Overlooking geriatric depression can cost you money

An elusive disease, depression often masks itself behind natural conditions of aging to the detriment of patients and an enormous cost to the health care system

Stephen A. Meldon, MD, an emergency physician at MetroHealth Medical Center in Cleveland, OH is fighting an elusive disease in many elderly patients. The condition can be debilitating, even disabling. And it is unlike anything most physicians are trained to detect, Meldon says.

It is so difficult to identify in that it can mask itself behind natural conditions of aging. Patients typically complain of vague symptoms of fatigue, inability to sleep, and cognitive disorders when actually they are suffering from the effects of mild-to-severe depression, Meldon says.

"Geriatric depression is one of the most difficult conditions to identify in the emergency department (ED). It is most often overlooked and therefore it usually goes untreated," says Meldon.

The subsequent cost to the health care system of treating these patients is enormous, psychiatrists say.

Nearly 30% of patients aged 65 and older who present at EDs with other ailments also suffer from mild-to-severe depressive symptoms. Usually, the ailments are unidentified by their own primary care physicians (PCPs). And unfortunately they also go undetected in the ED, according to findings of a recent study co-authored by Meldon.1

Medical system may be at fault

The reasons are many, but most focus on the nature of emergency and primary care medicine, most authorities suggest. Because the symptoms of depression are easily mistaken for physical ailments, most physicians lack either the time or sufficient training to follow through on their suspicions of mental illness. Busy physicians simply don't have the time or the training for a formal mental health evaluation, Meldon says. Quite often, even the history and physical will not yield any salient clinical markers for a depression diagnosis, Meldon says.

Some observers argue that ED personnel are ill-equipped in both training and orientation to meet most of the special medical needs of the elderly not just their mental health. "The disease-oriented model used for caring for non-elderly adults patients in the ED may not be appropriate for the elderly," says Arthur B. Sanders, MD, an emergency physician at the University of Arizona College of Medicine in Tucson. "Overall principles of care for the elderly patients seeking emergency care have not been defined as they have for other special populations such as children." Sanders states.

Therefore, geriatric depression isn't to be taken lightly. Physicians who lack the proper training and experience in identifying depressed patients mistakenly dismiss the symptoms as part of the normal aging process. But the facts bespeak a serious public health concern. Among groups of depressed and non-depressed patients hospitalized each year, as many as 40% of the depressed patients are likely to be aged, Meldon observes.

And once admitted, up to 35% of severely depressed geriatric inpatients are not treated in psychiatric units but are found in medical wards being treated for accompanying cardiac, pulmonary, or orthopedic ailments, according to the National Institute of Mental Health (NIMH) in Bethesda, MD. The suicide rate among older white males who are depressed is the highest in the nation, the NIMH reports.

Elderly depressed get overlooked in EDs

Some 40% of these patients see their PCPs a week prior to their deaths. Seventy percent seek primary care during the same month, says Barry Lebowitz, MD, chief of interventional research at NIMH. "We are obviously overlooking what these patients are telling us," Lebowitz says.

Frequently, the accompanying somatic conditions are either aggravated or caused by the depressive co-morbidity, Meldon states. "The diabetes often aggravates the diabetes or hypertension," he adds. But it frequently has physiological causes. In the elderly, the depression is commonly a result of cerebral vascular injury in which there has been damage to the neurotransmitter, Lebowitz says.

In the ED the patient is typically treated for an accompanying physical problem and discharged home. Yet, the existing literature reflects that these same patients account for repeat return visits to both the ED and outpatient clinics at a sizable cost.

A prospective cost study of depressed elderly patients enrolled in a health maintenance organization (HMO) found that their cost of treatment was nearly twice that of a similar group of non-depressed HMO members.2

For example, patients with significant depressive symptoms, according to the study, had higher median costs during the first year of the four-year study than patients without depressive symptoms. The first-year costs were $2,147 and $1,461, respectively. They also had higher median costs for the four-year period of $15,423 compared with $10,152, or 34% higher.

One other significant factor of the study was that researchers found roughly the same percentage increase in total costs at all levels of medical morbidity, which implies that the depressive condition drove up the total cost of treating these patients uniformly.

