MUCH MAJOR DEPRESSION IN NURSING HOMES SAID TO BE OVERLOOKED

BALTIMORE – Major depression is common in nursing home Residents and is associated with an increased risk of decompensating medical conditions and even death, yet it often goes unrecognized and untreated. Dr. Barry W. Rovner said at a geriatric symposium presented by the John Hopkins Medical Institutions.

Most nursing home Residents have variations of dementia, depression, anxiety or some other psychiatric disorder. “Nursing homes really are in some ways mental institutions,” said Dr. Rovner, of the department of psychiatry at John Hopkins University School of Medicine.

A psychiatric disorder was present in 80% of 455 new admissions to eight Baltimore-area community nursing homes. Dementia was diagnosed in 40% of the new nursing home residents; a further 27% of the residents had dementia complicated by depression, delusions, or delirium. Another 13% of the residents were found to have an affective disorder or other psychiatric condition.

Daily neuroleptic treatment was prescribed for about one-third of patients with complicated or uncomplicated dementia, about one-fourth of those with another psychiatric disorder, and about 10% of those with no psychiatric disorder. These findings suggest a misuse of medication, he said at the symposium also presented by the American Geriatrics Society.

A diagnosis of major depression was made in 13% of the residents studied. Another 18% were found to have depressive symptoms without meeting criteria for major depression, Dr. Tovner said.

Nursing home physicians recorded a diagnosis of depression in the charts of only 14% of patients with major depression and 14% of those with depressive symptoms.

In contrast, nurses reported depression in 65% and in 54% of those two groups. A false diagnosis of depression was made by physicians in 4% and by nurses in 34% of non-depressed Residents.

The findings “raise questions about the recognition rates of depression in nursing home Residents,” he said.

Only 21% of patients with major depression or depressive symptoms were receiving antidepressant medication. Antidepressants were prescribed for 10% of the Residents judged not to have depression.

Mortality was significantly elevated in Residents with major depression – nearly one-half died during 1 year of follow-up. The best predictor of death was a low rating on activities of daily living (ADL's); the second best predictor was male sex; major depression was the third best predictor. “Major depression is an independent and very powerful predictor of dying,” Dr. Rovner said.

The greatest demands on nursing staff time were made by patients with complicated dementia, followed by patients with uncomplicated dementia, other psychiatric disorders, and no psychiatric disorders. A similar pattern emerged for incidence of behavior problems, use of mechanical restraints and lack of participation in nursing home activity programs.

Only about 30% of Residents with any psychiatric disorder took part in activity programs, compared with about one-half of Residents with no psychiatric disorder. This suggests that nursing home activity programs are not geared to the patients most commonly cared for in the facilities, the physician said.

Clinical Psychiatry News - May 1991