SPECIAL ISSUE PAPER

Depression and cognitive impairment among newly

admitted nursing home residents in the USA
Christine M. Ulbricht1 , Anthony J. Rothschild2,3, Jacob N. Hunnicutt1,4 and Kate L. Lapane1,4
1
Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
2
Center for Psychopharmacologic Research and Treatment, Department of Psychiatry, University of Massachusetts Medical School,
Worcester, MA, USA
3
UMassMemorial Health Care, Worcester, MA, USA
4
Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts, Worcester,
MA, USA
Correspondence to: C. M. Ulbricht, PhD, E-mail: christine.ulbricht@umassmed.edu

Objective: The objective of this study is to describe the prevalence of depression and cognitive
impairment among newly admitted nursing home residents in the USA and to describe the treatment
of depression by level of cognitive impairment.
Methods: We identied 1,088,619 newly admitted older residents between 2011 and 2013 with an active
diagnosis of depression documented on the Minimum Data Set 3.0. The prevalence of receiving
psychiatric treatment was estimated by cognitive impairment status and depression symptoms. Binary
logistic regression using generalized estimating equations provided adjusted odds ratios and 95%
condence intervals for the association between level of cognitive impairment and receipt of psychiatric
treatment, adjusted for clustering of residents within nursing homes and resident characteristics.
Results: Twenty-six percent of newly admitted residents had depression; 47% of these residents also had
cognitive impairment. Of those who had staff assessments of depression, anhedonia, impaired
concentration, psychomotor disturbances, and irritability were more commonly experienced by
residents with cognitive impairment than residents without cognitive impairment. Forty-eight percent
of all residents with depression did not receive any psychiatric treatment. Approximately one-fth of
residents received a combination of treatment. Residents with severe cognitive impairment were less
likely than those with intact cognition to receive psychiatric treatment (adjusted odds ratio = 0.95;
95% condence interval: 0.930.98).
Conclusions: Many newly admitted residents with an active diagnosis of depression are untreated,
potentially missing an important window to improve symptoms. The extent of comorbid cognitive
impairment and depression and lack of treatment suggest opportunities for improved quality of care
in this increasingly important healthcare setting. Copyright # 2017 John Wiley & Sons, Ltd.
Key words: depression; cognitive impairment; nursing homes; Minimum Data Set 3.0
History: Received 01 November 2016; Accepted 21 March 2017; Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/gps.4723

Introduction adults living in long-term care facilities (Park &

The burden of depression in older adults is substantial.
The prevalence of depression varies considerably by
setting and diagnostic criteria, with the prevalence of
major depressive disorder ranging from 2% to 5% of
community-dwelling adults over age 60 years
(Mottram et al., 2006) to as many as 50% of older
Untzer, 2011). Depression in older adults is
associated with considerable morbidity and mortality,
including decreases in functioning, pain, self-neglect,
worsened outcomes for comorbid conditions,
increased health services uses, higher total healthcare
costs, and increased risk of suicide (Blazer, 2003; Oude
Voshaar et al., 2016). The diagnosis and treatment of

