SAN JUAN, P.R. – Dementia and depression appear to be quite common among residents in assisted living facilities, based on two analyses of facilities in Maryland that were presented at the annual meeting of the American Association for Geriatric Psychiatry.
Both analyses looked at data from the Maryland Assisted Living Study that included 22 facilities–10 large facilities (more than 15 beds) and 12 small (15 beds or fewer). Assisted living facilities are regulated at the state level, and the levels of regulation vary widely.
For the Maryland Assisted Living Study, residents of assisted living facilities were evaluated by a geriatric psychiatrist, a nurse (who was experienced with dementia evaluation), and a research assistant specializing in psychometrics.
Comprehensive evaluations of residents included information from caregivers and family members, a clinical exam and history, assessment with quantitative scales (function, behavior, depression, medical comorbidity, quality of life, caregiver activity/burden), and neuropsychological battery.
A consensus conference specialist determined diagnoses for residents and assessed whether residents had been worked up and whether they were being treated appropriately.
In particular, participants were assessed using the Cornell Scale for Depression in Dementia (CSDD), a 19-item clinician-administered instrument that uses information from interviews with both the patient and a nursing staff member. Those with scores greater than 7 were considered clinically depressed. The General Medical Health Rating was used to describe comorbidity and health status.
In the first analysis, researchers looked at levels of depression among 196 residents of assisted living facilities. “This is an important study for several reasons, but it is the first comprehensive assessment of psychiatric disease in the assisted living industry,” said Dr. Lea C. Watson, professor of psychiatry at the University of North Carolina at Chapel Hill. Subjects were an average of 86 years old, and were primarily women (79%) and white (84%).
Overall, 24% (47 subjects) met the criteria for clinical depression and 8% (15 subjects) met the criteria for severe depression (CSDD score greater than 12). Roughly two-thirds (67%) of participants had dementia. The third of the participants who did not have dementia–those with Mini- Mental State Examination scores greater than 22–were evaluated with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID IV). Of those, 13 met the criteria for depression.
Bivariate analysis revealed no differences between depressed and nondepressed individuals based on age, gender, number of social visits, or facility size. However, depressed individuals did have a greater number of comorbid conditions, required more assistance with activities of daily living, spent a greater number of days in bed per month, and participated in organized activities less frequently than did nondepressed individuals.
After the investigators controlled for several pertinent factors, (global health, supervision of activities of daily living, and social interaction), assistance with activities of daily living alone remained significantly associated with depression (odds ratio 3.8), while medical comorbidity showed a trend toward significance (odds ratio 1.9).
Only 43% of those who were currently depressed were being treated with antidepressants. Likewise, only 40% of those who were severely depressed were being treated with antidepressants. Those with depression were more likely to be treated with antidepressants if they lived in a larger facility (51% vs. 17%).
“Interestingly, 60% of those in these facilities with depression had no source of psychiatric care,” Dr. Watson said.
In the second analysis, researchers looked for any differences between large and small facilities for dementia frequency, detection, and management.
“Large facilities have most commonly arisen out of the hospitality industry and are more likely to be part of a chain,” said Quincy M. Samus, a graduate student at Johns Hopkins University in Baltimore, who presented a paper for Dr. Iracema Leroi of the University of Manchester (England), who could not attend the meeting. “Small facilities have evolved from the traditional board-and-care homes or group homes” for mentally ill individuals, Ms. Samus said.
This analysis included 198 residents (150 from large facilities and 48 from small facilities). Residents in smaller facilities were somewhat younger than were those in larger facilities–average age 82 years vs. 87 years.
Residents in both types of facilities were admitted primarily because of functional limitations. Those in large facilities were significantly more likely to be admitted for medical reasons than were those in small facilities.
Significantly more residents in small facilities had dementia than those in large facilities. Residents in small facilities also were slightly more likely to be diagnosed with Alzheimer's disease, though not significantly so, Ms. Samus said.
Almost all residents (98%) in small facilities had either dementia or some other psychiatric diagnosis. In comparison, 74% of those in large facilities had dementia or some other psychiatric diagnosis. Likewise, residents in small facilities had more cognitive difficulties as measured by the Mini-Mental State Examination, with an average score of 13 compared with 20 for those in large facilities.