Copyright eContent Management Pty Ltd. Contemporary Nurse (2008) 30: 2031.

The Cornell Scale for Depression

in Dementia in the context of the
Australian Aged Care Funding
Instrument: A literature review
ABSTRACT

Key Words
nursing; aged
care; depression
screening;
dementia;
assessment;
education

A new funding instrument has been introduced into residential aged care known
as the Aged Care Funding Instrument. As part of these requirements the assessment of depression for all residents admitted to an Australian aged care facility
has been implemented using the Cornell Scale of Depression in Dementia.This
literature review was undertaken on the depression prevalence for residents, the
Cornell Scale of Depression in Dementia as the assessment tool being utilised
and its application for residents who may or may not have dementia.The use of
the assessment tool and its reliability and validity are dependent on the assessors education and ability to understand depressive symptoms that are often
complicated by other co morbidities.There is a serious lack of qualified nursing
staff in residential aged care facilities in Australia, and the review and conclusions question whether the information collected through this tool will be of
value for the accurate assessment of the presence of depression in residents.
Received 9 April 2008

Accepted 19 July 2008

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ANITA DE BELLIS
Lecturer in Nursing
(Acute Care/Aged Care)
School of Nursing &
Midwifery
Flinders University
Adelaide SA, Australia

INTRODUCTION

JAYNE WILLIAMS
Registered Nurse
Repatriation General
Hospital
Daw Park SA, Australia

Appollonio, Riva, Spica, Ferrari, Trabucchi &

epression occurs as a primary syndrome Frattola 1998; Martin & Haynes 2002; Wu &
and is the most common psychiatric illness Kelley 2007). Undeniably the highest incidence
among people over sixty-five years of age (Gori, of depression is within residential aged care

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The Cornell Scale for Depression in Dementia

facilities (RACFs) where it is especially problematic and occurs in anything from 2561% of
low and high care residents (Fleming, Snowdon
& Dong 2004; Kerber, Dyck, Culp & Buckwalter
2005; Gruber-Baldini, Zimmerman, Boustani,
Watson, Williams & Reed 2005; Lyne, Moxon,
Sinclair, Young, Kirk & Ellison 2006; McCabe,
Davison, Mellor, George, Moore & Ski 2006;
Anstey, von Sanden, Sargent-Cox & Luszcz 2007;
Davison, McCabe, Mellor, Ski, George & Moore
2007). According to Ames (1994 cited in Fleming et al. 2004) depressive disorders are diagnosed between two and six times more often
in residents of nursing homes compared with
the elderly in the general community and
are strongly linked with factors of increased
dependency (Anstey et al. 2007).
Current projections state that by 2021 18%
of Australias population will be sixty-five or
older (AIHW 2002 cited in Hsu, Moyle, Creedy
& Venturato 2005). This high proportion of
older Australians, combined with the increased
incidence of depression and dementia in this
age group, underscores the importance of assessing depression and highlights the enormity
of the problem. Subsequently, these figures have
prompted an increased focus on the health care
needs of older people. However, despite this
increased focus, depression in older adults and
those persons with dementia continues to be
under recognised and under reported (Gori et al.
1998, Martin & Haynes 2002;Wu & Kelley 2007)
and, therefore, not treated (Birrer & Vemuri
2004; Eisses, Kluiter, Jongenelis, Pot, Beekman &
Ormel 2005; Kerber et al. 2005). Bagley, Cordingly, Burns, Mozley, Sutcliffe, Challis and Huxley (2000) state newly admitted residents are
particularly vulnerable to depression.
This under recognition of depression in persons with dementia is a direct result of the
challenging and complex processes involved in
identifying depression in later life, and is primarily connected to the overlap of symptoms and
secondary physiological co morbidities common
in advanced age (Anstey et al. 2007;Wu & Kel-