Copyright # 2017 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2017

depression in older adults may be further complicated
by cognitive impairment.
Older adults, particularly those living in nursing
homes, experience high rates of cognitive impairment.
Sixty-one percent of the 1.4 million nursing homes
residents in the USA in 2014 had moderate or severe
cognitive impairment (Centers for Medicare and
Medicaid Services, 2015a). Cognitive impairment is
associated with negative outcomes such as low levels
of thriving, pain, and intentional self-harm (Patomella
et al., 2016; Bjrk et al., 2016; Bauer et al., 2016; Neufeld
et al., 2015). Cognitive impairment has also been shown
to be inversely associated with receipt of depression
treatment in nursing homes (Brown et al., 2002).
In the community, 2050% of older adults with
depression also have cognitive impairment (Butters
et al., 2004; Sheline et al., 2006). How many older
residents of US nursing homes have both depression
and cognitive impairment is unknown. Understanding
the extent to which symptoms and treatment of
depression differ by cognitive impairment in the
nursing home setting is important. The relationship
between cognitive impairment and depression is
complex and possibly bidirectional, which complicates
the recognition and treatment of both conditions
(Wang & Blazer, 2015). Older adults with cognitive
impairment are at higher risk than those with
depression alone of experiencing depression relapse,
poor antidepressant treatment response, functional
impairment, preventable hospitalization, and suicide
(Lara et al., 2015; Davydow et al., 2014; Koenig et al.,
2014; Alexopoulos et al., 2005). Cognitive impairment
can be part of depression, with diminished cognitive
ability being one of the criteria symptoms for a
diagnosis of major depressive disorder (American
Psychiatric Association, 2013). Cognitive impairment
may also be a risk factor for depression and a marker
of unfavorable depression prognosis. Co-occurring
depression and cognitive impairment increase risk of
further cognitive decline and development of
dementia and related conditions (Diniz et al., 2013).
Because the co-occurrence of depression and cognitive
impairment additively increases the likelihood of
adverse health outcomes (Mehta et al., 2003), early
detection and proper treatment of these conditions is
imperative.
The challenges of properly managing depression
among nursing home residents have resulted in calls
for improving depression management in nursing
homes and the Centers for Medicare and Medicaid
Services using depression as an indicator of nursing
home quality (Shrank et al., 2007; Centers for
Medicare and Medicaid Services, 2015b). Studies of
Copyright # 2017 John Wiley & Sons, Ltd.
C. M. Ulbricht et al.
the role of cognitive impairment in depression in
nursing homes have been limited. To address this
gap, we sought (1) to estimate the prevalence of
depression and cognitive impairment among newly
admitted nursing home residents in the USA and (2)
to describe the symptoms and treatment of depression
by level of cognitive impairment.
Methods
This study was approved by the University of
Massachusetts Medical School Institutional Review
Board.
Study sample
Data for this study come from the national Minimum
Data Set version 3.0 (MDS 3.0). MDS 3.0 is an in-
depth, standardized, clinical assessment that is
federally mandated for all residents of Medicare-
certied and Medicaid-certied nursing facilities in
the USA (Centers for Medicare and Medicaid Services,
2016). Ninety-six percent of nursing homes are
Medicare/Medicaid certied and thus perform the
MDS. MDS 3.0 includes more than 450 items on
active disease diagnoses, health conditions, treatment,
mood and behavior, pain, functional status, and
cognitive status. Assessments are conducted by
specially trained registered nurses, who review
residents medical records and use the validated MDS
instrument to evaluate their health statuses (Saliba &
Buchanan, 2012). Assessments are conducted for each
resident at admission, quarterly, and annually. For this
study, we initially identied residents with MDS
assessments performed at admission between 2011
and 2013 who (1) were at least 65 years of age, (2)
were non-comatose, (3) were not admitted to a swing
bed provider, and (4) did not have possible or
probable delirium as assessed by the Confusion
Assessment Method (Inouye, 2014). Of the 4,196,686
residents meeting these criteria, 26% had an active
diagnosis of depression upon admission and were
included in this study (n = 1,088,619).
Measures
Depression. Depression (other than bipolar disorder)
was ascertained from the active diagnoses section of
the MDS 3.0. A diagnosis is considered active if it
has (1) been documented by a physician in the last
60 days and (2) a direct relationship to the residents
Int J Geriatr Psychiatry 2017
Depression and cognitive impairment
current functional, cognitive, mood or behavior status,
medical treatments, nursing monitoring, or risk of
death during the 7-day look-back period (Centers of
Medicare and Medicaid Services, 2016). Depression
severity was measured with the Patient Health
Questionnaire-9 (PHQ-9) for residents who were able
to self-report and with the PHQ-9 Observational
Version (OV) for those who were not able to self-report
(Saliba et al., 2012b). Staff members administrating
the MDS are instructed to complete the PHQ-9 OV
if a resident cannot be understood or is unwilling
to complete the assessment (Centers of Medicare
and Medicaid Services, 2016). The PHQ-9 OV contains
an additional question about the resident irritability.
Scores can range from 0 to 27 on the PHQ-9 and from
0 to 30 on the PHQ-9 OV. For the PHQ-9, severity
was categorized as minimal (score = 04), mild (59),
moderate (1014), moderately severe (1519), and
severe (2027). The categorization was the same for
the PHQ-9 OV except the severe depression category
included scores of 2030. When examining individual
depression symptoms, all items except the ninth item
on suicidal thoughts were scored as present if the
response was that the symptom occurred half or
more of the days or nearly every day. The item
on suicidal thoughts was considered to be present if
the response was that it occurred several days, half
or more of the days, or nearly every day (Kroenke
et al. 2001).
Cognitive impairment. Cognitive impairment was
measured with the Cognitive Function Scale (CFS),
which incorporates responses on the Brief Interview
for Mental Status (BIMS) for residents who are able
to self-report and the Cognitive Performance Scale
(CPS) for residents who are not able to complete the
BIMS and are assessed by staff (Thomas et al., 2015).
The BIMS includes three questions on temporal
orientation and two questions on recall (Saliba et al.,
2012a). The CPS assesses daily decision making, eating
self-performance, ability to make ones self understood,
short-term memory, and comatose state (Morris et al.,
1994). The CFS combines both of these instruments to
produce one measure that categorizes the severity of
resident cognitive functioning as intact cognition
(BIMS score of 1315), mild impairment (BIMS score
of 815 or CPS score 02), moderate impairment
(BIMS score of 07 or CPS score of 34), or severe
impairment (unable to complete the BIMS and CPS
score of 56) (Thomas et al., 2015). Although the CFS
has yet to be extensively validated against gold
standards such as the Mini-Mental State Examination
or the Montreal Cognitive Assessment, the CPS has
Copyright # 2017 John Wiley & Sons, Ltd.
been found to be comparable with the Mini-Mental
State Examination (Hartmaier et al., 1995) while the
BIMS is comparable with the Brief Cognitive
Assessment Tool-Short Form (Mace et al., 2016) for
rapidly assessing general cognitive impairment.
Psychiatric treatment. The use of antidepressant,
antipsychotic, antianxiety, and hypnotic medications
was assessed by a checklist in the medications section
of the MDS. Use refers to medications that were
received by the resident at any time in the 7 days prior
to the MDS assessment or since admission if
admission was less than 7 days before the MDS was
conducted (Centers for Medicare and Medicaid
Services, 2016). This section was completed by
reviewing the residents medical record and
documentation from other healthcare settings that
could have provided medication to the resident during
the look-back period.
A checklist in the special treatments, procedures,
and program section of the MDS is used to document
receipt of psychological therapy from any licensed
mental health profession. In order to be considered
therapy, the therapy must be medically necessary,
occur following admission, and documented in the
residents medical record (Centers for Medicare and
Medicaid Services, 2016). Therapy could have been
provided inside or outside the nursing home.
Additional ociodemographic and clinical characteristics.
MDS 3.0 also includes measures of sex, age group,
race/ethnicity, marital status (married and other),
functional impairment, pain, and active diagnoses of
comorbid conditions. Functional impairment in
activities of daily living (ADLs) was assessed with the
MDS-ADL Self-Performance Hierarchy (Morris et al.,
1999). Active diagnoses of comorbid conditions such
as anxiety disorders were measured similarly to
depression and included other psychiatric disorders
and conditions related to cognitive impairment.
Analysis
The primary purpose of this research was to provide
descriptive information relating to depression and
cognitive impairment among older adults upon
admission to a nursing home, a population oft
neglected by medical research. Given this, we
estimated the overall prevalence of depression and
levels of cognitive impairment. We also estimated
descriptive statistics of the demographic and clinical
characteristics of residents with depression by the
Int J Geriatr Psychiatry 2017

