Execute a therapeutic assessment interview with them for at least two interview sessions assessing their self-identified


Identify an older adult age 65 +, use a 1st and last initial. Execute a therapeutic assessment interview with them for at least two interview sessions assessing their self-identified:

  • Demographics, life time education and career/employment
  • Two most significant (positive) times in their lives
  • What past hardship or loss has the client successfully negotiated in the past?
  • Two personal strengths
  • Engage them in identifying what is healthy versus non-healthy coping skills
    Inquire of 2 healthy coping skills they have used in the past and/or now
  • Three (3) pieces of advice they would give to their younger self if they could?
  • Support the client in taking the Geriatric Depression Scale.pdf
  • Support the client in taking the Fulmer SPICES Assessment.pdf
  • Perform a Mini Mental State Exam.pdf and Patient_Stress_Questionnaire.pdf (attach here)
  • Perform a Hall, Hall, and Chapman Article.pdf
  • Report the findings from the Geriatric Depression Scale, Fulmer Spices, Patient stress questionnaire and the mini mental status exam
  • Discuss your older adult’s level of ego integrity vs. despair as described by psychoanalyst Erik Erikson. If you had to rate them on a scale of 1-10, with 1 representing a full state of despair and 10 representing full ego integrity, what rating would you give your older adult?
  • Describe at least two nursing diagnoses for this client.
  • Create a plan of care for the client to include at least three nursing goals with two nursing interventions each.

The assignment should be written in an APA-formatted essay. The essay should be at least 1500 words in length and include at least two scholarly sources other than provided materials.

Module 3 Assignment.html

Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.

Start by reading and following these instructions:

1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.

2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.

3. Consider the discussion and the any insights you gained from it.

4. Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.


Identify an older adult age 65 +, use a 1st and last initial. Execute a therapeutic assessment interview with them for at least two interview sessions assessing their self-identified:

  • Demographics, life time education and career/employment
  • Two most significant (positive) times in their lives
  • What past hardship or loss has the client successfully negotiated in the past?
  • Two personal strengths
  • Engage them in identifying what is healthy versus non-healthy coping skills
    • Inquire of 2 healthy coping skills they have used in the past and/or now
  • Three (3) pieces of advice they would give to their younger self if they could?
  • Support the client in taking the Geriatric Depression Scale.pdf
  • Support the client in taking the Fulmer SPICES Assessment.pdf
  • Perform a Mini Mental State Exam.pdf and Patient_Stress_Questionnaire.pdf (attach here)
  • Perform a Hall, Hall, and Chapman Article.pdf
  • Report the findings from the Geriatric Depression Scale, Fulmer Spices, Patient stress questionnaire and the mini mental status exam
  • Discuss your older adult’s level of ego integrity vs. despair as described by psychoanalyst Erik Erikson. If you had to rate them on a scale of 1-10, with 1 representing a full state of despair and 10 representing full ego integrity, what rating would you give your older adult?
  • Describe at least two nursing diagnoses for this client.
  • Create a plan of care for the client to include at least three nursing goals with two nursing interventions each.

The assignment should be written in an APA-formatted essay. The essay should be at least 1500 words in length and include at least two scholarly sources other than provided materials.

Record the time you spend interviewing the client and writing the assessment report as practice experience hours in Project Concert. It is expected to take you between two and four hours. Access Project Concert .

Geriatric Depression Scale.pdf

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

Best Practices in Nursing Care to Older Adults

general assessment series

Issue Number 4, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing

The Geriatric Depression Scale (GDS) By: Sherry A. Greenberg, PhD(c), MSN, GNP-BC,

Hartford Institute for Geriatric Nursing, NYU College of Nursing

WHY: Depression is common in late life, affecting nearly 5 million of the 31 million Americans aged 65 and older with clinically significant depressive symptoms reaching 13% in older adults aged 80 and older (Blazer, 2009). Major depression is reported in 8-16% of community dwelling older adults, 5-10% of older medical outpatients seeing a primary care provider, 10-12% of medical-surgical hospitalized older adults with 23% more experiencing significant depressive symptoms (Blazer, 2009). Recognition in long-term care facilities is poor and not consistent amongst studies (Blazer, 2009).

Depression is not a natural part of aging. Depression is often reversible with prompt recognition and appropriate treatment. However, if left untreated, depression may result in the onset of physical, cognitive, functional, and social impairment, as well as decreased quality of life, delayed recovery from medical illness and surgery, increased health care utilization, and suicide.

BEST TOOL: While there are many instruments available to measure depression, the Geriatric Depression Scale (GDS), first created by Yesavage, et al., has been tested and used extensively with the older population. The GDS Long Form is a brief, 30-item questionnaire in which participants are asked to respond by answering yes or no in reference to how they felt over the past week. A Short Form GDS consisting of 15 questions was developed in 1986. Questions from the Long Form GDS which had the highest correlation with depressive symptoms in validation studies were selected for the short version. Of the 15 items, 10 indicated the presence of depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13) indicated depression when answered negatively. Scores of 0-4 are considered normal, depending on age, education, and complaints; 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression.

The Short Form is more easily used by physically ill and mildly to moderately demented patients who have short attention spans and/or feel easily fatigued. It takes about 5 to 7 minutes to complete.

TARGET POPULATION: The GDS may be used with healthy, medically ill and mild to moderately cognitively impaired older adults. It has been extensively used in community, acute and long-term care settings.

VALIDITY AND RELIABILITY: The GDS was found to have a 92% sensitivity and a 89% specificity when evaluated against diagnostic criteria. The validity and reliability of the tool have been supported through both clinical practice and research. In a validation study comparing the Long and Short Forms of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from non-depressed adults with a high correlation (r = .84, p < .001) (Sheikh & Yesavage, 1986).