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ley 2007). For these reasons multiple assessment tools have been developed to differentiate
between disease aetiologies and the detection
and prevalence of depression in the elderly
population (Wu & Kelley 2007). The objective
of this review is to critique the advantages and
limitations of the Cornell Scale for Depression
in Dementia (CSDD) (Alexopoulos, Abrams,
Young & Shamoian 1988) in the context of its
application through the new Aged Care Funding
Instrument (ACFI) for residential aged care
with the goal of examining the systemic impact
in this area.
A significant focus is placed on the usability
and accuracy of this assessment tool when implemented by Australian nurses and personal
care workers as it is these individuals who will
be affected by the implementation of the ACFI
in March 2008 (Department of Health & Ageing
2007).The CSDD has been selected as the tool
of preference as it is a modified version of this
depression screening instrument that is the basis
of question 10 in the ACFI, which introduces
depression screening for all residents in Australian RACFs.This review is structured around
elements in the assessment of depression, the
development of the CSDD and its reliability,
validity and sensitivity, the introduction of the
ACFI into Australian RACFs and the implications in the systematic screening of depression
for all residents.

LITERATURE SOURCES
A comprehensive search of literature was
undertaken from 1988, as this is the year that
the CSDD was developed (Alexopoulos et al.
1988) to the present, in order to explore both
the utility and accuracy of the CSDD and the
possible implications when utilised within the
Australian residential aged care sector. Data
was sourced electronically through OVID (Psychiatric and Geriatric Info), MEDLINE (online
search dates 19962008), the American Psychiatric Association Psychiatry Online and the Australian Government Department of Health and

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Anita De Bellis and Jayne Williams

Ageing 2008. Further sources were accessed

through the Dementia Services Development
Centre 1996, Alzheimers Australia and the
Southern Mental Health Services for Older
People. The literature included both research
based articles and the grey literature surrounding depression in older persons with and without dementia.

ASSESSMENT OF DEPRESSION IN
RESIDENTIAL AGED CARE
FACILITIES
Depression is a treatable psychological illness
defined as comprising of a constellation of affective, cognitive and somatic or physiological
manifestations (Anstey et al. 2007;Wu & Kelley
2007).There are multiple symptoms of depression which include impaired social interactions,
feelings of hopelessness or sadness, loss of interest or pleasure, changes in activity levels,
changes in general sleep pattern, weight gain or
weight loss, fatigue, feelings of guilt, loss of
confidence or low self esteem, difficulty concentrating and reoccurring thoughts of death or
suicide (Pritchard 1999; Barrie 2002).
It is reasonable to correlate the high rates
of depression in long term care facilities with
the increased vulnerability of residents and the
many challenges faced by them when adjusting
to a new environment and predisposing them to
increased health problems during this transitional period (Brooke 1989 cited in Bagley et al.
2000). Evidence shows that newly admitted
nursing home residents use 7% additional staff
time, are 1.5 times more likely to die within
the first year post admission (Callahan et al.
1994 cited in Wagenaar, Colenda, Kreft, Sawade,
Gardiner & Poverejan 2003) and are particularly vulnerable to depression (Bagley et al. 2000).
In addition to the adjustment period, as psychiatric co morbidity is a risk factor for institutionalisation it is not surprising that there is a high
prevalence of depression in residents of long
term care facilities (Janzing 2003).
The high incidence of depression in residen22

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tial aged care facilities is especially problematic

for nursing staff. Draper (1999) draws attention
to the importance of this issue by outlining the
excess disability and distress caused by depression, not only to the individual, but also the care
providers. Shankar and Orrell (2000) along
with Wu and Kelley (2007) support this claim,
further stating that depression in the elderly is
associated with accelerated loss of function,
wandering, aggression, frequent requests for
help, high levels of utilising inpatient health
services and poor treatment adherence. The
most distressing consequences of untreated
depression are increased morbidity and mortality from medical illness and suicide (Wu &
Kelley, 2007).
Depressive symptoms can be treated however, which is why identification and assessment
is so critically important. Mellor, Davison, McCabe, George, Moore & Ski (2006) indicate the
assessment, services and treatment of depression among residents is unsatisfactory. Accurate
assessment paves the way for active treatment
and management, thereby improving quality
of life outcomes for affected individuals and
decreasing the stress and workload experienced
by carers.This highlights a relationship between
quality outcomes for residents and the working
life satisfaction of those who care for them.
Watson and Pignone (2003) claim that when
depression is detected and treated in older
patients, in addition to the relief of depressive
symptoms, both behaviour and cognitive functioning improves, as well as, their over all
quality of life.

