Depression In Nursing Home Residents Research Articles

Bayesian Analyses Showed More Evidence for Apathy than for Depression Being Associated With Cognitive Functioning in Nursing Home Residents

ObjectivesDepression, apathy, and cognitive impairments are widespread in nursing home (NH) residents. Scarce research that explicitly compares apathy to depression suggests that the association between apathy and cognitive functioning is stronger than the association between depression and cognitive functioning. This study in Dutch NH residents aimed to use Bayesian methods for comparing the evidence for the relationship of cognitive performance with apathy to that with depression. DesignCross-sectional. Setting and ParticipantsSixteen NH somatic care units (N = 190 residents; mean age 77.2 years, standard deviation 12.9), and 17 dementia special care units (N = 243 residents; mean age 82.8 years standard deviation, 6.8]). MeasuresThe Frontal Assessment Battery (FAB) and Mini-Mental State Examination (MMSE) were administered in residents for cognitive performance. Professional carers were interviewed for the Apathy Evaluation Scale and the Cornell Scale for Depression in Dementia. ResultsRegression models built with the BayesFactor package in R showed Bayesian factors (BFs) that implied extremely strong evidence in terms of the Jeffrey classification for the relationship of apathy with MMSE [standardized effect size, −0.57 (−0.66 to −0.48), BF = 3.4E+28], and with FAB [−0.50 (−0.59 to −0.42), BF = 3.0E+24]. Regarding depression, evidence was a minor fraction of that for apathy [MMSE, −0.17 (−0.27 to −0.06), BF = 15.45; FAB, −0.12 (−0.22 to −0.02), BF = 2.11]. The most evidence existed for the associations of apathy with MMSE orientation problems, especially orientation in time. Conclusions/ImplicationsThe study implies that cognitive assessments are important to differentiate apathy from depression in NH residents both with dementia and without dementia. More research is needed to clarify whether disorientation in time is a specific cognitive marker of apathy that may be used to reduce false positive depression diagnoses.

Intensity of Occupational Therapy Utilization in Nursing Home Residents: The Role of Sensory Impairments

ObjectivesUnaddressed functional limitations in nursing home (NH) residents can lead to unnecessary, excess disability that negatively affects residents’ quality of life. In order to enhance functioning, NH residents can receive rehabilitation such as occupational therapy (OT). However, little is known about factors that may aid or hinder full therapy utilization in NH residents. Hence, our study investigated sensory impairments (vision and hearing) and other important health-related variables (eg, cognitive functioning) as predictors of intensity of OT utilization. DesignRetrospective study with data extraction from electronic medical records (EMRs). SettingSkilled nursing facility. ParticipantsA sample of newly admitted NH residents (N = 121). MeasurementsSingle items for sociodemographic variables and clinician-rated extent of sensory difficulties (hearing and vision) as well as pain presence based on Minimum Data Set (MDS 3.0) assessments in EMRs. MDS 3.0 scales assess cognitive functioning, depressive symptoms, and functional dependency. Total hours of OT received during 90 days postadmission to the NH were extracted from the EMRs. ResultsA regression analysis demonstrated that better admission hearing and cognitive functioning, fewer admission depressive symptoms, and higher admission functional dependence were associated with more intense OT utilization—more hours used—over a 90-day period. ConclusionThis study emphasizes the importance of assessing and addressing hearing difficulties and depression in NH residents in order to optimize utilization of beneficial OT services and to promote most optimal independent functioning and quality of life.

Falls as Adverse Events in Psychosocial Treatment of Depression: Findings from a Clinical Trial in Nursing Homes.

Falls pose a significant health risk for nursing home residents and are associated with depression and medical treatments for depression. Data on falls as an adverse event to psychosocial treatments are lacking. We examined risk of falls as an adverse event in a clinical trial of a behavioral treatment for depression. Participants were 82 depressed nursing home residents. Adverse events were recorded at each research contact. We used the rate ratio based on the respective incidence densities in the treatment and control groups to measure association between fall rate and treatment. The treatment group had almost six times higher risk of falls than the control group, a statistically significant association. Findings suggest that it may be of value to include statistical analysis of falls as adverse events in trials of behavioral interventions for depression.