STRENGTHS AND LIMITATIONS: The GDS is not a substitute for a diagnostic interview by mental health professionals. It is a useful screening tool in the clinical setting to facilitate assessment of depression in older adults especially when baseline measurements are compared to subsequent scores. It does not assess for suicidality.

FOLLOW-UP: The presence of depression warrants prompt intervention and treatment. The GDS may be used to monitor depression over time in all clinical settings. Any positive score above 5 on the GDS Short Form should prompt an in-depth psychological assessment and evaluation for suicidality.

MORE ON THE TOPIC: Best practice information on care of older adults: www.ConsultGeriRN.org. The Stanford/VA/NIA Aging Clinical Resource Center (ACRC) website. Retrieved July 2, 2012, from http://www.stanford.edu/~yesavage/ACRC.html. Information on the

GDS. Retrieved July 2, 2012, from http://www.stanford.edu/~yesavage/GDS.html. Blazer, D.G. (2009). Depression in late life: Review and commentary. FOCUS, 7(1), 118-136. Greenberg, S.A. (2007). How to Try This: The Geriatric Depression Scale: Short Form. AJN, 107(10), 60-69. Harvath, T.A., & McKenzie, G. (2012). Depression in Older Adults. In M. Boltz, E. Capezuti, T.T. Fulmer, & D. Zwicker (Eds.), A. O’Meara (Managing Ed.), Evidence-

based geriatric nursing protocols for best practice (4th ed., pp. 135-162). NY: Springer Publishing Company, LLC. Koenig, H.G., Meador, K.G., Cohen, J.J., & Blazer, D.G. (1988). Self-rated depression scales and screening for major depression in the older hospitalized patient

with medical illness. JAGS, 36, 699-706. Sheikh, J.I., & Yesavage, J.A. (1986). Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In T.L. Brink (Ed.), Clinical

Gerontology: A Guide to Assessment and Intervention (pp. 165-173). NY: The Haworth Press, Inc. Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M.B., & Leirer, V.O. (1983). Development and validation of a geriatric depression screening

cale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format,

including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

Best Practices in Nursing Care to Older Adults

A series provided by The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

EMAIL hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE www.hartfordign.org CLINICAL NURSING WEBSITE www.ConsultGeriRN.org

general assessment series

Geriatric Depression Scale: Short Form

Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES / NO

2. Have you dropped many of your activities and interests? YES / NO

3. Do you feel that your life is empty? YES / NO

4. Do you often get bored? YES / NO

5. Are you in good spirits most of the time? YES / NO

6. Are you afraid that something bad is going to happen to you? YES / NO

7. Do you feel happy most of the time? YES / NO

8. Do you often feel helpless? YES / NO

9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO

10. Do you feel you have more problems with memory than most? YES / NO

11. Do you think it is wonderful to be alive now? YES / NO

12. Do you feel pretty worthless the way you are now? YES / NO

13. Do you feel full of energy? YES / NO

14. Do you feel that your situation is hopeless? YES / NO

15. Do you think that most people are better off than you are? YES / NO

Answers in bold indicate depression. Score 1 point for each bolded answer.

A score > 5 points is suggestive of depression.

A score ≥ 10 points is almost always indicative of depression.

A score > 5 points should warrant a follow-up comprehensive assessment.

Source: http://www.stanford.edu/~yesavage/GDS.html

This scale is in the public domain.

The Hartford Institute for Geriatric Nursing would like to acknowledge the original author of this Try This, Lenore Kurlowicz, PhD, RN, CS, FAAN, who made significant contributions to the field of geropsychiatric nursing and passed away in 2007.

Fulmer SPICES Assessment.pdf

Fulmer SPICES: An Overall Assessment Tool for Older Adults www.managedhealthcareconnect.com /article/6911

Best Practices in Nursing Care to Older Adults from The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

Issue Number 1, Revised 2007

Series Editor: Marie Boltz, MSN, APRN, BC, GNP Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP New York University College of Nursing __________________________________________________________________________________________________________

WHY: Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced by older adults include: sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. Familiarity with these commonly-occurring disorders helps the nurse prevent unnecessary iatrogenesis and promote optimal function of the aging patient. Flagging conditions for further assessment allows the nurse to implement preventative and therapeutic interventions (Fulmer, 1991; Fulmer, 1991).

BEST TOOL: Fulmer SPICES, developed by Terry Fulmer, PhD, APRN, FAAN at New York University College of Nursing, is an efficient and effective instrument for obtaining the information necessary to prevent health alterations in the older adult patient (Fulmer, 1991; Fulmer, 1991; Fulmer, 2001). SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention:

S is for Sleep Disorders P is for Problems with Eating or Feeding I is for Incontinence C is for Confusion E is for Evidence of Falls S is for Skin Breakdown

TARGET POPULATION: The problems assessed through SPICES occur commonly among the entire older adult population. Therefore, the instrument may be used for both healthy and frail older adults.

VALIDITY AND RELIABILITY: The instrument has been used extensively to assess older adults in the hospital setting, to prevent and detect the most common complications (Fulmer, 2001; Lopez, et al, 2002; Pfaff, 2002; Turner, J., et al, 2001; NICHE). Psychometric testing has not been done.

STRENGTHS AND LIMITATIONS: The SPICES acronym is easily remembered and may be used to recall the common problems of the elderly population in all clinical settings. It provides a simple system for flagging areas in need of further assessment and provides a basis for standardizing quality of care around certain parameters. SPICES is an alert system and refers to only the most frequently-occurring health problems of older adults. Through this initial screen, more complete assessments are triggered. It should not be used as a replacement for a complete nursing assessment.

Fulmer SPICES: An Overall Assessment Tool for Older Adults

Patient Name: Date:

SPICES EVIDENCE Sleep Disorders/ ______________________________________ Problems with Eating or Feeding/________________________ Incontinence/_________________________________________ Confusion/_____________________________________________ Evidence of Falls/____________________________________ Skin Breakdown/_______________________________________

Adapted from Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93. © Copyright Lippincott Williams & Wilkins, http://lww.com.