presence of cognitive impairment. We did not conduct
formal statistical tests for these descriptive statistics for
several reasons. First, the goal of the analysis was to
provide descriptive information, and as such, we had
no specic hypotheses to test. Second, in studies with
very large sample sizes, even trivial differences achieve
statistical signicance. Therefore, we used a threshold
of an absolute difference of at least 5% as a threshold
to consider differences across groups as noteworthy.
In addition to providing descriptive statistics, we
were also interested in examining if level of cognitive
impairment was related to receipt of any psychiatric
treatment in these residents with depression. We
evaluated the odds of treatment receipt using binary
logistic regression with generalized estimating
equations to account for clustering of residents within
nursing homes. We considered both unadjusted
models and a model adjusted for residents socio-
demographic and clinical characteristics.
Results
Twenty-six percent of newly admitted residents had an
active diagnosis of depression. For the majority of
residents, regardless of PHQ-9 assessment version,
depression severity was minimal (range: 66.477.2%).
Forty-seven percent of residents with depression
had cognitive impairment. Of those with cognitive
impairment, 41% had moderate impairment, and
6.9% had severe cognitive impairment. Overall, the
majority of newly admitted residents with depression
were women and had been admitted from an acute care
hospital. Newly admitted residents with depression also
commonly experienced anxiety disorder (31.8%),
hypertension (78.7%), diabetes (32.6%), or stroke
(12.9%).
Sociodemographic and clinical characteristics of the
residents with an active diagnosis of depression,
stratied by cognitive impairment status, are displayed
in Table 1. Compared with residents with depression
without cognitive impairment, those with both
depression and cognitive impairment were more likely
to be age 85 years or older (42.5% vs. 23.3%,
respectively). While the majority of residents in both
groups were admitted to the nursing home from an
acute hospital, more residents with cognitive
impairment than without impairment were admitted
from the community (11.6% vs 4.8%). The prevalence
of psychiatric comorbidities did not differ substantially
between the groups. Dementia and related disorders
were more common in those with cognitive impairment
than in those without. Forty-three percent of residents
Copyright # 2017 John Wiley & Sons, Ltd.
C. M. Ulbricht et al.
with cognitive impairment also had an active diagnosis
of dementia compared with almost 11% of those
without cognitive impairment. Experiencing any pain
occurred in more residents without cognitive
impairment (70.7%) than in residents with impairment
(47.3%). In addition to cognitive impairment, more of
these residents also had severe functional impairments
(27.4% of those with cognitive impairment versus
16.2% of those without).
Receipt of psychiatric treatment is shown in
Table 2. Almost half of all residents did not receive
any treatment despite all having a documented active
diagnosis of depression (48.348.5%). Approximately
one-fth of residents received a combination of
psychiatric treatment (18.720.5%) while almost
one-quarter of residents received antidepressant
medication alone (23.624.2%). The most common
combination was antidepressant medication plus
antianxiety medication (6.87.8%). Receipt of
antianxiety medication, antipsychotics, or hypnotics
alone was rare (1.07.1%). Less than 1% of residents
received any amount of psychological therapy.
As shown in Table 3, residents with severe cognitive
impairment were less likely than those with intact
cognition to receive psychiatric treatment (adjusted
odds ratio (aOR) = 0.95; 95% condence interval
(CI): 0.930.98). Younger age (6574 years old versus
85+ years old: aOR = 0.96; 95% CI: 0.940.97),
race/ethnicity (e.g., black versus white: aOR = 0.86;
95% CI: 0.850.88), and moderate functional
impairment (moderate versus extensive ADL
compromise: aOR = 0.85; 95% CI: 0.840.87) were
also associated with lowered odds of receiving
treatment. Conversely, having a psychiatric
comorbidity (aOR = 1.11; 95% CI: 1.101.12), being
in pain (aOR = 1.15; 95% CI: 1.141.17), and not
requiring assistance with ADLs (no assistance versus
severe assistance: aOR = 1.19; 95% CI: 1.141.24)
were most strongly associated with increased odds of
receiving treatment.
Table 4 presents the individual depression
symptoms from the PHQ-9 and PHQ-9 OV by
cognitive impairment status and antidepressant
medication receipt. Although depression severity was
staff-assessed rather than self-reported for more
residents with cognitive impairment than without
impairment (17.5% vs. 0.6%), depression severity
was similar for those with and without cognitive
impairment. Based on resident reports, the most
common depressive symptoms were similar for those
with and without cognitive impairment regardless of
receipt of antidepressants: depressed mood,
fatigue/loss of energy, sleep problems, and changes in
Int J Geriatr Psychiatry 2017
Depression and cognitive impairment

Table 1 Sociodemographic and clinical characteristics of newly admitted nursing home residents with depression (n = 1,088,619) by level of cognitive
impairment

