It is anticipated that the incidence and prevalence of Alzheimer’s disease and other forms of dementia will increase (Alzheimer’s Association, 2012) as our nation ages. It is therefore essential that depression and dementia, the two most common psychiatric syndromes in the older adult population, are routinely assessed. However, depression in older adults with and without dementia often goes undetected and untreated (Charney et al., 2003; Jeon et al., 2013, 2015; Kales, Chen, Blow, Welsh, & Mellow, 2005; Snowdon & Fleming, 2008). Estimates of the prevalence of depression in older adults with dementia vary greatly (Alexopoulos & Abrams, 1991; Debruyne et al., 2009; Lyketsos & Olin, 2002; Wragg & Jeste, 1989). This variation is attributed to differences in sampling, diagnostic criteria used to identify depression, and the way depression is assessed (Alexopoulos & Abrams, 1991; McCabe et al., 2006).
Despite expert recommendations (Alexopoulos et al., 2001) and increased availability of a range of depression treatment options (e.g., medication, psychotherapy, combination therapy, electroconvulsive therapy), depression remains a significant public health problem for older adults (HealthyPeople.gov, 2015).
Detection is the first essential step to improving depression care for patients with dementia. However, detection of depression in individuals with dementia is complicated by numerous barriers at the patient, clinician, and system level. These barriers include the inability of many individuals with Alzheimer’s disease and other forms of dementia to provide reliable reporting of emotional symptoms. Severely impaired patients are unable to express their needs or symptoms to their caregivers, which makes detection of depression and other conditions difficult. The health system and clinicians contribute additional factors that hinder the detection of depressive symptoms (Figure 1).
Diagram of barriers to detection of depression in older adults with dementia.
Major depression is a syndrome characterized by a number of signs and symptoms. In a study conducted in a nursing home, 25% of patients screened positive for major depression (Gruber-Baldini et al., 2005). This rate is close to that of major depression reported for individuals with Alzheimer’s disease (i.e., 15% to 20% [Alexopoulos & Abrams, 1991], 22% [Lyketsos et al., 1997], and 10% to 20% [Wragg & Jeste, 1989]). According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), at least five symptoms must exist that have been present during the same 2-week period and represent a change from previous functioning for a diagnosis of major depression to be made. At least one of the symptoms must be depressed mood or anhedonia.
In recognition of the fact that many patients with dementia experience clinically significant depression that may not meet full criteria for major depression, Olin et al. (2002b) proposed new provisional diagnostic criteria for depression of Alzheimer’s disease. Diagnostic criteria include fewer symptoms of depression (three versus five symptoms required for major depression). In addition, symptoms only need to be present for a short period of time given the fluctuating nature of depression in individuals with dementia (Abrams & Alexopoulos, 1994; Jost & Grossberg, 1996). However, research studies are still needed to validate these new depression criteria (Charney et al., 2003; Tappen & Williams, 2008).
Self-report scales are only appropriate for individuals with mild to moderate cognitive impairment, and more time-intensive and clinically sophisticated observer-rated approaches are required for individuals with severe cognitive impairment (American Geriatrics Society [AGS] & American Association for Geriatric Psychiatry [AAGP], 2003; Snowden, Sato, & Roy-Byrne, 2003). Additional research is needed to develop and validate a depression screening instrument that will accurately detect depression symptoms in dementia across the cognitive spectrum (Greenberg et al., 2004).
The current article is a condensed version of the revised guideline, Detection of Depression in Older Adults with Dementia (Brown, Raue, & Halpert, 2014). Readers are advised to obtain the full guideline, which includes copies of the assessment tools used in the current article along with process and outcome measures. The guideline may be purchased from the Hartford/Csomay Center for Geriatric Nursing Excellence (access http://www.iowanursingguidelines.com/category-s/125.htm).