MORE ON THE TOPIC: Best practice information on care of older adults: www.GeroNurseOnline.org.

Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91-93.

Fulmer, T. (1991). Grow Your Own Experts in Hospital Elder Care. Geriatric Nursing, March/April 1991, 64-66.

Fulmer, T. (2001). The geriatric resource nurse: A model of caring for older patients. American Journal of Nursing, 102, 62.

Lopez, M., Delmore, B., Ake, J., Kim, Y., Golden, P., Bier, J., & Fulmer, T. (2002). Implementing a Geriatric Resource Nurse Model. Journal of Nursing Administration, 32(11), 577-585.

Nurses Improving the Care of the Hospitalized Elderly (NICHE) project at the Hartford Institute for Geriatric Nursing, http: //www.hartfordign.org.

Pfaff, J. (2002). The Geriatric Resource Nurse Model: A culture change. Geriatric Nursing, 23(3), 140-144.

Turner, J. T., Lee, V., Fletcher, K., Hudson, K., & Barton, D. (2001). Measuring quality of care with an inpatient elderly population: The geriatric resource nurse model. Journal of Gerontological Nursing, 27(3), 8-18.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.GeroNurseOnline.org. E-mail notification of usage to: hartford.ign@nyu.edu. A SERIES PROVIDED BY The Hartford Institute for Geriatric Nursing EMAIL: hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE: www.hartfordign.org GERONURSEONLINE WEBSITE: www.GeroNurseOnline.org


  • Fulmer SPICES: An Overall Assessment Tool for Older Adults


Date:_______________ Birthdate_________________

Patient Stress Questionnaire* Name: __________________________________________

Over the last two weeks , how often have you been bothered by any of the following problems? (please circle your answer & check the boxes that apply to you)

No t a

t a ll

Se ve

ra l

da ys

M or

e th


ha lf

th e

da ys

Ne ar


Ev er

y da


1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed, or the opposite – being so fidgety or restless that you’ve been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead, or hurting yourself in some way 0 1 2 3 Total

(10) add


1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3 Total (8)

*adapted from PhQ 9, GAD7, PC-PTSD and AUDIT 1/24/11

add columns:

Provider:__________________________________ Please also complete back side

No Yes

No Yes

No Yes

No Yes

No Yes (3)

Please circle your answer 0 1 2 3 4

How often do you have one drink containing alcohol? Never

Monthly or less

2-4 times a month

2-3 times a week

4+ times per week

How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

How often do you have four or more drinks on one occasion? Never

Less than monthly Monthly Weekly

Daily or almost daily

…found that you were not able to stop drinking once you had started? Never

Less than monthly Monthly Weekly

Daily or almost daily

…failed to do what was normally expected from you because of drinking? Never

Less than monthly Monthly Weekly

Daily or almost daily

…needed a first drink in the morning to get yourself going after heavy drinking? Never

Less than monthly Monthly Weekly

Daily or almost daily

…had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or

almost daily

…been unable to remember what happened the night before because you had been drinking? Never

Less than monthly Monthly Weekly

Daily or almost daily

0 2 4 Have you or someone else been injured as a result of your drinking? No

Yes, during the last year

Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

No Yes, during the last year


Standard serving of one drink: 12 ounces of beer or wine cooler 1.5 ounces of 80 proof liquor 5 ounces of wine 4 ounces of brandy, liqueur or aperitif

Are you currently in any physical pain?

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month , you:

These questions are about your drinking habits. We’ve listed the serving size of one drink below.

How often during the last year have you……

4. Felt numb or detached from others, activities, or your surroundings?

3. Were constantly on guard, watchful, or easily startled?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?


1. Have had nightmares about it or thought about it when you did not want to?

Drinking alcohol can affect your health. This is especially important if you take certain medications. We want to help you stay healthy and lower your risk for the problems that can be caused by drinking.

Yes, but not in the last year

Yes, but not in the last year

Mini Mental State Exam.pdf


Mini-Mental State Examination (MMSE)

Patient’s Name: Date: Instructions: Ask the questions in the order listed. Score one point for each correct response within each question or activity. Maximum

Score Patient’s

Score Questions

5 “What is the year? Season? Date? Day of the week? Month?”

5 “Where are we now: State? County? Town/city? Hospital? Floor?”


The examiner names three unrelated objects clearly and slowly, then asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible. Number of trials: ___________

5 “I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …) Stop after five answers. Alternative: “Spell WORLD backwards.” (D-L-R-O-W)

3 “Earlier I told you the names of three things. Can you tell me what those were?”

2 Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them.

1 “Repeat the phrase: ‘No ifs, ands, or buts.’”

3 “Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.)

1 “Please read this and do what it says.” (Written instruction is “Close your eyes.”)

1 “Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)


“Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.)

30 TOTAL (Adapted from Rovner & Folstein, 1987)

Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410


Instructions for administration and scoring of the MMSE Orientation (10 points): • Ask for the date. Then specifically ask for parts omitted (e.g., “Can you also tell me what season it

is?”). One point for each correct answer. • Ask in turn, “Can you tell me the name of this hospital (town, county, etc.)?” One point for each

correct answer. Registration (3 points): • Say the names of three unrelated objects clearly and slowly, allowing approximately one second for

each. After you have said all three, ask the patient to repeat them. The number of objects the patient names correctly upon the first repetition determines the score (0-3). If the patient does not repeat all three objects the first time, continue saying the names until the patient is able to repeat all three items, up to six trials. Record the number of trials it takes for the patient to learn the words. If the patient does not eventually learn all three, recall cannot be meaningfully tested.