Depression with cognitive Depression without cognitive

Characteristic impairmenta (n = 514,666) impairmentb (n = 573,953)

Age (years, %)
6574 18.7 37.4
7584 38.8 39.3
85+ 42.5 23.3
Women (%) 66.3 71.3
Married (%) 33.2 35.2
Non-Hispanic white (%) 84.8 89.4
Entered nursing home from
Acute hospital 80.0 90.7
Community 11.6 4.8
Psychiatric hospital 1.4 0.5
Another nursing home or swing bed 4.9 2.2
Inpatient rehabilitation facility 1.2 1.3
Psychiatric comorbidities (%)
Anxiety disorder 30.4 33.1
Psychotic disorder 7.2 2.4
Schizophrenia 1.5 1.0
PTSD 0.3 0.4
Conditions associated with cognitive impairmentc (%)
Hypertension 77.7 79.6
Dementia 43.3 10.9
Diabetes 30.1 34.8
Cerebrovascular accident, TIA, or stroke 15.9 10.2
Alzheimers disease 14.3 1.9
Cancer 8.5 10.1
Parkinsons disease 6.4 4.2
Aphasia 3.3 0.7
Huntingtons disease 0.1 0.0
Seizure disorder or epilepsy 5.6 3.9
Traumatic brain injury 0.6 0.3
Any pain (%) 47.3 70.7
Severely compromised ADLsd (%) 27.4 16.2
Cognitive impairmente (%)
Mild 52.1
Moderate 41.0 N/A
Severe 6.9

PTSD, post-traumatic stress disorder; TIA, transient ischaemic attack; ADLs, activities of daily living; N/A, not applicable.
a
Dened as an active diagnosis of depression other than bipolar disorder with mild, moderate, or severe cognitive impairment as assessed by the
Cognitive Function Scale.
b
Dened as an active diagnosis of depression other than bipolar disorder with intact cognition as assessed by the Cognitive Function Scale.
c
Dened as active diagnoses in the 7 days prior to admission assessment.
d
Dened as score of 56 on MDS-ADL Self-Performance Hierarchy.
e
Cognitive Function Scale.

appetite. The largest difference was seen in impaired
concentration among those whose depression was
assessed by the staff. Of the residents assessed with
the PHQ-9 OV, 24% of those with cognitive
impairment had impaired concentration compared
with approximately 6% of residents without cognitive
impairment. The other most commonly noted
symptoms were depressed mood, anhedonia, and
changes in appetite. For those without cognitive
impairment, depressed mood was most commonly
present, followed by sleep problems and changes in
appetite.
Discussion
This study found that an active diagnosis of depression
was present for 27% of older adults being admitted to
nursing homes in the USA between 2011 and 2013.
Forty-seven percent of these new residents also

Copyright # 2017 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2017

Table 2 Psychiatric treatment received by presence of cognitive impairment
Depression with cognitive impairmenta
Treatment received (%)
No treatment
Combination
Antidepressant + antianxiety
Antidepressant + antipsychotic
Antidepressant + hypnotic
Antidepressant only
Antianxiety only
Antipsychotic only
Hypnotic only
Psychological therapy (any no. of minutes)
a
Dened as an active diagnosis of depression other than bipolar disorder with mild, moderate, or severe cognitive impairment as assessed by the
Cognitive Function Scale.
b
Dened as an active diagnosis of depression other than bipolar disorder with intact cognition as assessed by the Cognitive Function Scale.
experienced some level of cognitive impairment, with
52% having mild impairment. Residents with
depression and cognitive impairment were older and
more likely to have a comorbid diagnosis of dementia
or a related disorder and severely compromised
activities of daily living. Psychiatric treatment was
lacking for almost half of all residents with depression,
regardless of cognitive impairment status. Having
severe cognitive impairment was associated with being
less likely to receive any psychiatric treatment.
Our estimate of the prevalence of depression upon
nursing home admission is consistent with the
previous estimates (Bagchi et al., 2009; Brennan &
SooHoo, 2014). Given the Centers for Medicare and
Medicaid Services quality indicator highlighting the
importance of recognizing depression in the nursing
home setting, we were somewhat surprised that less
than half received any form of treatment for their
depression. Previous studies (albeit based on data
nearly two decades old, limited to specic states or a
handful of nursing homes, or among long-stay
residents) have reported treatment rates as high as
82% (Brown et al., 2002; Levin et al., 2007; Gaboda
et al., 2011). Effectively treating depression early is
important because when not adequately treated, it
can become a treatment-resistant problem (Untzer
& Park, 2012). Poor antidepressant treatment
response is associated with a more severe and chronic
course of depression, with cognitive impairment, and
with comorbid psychiatric disorders, particularly
anxiety. Treating depression by itself has been seen
to improve quality of life and the numerous
comorbidities associated with the disorder, such as
functional impairment, pain, diabetes, and anxiety
(Butters et al., 2011; Katon et al., 2010; Scott et al.,
Copyright # 2017 John Wiley & Sons, Ltd.
C. M. Ulbricht et al.
Depression without cognitive impairmentb
(n = 514,666) (n = 573,953)
48.5 48.3
20.5 18.7
6.8 7.8
5.7 2.1
1.9 3.9
24.2 23.6
1.0 1.0
1.0 0.4
3.7 7.1
0.9 0.9
2016). We do acknowledge, however, the need to
evaluate differential antidepressant treatment effects
among older nursing home residents with depression
who are often excluded from community-based
studies and clinical trials despite having unique heath
concerns, such as being at high risk of experiencing
side effects of psychotropic medications.
We also were somewhat surprised that
psychological treatment was rarely used at admission,
despite the fact that it is emphasized for older adults
with depression and cognitive impairment (Wang &
Blazer, 2015). Novel interventions for older adults
with depression being studied in other settings may
hold promise for the nursing home setting (Kiosses
et al., 2015). Problem-solving interventions might be
particularly helpful in both treating depression and
resolving disability. Novel interventions tailored to
older adults in nursing homes may be especially
warranted given that few residents, regardless of
antidepressant medication or cognitive impairment
status, had criterion depression symptoms such as
anhedonia. This nding echoes previous studies that
have found that depression in older adults does not
always resemble depression in younger adults (Gallo
& Rabins, 1999). Older adults tend to present with
somatic rather than emotional symptoms (Hegeman
et al., 2015) and not acknowledge having sad mood
but may have symptoms such as agitation and fatigue
(Thakur & Blazer, 2008). Furthermore, that the
prevalence of criteria depression symptoms differed
particularly for those residents who were unable to
self-report the PHQ-9 indicates that depression
symptoms may vary by level of both functional and
cognitive impairment. Additional research on
developing personalized interventions targeting
Int J Geriatr Psychiatry 2017
Depression and cognitive impairment