DEVELOPMENT OF THE CORNELL

SCALE FOR DEPRESSION IN
DEMENTIA (CSDD)
The CSDD is a nineteen-item depression
screening instrument specifically designed to
determine whether a person with dementia
also has depression. The CSDD has also been
utilised in the assessment of persons who do
not have dementia. This instrument provides a

The Cornell Scale for Depression in Dementia

quantitative measure of depressive symptoms
with all items derived from the concepts of
an phenomenological perspective of depression
at the time of assessment (Alexopoulos et al.
1988).The CSDD has a psychobiological orientation assessing a broad range of depressive
symptoms in the affective, cognitive, behavioural and somatic realms. The tool has been
designed for implementation by clinicians and
is most effective when completed and scored
through careful observation rather than an elaborate interview (Kurlowicz, Evans, Strumpf &
Maislin 2002).
The CSDD was specifically designed for rating symptoms of depression in people with a
diagnosis of dementia and takes approximately
thirty minutes to complete (20 minutes for an
interview with the persons care giver and 10
minutes with the person themselves) (Alexopoulos et al. 1988). In contrast to other scales
for rating depression, the CSDD does not rely
solely on information provided by the client,
something not always possible when assessing
individuals, especially those with severe dementia (Burns, Lawlor & Craig 2002). Instead, this
scale uses a multi-source approach to gathering
information by utilising patient responses, interviewer observation and informant reports.
This information is combined to form a general
opinion about the individuals signs and symptoms, with the interviewers clinical judgement
critical in the determination of which source
of information is most important (Shankar &
Orrell 2000; Steffens et al. 2006).The collected
information is collated into five areas: moodrelated signs, behavioural disturbances, physical
signs, cyclic function and ideational disturbances (Shankar & Orrell 2000).

RELIABILITY, VALIDITY AND

SENSITIVITY
The authors of the CSDD recruited 83 persons
with dementia with an age range of 6393
years.This sample included psychiatric hospital
inpatients, residents of well staffed skilled nurs-

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ing home facilities and residents from nursing

homes with low staff to resident ratios (Alexopoulos et al. 1988). It is critical to note that in
this initial study the CSDD was administered by
a psychiatrist trained in the use of the scale
(Alexopoulos et al. 1988). Two other psychiatrists reviewed medical records, obtained additional data and examined each patient jointly.
They then consigned a consensus diagnosis using
predetermined research diagnostic criteria.
Depressive symptomology was then rated using
the Hamilton Depression Rating Scale (Hamilton 1960) with the performance of the two
scales evaluated against each other (Alexopoulos
et al. 1988).
During this preliminary testing the CSDD
was found to be reliable, valid and sensitive
(Alexopoulos et al. 1988). The validity of the
study was based on comparisons between the
CSDD and the diagnosis given by the psychiatrists using the research diagnostic criteria and
the Hamilton Depression Rating Scale. In this
project the information rated was based on
information obtained from nursing staff members and a brief interview with the client. Alexopoulos et al. (1988) justified the use of nursing
staff claiming the nursing staff would be familiar
with the foundations of behavioural observation
and reporting.
Alexopoulos et al. (1988) found the CSDD
was able to rate depressive symptomology over
the entire range of severity and was effective
enough to distinguish between those with mild
depression and those with no depression. This
was explained by its unique method of administration and the use of multi source data collection. As ratings in the CSDD are based on two
interviews and complex clinical judgements are
required, the items are designed to be unambiguous and can be scored primarily on the basis
of behavioural observation (Alexopoulos et al.
1988). During this project the scale was not
tested on persons who did not have dementia,
limiting the application of these findings to a
cognitively diverse sample group.

