Nursing Home Quality Improvement Initiative

Quality Measure Fact Sheet:
Percent of Chronic-Care Residents Who Have Become
More Depressed or Anxious

Many elderly individuals become more depressed or anxious due to a change in environment (such as moving to a long term care facility) or to stressful losses (such as loss of autonomy in performing daily tasks, like eating or going to the bathroom). This measure refers to an increase in depressed mood, irritability, anger, uneasiness, apprehension, or dread, and/or an increase in combative or resistive behavior.

Why residents may have increased depression or anxiety despite receiving good care:
Depression and anxiety are common among patients in the long-term care setting. Situational factors that increase depression and anxiety include a change in environment, loss of autonomy, loss of privacy, loss of functional status, loss of body function, or loss of family member or friends.

Some medications may inadvertently cause or contribute to depression, affecting mood and level of consciousness. For example, some heart rhythm medication infrequently causes excessive sedation or confusion. Some residents are hospitalized and come back to the facility in a weakened, confused state. When the new assessment is done for either resident, they may show up as having increased depression or anxiety. Eventually good care will address these situations, but for a time they may affect this quality measure.

Many patients have one or more medical conditions that may increase the likelihood of depression or that may cause depressive symptoms (Alzheimer's disease, Parkinson's disease or coronary artery disease). Some residents have lifelong psychiatric conditions that periodically worsen and improve. Hearing or vision impairment may be severe enough to affect functional status, which may indirectly cause depression.

Once diagnosed, depression and anxiety usually respond to treatment with psychotherapy, medications, increased social support or a combination of these. The severity of illness appears to influence the speed of response to treatment. Complications of medical illness can also negatively affect recovery from depression and anxiety. Some residents may refuse treatment. Despite good care, some residents will still show up in the facility's percent for residents with increased depression and anxiety.

What conditions exclude a resident from this measure: (Risk adjustment)
Residents who were comatose and residents who were severely depressed at the last assessment are excluded from the facility's percentage.

Questions you can ask the facility if they are rated high in this measure: How many of these residents have been recently hospitalized and why? How many of these residents have worsening medical conditions or chronic psychiatric disease? How does the facility look for underlying causes of increased depression and anxiety? How does the facility decide that consultation with a psychiatric specialist is needed?