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Keywords:

  • depression;
  • nursing home;
  • nursing staff;
  • screening (descriptor);
  • validity (epidemiology)

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim:  To examine the utility of the Cornell scale for depression in dementia (CSDD), following its introduction as a routine measure in nursing homes.

Methods:  The CSDD is administered in Australian nursing homes as section 10 of the Aged Care Funding Instrument. CSDD, cognitive and behavioural ratings, and medication use, recorded in three Sydney nursing homes in 2008–2009 were reviewed. Staff discussed what actions were taken if CSDD scores indicated depression.

Results:  Of 223 residents, 23% scored >12 on the CSDD, indicating probable depression. Another 21% were possibly depressed and 29% not depressed. The CSDD had not been completed for 27%, commonly because preliminary screening indicated no depression, but sometimes because severe cognitive impairment made various CSDD items impossible to rate. Second CSDD assessments had usually not been made.

Conclusion:  Nursing homes need to document policies that will ensure best use is made of CSDD findings.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Studies around the world have shown the prevalence and incidence of depression in long-term care (LTC) homes to be high [1–4]. However, depression in these facilities is underrecognised [2,5–8] and commonly untreated [9], especially among residents with dementia. The Minimum Data Set is used routinely in USA nursing homes, but studies in these facilities have found it to be of limited clinical value in identifying depression [6,10].

The impact of mandatory depression screening on identification of cases of depression among nursing home residents with dementia has been examined [6]. Mandatory use of the Cornell scale for depression in dementia (CSDD) [11] resulted in a significantly higher percentage of depressed dementia participants receiving antidepressants than was the case before such screening (44 vs 20%).

In a consensus statement, the American Geriatrics Society and American Association for Geriatric Psychiatry [12] recommended using an observer-rated scale, such as the CSDD, to screen for depression among residents with moderate to severe dementia. They recommended that this occur 2–4 weeks after admission to a LTC home, and then at least every 6 months. They declared that a self-report scale such as the geriatric depression scale [13] should be used for screening only in cases of milder or no dementia.

Since March 2008, the CSDD has been included as an assessment component of the Australian Department of Health and Ageing's Aged Care Funding Instrument (ACFI), acknowledging that depression affects care needs. Scores on the CSDD contribute to a calculation of supplementary funding provided to LTC homes in recognition of residents' levels of behavioural, cognitive or depressive manifestations (the ‘behaviour domain’). Supplementary funding is also provided in relation to an ‘activities of daily living domain’ and ‘complex health-care domain’.

The CSDD provides an ‘objective way to test improvement’ and ‘increases staff awareness of signs and symptoms’[14]. However, its validity has been questioned [4], especially in populations with high levels of medical illness, functional disability and dementia [15,16]. Some symptoms rated by the CSDD overlap with those of dementia [17].

In late 2009, the Australian Government called for input to its review of the ACFI (http://www.health.gov.au/acfi-review). Our study was designed to provide such input.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Administrators of the three nursing homes in one local government area of Sydney provided access to ACFI data recorded over 1 year (2008–2009) and demographic details regarding residents. Approval for the study was given by the Ethics Committee of Sydney South West Area Health Service. Age, sex, date of admission, diagnosis and records of current psychotropic medication use were obtained, together with initial ACFI ratings of cognitive function and behavioural disturbance, and on CSDD items. For most residents, only one ACFI assessment had been recorded in the year, but in 10% there had been re-assessment (usually to seek a higher level of supplementary funding).

Rating instructions give guidance on questions to ask when interviewing residents and informants, and on factors to take into consideration when making ratings. For example, the item on loss of interest should be rated zero if: (i) it is long-standing; (ii) it is attributable to physical illness or disability; or (iii) the person has persistent apathy associated with dementia.

In addition, the authors of this paper (a psychiatrist and senior staff in the three nursing homes) discussed: (i) reasons why the CSDD was not administered in some cases; (ii) what arrangements were made for ensuring that staff and doctors were alerted to, and were prompted to continue monitoring, cases where CSDD scores were elevated; and (iii) when and whether repeat testing was arranged if screening indicated that a resident was depressed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The three nursing homes were medium-sized. Information was available for all 223 persons resident at the time the data were obtained; 97 (43.5%) were male and 126 (56.5%) female. The mean age was 79 (range 28–102) years. Fourteen residents (6%) were aged <60 years and 11 (5%) were aged 60–64 years. About 70% had been in the nursing home for over 1 year.

The proportion with ACFI-rated severe cognitive impairment was similar in the three nursing homes (average 52%). A diagnosis of schizophrenia had been made in 32 (14%), of whom 10 also had dementia. Of the 223, 15 were noted as developmentally disabled.

