Assessment and Treatment of Late-Life Depression

Functional Assessment

The diagnosis of LLD requires that symptoms cause significant distress or interfere with functioning. A functional assessment is especially important in the evaluation of the older adult in that it allows clinicians to determine an individual’s ability to live independently and attend to daily needs. Basic activities of daily living (ADLs) include bathing, dressing, grooming, toileting, and self-transferring. Instrumental activities of daily living (IADLs) include more complex daily activities such as preparing meals, administering medications, driving, managing finances, and using simple electronics such as the telephone or remote control [26]. Impairment in IADLs is associated with increased depression severity. Conversely, the severity of depressive symptoms along with associated cognitive impairment predicts IADL impairment [37]. The Philadelphia Multilevel Assessment Instrument is a tool that can aid in the assessment of ADLs and IADLs and has been utilized in studies examining disability in depressed elderly patients [37,38]. Other available scales to quantify functional status include OARS Physical Activities of Daily Living, OARS Instrumental Activities of Daily Living Scale, and Direct Assessment of Functional Status Scale [26].

Suicide Assessment

Assessment for suicidality is an integral part of all psychiatric evaluations and is especially important in the evaluation of the depressed older adult. According to the Centers for Disease Control and Prevention, the suicide rate for individuals age 65 and older is 16.6 per 100,000, a figure that is comparable to that for individuals 18–64 years of age [39]. Non-Hispanic Caucasian males age 85 and older have the highest rate of completed suicide (56.5 per 100,000), underscoring the importance of a thorough suicide assessment [39]. Suicidality can range from passive thoughts of death and wishing that one were not alive, to active thoughts of self-harm with plan and intent. A Canadian study found 2% of community-dwelling adults age 55 and older had suicidal thoughts over a 12-month period and, of these, 28% had major depression [40]. A suicide assessment begins with inquiring about the presence of suicidal thoughts, plans, and intent. The 3 most frequently used methods of completed suicide in the elderly are firearms (28%), hanging (24%) and poisoning (21%) [41]. Access to weapons or other lethal means of self-harm such has hoarding of medications should be ascertained.

A complete suicide assessment requires attention to suicide risk factors, protective factors, and warning signs of impending suicide. Risk factors for suicide in the older adult include mood disorders, chronic medical illnesses and associated functional impairment, chronic pain, and psychosocial factors such as social isolation [42]. Mood disorders are present in 54% to 87% of cases of completed suicide, with major depression being the most common [42]. Chronic medical illness and pain can result in functional impairment leading to feelings of excessive guilt or being a burden to loved ones. Protective factors such as social connectedness, spirituality, religious beliefs, and cultural attitudes against suicide may serve as buffers against these risk factors [43]. Warning signs of impending suicide may indicate preparations for suicide and include feelings of hopelessness or lack of purpose, feeling trapped, talking about death, threatening suicide, agitation, social withdrawal, increased substance use and reckless behavior. Warning signs should prompt action to ensure the safety of the individual [44,45].