Table 3 Correlates of receiving any psychiatric treatment example, temporal orientation and daily decision
Odds of receiving any psychiatric
making abilities, measured by the CFS were not
treatmenta domains that were impaired in those with dementia
but not cognitive impairment. Knowing the extent to
Unadjusted OR Adjusted ORb which residents have depression and cognitive
(95% confidence (95% confidence
interval) interval) impairment is necessary for the provision of
appropriate health care in these facilities and
Age (years) prevention of subsequent declines in health and
6574 0.97 (0.960.98) 0.96 (0.940.97)
7584 1.04 (1.031.05) 1.04 (1.031.05) quality of life. Depression and cognitive impairment
85+ Referent Referent can introduce substantial difculties for care because
Women 1.06 (1.061.07) 1.02 (1.011.03) of mood and behavioral issues, communication
Married 0.94 (0.930.95) 0.95 (0.940.96)
Race/ethnicity problems, and functional impairment (McCall &
White Referent Referent Dunn, 2003). These residents utilize more health
Black 0.85 (0.830.87) 0.86 (0.850.88) services than those without cognitive impairment.
Hispanic 0.92 (0.900.94) 0.93 (0.910.95)
Other 0.85 (0.820.88) 0.86 (0.830.90) Nursing home residents with mild cognitive
Any psychiatric impairment have more visits to the emergency
comorbidityc 1.12 (1.111.13) 1.11 (1.101.12) department than residents without impairment
Physical condition
associated with (Stephens et al., 2014). Older adults with dementia
cognitive impairmentd 1.02 (1.001.03) 1.04 (1.021.06) typically experience numerous care transitions
Any pain 1.15 (1.141.16) 1.15 (1.141.17) (Callahan et al., 2015). Such utilization is not only
ADL compromisee
None 1.19 (1.151.24) 1.19 (1.141.24) costly but any care transitions in complex patients
Minimal 1.01 (0.991.03) 1.00 (0.981.02) such as these can increase risk for further adverse
Moderate 0.86 (0.850.88) 0.85 (0.840.87) outcomes and excess disability (Coleman et al.,
Severe Referent Referent
Cognitive impairmentf 2003). Our estimates of concomitant depression and
Intact Referent Referent cognitive impairment may be useful for healthcare
Mild 1.01 (0.981.02) 1.03 (1.011.04) utilization planning.
Moderate 0.97 (0.960.98) 1.00 (0.991.02)
Severe 0.94 (0.910.96) 0.95 (0.930.98) This study must be considered with strengths and
limitations in mind. To our knowledge, prior to the
ADL, activity of daily living; OR, odds ratio; MDS-ADL, Minimum current work, the most recent estimates regarding
Data Set activity of daily living. depression and its treatment in US nursing homes
a
Includes receipt of antidepressant medication, antianxiety are more than 5 years old. Further, this is a national
medication, hypnotic medication, and/or psychological treatment. evaluation using the improved MDS 3.0 instrument
b
Model adjusted for all variables listed in this table.
c
Includes active diagnoses of bipolar disorder other than major
with validated measures for depression severity and
depressive disorder, anxiety disorders, psychotic disorders, cognitive function. Despite the MDS improvements,
schizophrenia, and PTSD. the CFS does not measure many domains of cognitive
d
Includes active diagnoses of hypertension, dementia, diabetes, impairment. Components of cognitive impairment in
cerebrovascular accident/TIA/stroke, Alzheimers disease, cancer, older adults with depression include decits in
Parkinsons disease, aphasia, Huntingtons disease, seizure
disorder/epilepsy, and traumatic brain injury.
information processing, executive function, and
e
MDS-ADL Self-Performance Hierarchy. working memory (Darcet et al., 2016). Our data did
f
Cognitive Function Scale. not allow us to further explore specic components
of cognitive impairment. Neuroimaging measures
were not available in the administrative data source.
specic patterns of depression symptoms and Ages of onset of both depression and cognitive
functioning is warranted. impairment were also unavailable. Compared with
Nearly half of the newly admitted residents with early-onset depression, late-onset depression is
depression had cognitive impairment as well. thought to be more frequently associated with
Unexpectedly, 10% of the residents who did not have cognitive impairment, executive dysfunction, and
cognitive impairment also had a diagnosis of subcortical and deep white matter pathology (Potter
dementia. This discrepancy may result from the CFS & Steffens, 2007). Additionally, the denition of
not being a diagnostic instrument and not including depression used in this study relies on physician
measures of executive functioning decits and thus documentation of an active depression diagnosis.
possibly missing some impairment (Chodosh et al., Although depression diagnoses among nursing
2008). It is also possible that the domains, for residents have increased in the recent years (Gaboda

Copyright # 2017 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2017
 C. M. Ulbricht et al.