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Anita De Bellis and Jayne Williams

CSDD AND RESIDENTIAL

AGED CARE
Throughout the literature there are mixed opinions about the effectiveness of the CSDD, especially in relation to its application and usability
within the residential aged care setting. Widespread screening and assessment is generally
reported to improve recognition and treatment
of depression (Pope, Watkins, Evans & Hess
2006; Bruhl, Luijendijk & Muller (2007). It is
widely accepted that within the aged care sector
nursing staff resources are strained and nurses,
especially Registered Nurses, have limited time
to spend with their clients. In a study by Snowden, Sato and Roy-Byrne (2003) it is argued
that with the scarcity of staff resources it would
be difficult to utilise the CSDD in the area of
aged care, as it is not only time consuming, but
also requires staff training in order to be accurately executed (Snowden, Sato & Roy-Byrne
2003; Eisses et al. 2005; Bruhl et al. 2007; Lyne
et al. 2007). As will be addressed in the discussion, there is an evident lack of trained
personnel specifically educated in the area of
depression in aged care settings.
According to Snowden (2007) the American
Geriatrics Society and American Association for
Geriatric Psychiatry recommend the use of
the CSDD in nursing homes, both as a tool for
identifying depression and for monitoring the
effects of treatment. Burns, Lawlor and Craig
(2002) support the use of the CSDD stating that
it is the best scale available to assess mood in the
presence of cognitive impairment. Ownby, Harwood, Acevedo, Barker & Duara (2001) agree
that for the assessment of depression in people
with Alzheimers Disease the CSDD is the most
comprehensive measure. Similarly, a Japanese
study on the screening of depressed and non
depressed individuals for late life depression
using the Geriatric Depression Scale (GDS), the
CSDD and the Hamilton Depression Scale, finds
the CSDD to be a sensitive instrument and
more accurate in detecting subthreshold depression than the other scales.This study comments
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the major advantage of the CSDD is in its

methodology of using an informant to confirm
the responses of the person with dementia who
has some degree of cognitive of linguistic disability (Schreiner, Hayakawa & Kakuma 2003).
Limitations of this tool are also recognised
and Greenberg (2004 cited in Snowden & Fleming 2007) states that the psychiatrists diagnosis
did not correlate well with scores on the CSDD,
and furthermore that no scale is accurate enough
to ascertain depression in persons with an advanced dementia. Additional concerns are raised
by Kurlowicz et al. (2002) in the ability of the
scale to clearly separate somatic and vegetative
symptoms from the core depressive factors. Primarily this is understood to be due to the use of
this scale in a population with high levels of
medical illness, functional disability and dementia. Due to the overlapping symptoms seen in
many of these conditions it is argued that for
the untrained care giver difficulty differentiating
between these symptoms could affect the validity of the scale. For example, care givers may be
unable to distinguish between sleep disturbances
associated with depression and those which
result simply due to the fact that within the residential aged care environment quality sleep may
be compromised by noise and intrusions by staff
and other residents.Therefore, in these settings,
a disturbed sleep cycle may be a poor indication
of depression (Kurlowicz et al. 2002).This study
concludes that the utilisation of the CSDD can
be contaminated with symptoms of depression
and medical illnesses, and depression rating
scales with fewer somatic and disturbed sleep
items may be more accurate for the detection
of depression in a highly dependent population
(Kurlowicz et al. 2002).
In a more recent study by McCabe et al.
(2006) particular concern is raised that the
validity of the scale would not stand up in trials
using untrained care staff. In many studies high
levels of training are provided to the administrators to ensure there is a high level of competence in producing a score (McCabe et al.

