Depression among the elderly is widespread in the United States. In the aged, depression is typically triggered by poor health, hospitalization or placement into a long term care facility. Depression is a very serious illness affecting approximately 25% of individuals with chronic illnesses and just about 50% of nursing home residents. Depression is often undetected and hence under treated in long term care. Symptoms are overlooked in the milieu of multiple physical conditions overshadowing this veritable disease. Depression most commonly affects individuals with continual illnesses such as Stroke, Cancer, Ischemic Heart Disease, Parkinson’s, Alzheimer’s and Multiple Sclerosis. Therefore, it takes a keen eye to evaluate and determine if a resident has a depressive illness. Both symptoms and behaviors need to be monitored to trigger a more intensive examination.
Although residents may have intermittent feelings of sadness, it is the persistent feelings, which impact normal activities of daily living that categorize for Depression. When a resident is no longer functioning or participating at his/her prior level of function, this is a prompt for scrutiny. Symptoms may vary resident to resident and may include the following:
- Unrelenting grief, sorrow and unhappiness
- Difficulty sleeping or concentrating
- Feeling slowed down
- Withdrawal from regular social activities
- Excessive worries about fiancés and health problems
- Weight/appearance changes
- Feeling worthless or helpless
- Thoughts of suicide and death
In the Nursing Home environment, many residents have difficulty expressing their needs. Often times, Dementia is mistakenly diagnosed. In these cases, a heighted focus on behaviors is critical as Depression can manifest itself through persistent complaints of pain, headache, exhaustion, restlessness, tearfulness, pacing and fidgeting, along with gastrointestinal issues.
Depression is one of the most successfully treated illnesses. When properly diagnosed and treated, approximately 80% of patients return to normal activities. The RAI User's Manual supports early identification and treatment of signs and symptoms of depression.
The intent of the MDS 3.0 Section D: Mood Disorders is to identify the presence or absence of specific clinical mood indicators to facilitate care planning and management of these symptoms. Facility staff should recognize these indicators and consider them when developing the resident’s individualized care plan. The accurate completion of this section hinges on patient or staff interview/assessment.
Section D of the MDS 3.0 contains the 9-item Patient Healthcare Questionnaire (PHQ-9). The questionnaire is designed to identify signs of depression. It is standardized and copyrighted which results in a severity score and a rating for each patient. The look-back period for this item is 14 days. There are 9 interview questions that are reported by symptom presence and symptom frequency. The items in this section address mood distress, a serious condition that is associated with significant morbidity. The interview/assessment process should not be taken lightly. A proper environment is essential for accurate outcomes.
Some tips for conducting the interview include:
- Conduct the interview in a private, quiet and non-distracting environment
- Offer the resident an interpreter
- Sit so that the resident can see your face, with lighting that is not too bright or too dim
- Confirm that the resident can hear the assessor
Residents may respond to questions:
- Pointing to answers on the cue card, OR
- Writing out their answers
(Note: Coding the presence of indicators in Section D does not automatically mean that the resident has a diagnosis of depression or other mood disorder).
If a resident is unable to complete the Resident Mood Interview, a staff interview is to be completed. The identification of symptom presence and frequency as well as staff observations are important to the detection of mood distress, as they may provide information regarding the need for and type of treatment. Assessors do not make or assign a diagnosis in Section D; they simply record the presence or absence of specific clinical mood indicators.
The cost of depression in the United States is estimated above 40 billion dollars per year. Undetected depression in the elderly exacerbates medical conditions leading to more resources necessary to care for the resident. These additional resources are reimbursed under the PPS RUG system. The RUG classification’s “End Splits” identify the presence or absence of mood qualifiers within the Special Care and Clinically Complex RUG categories. Proper assessment skills combined with MDS accuracy are critical for the MDS to properly reflect the patient’s true medical condition and correct reimbursement.
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