Scores on the CSDD are shown in Table 1. Whereas ratings of degree of behavioural disturbance and cognitive function were made in all cases, CSDD ratings were not made at all in 55 cases and were made on fewer than seven items in another six. In 47 other cases, between one and nine items were recorded as ‘unable to score’. Items 16–19 relate to suicidal ideation, poor self-esteem, pessimism and mood-congruent delusions, and ‘unable to score’ was recorded for all four in 12 cases and for three in 10 cases (adding to 10% of 223). An average of 154 ratings were made on items 1–15 (range 150–159), but the average for items 16–19 was only 134. Items with the highest mean scores (rated 0, 1 or 2) were anxiety (1.06), irritability (1.01), agitation (0.89) and sadness (0.78). Those with the lowest were suicidal ideation (0.12) and weight loss (0.19).

Table 1. CSDD scores of residents in three Sydney nursing home
CSDD score0–78–1213+Not rated (n= 55) or rated on less than seven itemsTotal
  1. CSDD, Cornell scale for depression in dementia.

No. of residents64475161223
% of total number29212327 
No. (%) with severe dementia26 (41)28 (60)20 (39)44 (72)118 (53)
No. (%) on antidepressants17 (27)11 (23)21 (41)11 (18)60 (27)
No. (%) on therapeutic doses of antidepressants11 (17)7 (15)16 (31)6 (10)40 (18)

Discussions with senior staff clarified why CSDD ratings were not made at all for 55 residents or on most items for another six. Half of the 61 (14% of 223) were severely cognitively impaired and virtually unable to communicate or to express feelings. Staff found it impossible to make meaningful ratings in these cases. Furthermore, they said that items 16–19 were often not rated, even if other items were, because ideational disturbance was too difficult to rate if a subject could not converse intelligibly or convey meaning.

In one of the nursing homes, a short screening tool is used to identify those who staff believe are clearly not depressed and thus do not require time to be spent on administration of the CSDD. Thirty of those not rated on the CSDD had been assessed on preliminary screening as non-depressed. Some of them had severe dementia.

Although high CSDD scores were drawn to the attention of residents' doctors, there were no documented policies regarding re-assessment of those with high scores or the need to monitor symptoms identified as present. There was no evidence of reminders for review of those residents identified as scoring in the depressed range on the CSDD.

Supplementary funding in relation to elevated CSDD scores is partly dependent on a diagnosis of depression being documented by the doctor. Thus, there is an incentive to alert doctors to the possibility of depression. Inspection of resident records gave an impression that, in most cases, elevated CSDD scores did not result in changes in medication or therapy orders by the doctors.

Table 1 shows that 31% of residents scoring 13+ on the CSDD, but only 14% of the other residents, were taking therapeutic dosages of antidepressants. Of those scoring 13+ on the CSDD, 80% were taking psychotropic medication other than hypnotics; the corresponding figure in the other 172 cases was 44%.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

An aim of this study was to examine whether routine use of a screening scale to identify depression in nursing homes has proved beneficial, especially in cases of dementia. It appeared that, although knowledge of CSDD scores may have fostered discussion (among staff and with doctors) about need for strategies to reduce depression levels in some cases, there was little ongoing discussion or measurement relating to the outcomes of interventions. Although staff knew that CSDD administration has funding implications, there was less evidence that they viewed it as potentially important in considering care needs.

In the present study, raters found themselves unable to make CSDD ratings in 14% of cases because of severe dementia, and rating ideational disturbance proved impossible in another 10%. Thus, meaningful CSDD ratings were not available for a substantial proportion of the residents. In a previous Australian study [18], a psychiatrist had similar difficulty when examining certain residents who scored zero on the Mini-Mental State Examination [19]. Some were unable to respond verbally or were too dysphasic.

In that previous study, it was found that 18.4% of testable high care (nursing home) residents scored 13+ on the CSDD and 22.1% scored 8–12, whereas 60.5% scored 0–7 [18]. Figures in the current study were not dissimilar, given that preliminary screening showed many of those not rated on the CSDD were not depressed.

A limitation of this study was the selective nature of the resident population. The mean age was below the average in Australian nursing homes; the proportion with a diagnosis of schizophrenia was considerably higher than would be found in most nursing homes.

To best use the CSDD's potential, nursing homes need to ensure that residents' doctors and staff are alerted to CSDD scores that may indicate depression, and that (if considered appropriate) depression management strategies are initiated, with monitoring of their effects. Because high CSDD scores do not always correspond with diagnoses of depressive disorder, comprehensive assessment is important. A study of a large and representative group of aged care facilities in different Australian states, after providing more education on how best to use the CSDD in identifying and treating depression, is recommended.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Many thanks are due to the administrators and staff of the three nursing homes for providing access to residents' ACFI files and medication details.

Key Points

  • • 
    Routine use of the CSDD in nursing homes facilitates recognition and discussion by nursing staff of depressive features among residents.
  • • 
    Nursing homes need to have policies in place to ensure that elevated CSDD scores receive attention, including antidepressive measures and later review to see whether interventions have been beneficial.
  • • 
    CSDD findings are unlikely to be meaningful among those with very severe cognitive impairment.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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