The Cornell Scale for Depression in Dementia

2006). In contrast to this, it is suggested that
nursing home staff who interact with residents
consistently are the most likely persons to observe and identify expressions of sadness and
low self worth both verbally and non verbally. It
is argued that these more subtle signs of depression may be overlooked by physicians or during
a formal interview process, and are more likely
to be observed over a period of time by people
engaged in therapeutic and interpersonal relationships with their clients regardless of their
expertise (Kurlowicz 2002).

ACFI AND THE MANDATORY

SCREENING FOR DEPRESSION
From March 2008 a new funding model for residential aged care, the ACFI, was introduced
into Australian RACFs (Department of Health &
Ageing 2007).The ACFI has been developed in
response to the reviews of pricing arrangements
in 2003 and 2004 based on the relative dependency of residents using the Resident Classification Scale (RCS). The Department of Health
and Ageing (2007) claims that the ACFI instrument is designed to reduce the documentation
in aged care, as well as better match the needs
of the residents with the funding provided and
the judgements of the aged care staff with those
of the departmental review officers during validation.
In order to justify the care provided and
funding mechanisms in RACFs, documentation
is required to appraise the needs of residents
and to support the claims for subsidies that support care.The ACFI is a funding tool which will
replace the RCS as the mechanism that provides
for government funding and is based upon
evidence of the residents relative level of
dependence (Department of Health & Ageing
2007). The assessments to be completed, including the CSDD, are based upon the formulation of dynamic, individualised care plans for
each resident and the appropriate care interventions and treatments.This form of professional
assessment and documentation is characteristic

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of the nursing process, however, any employee

involved in the nursing care of residents will be
required to assess and document for funding
purposes. The new ACFI follows the format of
12 questions which are grouped under the
headings of mental health and medical diagnosis, activities of daily living, behaviour supplement and complex health supplement. Scores
from each of the questions and the collected
diagnostic and behavioural information are used
to categorise each resident as having low, medium or high care needs (Department of Health &
Ageing 2007).
Within the ACFI assessment requirements is
tool for assessing depression, which is a modified version of the CSDD. It follows the same
format, includes the same nineteen-item instruments and has the same defined grades for
rating the severity of each item.The only difference between this and the original scale is that it
contains explanatory notes under each of the
nineteen instruments. The ACFI introduction
pack explains how this scale should be implemented through semi structured interviews
with an informant (carers or care workers), an
interview with and observation of the resident
and a review of relevant charting that may be
supportive of the observed symptoms, including
sleep and weight assessments (Department of
Health & Ageing 2007). Considering the content and format is nearly an exact mirror of the
original CSDD, it is reasonable to assume that
the same limitations will be applicable.
The main concern is the lack of trained staff
available to implement this instrument, which is
critical, because as identified by Steffens et al.
(2006), it is the clinical judgement of the assessor in determining which source of information
is the most important. This is also identified in
the ACFI training package that claims it is the
final rating of the CSDD as a representation of
the clinical assessors impression that will be
accountable rather than the informant or residents responses (State of NSW Department of
Education and Training 2008). Providing com-

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Anita De Bellis and Jayne Williams

