Age and Ageing Advance Access originally published online on March 17, 2008
Age and Ageing 2008 37(4):475-478; doi:10.1093/ageing/afn052
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‘Do you feel that your life is empty?’ The clinical utility of a one-off question for detecting depression in elderly care home residents
SIR—There is a high prevalence of depression in the elderly living in residential care homes (6–11% for major depression and 30% for depressive symptoms) [1, 2]. The National Institute for Health and Clinical Excellence (NICE) recommends the use of ultra-short questions as a screening method for depression [3]. The Geriatric Depression Scale (GDS) is effective in screening for depression in the elderly [4]. Shorter versions have been designed for use in primary care, medical ward and residential care settings [5–8]. D'Ath et al. found the question ‘Do you feel that your life is empty?’ to be the best question of the GDS-15 when screening for depression in elderly primary care patients (sensitivity of 59% and specificity of 75%) [5].Lack of recognition of depression by care home staff is a major obstacle to the provision of adequate treatment [9]. However, detecting depression in a population with a high prevalence of dementia is difficult. For example, the full GDS was found not to be particularly sensitive in a sample with severe cognitive impairment [8]. The Cornell Scale for depression in dementia (CSDD) [10] is validated in this population, but can be difficult to complete as it requires the observer-rater to score the older person on items relating to his/her well-being during the previous 2-week period.
We decided to determine the utility of the single question ‘Do you feel that your life is empty?’ as a predictor of depression in a sample of care home residents with a high prevalence of dementia by comparing the result to the CSDD score.
The study was an ancillary component of the FEVER trial, a randomised controlled trial of the efficacy of testing elderly care homes residents' antibody response to routine influenza vaccine and administering a booster dose if response was inadequate, versus standard practice [11]. The inclusion criteria for the study were as follows: residents should be over 60 years old, living in a nursing home or in residential care in the same facility in three south London boroughs and in receipt of an annual influenza vaccine. Residents who had been administered influenza vaccination in the previous 6 months or had a known reaction to the vaccine were excluded from the study.
At the start of the assessment the researcher asked each participant the question, ‘Do you feel that your life is empty?’ and their answer was recorded as yes/no/unable to answer. Participants were scored on the Mini Mental State Examination (MMSE) [12] and the CSDD. Given the difficulty of performing a structured depression interview schedule in a population with high rates of dementia, the CSDD was chosen as the reference measure of depression. Different CCSD cut-points to define patients as probably depressed (CSSD depression) were used.
The residents were divided into two groups—with and without dementia (using an MMSE cut-point of 24)—to see if the results varied between these. Those with cognitive impairment were further divided into those with an MMSE score below 15 and those an MMSE score above 15 [8].
Of the 277 residents who entered the main study (FEVER), 77 were excluded from analysis as they were missing data (they were not asked the question ‘Do you think that your life is empty?’) or were unable to answer the question. However, there were nine residents who were not randomised in the FEVER trial but who had baseline assessments, whose data were usable for this study. Thus, there were 209 participants in total. The mean age of residents was 81.4 years. Sixty-five per cent of them were female and 89.3% were Caucasian. There were no significant differences between the residents for whom there were complete data and for those with missing data in terms of age, gender and ethnicity. However, residents who were unable to answer the question were less likely to be able to give consent and more likely to live in an elderly mentally infirm (EMI) home (a type of residential home for elderly people with dementia with behavioural problems). Details of the participants' demographics and the study's sampling procedure are described elsewhere [11].
Table 1 reports the sensitivity, specificity, positive predictive value and negative predictive value of the question ‘Do you think that your life is empty?’ in determining depression using four different cut-points on the CSDD [6, 8, 10, 12]. Sensitivity and specificity varied little with the different cut-points.
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Using a standard cut-point of 8, the positive likelihood ratio (PLR) was 2.1 (95% CI 1.2–3.7) and the negative likelihood ratio (NLR) was 0.8 (95% CI 0.7–1). The diagnostic odds ratio (PLR/NLR) was 2.5 (95% CI 1.2–5.3). The prevalence of depression was 26.8% (95% CI 21.3–33.2%), so the pre-test odds of a positive response to the question ‘Do you feel your life your life is empty?’ in a similar population are 0.4; the post-test odds are 0.8; and the post-test probability is 0.4.