Table 4 Depression symptoms as reported by residents and staff, by cognitive impairment status, and receipt of antidepressant treatment

Resident-assessed depression

Depression with cognitive impairmenta Depression without cognitive impairmentb

Received Did not receive Received Did not receive

antidepressant antidepressant antidepressant antidepressant
medication medication medication medication
(n = 184,478) (n = 233,334) (n = 237,331) (n = 332,588)

PHQ-9 item (%)

Anhedonia 10.2 8.5 9.3 7.3
Depressed mood 19.4 17.7 18.4 16.5
Sleep problems 13.1 12.3 17.2 16.0
Fatigue/loss of
energy 15.7 14.0 16.5 14.1
Increased/decreased
appetite 13.2 12.0 13.8 12.5
Guilt/worthlessness 6.9 5.7 6.4 5.2
Impaired concentration 10.1 9.7 6.0 5.0
Psychomotor agitation
or retardation 6.1 5.8 5.0 4.7
Suicidal ideation 3.6 2.8 3.0 2.2
PHQ-9 severity (score ranges) (%)
Minimal (04) 68.8 71.2 69.5 72.4
Mild (59) 20.7 19.6 20.6 19.2
Moderate (1014) 7.3 6.5 6.9 6.1
Moderately severe (1519) 2.6 2.1 2.40 1.9
Severe (2027) 0.7 0.5 0.6 0.5

Staff-assessed depression

Depression with cognitive impairmenta Depression without cognitive impairmentb

Received Did not receive Received Did not receive

antidepressant antidepressant antidepressant antidepressant
medication medication medication medication
(n = 39,531) (n = 50,649) (n = 1525) (n = 2118)

PHQ-9 item (%)

Anhedonia 16.4 14.4 10.8 8.6
Depressed mood 16.3 13.6 15.3 13.2
Sleep problems 12.2 11.9 12.9 10.5
Fatigue/loss of energy 11.4 10.5 10.7 8.4
Increased/decreased appetite 15.4 14.6 12.2 9.6
Guilt/worthlessness 1.3 1.1 2.8 2.5
Impaired concentration 24.1 23.7 6.1 5.5
Psychomotor agitation or
retardation 10.3 10.2 5.6 3.9
Suicidal ideation 1.2 1.0 2.1 1.6
Irritability 9.3 8.4 3.9 4.8
PHQ-9 severity (score ranges) (%)
Minimal (04) 65.6 67.0 75.5 78.4
Mild (59) 21.0 20.6 14.8 14.6
Moderate (1014) 8.7 8.4 6.6 4.3
Moderately severe (1519) 3.7 3.2 2.4 2.0
Severe (2030) 1.0 0.8 0.8 0.6

PHQ-9, Patient Health Questionnaire-9.

a
Dened as an active diagnosis of depression other than bipolar disorder with mild, moderate, or severe cognitive impairment as assessed by the
Cognitive Function Scale.
b
Dened as an active diagnosis of depression other than bipolar disorder with intact cognition as assessed by the Cognitive Function Scale.