petent care to older adults is complex, especially in the context of residential aged care where
there is a lack of qualified nursing staff. Heath
and Schofield (1999 cited in Kelly, Tolson,
Schofield & Booth 2005) describe the process
of nursing the elderly as one which involves
advanced skills, knowledge and expertise while
adopting a lifespan perspective for the delivery
of nursing care. It can be argued that with the
time constraints and the lack of qualified nurses
inherent in the aged care system, the implementation of an accurate depression assessment
scale will falter as quality nursing care is
intrinsically linked to quality decision making
through thoughtful and well processed judgements and assessments (Dowding & Thompson
2003, cited in Kelly et al. 2005).
The changes in the residential aged care system, the capacity for the assessment of residents
and the multifaceted issues surrounding the
delivery of care due to political, economic and
social factors are of major concern. Once again,
an assessment tool designed to validate funding
impedes on the precious time of Registered
Nurses and other nursing care staff. Any increase in the responsibilities of regulatory and
documentation tasks compromises the time
Registered Nurses have to provide the direct
and holistic care residents are entitled to. Additionally, in RACFs general practitioners are not
readily available, therefore, it is the Registered
Nurse who is required to facilitate early recognition and treatment of psychiatric illnesses
(Bagley et al. 2000) if indeed a Registered
Nurse is available. While nursing staff are not
responsible for the diagnosis of depression they
are in a position to recognise, assess and contribute important information about depressive
symptoms (Bagley et al. 2000).To do this, however, they need adequate training, time, knowledge and skills so that their clients can be
identified and referred appropriately. The importance of this knowledge and the staffing
issues have taken on a new emphasis with the
ageing population and an increase of mental ill26

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nesses in the elderly (Ferguson & Keady 2001

cited in Hsu et al. 2005) when combined with
the new funding requirements and the lack of
qualified nursing staff in residential aged care.

SYSTEMATIC DEPRESSION

SCREENING IN RACFS
Change is necessary in order to address the
current and impending crisis of depression for
persons residing in RACFs. The traditional as
needed models of mental health care in the
aged care sector are inadequate, as evidenced by
the high rates of under diagnosed and under
treated depression (Streim, Beckwith, Arapakos
et al. 2002; Bartels, Moak & Dums 2002 cited
in Snowden 2007). A panel of experts in the US
with a focus on improving the management and
recognition of depression in the elderly recommend residents of long-term care facilities
should be screened for depression 24 weeks
after admission and every six months there after
(American Geriatrics Society and American
Association for Geriatric Society 2003).This is
based upon the belief that although screening is
not synonymous with a diagnosis of depression,
it can be used to focus attention on this group
of people where diagnostic assessment is warranted (Ganguli & Hendrie 2005). The basis of
this theory is that in recognising a resident is or
may be depressed increases the likelihood of
them receiving treatment through appropriate
interventions.
Screening for depression in RACFs has also
been viewed as a cheaper and more comprehensive method than educational programs that can
place financial strain on the services (Cohen,
Hyland & Kimhy 2003).The proposed ability of
mass screening is confirmed in a recent study of
four US nursing homes demonstrates that clinical staff in the nursing home environment could
easily use the CSDD and depression screening
results in significantly more clients receiving
antidepressants and other appropriate therapy.
This study also indicates that nursing staff with
enhanced psychological assessment skills are

The Cornell Scale for Depression in Dementia

sensitive to recognising depression generating
higher levels of treatment (Cohen, Hyland &
Kimhy 2003).
An Australian report entitled Recognising
and Managing Depression in Residents of Aged
Care Homes presents new information about
the face of depression in elderly Australians.
This report details a major nationwide study of
depression in Australian RACFs with residents
from 168 facilities screened using the GDS and
the CSDD. Fleming et al. (2004) state the selection of the scales was based on their validity
when used with elderly populations. The GDS
was selected for use in persons without a diagnosis of dementia as defined by a cut off score
on the Mini Mental State Examination (MMSE).
The use of this scale is further justified using
a study by Snowdon and Lane (1999) where
screening of elderly residents had been carried
out accurately by an Australian nurse who had
received no prior training with the GDS. The
CSDD was selected for use in those residents
who exceeded the cut off score on the MMSE
and, therefore, too cognitively impaired to be
assessed using the GDS determined to be suitable only for people who do not have severe
dementia (Fleming et al. 2004). The authors
justify the use of the CSDD by emphasising it is
a validated tool in persons who have dementia
or do not have dementia, and was thus suitable
for all residents. After implementing both assessment tools Fleming et al. (2004) maintains
the GDS to be the more accurate tool than
the CSDD, and emphasise that without going
through this systematic approach to the screening process, large numbers of residents with
depression may go unidentified.
The recognition of residents with cognitive
impairment undergoing depression screening is
highly valid, although complex, as depression
and the behavioural symptoms associated with
dementia remain two of the most significant
mental heath issues for nursing home residents
(Snowden, Sato & Roy-Byrne, 2003). Additionally, the coexistence of depression and dementia

