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

OBJECTIVE

Nurses commonly observe more depression than is diagnosed and treated in nursing homes. Accordingly, we aimed to describe the clinical features of untreated nursing home residents whom nurses identify as depressed and to compare nurse ratings of depressed nursing home residents with ratings from direct interviews and patient self-reports.

DESIGN

Cross-sectional survey followed by semi-structured diagnostic interviews of depressed patients and their nurses.

SETTING

A large academic, multi-level, long-term care facility.

PARTICIPANTS

Thirty-seven patients aged 74-99 (mean age 88.4) whom nurses identified as having daily symptoms of depression. Subjects had Mini-Mental State Exam (MMSE) scores > 10 (mean score 21.2), were not acutely or terminally ill, and were able to participate in an interview.

MEASUREMENTS

DSM-III-R mood diagnoses and separate ratings of interviews with nurses and patients using the Cornell Scale for Depression.

RESULTS

Nurses observed daily symptoms of depression in 110 of 495 (22%) long-term care residents on units not reserved for advanced dementia. Of these 110 patients, 58 (53%) were not receiving antidepressants. Of 37 patients eligible for interviews, nine met criteria for major depression, 20 met criteria for another non-major depression diagnosis, and eight did not have a diagnosable mood disorder. Cornell scale ratings derived exclusively from interviews of nurses were similar across the three diagnostic groups (12.5, 9.9, and 9.5, respectively; P = .31; mean 10.5), whereas Cornell scale ratings from patient interviews differed among groups (15.9, 6.9, and 4.1, respectively; P < .001; mean 8.4). Correlation between nurse Cornell ratings and patient Cornell ratings was poor (r = .27), especially for patients with non-major forms of depression (r = -.20). MMSE and Cumulative Illness Rating Scale (CIRS-G) scores were similar in the three groups.

CONCLUSIONS

Nurses frequently observed symptoms of depression in a long-term care setting, and many symptomatic patients were not being treated with antidepressants. In these patients, nurse-derived symptom ratings did not vary across DSM-III-R diagnostic categories and correlated poorly with ratings from direct patient interviews. These findings suggest that nurse caregivers may contribute important diagnostic information about non-major depression and raise questions about the application of standard diagnostic categories to late-life depression in the nursing home.

Thyrotropin response to thyrotropin-releasing hormone in patients with dementia of the Alzheimer type

Eleven patients with senile dementia of the Alzheimer type and 11 age-matched control subjects were given the thyrotropin-releasing hormone (TRH) test. The two groups did not differ with respect to peak thyrotropin (TSH) response or TSH levels at baseline, 20, 30, and 45 min after TRH injection. There were significant differences between the groups on Hamilton Depression Rating Scale scores (p < 0.03), although neither group met clinical criteria for depression. Items that were significantly different pertained to depressed mood, loss of interest, loss of insight, suicidal ideation, and obsessional symptoms.

Rapid eye movement sleep deprivation: a central-neural change during wakefulness

Three adult cats were deprived of rapid eye movement sleep for six separate periods of up to 32 days. Animals were allowed normal amouints of sleeping time during which rapid eye movement sleep was interrupted, whenever it occurred, by human observers who continually monitored the animals and their electrocortical activity. Cortical responses evoked by pairs of acoustic clicks were recorded during wakefulness. Recovery functions derived from these data were facilitated during periods of deprivation of rapid eye movement sleep and returned to base-line values when animals were allowed normal amounts of this sleep phase. This change was noted repeatedly within, as well as between, subjects. It did not occur during control periods when non-rapid eye movement sleep was interrupted on identical schedules, nor did it occur when the cats were deprived of all sleep for 22 hours a day for 5 days.