• After completing this task, tell the patient, “Try to remember the words, as I will ask for them in a little while.”

Attention and Calculation (5 points): • Ask the patient to begin with 100 and count backward by sevens. Stop after five subtractions (93,

86, 79, 72, 65). Score the total number of correct answers. • If the patient cannot or will not perform the subtraction task, ask the patient to spell the word “world”

backwards. The score is the number of letters in correct order (e.g., dlrow=5, dlorw=3). Recall (3 points): • Ask the patient if he or she can recall the three words you previously asked him or her to

remember. Score the total number of correct answers (0-3). Language and Praxis (9 points): • Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a pencil. Score

one point for each correct naming (0-2). • Repetition: Ask the patient to repeat the sentence after you (“No ifs, ands, or buts.”). Allow only one

trial. Score 0 or 1. • 3-Stage Command: Give the patient a piece of blank paper and say, “Take this paper in your right

hand, fold it in half, and put it on the floor.” Score one point for each part of the command correctly executed.

• Reading: On a blank piece of paper print the sentence, “Close your eyes,” in letters large enough for the patient to see clearly. Ask the patient to read the sentence and do what it says. Score one point only if the patient actually closes his or her eyes. This is not a test of memory, so you may prompt the patient to “do what it says” after the patient reads the sentence.

• Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence; it should be written spontaneously. The sentence must contain a subject and a verb and make sense. Correct grammar and punctuation are not necessary.

• Copying: Show the patient the picture of two intersecting pentagons and ask the patient to copy the figure exactly as it is. All ten angles must be present and two must intersect to score one point. Ignore tremor and rotation.

(Folstein, Folstein & McHugh, 1975)

Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410


Interpretation of the MMSE

Method Score Interpretation

Single Cutoff <24 Abnormal

Range <21


Increased odds of dementia

Decreased odds of dementia





Abnormal for 8th grade education

Abnormal for high school education

Abnormal for college education





No cognitive impairment

Mild cognitive impairment

Severe cognitive impairment Sources: • Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state

examination by age and educational level. JAMA. 1993;269(18):2386-2391. • Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state

of patients for the clinician. J Psychiatr Res. 1975;12:189-198. • Rovner BW, Folstein MF. Mini-mental state exam in clinical practice. Hosp Pract. 1987;22(1A):99, 103, 106,

110. • Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc.


Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410

Hall, Hall, and Chapman Article.pdf


Clinical Geriatrics Volume 11, Number 10 October 2003 WWW.MMHC.COM

Identifying Geriatric Patients at Risk for Suicide and Depression Ryan C. W. Hall, MD, Richard C. W. Hall, MD, and Marcia J. Chapman


Dr. Ryan C. W. Hall is a Medical In- tern, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD; Dr. Richard C. W. Hall is Courtesy Clinical Professor of Psy- chiatry at University of Florida, Gainesville; and Ms. Chapman is a Re- search Assistant to Dr. Richard Hall.

S uicide represents a major cause of death in the United States, accounting for 31,000 deaths per year and an overall rate of 11.2/100,000 persons/year.1-3 Few realize that there is a bimodal age distribution to the suicide curve.4 The elderly and adoles- cents/young adults are the groups at greatest risk.3,5 About one-

fifth of all successful suicides are committed by persons over age 65,6 with men over the age of 69 having the highest rate of completed suicide.7 In 1988, the rate of completed suicide for individuals age 80-84 was 26.5/100,000 per- sons/year, compared to a rate of 12.4/100,000 persons/year for the general population.8 An interesting trend, which has occurred since the early 1990s when managed care became prevalent, is an increase in number of suicides.3

Recent studies show completed suicide rates of between 40 and 60/100,000 persons/year in men over the age of 80.3,4,9,10

Elderly patients, particularly men, are more likely to successfully com- mit suicide when an attempt is made, because they are less likely to “cry for help,” have access to potentially harmful medications, and may use more lethal means (gunshots or hangings).3,11 In addition, they are less physi- cally resilient due to comorbid medical conditions.3,5,8A recent paper notes that more than 75% of the elderly who were successful in committing sui- cide had been recently diagnosed with a first episode of major depression, which was judged to be only “moderately severe” by their physicians.8 Ap- proximately 75% had seen their primary care physician within one month of their completed suicide.12

Suicide risk factors in elderly populations include presence of mental and/or emotional disorders and moderate to heavy alcohol consumption.3,5,6,12-14 These two factors are consistent with general population studies, which indicate that more than 90% of all people who commit suicide have a diagnosable psychi- atric disorder at time of death.3,5,8 Other identifiable risk factors in the elder- ly include quality-of-life issues, separation, divorce, recent death of a spouse, high comorbid medical disease rates, and being male and Caucasian. Comorbid


Clinical Geriatrics Volume 11, Number 10 October 2003 WWW.MMHC.COM

S U I C I D E / D E P R E S S I O N

medical conditions, which have low survival rates and are as- sociated with chronic pain (eg, cancer), are another impor- tant risk factor.3,5,8,12,13,15


It is important for physicians to be able to detect the pa- tient who is at risk for committing suicide. The best way to accomplish this is through the use of a thorough med- ical and psychiatric history (Table I). The information gained from the psychiatric history is helpful for defining a patient’s “imminent risk” for suicide. Patients are at im- minent risk if it is believed they are likely to commit sui- cide within the next 48 hours. Patients are at “short-term risk” if they are likely to commit suicide within days to weeks and at “long-term risk” if they have sufficient risk factors associated with an eventual death by suicide.5

Hirschfeld and Russell5 note that a patient should be con- sidered at imminent risk (within 48 hours) for commit- ting suicide if the patient expresses the intent to die, has a cogent plan, and has a lethal means available to him (eg, prescription medications for overdose, a gun). Secondary factors that further increase risk of an imminent suicide are expressions of despair, hopelessness, extreme pessimism about the future, high levels of anxiety, and psychotic thought processes, particularly command hallucinations di-

recting suicide. Any patient deemed at imminent risk for suicide should be hospitalized immediately for treatment.5

