Assessing Depression in Dementia with the Cornell Scale
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16m
Updated 07 Mar 2024
Content warning: Please be aware that this Article contains references to self-harm and suicide.
Depression is estimated to be three to four times more common in older adults with dementia than those without (Dementia Australia 2020).
However, while depression co-occurs in about 20 to 30% of people with dementia, it can be difficult to determine whether an older adult actually has both depression and dementia, has depression only or has dementia only due to similarities between the two conditions (Dementia Australia 2020).
Being able to identify and distinguish between depression and dementia correctly is crucial in ensuring those with depression are able to receive the treatment and support they require, those with dementia do not have unrealistic expectations of improvement placed upon them, and those with both undergo appropriate treatment (Dementia Australia 2020).
Causes of Depression in Dementia
Depression might develop in people with dementia due to factors such as:
Decreased confidence and self-esteem due to loss of functional capacity
Loss of independence and increased reliance on others
Being unable to participate in activities or perform daily tasks
Anxiety and agitation
Confusion and impaired memory
Changes to the brain
Untreated pain.
(Dementia Australia 2020)
Why Are Depression and Dementia Often Confused?
There are a variety of reasons why it can be difficult to determine whether an older adult has depression, dementia or both. These include:
Certain symptoms of depression are similar to those of dementia, for example:
Impaired cognition and concentration
Impaired memory
Impaired motivation and initiative
Changes in mood
Social withdrawal
Lack of interest in the self or other people
The belief that it’s ‘normal’ for older adults, especially those with dementia, to be depressed
The older adult may be unable to describe symptoms of depression due to dementia-related communication difficulties
The older adult’s personality, e.g., someone who has always had a negative and depressive cognitive style.
(Dementia Australia 2020; Kitching 2015)
Recognising Depression in Dementia
Despite the potential for confusion, there are some significant differences between depression and dementia that can aid in diagnosis. For example:
Depression typically develops more quickly than dementia (over weeks or months).
Issues related to speech and awareness of time and place are common in dementia but uncommon in depression.
Those with depression may state they have forgotten something but will remember when prompted. On the other hand, those with dementia are unlikely to remember and may instead hide their memory loss.
Impaired cognition and memory in depression are often caused by poor concentration and will get better with treatment or an improvement in the condition. This will not occur in dementia.
(Alzheimer's Society 2024)
There are a variety of reasons why it can be difficult to determine whether an older adult has depression, dementia, or both.
What is the Cornell Scale for Depression in Dementia?
The CSDD takes into account non-verbal symptoms of potential depression, including observations and physical signs that a person with cognitive impairment may be unable to vocalise (Heerema & Patel 2023).
The CSDD should be performed by a caregiver who has regular contact with the older adult (DSA 2024).
The assessment needs to be conducted by two groups of people:
Someone who has regular contact with the person, such as a caregiver
Members from the person’s care team, such as nursing staff or their general practitioner.
(DSA 2024)
The CSDD measures 19 items over 5 categories of assessment:
Mood-related signs
Behavioural disturbance
Physical signs
Changes in daily/nightly mood and behaviours
Ideational disturbance.
(DSA 2024)
Each of these 19 items should be assessed for severity and assigned one of the following scores:
0 = Absent
1 = Mild or intermittent
2 = Severe.
(DSA 2024)
Before undertaking the CSDD, remember that symptoms caused by physical disability or illness should not be used in the assessment, as they are not related to depression (DSA 2024).
Does the older adult have an anxious, tense, distressed or apprehensive expression?
Have they felt anxious during the past week?
Have they worried about things they wouldn't usually worry about or ruminated over things that might not be particularly important?
2. Sadness (sad expression, sad voice, tearfulness)
Has the older adult felt down, sad or blue over the past week?
Have they cried at all over the past week?
How many days over the past week have they felt sad, and for how long each day?
3. Lack of reactivity to pleasant events (does not cheer up when offered pleasant activities)
Does the older adult respond to friendly or supportive remarks or humour?
If a pleasant event occurred today (e.g. visit from family), would they be able to enjoy themself fully, or would their mood impede their interest in the event?
Does their mood affect any of the following:
Ability to enjoy activities that used to give them pleasure?
Their surroundings
Their feelings for family and friends
4. Irritability (easily annoyed, short-tempered)
Has the older adult felt short-tempered or easily annoyed during the past week?
Have they felt irritable, impatient or angry over the past week?
Based on your observations, has the older adult been talking or moving slower than what is typical for them? For example:
Slow speech
Delayed answers to questions
Decreased motor activity and/or reactions.
7. Multiple physical complaints (complaints about physical health more than is reasonable)
Has the older adult experienced any of the following symptoms in excess of what is normal for them over the past week?
Indigestion
Constipation
Diarrhoea
Abdominal cramps
Belching
Heart palpitations
Headaches
Muscle aches
Joint pain
Back pain
Hyperventilation
Urinary frequency
Sweating
If yes to the above:
How many of these symptoms have been bothering them?
How severe are the symptoms, and how often have they occurred over the past week?
Note: This does not include symptoms that are related to medicines the older adult is taking or gastrointestinal ailments.
8. Loss of interest (less involved in usual activities)
How has the older adult been spending their time over the past week?
Have they been interested in their usual activities and hobbies?
Have they spent less time than normal engaging in their usual activities and hobbies?
Have they needed to be prompted to participate in activities they normally enjoy?
Have they stopped participating in activities they used to do?