Purpose of the Guideline
The purpose of this evidence-based guideline is to improve detection of depression in older adults with dementia. This guideline may be used by physicians, advanced practice nurses (APNs), RNs, licensed practical nurses (LPNs), and social workers across a variety of settings, including inpatient and outpatient, long-term care, assisted living, and home care. This guideline was developed from an exhaustive literature review and synthesis of current evidence on detection of depression in older adults with dementia. Research and other evidence, such as guidelines and standards from professional organizations, were critiqued, analyzed, and used as supporting evidence.
Systematic Depression Assessment
Risk factors for depression are listed in the Table. Any individual older than 60 should be screened for depression periodically. The AGS recommends depression screening 2 to 4 weeks after admission to a nursing home and then repeated screening at least every 6 months after admission (AGS & AAGP, 2003). In all nursing homes, patients should be screened at least every 6 months (AGS & AAGP, 2003; Snowden et al., 2003). The estimated 1.5 million nurses (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, & National Center for Health Statistics, 2013) working across long-term care settings are positioned well to improve depression detection in individuals across the cognitive spectrum.
Risk Factors for Depression
The three-step depression screening process can be implemented by an individual health care provider or by using a team approach. The authors suggest first that a series of five patients be assessed by the user with the supervision of a mental health expert. Organizational support for training and implementation of the screening process are required. Implementation time will vary.
Populations and Settings
The nursing home and home health care service sectors are both currently federally mandated to conduct periodic depression screening. Regulatory requirements in the nursing home require the completion of the Minimum Data Set (MDS) Version 3.0, a core set of screening and functional status elements including common deficiencies and coding categories. The MDS forms the foundation of comprehensive assessment for all patients of long-term care facilities certified to participate in Medicare or Medicaid (Centers for Medicare & Medicaid Services [CMS], 2009, 2012a, 2015a). In home health care, regulatory requirements require the completion of the Outcome Assessment and Information Set (CMS, 2012b, 2015b), a set of data that evaluates a variety of patient domains and documents outcomes in home health care.
Description of the Practice
The assessment is a three-step procedure that can be used across health care settings to screen for the presence of depressive symptoms. This is a screening guideline, not a diagnostic process. Positive screens should be followed with a diagnostic evaluation by a skilled health care provider. Implementation of the evidence-based guideline requires:
To further describe the screening process for detection of depression in individuals with dementia, “The Algorithm for Detection of Depression in Older Adults With Dementia Population” was developed, which is illustrated in Figure 2. The Algorithm is designed to be used by nurses, physicians, and social workers.
Algorithm for detection of depression in older adults with dementia population.
In addition, the following screening tools are used for the detection of depression, as mentioned above.
The Mini-Mental State Examination
The MMSE* (Folstein et al., 1975) is a widely used method for assessing the cognitive functioning of older adults. The MMSE contains items that assess orientation, attention and calculation, immediate and short-term recall, and language and the ability to follow simple written and verbal commands. It yields a maximum score of 30 and a minimum score of 0. A cutoff score ≤23 for the presence of dementia has demonstrated high sensitivity and specificity (Folstein et al., 1975).
*: The copyright of the MMSE is owned by Psychological Assessment Resources and payment is required when used. There are options for clinicians who cannot pay (Newman, 2015).