Prescribing Antidepressants in Depressed Nursing Homes Residents with Dementia: Is it Evidence-based?

Depression and dementia are common comorbidities among Nursing Home (NH) residents. Antidepressants are widely used in this vulnerable population. However, the evidence for anti-depressant use, including from randomized controlled trials, systematic reviews, and evidence-based clinical practice guidelines, is inconsistent and conflicting. Additionally, antidepressants are associated with multiple adverse effects. Long-term care providers often need to deal with requests from patients’ families, nursing staff, and colleagues to prescribe antidepressants, while following recommendations from pharmacists and regulations from the Center for Medicare and Medicaid Service (CMS) and Federal Drug Administration (FDA) not to prescribe or to discontinue antidepressants. It is difficult for long-term care providers to decide whether they should prescribe antidepressants and meet regulations and quality of care standards based on the few Randomized Controlled Trials (RCTs). A large randomized control study to examine the efficacy of antidepressants among depressed NH residents with dementia is urgently needed. We propose a practical step-wise approach to prescribe antidepressants for this vulnerable population.

Depression in Nursing Home Residents: Prevalent and Serious

Clinical depression affects 15% to 25% of nursing home residents and is associated with earlier mortality, but evidence is lacking to support interventions that might relieve or prevent depression in this setting. In two studies, investigators assessed the effects of particular interventions on prevalence of depression in nursing home residents. In a study from the …

A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial

Depression in nursing-home residents is often under-recognised. We aimed to establish the effectiveness of a structural approach to its management. Between May 15, 2009, and April 30, 2011, we undertook a multicentre, stepped-wedge cluster-randomised trial in four provinces of the Netherlands. A network of nursing homes was invited to enrol one dementia and one somatic unit per nursing home. In enrolled units, nursing-home staff recruited residents, who were eligible as long as we had received written informed consent. Units were randomly allocated to one of five groups with computer-generated random numbers. A multidisciplinary care programme, Act in Case of Depression (AiD), was implemented at different timepoints in each group: at baseline, no groups were implenting the programme (usual care); the first group implemented it shortly after baseline; and other groups sequentially began implementation after assessments at intervals of roughly 4 months. Residents did not know when the intervention was being implemented or what the programme elements were; research staff were masked to intervention implementation, depression treatment, and results of previous assessments; and data analysts were masked to intervention implementation. The primary endpoint was depression prevalence in units, which was the proportion of residents per unit with a score of more than seven on the proxy-based Cornell scale for depression in dementia. Analyses were by intention to treat. This trial is registered with the Netherlands National Trial Register, number NTR1477. 16 dementia units (403 residents) and 17 somatic units (390 residents) were enrolled in the course of the study. In somatic units, AiD reduced prevalence of depression (adjusted effect size -7·3%, 95% CI -13·7 to -0·9). The effect was not significant in dementia units (0·6, -5·6 to 6·8) and differed significantly from that in somatic units (p=0·031). Adherence to depression assessment procedures was lower in dementia units (69% [SD 19%]) than in somatic units (82% [15%]; p=0·045). Adherence to treatment pathways did not differ between dementia units (43% [SD 33%]) and somatic units (38% [40%]; p=0·745). A structural approach to management of depression in nursing homes that includes assessment procedures can reduce depression prevalence in somatic units. Improvements are needed in depression screening in dementia units and in implementation of nursing-home treatment protocols generally. The Netherlands Organization for Health Research and Development.

Nijmegen Observer‐Rated Depression scale for detection of depression in nursing home residents

