The utility of mandatory depression screening of dementia patients in nursing homes.
Cohen CI, Hyland K and Kimhy D;
Commented by , 30 Dec 2003
Aim of the study
To examine the process and outcome of implementing a mandatory depression screening programme for depressed dementia patients in nursing homes.
Method
The study was performed in 4 nursing homes in New York City; 2 of these homes (199-bed and 320-bed) were the experimental group, the other 2 (123-bed and 240-bed) the control group. The homes were broadly similar in their staffing, though one of the control group homes routinely had 3 psychologists and 3 psychiatrists providing consultation and staff education (the authors called this an “enriched” home).
Residents were initially screened for presence of dementia, defined by Mini Mental State Examination (MMSE) score of <24 and Global Deterioration Scale (GDS) score >3.
Consenting residents with moderate dementia (scoring <7 on GDS) were then screened further for depression, as defined by a score of >4 on the Cornell Scale for Depression in Dementia. Residents in the experimental group were then treated for depression, and both groups assessed for outcome by researchers after 12 weeks. Statistical analysis was performed with t-tests, chi-square tests, and analysis of variance.
Results
There were no significant differences in age, MMSE score, or gender among eligible subjects in the experimental and comparison groups.
Mandatory screening had a significant effect on the 2 experimental homes. Before screening, only 16 % of subjects with Cornell Scale scores >4 were treated with antidepressants, 36 % were treated after screening. The difference was even more marked the more severe the depression, as ranked by Cornell’s score. Subjects with depression and dementia in the “enriched” control home were in the main, already being treated.
Experimental group patients, both newly treated and already receiving antidepressants, improved significantly on 12-week follow-up versus subjects in the comparison group who had been receiving antidepressants. The authors speculated that this was partly due to inadequate treatment of the comparison group.
Discussion
Existing literature suggests that depression in nursing homes is underdiagnosed and undertreated, and that depression can lead to poor nutrition, physical ill health, poor compliance with treatment, behavioural problems and excess mortality. Co-morbid dementia compounds these problems.
Overall, this study has limitations in terms of its design and the small final numbers in the treatment group. This is a difficult group of patients to care for, and research into. However, it does provide some supportive evidence that screening for depression in dementia is possible in nursing homes, and that improved outcome may occur in some individuals with rigorous treatment. It reinforces the message : “start low, go slow . . . but keep going” with respect to antidepressant treatment.