Are they looking forward to anything, or have they lost interest in activities and hobbies they used to derive enjoyment from?
Remember to only score the older adult for this item if the loss of interest occurred acutely and/or has lasted for under one month. Assign a rating of 0 for this item if:
The loss of interest has been occurring for longer than one month and has not worsened, or
The older adult has been unable to engage in activities and hobbies due to physical illness, disability or dementia-related apathy.
(Adapted from DSA 2024)
Physical Signs
9. Appetite loss (eating less than usual)
How has the older adult’s appetite been over the last week when compared to normal?
Has their appetite decreased?
Have they felt less hungry or needed to be prompted to eat?
Have other people needed to force or urge them to eat?
Score 1 if their appetite was reduced but they were still eating on their own
Score 2 if they only ate after being encouraged or urged by others
10. Weight loss (decrease in weight)
Has the older adult experienced unplanned weight loss over the last month? (If unsure, you can check whether their clothes have become looser)
If weight loss is related to present illness (not diet or exercise), how many kilograms have they lost?
Score 2 if they have lost more than 2.5 kg over the past month.
11. Lack of energy (fatigues easily, unable to sustain activities)
Does the older adult appear to be fatigued or drained of energy?
How does their energy over the past week compare to what is normal for them?
Have they been tired all the time?
Have they needed to take naps due to fatigue?
Have they experienced any of the following symptoms over the past week due to a lack of energy? (not related to physical problems)
Limb, back or neck heaviness
Feeling as if they are dragging through the day
Feeling fatigued more easily
This item should be scored according to the older adult’s energy over the past week. Therefore, do not score this item if the fatigue has been occurring for longer than one month and has not worsened.
(Adapted from DSA 2024)
Changes in Daily/Nightly Mood and Behaviours
12. Changes in mood (mood changes as the day progresses, with symptoms worse in the morning)
In terms of mood, is there any time of day when the older adult feels better or worse, or does the time of day not make any difference?
If yes, are the depressive symptoms worse in the morning or evening? If worse in the morning, is it a mild or noticeable difference?
In order for this item to be scored 1 or 2, the older adult must feel consistently worse in the mornings than in the evenings.
13. Difficulty falling asleep (later than usual for this individual)
Has the older adult had difficulty falling asleep over the past week?
Has it taken them longer than usual to fall asleep once in bed (e.g. more than 30 minutes)
Score 1 if they had difficulty falling asleep for a few nights during the past week
Score 2 if they had difficulty falling asleep every night during the past week
14. Multiple awakenings during sleep (wakes up more than usual for this individual)
Has the older adult woken up in the middle of the night during the past week?
If yes, did they get out of bed?
Score 0 if they only woke up to go to the bathroom and were able to fall back asleep easily
Score 1 if they had restless sleep and were only disturbed occasionally during the past week
Score 2 if they got out of bed in the middle of the night (for reasons other than voiding) and/or woke up every night over the past week
15. Early morning awakenings (earlier than usual for this individual)
Has the older adult woken up earlier than usual over the past week (without an alarm)?
If yes, how much earlier? Do they get out of bed when they wake up early or stay in bed/go back to sleep?
Score 1 if they woke up early on their own but went back to sleep
Score 2 if they woke up early and then got out of bed for the day (couldn’t get back to sleep)
(Adapted from DSA 2024)
Ideational Disturbance
16. Suicide (feels life is not worth living, has suicidal wishes)
Note: If suicide is suspected, this should be escalated immediately to the rest of the care team
Has the older adult had thoughts that life isn’t worth living over the past week?
Have they had thoughts about self-harm?
Score 1 for passive suicidal ideation (e.g. feeling that life isn’t worth living)
Score 2 for active suicidal wishes and/or any recent suicide attempts, gestures or plans
Note: History of suicide attempts in an older adult who has no current passive or active suicidal ideations should be scored 0.
17. Poor self-esteem (self-blame, poor self-esteem, feelings of failure)
How has the older adult been feeling about themself during the past week?
Have they been feeling critical of themself or felt like they’ve let others down?
Have they felt guilty about anything they have/haven’t done?
Have they compared themself to others, felt worthless or felt like a failure?
Have they described themself negatively (e.g. ‘worthless’, ‘no good’ or ‘inferior’?)
Score 1 for loss of self-esteem or self-reproach
Score 2 for feelings of failure or making negative statements about themself
18. Pessimism (anticipation of the worst)
Has the older adult felt pessimistic or discouraged about their future over the past week?
Do they think their situation will improve?
Can they be reassured that their situation will improve?
Score 1 for pessimism but receptiveness to being reassured
Score 2 if they feel hopeless and cannot be reassured
19. Depressing delusions (delusions of poverty, illness, or loss)
Has the older adult had ideas that other people might find strange?
Do they believe their illness is a punishment or that they have somehow brought it upon themself?
Do they believe they have less money or material possessions than they actually have?
(Adapted from DSA 2024)
Final Score
Once all 19 items of the CSDD have been assessed, add the older adult’s scores for each item together:
Total Score
Meaning
> 18
Definite major depression
> 10
Probable major depression
> 6
Absence of significant depressive symptoms
(Adapted from DSA 2021)
Note: Remember that the CSDD is a screening tool, not a diagnostic tool. Therefore, further investigations might be required.
True or false: When completing the Cornell Scale for Depression in Dementia, you should include symptoms caused by physical disability or illness in the older adult’s score.
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