This study aims to test the accuracy of the Nijmegen observer-rated depression (NORD) scale, a new short scale for screening of depression in nursing home (NH) residents with and without dementia. This cross-sectional study with 103 residents with dementia (N = 19 depressed) and 72 residents without dementia (N = 10 depressed) was undertaken in 13 Dutch NH units. An elderly care physician and a psychologist of each unit assessed residents for the presence of clinical depression. Primary professional caregivers administered the NORD scale. Five of the six proposed items showed acceptable performance in screening for depression. Receiver operating characteristic analyses revealed significant areas under the empirical curve (AUC) for the 5-item NORD scale in the total sample (AUC = 0.83, p < 0.001), as well as in residents with dementia (AUC = 0.84, p < 0.001) and without dementia (AUC = 0.84, p < 0.001). The cutoff score of >1 showed the highest sum of sensitivity (100) and specificity (69) in non-dementia and >2 the highest sum of sensitivity (79) and specificity (77) in dementia. The cutoff score of >1 showed the lowest negative likelihood ratio of 0.0 in non-dementia and of 0.2 in dementia. The highest positive likelihood ratios were found for the cutoff of >2 in non-dementia (3.4) and for >4 in dementia (26.5). The 5-item NORD scale showed acceptable accuracy comparable with those of more extensive scales in other studies. It is easy and quick to administer and can be used for screening of depression in NH residents with or without dementia.

A review of the effectiveness of antidepressant medications for depressed nursing home residents.

Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population. To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents. The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimer's disease. A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group. The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.

A Hope Intervention Compared to Friendly Visitors as a Technique to Reduce Depression among Older Nursing Home Residents

Depression is common among older persons. An experimental study was undertaken to test the impact of a four-week hope program on depressed nursing home residents. Residents aged 65 or older, who met the criteria for this pilot study and agreed to participate, were randomly assigned to (a) an intervention group, and provided with weekday hope interventions mainly involving positive messages and pictures or (b) a modified control group, and provided with a friendly weekday greeting. The structured hope intervention was not proven effective for reducing depression or raising hope. Instead, a significant reduction in depression among the control subjects was found, as well as a nonsignificant increase in their level of hope. Although these findings suggest friendly visitors may be a more efficacious nonpharmacological approach for reducing depression, further investigations are needed to confirm this and to explore the impact of other hope interventions.

Risk Factors and Intervention Programs for Depression in Nursing Home Residents: Nursing Home Staff Interview Findings

The in-depth qualitative interviews with 25 nursing home staff members were done to examine (a) their perceptions and experiences of risk factors for residents' depression, (b) current depression intervention programs, and (c) specific needs for staff training. The interviewees identified the residents' sense of loss and grief and feelings of isolation and loneliness as the causes of their depression and in-house activities and contract mental health services as current services aimed at reducing depression. They also pointed out the following barriers to providing effective depression interventions: too much dependence on antidepressant medication, low Medicaid reimbursement rate, staff shortage, residents' attitudes, and nursing home culture. The types of training that the staff members desired were: skills to monitor nonverbal signs and changes and to systematically screen different types of depression; education about antidepressants and their effects, side effects, and interaction effects with other medication; and systematic training in different types of psychosocial and behavioral interventions for late-life depression in residents with various levels of physical disabilities and cognitive impairments.

Malnutrition and depression in the institutionalised elderly

Malnutrition and depression are highly prevalent in the institutionalised elderly and can lead to unfavourable outcomes. The aim of the present study was to assess associations between nutritional status and depressive symptoms and to explore their impact on self-caring capacity and quality of life (QoL) in elderly nursing-home residents (NHR). We conducted a cross-sectional study with 114 NHR (eighty-six female) with a mean age of 84.6 (sd 9.1) years. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Depressive symptoms were rated with the Geriatric Depression Scale (GDS). Self-caring capacity was measured with the Barthel index (BI) and QoL was assessed with the short-form thirty-six-item (SF-36) questionnaire. Of the NHR, twenty-six (22.8 %) were malnourished according to the MNA and sixty-six (57.9 %) were at nutritional risk. Of the residents, seventy-five could be assessed with the GDS, whereof sixteen (21.3 %) had major and twenty-six (34.7 %) had minor depressive symptoms. GDS scores tended to be higher in patients with impaired nutritional status (5.4 (sd 3.6) in well-nourished subjects and 6.9 (sd 3.2) in residents with malnutrition or at risk of malnutrition). The MNA correlated significantly with the GDS (r - 0.313; P = 0.006) and the GDS emerged as the only independent risk factor for malnutrition in a multiple regression analysis, whereas age, sex, care level, number of prescriptions and self-caring capacity had no influence. The BI was not reduced in patients with a high GDS. QoL was affected in malnourished residents as well as in study participants with depressive symptoms. The results of the present study point towards an association between malnutrition and depressive symptoms. However, the relationship is complex and it remains unclear whether depression in NHR is the cause or consequence of impaired nutritional status. Further studies are needed to identify the direction of this relationship and to assess the effect of depression treatment on nutritional and functional status as well as on QoL.