A Washington state study by Florio et al6 looking at risk factors in a community of seniors elicited a similar list of warning signs. They found that the historical items that differentiated the suicidal from the nonsuicidal elderly were age (suicidal elders were younger), separation or divorce, and previous history of suicidal behavior. Additional risk factors included medical illness, family conflict, and loss of a relationship, particularly with a long-term spouse. An interesting unexpected finding was that patients who com- pleted suicide were more likely to be treated by family physi- cians than by internists or psychiatrists. Most of the pa- tients who committed suicide had seen their primary care physician within one month prior to their suicide.12

Older adults who commit suicide are likely to suffer from a long-term (months to years) persistent depression and/or anxiety disorder. They are less likely to commit suicide due to acute psychological stress than are younger patients.12 Doc- tors need to inquire whether their elderly patients are under chronic stress, particularly loss of independence or fear of fi- nancial ruin, which are the two chronic stress risk factors most frequently associated with geriatric suicide.12

When a physician is concerned that a patient may be suicidal, he/she should speak with the patient’s immediate

family, because 60% of patients who com- mit suicide have dis- cussed having suicidal ideations with their spouse within a year of their deaths, whereas only 18% of successful geriatric suicides dis- cussed their intentions with a trained profes- sional beforehand.12

Important Questions to Ask in Psychiatric History

• Is life worth living? Do you get enjoyment out of life? • Do you think of ending it, committing suicide, or just not waking up? • Have you ever attempted suicide in the past? • Have you ever sought psychiatric treatment? Inpatient or outpatient? • What psychiatric medication do you currently take? What have you taken in the past?

(Source of medications for possible overdose) Which medicine has helped you the most? • Any family history of mental illness or suicide? • Are there things happening to you that are particularly stressful or cause you to worry

a lot? How long have they been going on? • Do you have an active suicide plan? How would you end your life? • How close are you to carrying out this plan? Are you experiencing command halluci-

nations? Do you see or hear things others do not? Do you hear voices talking to you or telling you to do things? Do they tell you to kill or injure yourself or someone else?





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There is a medical myth that asking a patient about suicide will en- courage the act. Physi- cians are often reluctant to simply ask, “Are you thinking of suicide, just not waking up, or harming yourself?” Studies, however, show that addressing the pos- sibility of suicide with depressed or distraught patients reduces their risk of suicide.5


There is a strong correlation between alcohol use and abuse in the elderly and suicide. In a California study of 11,888 retirement community residents, risk of suicide was increased 3.5 times for those who consumed three or more drinks a day.14 The same study found those who drank less than two drinks a day had a lower risk of both suicide and accidental death.


Of all patients with untreat- ed major depression, 15% will eventually commit sui- cide.3,5,12,16,17 In fact, 80% of patients suffering from a major depression experience suicidal ideation.12 Many physicians miss or dismiss the telltale signs of depression in the elderly as normal complaints associated with aging. This lack of recogni- tion is compounded by the

fact that depression often presents differently in the elderly and can be confused with other ex- isting medical condi- tions.8,18 In the general population, the symp- toms of depression are defined by the mnemon- ic SIGECAPS (Table II).8 Other associated signs of depression in-

clude psychotic symptoms, mood congruent delusions, and hallucinations.

Elderly persons suffering from depression often present with fewer mood-related symptoms and instead complain of fatigue, trouble concentrating, diminished memory, and lack of initiative.18,19 This makes establishing the diagnosis and initiating treatment difficult given that the DSM-IV requires a critical number of different symptoms (traditionally five out of nine) to make the diagnosis of major depressive disorder. Gallo et al,20 in a 13-year study of men over 50, found that

those who reported hope- lessness, worthlessness, or thoughts of impending death or suicide, and had at least two other symptoms of de- pression were at increased risk for functional disability, im- pairment in activities of dai- ly living, cognitive impair- ment, psychological distress, and death. The symptoms that were usually denied were sadness and/or loss of inter- est or pleasure in activities formerly enjoyed. This type

Mnemonic SIGECAPS for Depression in the General Population8

S = changes in Sleep I = lack of Interest or anhedonia G = feelings of excessive or inappropriate Guilt E = decreased Energy C = decreased Concentration (unable to follow TV

show or newspaper article) A = decreased or increased Appetite P = decreased Psychomotor activity (“I feel like I

am walking with lead clothes”) S = presence of Suicidal ideation





Presentation of Masked Depression in the Elderly

1. Weight loss 2. Focus on multiple somatic complaints 3. Unexplained somatic complaints 4. Minimizing or denying presence of

mood-related symptoms 5. Weakness 6. Lassitude 7. Hopelessness 8. Helplessness 9. Anxiety, worry, rumination 10. Memory complaints with or without

objective signs of cognitive impairment 11. Loss of feelings of pleasure (anhedonia) 12. Slowed movement 13. Irritability 14. Lack of interest in personal care






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of presentation is referred to as “nondysphoric depression” or “masked depression” (Table III).19 Gallo, in another study, re- ported that African-American men over the age of 60 who suf- fered with depression had decreased reporting of mood changes or dysphoria when compared to Caucasian men. Elderly African-American men were also more likely to ruminate about death when depressed than were Caucasians.21

The elderly are more likely to experience weight loss dur- ing a depressive episode than is the general population.8 This weight loss is often mistakenly attributed as a normal part of aging (ie, loss of taste receptors), other medical condi- tions such as cancer, or the existence of social problems such as inability to obtain food.