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is very common and the Victorian Government

of Australia (2002) suggests that depressive
symptoms occur in 4050% of people with
Alzheimers Disease. Despite this high percentage many cases, possibly up to 3040%, go
undiagnosed. Statistical results reveal that of
the residents with low to moderate cognitive
impairment, 51% of high care residents and
31.1% of low care residents scored on or above
the cut off score for depression when assessed
using the GDS (Fleming et al. 2004). In individuals with moderate to severe cognitive impairments, the CSDD reported that 37.9% of high
care residents and 26.4% of low care residents
fell into the depressed category (Fleming et al.
2004). Residents assessed as needing a high
level of care usually have multiple physical illnesses and high levels of physical and/or cognitive disability. As the likelihood of being affected
by depression is strongly correlated to physical
illness and disability, this connection partially
explains some of the elevated levels of depression found in high care residents.
The findings in this area are constructive and
reflect that by implementing theCSDD tool
through mandatory depression screening of
residents in Australian RACFS, the ACFI can
provide a solution for enhancing the treatment
of depression within this population (Cohen
2003). This strongly supports the implementation of the CSDD which will encourage staff to
be more aware of and assess for depressive
symptoms in the residents, especially soon after
admission when practical measures can be implemented early. Further evidence suggests that
when nurses are guided through the available
information their depression recognition skills
improve and as a result larger numbers of
residents are accurately identified and treated
(Fleming et al. 2004).

DISCUSSION
The implementation of the ACFI and the CSDD
tool is a positive step in the process of raising
the profile of depression in residents of RACFs

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Anita De Bellis and Jayne Williams

who have or do not have dementia.The screening also has the potential to significantly
increase the numbers of residents assessed
for and subsequently treated for depression.
Unfortunately, in practice, screening is often
implemented without appropriate education on
the assessment process and the relevant follow
up care (Ganguli & Hendrie 2005). This is
addressed in the ACFI depression assessment
because in order for the residential care facility
to make a claim, which results in greater funding for depression under question 10, the resident must not only have the CSDD completed,
but also a formal or provisional diagnosis of
depression by a medical practitioner made within the last twelve months (Department of
Health & Ageing 2007).
The CSDD is proven to have good psychometric properties and maintains its accuracy
in both persons with dementia and with non
dementia populations. It has also been implemented as a very effective assessment tool in
several trials in the US and Australian RACFs,
proving to be an adequate resource for equipping qualified nursing staff to screen for depression. Predominantly the limitations of this tool
come from well founded concerns about the
lack of trained nursing staff within the aged care
sector and the time available to adequately
assess as the CSDD takes approximately 20 to
30 minutes to complete. It is important to note
this instrument was developed and initially tested by psychiatrists trained in the use of depression screening scales, and symptoms can be
misinterpreted and misconstrued when appropriate education does not accompany the implementation of this assessment for depression.
Although it is clear the CSDD is an accurate
and valuable tool, it is only one factor in the
complicated process of identifying depression
in the elderly, especially those with dementia.
Evidence from multiple sources conclusively
suggests the level of knowledge about mental
illness among aged care workers and nurses is
poor in Australia, and despite the high preva28