Are there predictors of outcome in depressed elderly nursing home residents during treatment with mirtazapine orally disintegrating tablets?

Treatment studies of depression in residential care are limited. Reports of predictors of response are rare. In the largest nursing home prospective antidepressant trial reported, we examined predictors of response. This was a 12-week open-label study of mirtazapine orally disintegrating tablets performed in 30 US nursing homes. Subjects were men and women aged >or=70, with a Mini Mental State Exam (MMSE) score >or=10, who had a depressive disorder that required antidepressant treatment. Mirtazapine was started at 15 mg at bedtime, and adjusted to 15-45 mg/day. A 16-item Hamilton Depression Rating Scale was used to assess depression at baseline, weeks 2, 4, 8, and 12 or early termination. One hundred and twenty-four patients received at least one dose of study drug and of these, 119 had at least one post-drug assessment. Mean age was 82.9 years and 72% were female. Response rates at 12 weeks were 47% on the HAMD and 54% on the CGI. Age, sex, MMSE score, medical burden, history of prior depression, and baseline HAMD severity were not significantly associated with HAMD response (>or=50% improvement) and in most cases correlations were trivial, <0.1. Advanced age, medical burden, and cognitive impairment did not predict adverse events. In this sample of depressed nursing home residents treated with mirtazapine orally disintegrating tablets, advanced age, medical illness, and cognitive impairment did not predict response. The findings suggest that these variables need not be viewed as obstacles to treatment.

Mirtazapine orally disintegrating tablets in depressed nursing home residents 85 years of age and older

Treatment studies of depression in the very oldest patients are infrequent. For these reasons, this study of mirtazapine orally disintegrating tablets was carried out in nursing home residents>or=85 years old with physician-diagnosed depression. The naturalistic conditions of the study allowed us to include patients with cognitive impairment, concomitant medications and comorbid illness. This was a subgroup analysis of nursing home residents>or=85 years old who took part in a larger 12-week open-label trial. Patients were eligible if they had physician-diagnosed depression, and a Mini-Mental State Exam score>or=10. The physician or nurse coordinator obtained data from healthcare professionals in daily contact with the patient to complete the Clinical Global Impression (CGI) scale, a modified 16-item Hamilton Depression Scale (HAM-D), and the Cornell Scale for Depression in Dementia (CSDD). Treatment-emergent adverse events were recorded. Of the 50 patients enrolled at 23 sites, 72% completed the 12-week trial. The mean age of the participants was 89.3 years. The mean HAM-D score declined from 16.9 at baseline to 7.3 at endpoint (ITT, LOCF analysis) For the CSDD, the mean score declined from 15.1 to 7.1. The percentage of responders on the CGI-Improvement (CGI-I) scale increased at each assessment reaching 55% at endpoint. Only 10% of the patients discontinued treatment because of adverse events. There was a mean increase in weight of 1.32 lbs (0.6 kg) at day 84. Although lacking a placebo control, this naturalistic study suggests that mirtazapine orally disintegrating tablets were effective and well tolerated in this sample of depressed nursing home residents>or=85 years of age.

Venlafaxine offers no benefit over sertraline and is less well tolerated in depressed nursing home residents

Oslin DW, Ten Have TR, Streim JE, et al . Probing the safety of medications in the frail elderly: evidence from a randomized clinical trial of sertraline and venlafaxine in...