Three-fourths of the sample of residents scored below 24 on the MMSE. Half scored less than 15 and 38% between 15 and 24. Fifteen per cent had scores of 24 or above. When the population was divided by degree of cognitive impairment there was little variation in specificity against the CSDD cut-point 8 but a slight decrease in sensitivity in the severely impaired group (Table 2).
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Fourteen per cent of the sample of residents were receiving an antidepressant according to their drug chart. Of those with a CSDD score greater than 8, only 12.5% were prescribed antidepressant treatment.
The question ‘Do you feel that your life is empty?’ may be useful for screening for depression in a residential care home setting with a high prevalence of dementia. Sensitivity and specificity did not vary substantially when different cut-points were used on the CSDD or when levels of cognitive impairment were considered. Broadly speaking, a ‘yes’ response indicated the resident was twice as likely to have depression (likelihood ratio) and a ‘no’ response meant that there was a three in four chances that they did not have depression (NPV).
Compared to D'Ath's primary care sample, we found a higher specificity (86% versus 75%) but a lower sensitivity (28% versus 59%) for the question ‘Do you think that your life is empty?’ [5]. Lam et al. used a one-off question in a Chinese population with dementia with similar findings and with its performance varying little with different CSDD cut-points [13]. Mitchell and Coyne conducted a recent meta-analysis of 22 studies evaluating the performance of ultra-short instruments in screening for depression (the sample included both working age and older adults) [14]. The results of the pooled analyses for single question tests in terms of sensitivity (32%), specificity (97%), PPV (56%) and NPV (93%) were similar to the performance of the question ‘Do you feel that your life is empty?’
Rates of dementia were high in our population (three-fourths of the sample, as determined by an MMSE score of less than 24), but were in keeping with the prevalence of this condition in south London residential homes. The decision to divide the degree of cognitive impairment around an MMSE score of 15—rather than using standard classification, such as used by the NICE (who define moderate dementia as those with an MMSE score of 10–20) [15]—was based on previous work, which found that the GDS was insensitive with an MMSE score below 15 [8].
The main limitation of this study is that the question ‘Do you feel that your life is empty?’ was compared to the score on a rating scale for depression (CSDD) rather than a formal diagnosis. However, there is no gold standard for diagnosing depression in dementia, especially at the severe end of the spectrum. A further limitation relates to the representativeness of the sample. A participation bias occurred in the FEVER trial which affected this study too; fewer residents living in EMI (cf. Non-EMI) were successfully recruited compared to the numbers of residents approached from those types of homes. The under-representation of residents from EMI homes is probably explained by the difficulty in obtaining assent by proxy, as is often needed in this group. A similar bias occurred in this study as well in relation to residents with missing data or those who were unable to answer the question ‘Do you feel that your life is empty?’ These two sets of biases probably mean that residents with advanced dementia were under-represented. However, the large number of residents—most of whom had cognitive impairment—in the study and the similarity of the results to those of Michell and Coyne's meta-analysis mean that the findings are probably robust.
The sensitivity of ‘Do you think that your life is empty?’ was low and, as such, the question is not recommended as a replacement for a clinical interview or the CSDD. Mitchell and Coyne found—in a different population than ours—that two and three question tests had acceptable sensitivity when screening for depression. We recommend that if the answer to the question ‘Do you feel that your life is empty?’ is ‘yes’, then clinicians proceed to use further questions from an instrument such as the GDS or administer the CSDD to screen more accurately for depression.
- Previous work found the question ‘Do you feel that your life is empty?’ to be the best item from the GDS-15 in predicting depression in an elderly primary care population.
- In an elderly care home setting with high rates of dementia, the one-off question was highly specific (84.3%) but not sensitive (28.6%) in identifying depression, and the positive and negative predictive values were 43.2 and 76.7% respectively.
- The performance of the one-off question varied little when different Cornell scale for depression in dementia cut-points (to which it was compared) were used and across different levels of cognitive impairment of the residents.
- The results are in keeping with a recent meta-analysis of ultra-short screening questions for depression.
1 South London and Maudsley NHS Trust, Mental Health of Older Adults, London, UK
2 South London and Maudsley NHS Foundation Trust, Ladywell Unit, London, UK
3 Institute of Psychiatry, Mental Health and Neuroscience Clinical Trials Unit, London, UK
4 Institute of Psychiatry, King's College, London, UK
5 Institute of Psychiatry, London, UK
* To whom correspondence should be addressed E-mail: pwhelan{at}gotadsl.co.uk
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