Other typical presenting features of depression in the el- derly include the patient being focused on multiple vague somatic complaints, social withdrawal, a decline in activi- ties of daily living, increasing irritability, and minimization or denial of any change in mood.8,13,17-19

The Epidemiologic Catchment Area (ECA) study showed a one-month prevalence of major depression in the elderly of 0.7% compared to 2.2% for all adults.8,22,23 Simi- lar results were reported by the Epidemiologic Studies of the Elderly.23 There is much debate about the accuracy of these numbers and of possible biases that may have skewed these results. Explanations for the decreased prevalence of depres- sion in the elderly include nonrecognition of early depressive symptoms (you just feel this way when you get old), under- diagnosis of depression due to the atypical symptoms displayed by the elderly, and a cohort effect of the studies.22-24

Barry et al25 reported rates higher than the ECA of 5.7% of men and 10.6% of women over age 60 meeting diagnostic criteria for a current depression. The ECA study did report that 2% of the elderly population suffered from dysthymia and that up to 20% of community-dwelling elderly had sig- nificant subsyndromal depressive symptoms. Others have reported a rate of depression of between 7% and 12% in residential treatment settings.8 For patients who are de-

mented and in a residential treatment facility, the rate climbs to 20%.8 In the general population the ratio of women to men suffering from a mood disorder is approximately 2:1, but the ratio for people in their 90s increases to 1:1.8 This increased incidence of depression with advancing years in men has been attributed to their loss of physical and cog- nitive abilities, which diminish their self-esteem and self- image more than similar changes in aging women.26

The mortality from comorbid medical conditions is in- creased in the elderly suffering from depression.18 Moore and Bona12 found that elderly nursing home patients with major depression and two additional comorbid medical con- ditions had a 59% higher mortality rate than nondepressed age-matched controls with two or more similar medical con- ditions. Many of these depressed patients had lost their will to live, gave up on medical treatment, and became med- ically noncompliant.

The Geriatric Depression Scale (GDS) is a 30-question, self-reporting written scale used as a specific screening tool for depression in the elderly.27 Another effective screening tool is the Beck Depression Inventory.27 Both of these scales identify 90% of seniors with depression. It should be not- ed that their sensitivity might be diminished in patients with underlying dementia and in African Americans.23 Patients who should be specifically tested for depression with these scales include elderly men with a positive personal or fam- ily history of depression or suicide, those with multiple med- ical problems, alcoholism, and those experiencing acute psy- chosocial stressors (eg, living alone or in nursing homes).23,25

One of the criticisms of the GDS is that its length makes it difficult to use for patients with depression who have trou- ble concentrating, and that the time available for adminis- tration may be too limited in an outpatient or emergency de- partment setting. When these factors apply, the Zung Self-Rating Depression Scale or the modified Koenig Scale (an 11-question yes/no test [Table IV]) may be used.28 The Koenig Scale was originally developed for use in medically


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more abnormal changes, particularly subcortical encephalo- malacia and deep white matter changes, than do those of age- matched controls.8 Other central nervous system changes more frequently seen in late-onset depression include cortical at- rophy, enlargement of the lateral ventricles, and lesions of the pons and the subcortical gray nuclei.8 Whenever a late-on- set depression is found (Table V), it is important to rule out or identify reversible/medical causes that can be treated, such as medication effects or medical/neurologic diseases known to produce this condition.8,29-32


Fortunately, both early- and late-onset depressions respond well to treatment.8 Menza and Liberatore8 found that 69% of elderly patients with depression responded well to ini- tial treatment, whereas 57% of the remaining refractory pa- tients had improved at one year.8 Currently, the drugs of choice for treating depression in the elderly are the selec- tive serotonin reuptake inhibitors (SSRIs).8,18,23 These med- ications have a low incidence of side effects, few significant adverse cardiac effects, and are generally effective in treat- ing depression in the elderly.8

ill patients in Veterans Administration hospi- tals. Validation studies employing male and fe- male geriatric inpatients using a modified Koenig Scale (oral presentation with modified pronouns) found the test to have a sensitivity of 100% and a specificity of 85% for detect- ing depression using DSM-III criteria, when cutoff scores of four positive responses were used.28 Recently, Meldon et al28 used the mod- ified Koenig Scale in the emergency room and found that it detected depression in 27% of geriatric patients.


The usual age of first onset of major depression is in the third decade of life.8 If a geriatric patient has a history of multiple depressive episodes dating back to his young adult- hood, the current bout is a recurrence of a lifelong disease state. In these cases, each bout is likely to be more severe than the previous one and carry with it a higher likelihood of suicide and recurrence. Patients are also at a significantly higher risk for suicide, 224 per 100,000 person years, if they have a past history of psychiatric hospitalization.3,5,12

If the first episode of depression occurs after the age of 65, it is referred to as a late-onset or geriatric-onset depres- sion.8 Although the DSM-IV does not have a separate cate- gory for this type of depression, it is well described in the lit- erature.8 Late-onset depressions often present differently than depressive disorders that occur earlier in a patient’s life. Psy- chotic and delusional symptoms occur in 45% of cases of late-onset depression.8 Psychosis is a powerful risk factor in determining if a patient is at imminent risk for committing suicide.5 Patients suffering from late-onset depression are al- so less likely to have a positive family history of depression and are more likely to present with masked depressions.8 Neu- roimaging studies of patients with late-onset depressions show

The Modified Koenig Depression Scale28

1. Do you often get bored? Yes No 2. Do you often get restless or fidgety? Yes No 3. Do you feel in good spirits? Yes No 4. Do you feel you have more problems with

memory than most? Yes No 5. Can you concentrate easily when

reading the papers? Yes No 6. Do you prefer to avoid social gatherings? Yes No 7. Do you often feel downhearted and blue? Yes No 8. Do you feel happy most of the time? Yes No 9. Do you often feel helpless? Yes No 10. Do you feel worthless and ashamed

about yourself? Yes No 11. Do you often wish you were dead? Yes No

Positive responses are boldfaced. Geriatric Depression likely if 4 or more are positive.






