Mohammed T. Abou-Saleh

430 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYsuicidal intent and ideation and treatment of underlying disorders;and (c) the improvement of intrapsychic capabilities, personalfactors and psychosocial circumstances to facilitate coping afterdischarge and decreasing risk of the return of suicidality.However, implementation of these treatment plans is predictedon the initial detection of suicidality.Careful assessment of suicide risk in depressed older adults isthus vital. The elderly are less likely to have made a prior suicideattempt, but they consistently demonstrate a higher rate ofcompleted suicides 10 . The ratio of attempted to completed suicidesdecreases with age from 200:1 in young adulthood to 4:1 in theelderly 11 . The higher rate is due primarily to the increasedfrequency of deaths among older, White males. In 1992, persons65 and older accounted for 13% of the population but almost20% of suicides. Even though the frequency of suicide hasincreased among older persons in the USA, the prevalence is notas high as that of other industrialized societies 10 .Recognition of variables such as gender and race may influencemanagement decisions. Risk factors for suicide in late life includeincreased age, with the highest prevalence of suicide of personsolder than 85 10 . Also, being male, White, single, separated ordivorced, or widowed are risk factors for suicide. Other riskfactors implicated in late-life suicide include: a positive psychiatrichistory (especially depression and alcohol abuse and dependence);physical illness and functional disability (especially diseases of thecentral nervous system, malignancies, cardiopulmonary conditions,and urogenital diseases in men); previous suicide attempts;psychological factors (i.e. hopelessness); social factors (stressfullife events, e.g. bereavement); and biological susceptibility(dysregulation of the hypothalamic–pituitary–adrenal axis or theserotonin system).Most older people who commit suicide have seen a primary careprovider within 30 days of death 11 . This observation stresses theneed for collaborative efforts with primary care physicians and theneed to make careful assessment based on risk factors.A number of assessment guidelines have been developed to aidin the evaluation of potentially suicidal patients. A four-itemscreen for identification of suicidal ideation among generalmedical patients was developed by Cooper-Patrick et al. 12 .1. Have you ever felt that life is not worth living?2. Have you ever thought of hurting or harming yourself?3. Have you considered specific methods for harming yourself?4. Have you ever made a suicide attempt?This four-fold layered approach to assessment is useful inobtaining the necessary data without disrupting the therapeuticrelationship. If the answer to the first or second question isnegative, then the inquiries can cease and the older person may beconsidered at low risk for suicide 10 . This approach has advantagesover other assessment tools, which usually suggest one question tobe asked to assess suicidal risk.DELUSIONS AND LATE-LIFE DEPRESSIONAccurate diagnosis and effective treatment of depressed elderlypatients with delusions can be hindered by their impairment ofreality testing. Their sometimes well-organized and complexdelusions may make them distrust medicine and the physicianwho prescribes it. This disorder is less frequent in the communityand more prevalent in the hospital setting 13,14 . Accurate diagnosisis necessary, as some studies have suggested that the depression ismore severe 14,15 and it has been associated with suicide 13 . Varyingreports also demonstrate decreased cognitive functioning andsocial functioning among patients with delusional depression 16 .These patients are best treated in the hospital. They cannot berelied upon to take accurate doses of medications. Effectivepharmacologic treatment for delusional depression requirescombination treatment with high-dose antipsychotic medicationand antidepressants 15 . ECT has been successful for the treatmentof delusional depression 17–19 and can be performed on anoutpatient basis only with adequate social support.COGNITIVE DYSFUNCTION AND LATE-LIFEDEPRESSIONA full discussion of how depression is distinguished fromdementia is given elsewhere in this book. To summarize, diagnosisis difficult because several symptoms of depression and dementiaoverlap, such as a flattened affect, psychomotor retardation andpresence, at times, of delusions 20 . Delusions are reported to occurin up to 40% 13 of Alzheimer’s disease patients, although they aredescribed as transient and less organized than in delusionaldepression 13 . Major depression occurs in over 20% of patientswith Alzheimer’s disease and vascular dementia 4,21 . This significantco-morbidity may lead to profound disability 22 .The diagnosis of depression in dementia usually requires theinput of family members or nursing personnel 23,24 . The patientwith cognitive dysfunction and impaired reality testing cannotreliably report symptoms, take medication accurately, or reliablyreport side effects.Dementia with depression and behavioral disturbance isfrequently too complex to treat on an outpatient basis. Thesepatients may even require involuntary commitment. Aggressionmay be verbal or physical. Aggression and agitation in dementiamay be as high as 50% in the outpatient population 25,26 . Thehospital environment is the only setting with constant monitoringto make an accurate diagnosis, contain behavior and monitormedication.The reversible cognitive impairment that may accompanydepression also increases disability 27 . With treatment, thecognitive impairment usually improves. However, these patientsare at higher risk to develop an irreversible dementia in thefuture 28 .CONCLUSIONSThe patient with late-life depression frequently presents in acomplex manner that may require hospitalization. Accuratediagnosis and treatment of these patients is essential to preventdisability, caregiver burden and nursing home placement. Confusion,suicidality and aggression represent psychiatric emergenciesin the elderly and may require hospitalization for effectivemanagement.REFERENCES1. Montano CB. Primary care issues related to the treatment ofdepression in elderly. J Clin Psychiat 1999; 60(suppl. 20): 45–51.2. Mulsant B, Ganguli M. Epidemiology and diagnosis of depression inlate life. J Clin Psychiat 1999; 60(20): 9–14.3. Unutzer J, Katon W et al. Treating depressed older adults in primarycare: narrowing the gap between efficacy and effectiveness. MillbankQu 1999; 77(2): 225–56.4. Edelstein B, Kalish K et al. Assessment of depression and bereavementin older adults. In Lichtenberg P, ed., Handbook of Assessment inClinical Gerontology. New York: Wiley, 1999; 11–58.5. Das Gupta K. Treatment of depression in elderly patients: recentadvances. Arch Fam Med 1998; 7(3): 274–80.6. Roose S, Spatz E. Treatment of depression in patients with heartdisease. J Clin Psychiat 1999; 60(20): 34–7.