Improved Screening and

Management of Depression in the

Skilled Nursing Facility and
Long-Term Care Setting
Center for Medicare & Medicaid Services
(CMS) Special Study

Presented by: Vicki Boyle, RN, BSN, Project Manager

To the Alliance for Health

Presentation Outline
Project background
Project objectives
Project design
MPRO interventions
Data analysis and findings
Questions and discussion

Project Background
One of two CMS projects awarded to Quality
Improvement Organizations (QIO) on the
topic of Depression in 2001
Michigan QIO (MPRO) is working in the nursing
home setting
New York QIO (IPRO) is working in the cardiac
rehab setting
Projects began July 2001

Incidence and Significance of

Depression in the Elderly

4.8 million (16%) of Americans older than 65

suffer significant depressive symptoms1
30-50% of nursing home residents are
depressed2
15-25% of depressed nursing home residents3
meet criteria for Major Depressive Disorder
Older adults are at a greater risk for chronicity
of depression than younger persons4
Illness increases the risk of depression and
depression increases the risk of illness
1.
2,3.
4.

Unutzer et al. Am J Geriatr Psychiatry, 1999:7(3):235-432

Rosen et al. Int J Geriatr Pyschiatry, 2000;15:177-80
Unutzer, et al. MilbankQ. 1999;77:225-256.

Geriatric Depression: Lack of

Recognition
50% of depressed nursing home
residents are not appropriately
diagnosed

Less than 25% of depressed elderly

receive adequate treatment

WHY?

Reasons for Missed Diagnosis

Depression symptoms are attributed to age,
other physical illness, bereavement, or
dementia
Stigma associated with mental illness
Depression is masked by somatic symptoms
Patients deny psychiatric symptoms
Inadequate assessment of elderly in nursing
homes
Depressed patients often present no
management problems

Consequences of Missed Diagnosis

or Inadequate Treatment
Suicide

17% of suicides occur in patients 65 and older

(Callahan CM, 2000)

Older adults account for 12% of the US

population but 20% of the more than 30,000
suicide deaths annually (Callahan CM, 2000)
Elderly white men age 85 and older suicide
rate is 6 times higher than the general
population (Hoyert et al, 1999)
70% of suicides see their primary care
physician within one month of suicide
(Conwell 1994)

Consequences (continued)
Greater Morbidity
Impaired ability to manage other illnesses
Decreased quality of life
Strain on family and health care workers
Decreased compliance with medical treatment
Depression increases morbidity and mortality
in patients with congestive heart failure (CHF)
Depression worsens morbidity post-stroke
and myocardial infarction (heart attack)

Consequences (continued)
Increased Mortality
Increased risk of death by 59% in the nursing
home setting
Depression may worsen outcomes of cancer,
diabetes, and AIDS

Consequences (continued)
Co$t
Increased use of medical services
Chronicity: 1 in 4 depressed patients will be ill for
> 2 years
Recurrence: More than 50% will have a
recurrence
Premature placement in nursing facilities
Increased risk of hip fracture due to falls

Prevalence of Depression as a
Concomitant Condition
50%

25%

0%

Cancer

Diabetes

PostPartum

PostStroke

Post MI

Massie & Holland, 1995; Lustman et al, 1998; Dobie & Walker,
1992; Morris et al, 1990

Project Objectives
Short-term Objectives
Increase the screening and identification of
depression in newly admitted residents
Increase treatment for residents diagnosed
with depression or exhibiting depressive
symptomology
Assess the relevance and usefulness of the
Minimum Data Set (MDS) as a data source
Assess the correlation between the MDS and
Geriatric Depression Scale
Compare outcomes of various types of
interventions for depression

Project Objectives
Long-term Objective

Improvement in depressive symptoms for the

resident with an increase in daily function
Improve systems for depression management

Project Design
20 facilities were recruited and 14 agreed to participate
(70%)
Data source is the MDS (5, 14, 30 and 60 day) and
charts (GDS, progress notes, medication record, etc.)
Sample methodology MDS and chart abstraction
Baseline measurement 1/2001 through 6/2001
Intervention phase 4/2002 through 6/2002
Remeasurement in September 2002 (data from
4/1/2002 6/30/2002)
Baseline and interim data reports supplied to the
facilities (May 2002 and November 2002)

MPRO Interventions
Readiness assessment of the facilities to determine
characteristics and resources
Educational sessions (CEs for nurses/assistants; CME
for physicians, family/resident education)
Project toolkit
On-site visits/technical assistance
CQI consultation and tools
Data collection and analysis/Develop data collection tool
Data reports and discussion (May 2002 and November
2002)
Assist facilities to develop a systematic process for
depression screening, assessment, and treatment
Interdisciplinary approach

Development of Indicators
Using existing literature and practice
guidelines, MPRO developed objectives for
the project
These objectives were then reviewed with
the Technical Expert Panel (TEP); data
availability from the MDS was investigated

Quality Indicator 1a and Results

Proportion of newly admitted residents who are
assessed for depression using the Geriatric
Depression Scale (GDS) by day 7 of stay
D= All residents who fulfill the inclusion and exclusion
criteria = 818
N= Those in the denominator with assessment done by day
7 = 71
Rate = 9%