Geriatric Depression Scale
The Geriatric Depression Scale (GDS), available in many languages, is a depression screening tool that takes approximately 5 minutes to administer and has been validated for community-dwelling, hospitalized, and institutionalized older adults (Koenig, Meador, Cohen, & Blazer, 1988; Lesher & Berryhill, 1994; Sheikh & Yesavage, 1986). The SGDS is a 15-item yes/no screening tool for depression in older adults that does not focus on somatic symptoms of depression, which may be the result of physical illness in the elderly. This scale discriminates between normal, mildly depressed, and severely depressed individuals. It has been validated in community-dwelling, hospitalized, and institutionalized older adults (Koenig et al., 1988; Lesher & Berryhill, 1994; Sheikh & Yesavage, 1986). The SGDS, at a threshold score of 6, has a high correlation with the longer form GDS (r = 0.85) (Sheikh & Yesavage, 1986). This cutoff has been shown to have high specificity and sensitivity in the mild and moderately cognitively impaired population (McCabe et al., 2006). The tool retains validity for MMSE scores ≥15 (Burke, Houston, Boust, & Roccaforte, 1989; Canuto et al., 2009; Feher, Larrabee, & Crook, 1992; Kafonek et al., 1989; McCabe et al., 2006; McGivney, Mulvihill, & Taylor, 1994; Müller-Thomsen, Arlt, Mann, Mass, & Ganzer, 2005). The GDS can be administered as a self-report or by oral interviews (Koenig et al., 1988; McGivney et al., 1994).
Cornell Scale for Depression in Dementia
The CSDD is a depression severity tool that can also be used for screening. The tool has been validated to rate depressive symptomology over the entire range of cognitive impairment (Alexopoulos et al., 1988). The CSDD has been translated and used in several countries and has been shown to be a reliable and valid measure (Barca, Engedal, & Selbaek, 2010; Lin & Wang, 2008). Although the CSDD has been validated as a severity instrument (Alexopoulos et al., 1988), the AGS/AAGP (2003) Consensus Statement also recommended its use as a screening instrument for moderately to severely cognitively impaired individuals (Snowden et al., 2003). Because some patients provide unreliable self-reports, the CSDD combines use of both an informant and patient interview. A cutoff score of ≥11 has been identified as indicating probable or definite major depression (Alexopoulos, 2002).
Despite strong evidence of reliability and validity of the CSDD by trained researchers or specialist clinicians, studies examining its administration in routine care have found lower diagnostic accuracy (Jeon et al., 2015; Watson, Zimmerman, Cohen, & Dominik, 2009). These findings highlight the importance of using well-trained staff and multiple sources of information, including reliable informants.
A concern identified about using the CSDD in practice is the time required to train staff and administer the instrument. To help facilitate training and administration, a unique format is provided in the guideline. Figure 3 displays one of the 19 CSDD items, in addition to a set of questions to facilitate administration. All 19 CSDD items, description of administration, interpretation, and documentation are included in the full complete version of the evidence-based guideline (access http://www.iowanursingguidelines.com/category-s/125.htm) on which the current article is based.
Agitation item of the Cornell Scale for Depression in Dementia.
A number of outcome indicators are expected to change or improve following consistent use of the guideline. The major outcome indicators that should be monitored over time include:
- increased percentage of patients receiving a mental health referral for depression (Callahan et al., 2006);
- increased recognition of depression symptoms in patients with dementia; and
- improved detection, treatment, and course of depression in normal practice (Eisses et al., 2005).
Summary and Conclusion
Detection of depression in individuals with dementia is hindered by lack of a validated, brief screening tool. More research is needed on the use of such screens among older adults with cognitive impairment. Self-report scales are only appropriate for individuals with mild to moderate cognitive impairment, whereas more time-intensive and clinically sophisticated observer-rated approaches are required for severe cognitive impairment (AGS & AAGP, 2003; Snowden et al., 2003). Additional research is needed to develop and validate a depression screening instrument that will accurately detect depression symptoms in dementia across the cognitive spectrum (Greenberg et al., 2004).
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Risk Factors for Depression
|Prior episode of major depression
|Severe psychosocial events or stressors (e.g., death of a loved one, marital separation, divorce)
|Chronic medical conditions
|Substance dependence issues
|Family history of depressive disorders
|Loss of independent functioning (Rovner & Ganguli, 1998)
|Acutely disabling conditions (e.g., stroke, myocardial infarction) (Alexopoulos et al., 1997; Lespérance, Frasure-Smith, & Talajic, 1996)
|Physical disability (Bruce, Seeman, Merrill, & Blazer, 1994).