And Sanders cites data that although the elderly comprise about 12% of the population, they account for 43% of hospital admissions and 15% of all ED visits. Once in the ED, they are five times more likely to be admitted than non-elderly patients.3

These cost factors haven't been lost on health plans. Yet, managed care organizations (MCOs) have long recognized the validity of depression as a treatable medical condition, and therefore they've been quite willing to pay for treatments, Lebowitz says. But the existence of depression in a diagnosis involving co-morbidity isn't a simple matter from a payment standpoint.

Health plans may question medical necessity

Treatment for depression in an acute-care setting such as the ED presents a host of other problems, says Meldon. "The payer might recognize the depressive symptoms but question the legitimacy of paying for it in the emergency setting," he adds.

While the Meldon study didn't directly address the reimbursement aspects of triaging and evaluating depression co-morbidity, it does denote ways in which ED physicians can recognize the condition. And Meldon separately has prescribed steps providers can take to ensure that the physicians' clinical decision-making will justify a higher evaluation and management code on the medical claim.

There are several ways to confirm the existence of depression in older patients. But the most effective in an emergency setting appears to be a short, easily administered screening system called the Koenig scale, named after the researcher at the University of Pennsylvania in Philadelphia who developed the system in the early 1990s.

Using a simple, five-minute questionnaire, the Koenig scale will yield sufficient information for providers to validate a suspicion of depression in older patients, according to Meldon.

The questions are fundamental and involve yes-or-no verbal responses. In the Meldon study, a predetermined cutoff score of four yes-answers was used to identify depression. Questions used in the screening would typically involve: Do you often get bored? Do you often get restless and fidgety? Do you feel happy most of the time?

But there are drawbacks to the Koenig scale. The test doesn't accurately distinguish between major and minor depression. And it has shown to stand up poorly to ethnic variability in patients such as male blacks, Meldon observes.

The scale is an offshoot of the Geriatric Depression Scale (GDS), a longer, more formal screening instrument widely used in psychiatry specifically to evaluate geriatric patients. The GDS is reasonably accurate in detecting depression compared with the standard psychiatric interview. It has a 92% sensitivity and 89% specificity in detecting the condition in recorded trials, according to the Meldon study.

Question patients regarding lifestyle issues

But when should you use these self-rated screenings? Lebowitz of NIMH feels you may not have to with every patient who presents in the ED. However, if patients reveal problems in three key areas of daily life, providers should consider them candidates for further testing.

Posed verbally as questions during the initial evaluation, the areas should focus on: How are things at home? How are you sleeping? And are you having any fun?, Lebowitz says. The questions may seem mundane, even simplistic. But "examine the patient further if you don't like what you hear," Lebowitz advises.

Applying screening devices such as the Koenig scale early in the evaluation process is likely to prepare physicians when contacting both the payer and the patient's PCP. ED physicians should consult with the PCP to advise the provider that follow-up evaluation and treatment for depression is indicated either in a dedicated psychiatric consult or mental health clinic, Meldon says.

The screening should also justify documenting a higher-intensity CPT-4 evaluation and management code to the health plan. The HCFA 1500 form has up to four spaces in which to document separate diagnoses. The UB92 has as many as 25.

However, some payers are likely to reject the medical necessity of evaluating the depression as part of the presenting somatic diagnosis. But at least the review and interpretation of the Koenig screening will help justify the higher-level coding, Meldon states.

But payment considerations should not obscure the necessity for physicians to correctly assess depression's role in acute co-morbidity and recommend appropriate follow-up care, says Lebowitz. "The condition is treatable. Payers have been extremely supportive of treatment. However, what we don't know yet is exactly how much care is appropriate," Lebowitz says.


    1. Meldon SW, Emerman CL, Schubert DSP, et al. Depression in geriatric ED patients: Prevalence and recognition. Ann Emerg Med 1997;30:141-144.

    2. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. JAMA 1997;277:1618-1622.

    3. Sanders AB. Care of the elderly in emergency departments: Conclusions and recommendations. Ann Emerg Med 1992;21:830-834.