Quality Indicator 1b and Results

Proportion of newly admitted residents who
are assessed for depression using the GDS by
day 14 of stay
D= All residents who fulfill the inclusion and exclusion
criteria = 818
N= Those in the denominator with assessment done by
day 14 = 92
Rate= 11%

Quality Indicator 2a and Results

Proportion of depressed residents who
receive depression treatment by day 7 of stay
D= Residents with symptoms and/or a diagnosis of
depression by day 7 of stay = 269
N= Those in the denominator who receive depression
treatment by day 7 of stay = 203
Rate = 75%

Quality Indicator 2b and Results

Proportion of depressed residents who receive
depression treatment by day 14 of stay
D= Residents with symptoms and/or a diagnosis of
depression by day 14 of stay = 313
N= Those in the denominator who receive depression
treatment by day 7 of stay = 248
Rate= 79%

Criteria for QIs 2a and 2b

Depression diagnosis/symptoms may be found
in the chart or MDS
Depressed residents must exhibit symptoms
including sad mood and two or more of the
following:

Negative statements

Agitation or withdrawal

Waking with an unpleasant mood or not being awake

for most of the day and not comatose

Being suicidal or having recurrent thoughts of death

Weight loss

Criteria for QIs 2a and 2b

Treatment includes (any of the following)

Antidepressant medication
Psychological therapy by any licensed mental
health professional
Group therapy

Prevalence of Depression and

Treatment
New ly diagnosed
13%
n=108

Not depressed
56%
n=459

Depressed prior to
admission
31%
n=251

Rx prior to
admission
81%
n=203

No Rx prior to
admission
19%
n=48

Quality Indicator 3 and Results

Proportion of residents assessed positive
for depression by the GDS by day 14 who are also
assessed positive for depression by the MDS
assessment
D= Residents who were positive for depression by the
(score 5 or more) by day 14 of stay = 42

GDS

N= Those in the denominator with symptoms and/or a diagnosis

of depression noted in either the MDS 5 day or 14 day
assessment = 26
Rate= 62%

Diseases that Appear More Often in

Residents whose Symptoms
Did Not Improve
100%
80%
60%
40%

57%

35%

52%
41%

40%

34%
23%
18%

20%
8%

27%

23%
15%

36%

49%

38%

27%

19%

7%

0%
Allergies

Seizure disorder

Symptoms Improved

Osteoporosis

Emphys/COPD

Symptoms Did Not Improve

Anemia

Arthritis
Sample

Diseases that Appear More Often in

Residents whose Symptoms Improved

100%
85%
80%

66%

73%

60%
46%
40%

27%
27%

46%
25%

38%
30%

31%

23%
22%

20%

16%

31%
16%

20%
13%

0%
Diabetes

CHF

Symptoms Improved

Stroke

Hypertension

Symptoms Did Not Improve

Periph vasc dis

Hemiplagia
Sample

What Happens to Residents

who are Treated?

What Happens to Residents who

are Treated?
TI 2 indicated that 32 out of 35 people who are
treated and whose condition worsened were
reassessed by day 60 of stay
Diagnosis confirmed/response evaluated = 19
(59%)
Medication changed/dosage adjusted/medication
augmented and documented = 13 (41%)
TI 4 indicated that medication was the primary form
of treatment among both groups; those whose
symptoms improved and those whose symptoms
did not improve

Conclusions
QI 1: The GDS is not consistently used by the
14 participating facilities to screen for
depression
QI 2, TI: The majority of the residents identified
with depression are receiving treatment
QI 3: The MDS is not sufficient by itself to
identify depression
QI 2, TI 3 & 4: Antidepressant medication is the
prevalent method of treatment
TI 3 & 4: The majority of the residents receiving
treatment are not improving by day 60

Conclusions
The majority of the 32 residents with 60-day
stays were reassessed after treatment for
depression was initiated, but in 59% NO
ACTION was taken other than confirming the
diagnosis and documenting the medication
BOTTOM LINE: Treatment is not being
modified or intensified by 6-8 weeks

Interim Remeasurement Results

100%
75%

80%
60%

60%

47%

69%

79% 76%
62%
52%

Interim

40%
20%

9%

Baseline

11%

0%
nB=818 nI=586
nB=818 nI=586
nB=269 nI=159
nB=313 nI=180
nB=42 nI=77
Assessed by Day Assessed by Day
Depressed
Depressed
Assessed Positive
7
14
Residents Treated Residents Treated by GDS also
by Day 7
by Day 14
Assessed Positive
by MDS

Algorithm for Treatment of Geriatric

Depression

Adjusting Treatment of Depression

if Initial Response is Inadequate
Increase dose of initial antidepressant
medication
Change to new antidepressant medication
Add psychosocial interventions
Implement augmentation strategy

When to Refer to a Psychiatrist

Referral definitely indicated:
Psychotic depression
Bipolar disorder
Depression with suicidal ideation

Referral usually indicated:

Depression with comorbid substance abuse
Depression with comorbid dementia
Depression that has not responded to an
adequate trial of antidepressant medication

Conclusions/Recommendations
It appears that treatment initiation has
improved from pre-OBRA 1980s
The current issue may not be the initiation of
treatment, but the algorithm for treatment
The algorithm for treatment should include
strategies to optimize treatment and manage
responses in the geriatric resident

Questions?
Thank you!

Contact Information:
Vicki Boyle, RN, BSN
734-459-0900, ext. 515
Email: Vboyle @ mpro.org