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Although tricyclic antide- pressants are equally effica- cious, they should not be used as a first-line treatment in the elderly due to their significant side-effect profiles. Many of the tricyclics have high affin- ity for histaminic, alpha1, and cholinergic receptors, which account for their side effects of sedation, orthostatic hy- potension, and their anti- cholinergic side effects such as urinary retention, constipa- tion, tachycardia, dry mouth, and memory impairment.8 All tricyclic antidepressants slow heart conduction to some de- gree, producing at least some PR and QT prolongation. The QT prolongation is the more serious of these effects because it can lead to idioventricular arrhythmias and other fatal heart arrhythmias if the drug concentration becomes too high.8 Pa- tients with ventricular arrhythmias and/or ischemic heart dis- ease have been shown to be at increased risk for developing these arrhythmias and sudden death, even with therapeutic blood levels of tricyclics.8 Another major disadvantage of the tricyclics is their lethality on overdose. The drugs most com- monly used to commit suicide, in the general population, are the neuroleptics (used in 74.3% of overdoses) and antide- pressants (used in 77.4% of overdoses).33

For patients who are acutely suicidal, those with unstable medical conditions, and those with severe and/or refractory depression, electroconvulsive therapy (ECT) remains an im- portant option. ECT should be considered for patients who are acutely suicidal and where immediate mood changes are necessary.34 It should also be considered for patients having major depressions withpsychotic features, for those who can- not tolerate or do nothave a response to antidepressant med- ications, and for patients who have medical conditions that

preclude their use (eg, severe liver disease).5 It must be re- membered that it can take the SSRIs 6-8 weeks to become fully effective in younger pa- tients and up to 12 weeks in geriatric patients.18 ECT is safe for seniors but should not be used where relative con- traindications occur (ie, in- creased intracranial pressure, intracerebral hemorrhage, pheochromocytoma, space- occupying intracerebral le-

sions, vascular aneurysms or malformations) unless there is no better alternative.35

Although any physician can write a prescription for an SSRI, patients who receive early psychiatric consultation for their depression have been shown to do better. This is espe- cially true for patients with suicidal tendencies and those hav- ing psychotic, delusional, and stuporous depressions. Bene- fits from early consultation include a higher rate of recovery, quicker onset of recovery, reduced suicide rates, and a lower rate of relapse or recurrence.36 Even with their high rate of overall mental illness, particularly of depression and suicide, the elderly are underutilizers of mental health services. It is estimated that only 2% of the elderly see a private psychia- trist and only 6% receive any services from community men- tal health programs.37 The reasons for this underutilization include the stronger stigma of mental illness seen in older gen- erations, decreased mobility with a decreased ability to phys- ically reach appointments, and lack of knowledge of geriatric directed programs.37 It is important for primary care providers to help their patients access these services. Options that can be looked into for the elderly include crisis inter- vention centers, case management, counseling, group ther- apy, case consultation, day treatment or partial hospitaliza-

Medical Workup for Late-Onset Depression8,30

Review medication interactions CBC Serum electrolytes Glucose Renal function tests Liver function tests Calcium Serum B12 Folate Syphilis serology (RPR) Thyroid function tests (including TSH) Urinalysis

CBC = complete blood count; TSH = thyroid stimulating hormone; RPR = rapid plasma rea- gin (re: syphilis test).





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tion, geriatric support groups, and peer counseling.37 In gen- eral, funding should not be an issue because most of these programs receive funds from Medicare, Medicaid, private in- surance, local public revenues, the Older Americans Act, and/or Social Services Block Grants.37

An interesting study done by Gallo,38 looking at knowl- edge and attitudes about depression by internists and fami- ly practitioners, found that both groups had roughly equiv- alent knowledge about depression. Both groups also expressed considerable uncertainty in their knowledge of psychother- apy and in their evaluation of the effectiveness of strategies for prevention of recurrent depression. Family practitioners, however, rated themselves as being more skilled in manag- ing depression than did internists. Family practitioners were more likely to provide SSRIs and to counsel patients with moderate to severe depression. What is noteworthy is that they were less likely to refer patients to competent mental health specialists than internists and, as was noted earlier, their patients were more likely to commit suicide.12


Data from the state of Oregon, where physician-assisted sui- cide has been legalized, provides some interesting results. The results are presented and commented on to provide a more complete picture when identifying elderly or terminally ill patients who might commit suicide. It is beyond the scope of this article to address the ethical issues involved with eu- thanasia. A recent New England Journal of Medicine article reported on a retrospective study in which nurses and social workers commented on the reasons patients choose eu- thanasia.39 Previous research has suggested that up to 20% of patients seeking to enter the Oregon state program were depressed and not allowed to enroll.39 The state does man- date that to be considered for the program the patient needs to be free from depression. This, in theory, provides a sam- ple of the population who wishes to die without being in-

fluenced by depression. The key factors listed in the study as reasons why individuals wanted to end their lives included: to control the circumstances of their death, to maintain dig- nity, a desire to die at home, being ready to die, the belief that continuing to live was pointless, an inability to engage in pleasurable activities, and a poor quality of life. The arti- cle did point out that the last three reasons could be mani- festations of “occult depression.”39

The mean age of the patients in the Oregon program was 63.6 ± 11.5 years. Of these patients, 83% had cancer, 12% had cardiopulmonary disease, and 9% had neurologic diseases (some patients reported to have more than one dis- ease). Of these patients, 43% resided in rural areas, 34% in towns, and 23% in cities. Depression and other psy- chiatric disorders, lack of social support, and concern about being a financial drain were deemed unimportant factors by evaluating nurses. The nurses reported that 77% of those who listed loss of control as an important reason for want- ing euthanasia seemed to be “more fearful” about this is- sue than were other hospice patients, but only 8% were list- ed as less fearful. Whereas 62% were more concerned about loss of independence, only 9% were less concerned about loss of independence than other hospice patients. Pain re- lief was rated as an important factor in the request for eu- thanasia, but it was not the most important. Fatigue and dyspnea were reported as only moderately important. It is interesting to note that patients in the euthanasia program were concerned about being a burden to their families but, as observed by nurses and social workers, the families seemed less burdened than other hospice families.

