vs. 6.51%; P < 0.01), but more likely than whites to receive opioids (14.63% vs. 11.27%; P = 0.03).

CONCLUSION

There appears to be racial differences in the overall use of antihistamines and CNS medications and some of their subclasses.