Using the Minimum Data Set 2.0 Mood Disturbance Items as a Self-Report Screening Instrument for Depression in Nursing Home Residents

Objective Seeking to enhance nursing home residents' involvement in their care, the authors examined whether the Minimum Data Set, Version 2.0 (MDS) Mood Disturbance items could be administered by self-report. They compared the MDS to the Geriatric Depression Scale (GDS) in terms of its association with depression diagnosis. Methods Subjects (N=204) were nursing home residents who were interviewed with a psychiatric diagnostic instrument, the GDS, and a self-report version of the MDS mood disturbance items. Results Analyses of variance and receiver operating characteristics analyses demonstrated that MDS items distinguished subjects with any versus no depression about as well as did the GDS. This pattern held within cognitive, gender, and ethnicity subgroups. Conclusion The MDS Mood Disturbance items can be reliably and validly administered via self-report to persons scoring at least 12 on the Mini-Mental State Exam. Seeking to enhance nursing home residents' involvement in their care, the authors examined whether the Minimum Data Set, Version 2.0 (MDS) Mood Disturbance items could be administered by self-report. They compared the MDS to the Geriatric Depression Scale (GDS) in terms of its association with depression diagnosis. Subjects (N=204) were nursing home residents who were interviewed with a psychiatric diagnostic instrument, the GDS, and a self-report version of the MDS mood disturbance items. Analyses of variance and receiver operating characteristics analyses demonstrated that MDS items distinguished subjects with any versus no depression about as well as did the GDS. This pattern held within cognitive, gender, and ethnicity subgroups. The MDS Mood Disturbance items can be reliably and validly administered via self-report to persons scoring at least 12 on the Mini-Mental State Exam.

Using the Minimum Data Set 2.0 Mood Disturbance Items as a Self-Report Screening Instrument for Depression in Nursing Home Residents

Seeking to enhance nursing home residents' involvement in their care, the authors examined whether the Minimum Data Set, Version 2.0 (MDS) Mood Disturbance items could be administered by self-report. They compared the MDS to the Geriatric Depression Scale (GDS) in terms of its association with depression diagnosis. Subjects (N=204) were nursing home residents who were interviewed with a psychiatric diagnostic instrument, the GDS, and a self-report version of the MDS mood disturbance items. Analyses of variance and receiver operating characteristics analyses demonstrated that MDS items distinguished subjects with any versus no depression about as well as did the GDS. This pattern held within cognitive, gender, and ethnicity subgroups. The MDS Mood Disturbance items can be reliably and validly administered via self-report to persons scoring at least 12 on the Mini-Mental State Exam.

Treating depression in nursing homes: practice guidelines in the real world.

Depression in nursing home residents is a common phenomenon, though there is a wide range in the severity of this disorder as experienced by elderly adults in the United States. Treating older patients for depression is costly in both human and financial terms. The authors review guidelines and recommendations for the diagnosis of depression and medical treatment of depressed elderly adults from the 1993 Clinical Practice Guidelines for Depression in Primary Care by the US Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), making note also of similar guidelines provided by the American Medical Directors Association in 1996 and those provided by the American Psychiatric Association in 2000. In November 1999, the authors used a Delphi survey to gather data from prescreened panelists (N = 10) to have the panel review and clarify the importance and feasibility of each "A" rated item in the US Agency for Health Care Policy and Research guidelines. This research allows health care providers to evaluate the importance and feasibility of items related to the delivery of mental health services for the elderly in nursing homes.

Pleasant Events-Based Behavioral Intervention for Depression in Nursing Home Residents

ABSTRACT In this theoretical/review article, we set forth a conceptual model and empirical evidence as the foundation for a behavioral intervention in nursing homes involving pleasant events. The risk for depression is nearly twice as great among nursing home residents as it is for community-residing elders, with up to 50% of nursing home residents affected by significant depressive symptoms. Although we now have a good understanding of the epidemiology and manifestations of depression in late life, and are beginning to apply effective treatments to some groups of elders, the benefits of the past decade of research have yet to reach the frailest elders living in nursing homes. The health and cognitive multiple comorbidity of this population makes treatment extremely challenging. The behavioral model we describe is based on the work of Lewinsohn and others. The intervention would adapt work already completed by Teri and her colleagues with elderly dementia patients and their families. We make specific recommendations concerning adapting this treatment approach to nursing homes, and evaluating its effects.

Development of a minimum data set-based depression rating scale for use in nursing homes.

depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff. to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument. we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses. a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale. items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed.

Encouraging Social Interaction Among Depressed Nursing Home Residents

This paper will examine different strategies for developing social interaction among depressed nursing home residents. Examples of various activities will also be discussed.