The Oregon data suggest that loss of physical function and issues of declining health can lead patients without de- pression to contemplate suicide. The important factors iden- tified were illnesses that caused continuous pain, patient-per- ceived limited quality of life, and illnesses that interfered with a patient’s autonomy and dignity. These patients’ perceptions of their condition and degree of incapacitation were usual-


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ly more severe than that of their family, caregivers, or other hospice patients. These patients saw themselves as a burden, were apprehensive, and feared loss of control over their lives.


The geriatric patient most likely to commit suicide is a wid- owed or divorced white man suffering from a masked de- pression with high anxiety, who has been ill for an extended time (months to years), is isolated or living in a nursing home, has comorbid medical or neurologic illness, and has a height- ened fear of losing control and loss of dignity. He consumes three or more alcoholic drinks a day, has lost hope, and views life as pointless. Older women have similar risk factors. Ef- fective treatment for these individuals does exist; the earlier the intervention, the better the outcome.

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man MF. Advanced report of final mortality statistics, 1994. Mon Vital Stat Rep 1996;45(suppl 1).

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4. Snowdon J. Suicide rates and methods in different age groups: Australian data and perceptions. Int J Geriatr Psychiatry 1997;12:253–258.

5. Hirschfeld RMA, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med 1997;337:910-915.

6. Florio ER, Hendryx MS, Jensen JE, et al. A comparison of suicidal and nonsuicidal elders referred to a community mental health center program. Suicide Life Threat Behav 1997;27(2):182-193.

7. National Center for Health Statistics. Death rates for 72 selected causes, by 5-year age groups, race and sex: United States, 1994. Hyattsville, MD: Public Health Service, 1996.

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11. NIH Consensus Conference. Diagnosis and treatment of depression in late life. JAMA 1992;268:1018-1024.

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13. Grabbe L, Demi A, Camann MA, et al. The health status of elderly persons in the last year of life: A comparison of deaths by suicide, injury, and nat- ural causes. Am J Pub Health 1997;87:434-437.

14. Adams WL. Alcohol and the health of aging men. Med Clin North Am 1999;83(5):1195-1211.

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17. Alexopoulos GS. Mood disorders. In: Kaplan HI, Saddock BJ, eds. Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, MD: Williams & Wilkins, 1995;(2):2566–2568.

18. Lantz MS. Depression in the elderly: Recognition and treatment. Clinical Geriatrics 2002;10(10):18-24.

19. Gallo JJ, Rabins PV. Depression without sadness: Alternative presentations of depression in late life. Am Fam Physician 1999;60(3):820-826.

20. Gallo JJ, Rabins PV, Lyketsos CJ, et al. Depression without sadness: Func- tional outcomes of nondysphoric depression in later life. J Am Geriatr Soc 1997;45:570-578.

21. Gallo JJ. Depressive symptoms of whites and African Americans aged 60 years and older. J Gerontol B Psychol Sci Soc Sci 1998;53(5):277-286.

22. Heithoff K. Does the ECA underestimate the prevalence of late life depres- sion? J Am Geriatr Soc 1995;43(2):2-6.

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24. Shulman KI, Herrmann N. The nature and management of mania in old age. Psychiatr Clin North Am 1999;22(3):649-665.

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28. Meldon SW, Emerman CL, Schubert DS, et al. Depression in geriatric ED pa- tients: Prevalence and recognition. Ann Emerg Med 1997;30(2):141-145.

29. McGann PE. Geriatric assessment for the rheumatologist. Rheum Dis Clin North Am 2000;26(3):415-432.

30. Hall RCW. Depression. In: Hall RCW, ed. Psychiatric Presentations of Med- ical Illness: Somatopsychic Disorders. New York: Spectrum;1980:37-63.

31. Hall RCW, Levenson AJ, LeCann AF. Evaluation and assessment of non- functional psychiatric illness in the elderly. In: Levenson AJ, Hall RCW, eds. Neuropsychiatric Manifestations of Physical Disease in the Elderly. New York: Raven Press;1981:133-149.

32. Hall RCW, Beresford TP, Blow FC. Depression and medical illness: An overview. In: Cameron OG, ed. Presentations of Depression – Depressive Symptoms in Medical and Other Psychiatric Disorders. New York: John Wiley;1987:401-414.

33. Ohberg A, Vuori E, Ojanperä I, et al. Alcohol and drugs in suicides. Br J Psychiatry 1996;169:75-80.

34. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life: Consensus statement update. JAMA 1997;278(14):1186-1190.

35. Loosen PT, Beyer JL, Sells SR, et al. Mood disorders. In: Erbert MH, Loosen PT, Nurcombe B, eds. Current Diagnosis and Treatment in Psychiatry. New York: Lange Medical Books/McGraw-Hill;2000:304-305.

36. Goldstein MZ. Depression and anxiety in older women. Prim Care 2002;29(1):69-80.

37. Anetzberger GJ. Community resources to promote successful aging. Clin Geriatr Med 2002;18(3):611-625.

38. Gallo JJ. Do family physicians and internists differ in knowledge, attitudes, and self-reported approaches for depression? Int J Psychiatry Med 2002;32(1):1-20.

39. Ganzini L, Harvath TA, Jackson A, et al: Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. N Engl J Med 2002;347(8):582-588.

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