Copyright # 2017 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2017
Depression and cognitive impairment
et al., 2011), our denition could have led to issues
with accurate ascertainment of depression because
physician recognition of late-life depression can be
poor (Gregg et al., 2013). Lastly, the cross-sectional
nature of the study limited our ability to evaluate
the course of depression and cognitive impairment
throughout the nursing home stay. Despite these
limitations, this study offers a rare contemporary
look at the entire nursing home population in the
USAa vulnerable population often excluded from
research.
Conclusion
Many older adults have an active diagnosis of
depression and some degree of cognitive impairment
upon nursing home admission. Despite the prevalence
of depression in this population, psychiatric treatment
is not common and does not differ by level of
cognitive impairment. While previous research on
nursing home residents indicate that use of
antidepressants among those with depression is
common (Gaboda et al., 2011), our study suggests that
pharmacological treatment in newly admitted
residents is lower. This study is a rst step in better
understanding the relationship between depression
and cognitive functioning among older adults. Such
research is necessary to properly treat both conditions
and potentially reduce the risk of developing
additional disorders such as dementia. Understanding
more about the longitudinal course of depressive
symptoms, treatment, and cognitive functioning is
urgently needed (Hammar & Ardal, 2009).
Conict of interest
No competing nancial interests exist for Mr.
Hunnicutt and Dr. Ulbricht. Dr. Rothschild has
received research support from Alkermes, Allergan,
Janssen, the National Institute of Mental Health, and
Takeda; has served as a consultant to GlaxoSmithKline,
Eli Lilly, OmniCare, and Pzer; has received royalties
from UpToDate, from UMass Medical School for the
Rothschild Scale for Antidepressant Tachyphylaxis
(RSAT), and from American Psychiatric Press, Inc.
for Psychoneuroendocrinology: The Scientic Basis
of Clinical Practice (2003), Clinical Manual for
Diagnosis and Treatment of Psychotic Depression
(2009), The Evidence-Based Guide to Antipsychotic
Medications (2010), and The Evidence-Based Guide
to Antidepressant Medications (2012). Dr. Lapane
has received research support from Merck, Cubist,
Copyright # 2017 John Wiley & Sons, Ltd.
and the National Institutes of Health (contract:
HHSN268201000020C).
Key points
Depression is commonly noted as an active
diagnosis on admission to nursing home.
Nearly half of all newly admitted nursing home
residents with depression have some level of
cognitive impairment.
Depression symptoms appear similar by cognitive
impairment.
Nearly half of residents do not receive any
treatment for depression, regardless of cognitive
impairment status.
Acknowledgement
This work was supported in part by the National
Institutes of Health (TL1 TR001454 and R21CA198172.)
References
Alexopoulos GS, Kiosses DN, Heo M, et al. 2005. Executive dysfunction and the
course of geriatric depression. Biol Psychiatry 58(3): 204210.
American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental
Disorders: DSM-5. American Psychiatric Association: Washington, DC.
Bagchi AD, Verdier JM, Simon SE. 2009. How many nursing home residents live with
a mental illness? Psychiatr Serv 60(7): 958964.
Bauer U, Pitzer S, Schreier MM, et al. 2016. Pain treatment for nursing home
residents differs according to cognitive statea cross-sectional study. BMC Geriatr
16: 124.
Bjrk S, Juthberg C, Lindkvist M, et al. 2016. Exploring the prevalence and variance of
cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency
among persons living in nursing homes: a cross-sectional study. BMC Geriatr
16: 154.
Blazer DG. 2003. Depression in late life: review and commentary. J Gerontol A Biol Sci
Med Sci 58(3): 249265.
Brennan PL, SooHoo S. 2014. Psychiatric disorders and pain treatment in community
nursing homes. Am J Geriatr Psychiatry 22(8): 792800.
Brown MN, Lapane KL, Luisi AF. 2002. The management of depression in older
nursing home residents. J Am Geriatr Soc 50(1): 6976.
Butters MA, Whyte EM, Nebes RD, et al. 2004. The nature and determinants of
neuropsychological functioning in late-life depression. Arch Gen Psychiatry 61(6):
587595.
Butters MA, Bhalla RK, Andreescu C, et al. 2011. Changes in neuropsychological
functioning following treatment for late-life generalised anxiety disorder. Br J
Psychiatry 199(3): 211218.
Callahan C, Tu W, Unroe KT, et al. 2015. Transitions in care in a nationally
representative sample of older Americans with dementia. J Am Geriatr Soc 63(8):
14951502.
Centers for Medicare and Medicaid Services, 2015a. Nursing Home Data.
Compendium 2015 Edition, Available at: https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certication/CerticationandComplianc/Downloads/nursinghome
datacompendium_508-2015.pdf. [Accessed March 14, 2016].
Centers for Medicare and Medicaid Services. 2015b. Nursing Home Quality
Initiative: Overview Available at: https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.
html?redirect=/NursingHomeQualityInits/ Accessed March 14, 2016.
Centers for Medicare and Medicaid Services, 2016. Long-Term Care Facility
Resident Assessment Instrument 3.0 Users Manual Version 1.14, Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
NursingHomeQualityInits/MDS30RAIManual.html. [Accessed March 14, 2016].
Int J Geriatr Psychiatry 2017