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lence of depression, nurses are not prepared to

detect symptoms of this disorder (Bagby et al.
2000;Wood et al. 2002; Hsu et al. 2005; Eisses
et al. 2005). Additionally, despite the obvious
need for trained professionals in this area, the
numbers of nurse specialists in the areas of
mental health and gerontic nursing are very low
in Australia (Halpain et al. 1999; Nay & Closs
1999 cited in Hsu et al. 2005).
This is further compounded if untrained
and unqualified personal care workers will be
undertaking assessments for the ACFI. It is
imperative that training and education regarding
depression is provided to all nursing staff undertaking the assessment for accuracy and the
appropriate interventions to be implemented
with better outcomes for residents (Bagley et al.
2000; Bruno & Ahrens 2003; Eisses et al. 2005;
Lyne et al. 2006; Burgio 2006; Bruhl et al.
2007). Simply undertaking mandatory assessment is not adequate in addressing depression
of residents in RACFs. Nursing education is
the common thread that underpins the entire
process and will enhance the likelihood of
improved patient outcomes.
Nursing education is partially addressed in
the ACFI Training CD (State of NSW Department of Education and Training 2008) which
illustrates the implementation of the CSDD in
several areas including the history, development
and implementation of the tool, and also details
guidelines of each of the questions both for the
informants and the resident. There is a video
which shows a role play of the CSDD being
conducted both with an informant and a resident. Under the scoring guidelines there are
three interactive case studies that include elements of reviewing CSDD scores, the diagnostic
requirements and lodging a claim (State of NSW,
Department of Education and Training 2008).
Despite the fact that the information provided
in the learning tool is practical, concise and
informative, the usability and utilisation is very
limited in relation to the education of nursing
and care staff in the area of depression. This

The Cornell Scale for Depression in Dementia

training in the use of the CSDD is focused on a
claim for funding, rather than being resident
focused and providing the needed education on
depression and its assessment. Therefore, the
place of the CSDD in promoting client centred
care and for the improved assessment and treatment of depression for residents of RACFs is
questionable.

CONCLUSION
According to the literature, the CSDD is considered to be the most comprehensive tool for
screening for depression in people with dementia and elderly persons who do not have dementia making it the most suitable for use in
RACFs. The success of this tool for residents is
due to its design and structure which allows for
a multisource collection of information minimising the inaccuracies that arise when collecting subjective information from individuals who
are cognitively impaired. Given the increasing
incidence of depression in a rapidly ageing population and the number of residents in RACFs
with dementia the introduction of a comprehensive, cost effective and logistically applicable
depression screening tool is critical and worthwhile.
Clearly the introduction of a systematic
method of screening residents for depression
using the CSDD as part of the ACFI is an advancement, in contrast to the current as needed model of mental health care in the aged care
sector , and it paves the way towards recognition and active treatment for residents with
depression. The preliminary studies in the US
and Australian facilities identifies promising evidence that a substantial improvement in the
identification and treatment of depression is
an obtainable reality. However, not only does
this review highlight the distinct need and value
of systematic screening for depression, it further reinforces how critical nursing education
is to the wellbeing and safety of our ageing population and in the assessment of depression
in residents with dementia and those who do

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not have dementia.There is a concern that without appropriate education and suitably qualified
nursing staff with the ability to accurately
administer the CSDD using complex clinical
judgements, in this context its reliability and
validity has to be questioned. Additionally, a
scarcity of staff resources and time will undoubtedly hinder the thorough evaluation of
residents, potentially leading to inaccurate
assessments and deficiencies in the provision of
nursing care.
The issue of assessing and treating depression
in residents of Australian RACFs is not a simple
matter of introducing the CSDD for screening
of all residents. The improvement of resident
outcomes would involve a systemic effort
geared towards education rather than training
and having qualified nursing staff available and
able to accurately assess depression and refer
residents for treatment. A serious review of the
political and economic constraints, as well as
the staffing profile currently governing nursing
practice in the aged care sector will be required
if resident outcomes are to be impacted upon
relative to the prevalence and treatment of
depression in residents of RACFs.

Acknowledgements
The authors would like to thank the South
Australian and Northern Territory Dementia
Training Study Centre for the provision of a
Summer Scholarship to undertake this study.
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