Chodosh J, Edelen MO, Buchanan JL, et al. 2008. Nursing home assessment of
cognitive impairment: development and testing of a brief instrument of mental
status. J Am Geriatr Soc 56(11): 20692075.
Coleman E, Boult C, Committee AGSHCS. 2003. Improving the quality of transitional
care for persons with complex care needs. J Am Geriatr Soc 51(4): 556557.
Darcet F, Gardier AM, Gaillard R, et al. 2016. Cognitive dysfunction in major
depressive disorder. A translational review in animal models of the disease.
Pharmaceuticals 9(1) pii: E9. https://doi.org/10.3390/ph9010009.
Davydow DS, Zivin K, Katon WJ, et al. 2014. Neuropsychiatric disorders and
potentially preventable hospitalizations in a prospective cohort study of older
Americans. J Gen Intern Med 29(10): 13621371.
Diniz BS, Butters MA, Albert SM, Dew MA, Reynolds CF 3rd. 2013. Late-life depression
and risk of vascular dementia and Alzheimers disease: systematic review and
meta-analysis of community-based cohort studies. Br J Psychiatry 202(5): 329335.
Gaboda D, Lucas J, Siegel M, Kalay E, Crystal S. 2011. No longer undertreated?
Depression diagnosis and antidepressant therapy in elderly long-stay nursing home
residents, 1999 to 2007. J Am Geriatr Soc 59(4): 673680.
Gallo JJ, Rabins PV. 1999. Depression without sadness: alternative presentations of
depression in late life. Am Fam Physician 60(3): 820826.
Gregg JJ, Fiske A, Gatz M. 2013. Physicians detection of late-life depression: the roles
of dysphoria and cognitive impairment. Aging Ment Health 17(8): 10301036.
Hammar A, Ardal G. 2009. Cognitive functioning in major depressiona summary.
Front Hum Neurosci 3: 26.
Hartmaier SL, Sloane PD, Guess HA, et al. 1995. Validation of the Minimum Data Set
Cognitive Performance Scale: agreement with the Mini-Mental Status
Examination. J Gerontol A Biol Sci Med Sci 50(2): M128M133.
Hegeman JM, de Waal MW, Comijs HC, Kok RM, van der Mast RC. 2015.
Depression in later life: a more somatic presentation? J Affect Disord 170: 196202.
Inouye, SK, 2014. The Short Confusion Assessment Method (Short CAM): training
manual and coding guide. Hospital Elder Life Program.
Katon WJ, Lin EH, Von Korff M, et al. 2010. Collaborative care for patients with
depression and chronic illnesses. N Engl J Med 363(27): 26112620.
Kiosses DN, Ravdin LD, Gross JJ, et al. 2015. Problem adaptation therapy for older
adults with major depression and cognitive impairment: a randomized clinical
trial. JAMA Psychiat 72(1): 2230.
Koenig AM, Bhalla RK, Butters MA. 2014. Cognitive functioning and late-life
depression. Journal of the International Neuropsychological Societ 20(5): 461467.
Kroenke K, Spitzer RL, Williams JB. 2001. The PHQ-9: validity of a brief depression
severity measure. J Gen Intern Med 16(9): 606613.
Lara E, Olaya B, Garin N, et al. 2015. Is cognitive impairment associated with
suicidality? A population-based study. Eur Neuropsychopharmacol 25(2): 203213.
Levin CA, Wei W, Akincigil A, et al. 2007. Prevalence and treatment of diagnosed
depression among elderly nursing home residents in Ohio. J Am Med Dir Assoc
8(9): 585594.
Mace R, Mansbach W, Clark K. 2016. Rapid cognitive assessment of nursing home
residents: a comparison of the Brief Interview for Mental Status (BIMS) and Brief
Cognitive Assessment Tool-Short Form (BCAT-SF). Res Gerontol Nurs 9(1): 3544.
McCall WV, Dunn AG. 2003. Cognitive decits are associated with functional
impairment in severely depressed patients. Psychiatry Res 121(2): 179184.
Copyright # 2017 John Wiley & Sons, Ltd.
C. M. Ulbricht et al.
Mehta KM, Yaffe K, Langa KM, et al. 2003. Additive effects of cognitive function and
depressive symptoms on mortality in elderly community-living adults. J Gerontol A
Biol Sci Med Sci 58(5): M461M467.
Morris JN, Fries BE, Mehr DR, et al. 1994. MDS Cognitive Performance Scale. J
Gerontol 49(4): M174M182.
Morris JN, Fries BE, Morris SA. 1999. Scaling ADLs within the MDS. J Gerontol A Biol
Sci Med Sci 54(11): M546M553.
Mottram PG, Wilson K, Strobl JJ. 2006. Antidepressants for depressed elderly.
Cochrane Database of Systematic Reviews.
Neufeld E, Hirdes JP, Perlman CM, Rabinowitz T. 2015. Risk and protective factors
associated with intentional self-harm among older community-residing home care
clients in Ontario, Canada. Int J Geriatr Psychiatry 30(10): 10321040.
Oude Voshaar RC, van der Veen DC, Hunt I, Kapur N. 2016. Suicide in late-life
depression with and without comorbid anxiety disorders. Int J Geriatr Psychiatry
31(2): 146152.
Park M, Untzer J. 2011. Geriatric depression in primary care. Psychiatr Clin North
Am 34(2): 469487 ixx.
Patomella AH, Sandman PO, Bergland , Edvardsson D. 2016. Characteristics of
residents who thrive in nursing home environments: a cross-sectional study. J
Adv Nurs 72(9): 21532161.
Potter G, Steffens D. 2007. Contribution of depression to cognitive impairment and
dementia in older adults. Neurologist 13(3): 105117.
Saliba D, Buchanan J. 2012. Making the investment count: revision of the Minimum
Data Set for nursing homes, MDS 3.0. J Am Med Dir Assoc 13(7): 602610.
Saliba D, Buchanan J, Edelen MO, et al. 2012a. MDS 3.0: brief interview for mental
status. J Am Med Dir Assoc 13(7): 611617.
Saliba D, DiFilippo S, Edelen MO, et al. 2012b. Testing the PHQ-9 interview and
observational versions (PHQ-9 OV) for MDS 3.0. J Am Med Dir Assoc 13(7):
618625.
Scott EL, Kroenke K, Wu J, Yu Z. 2016. Benecial effects of improvement in
depression, pain catastrophizing, and anxiety on pain outcomes: a 12-month
longitudinal analysis. J Pain 17(2): 215222.
Sheline YI, Barch DM, Garcia K, et al. 2006. Cognitive function in late life depression:
relationships to depression severity, cerebrovascular risk factors and processing
speed. Biol Psychiatry 60(1): 5865.
Shrank WH, Polinski JM, Avorn J. 2007. Quality indicators for medication use in
vulnerable elders. J Am Geriatr Soc 55(Suppl 2): S373S382.
Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. 2014. The effects of
cognitive impairment on nursing home residents emergency department visits
and hospitalizations. Alzheimers Dement 10(6): 835843.
Thakur M, Blazer DG. 2008. Depression in long-term care. J Am Med Dir Assoc 9(2):
8287.
Thomas KS, Dosa D, Wysocki A, Mor V. 2015. The Minimum Data Set 3.0 Cognitive
Function Scale. Med Care https://doi.org/10.1097/MLR.0000000000000334. [Epub
ahead of print]
Untzer J, Park M. 2012. Older adults with severe, treatment-resistant depression.
JAMA 308(9): 909918.
Wang S, Blazer DG. 2015. Depression and cognition in the elderly. Annu Rev Clin
Psychol 11(1): 331360.
Int J Geriatr Psychiatry 2017