Depression, Anxiety and other Mental Health Concerns: Risk Factors for Elder Abuse and Neglect

A Supplement to the CANE Annotated Bibliography of October 2000

The impact of mental illness upon older adults has been recognized nationally and internationally as a significant area of societal concern. At the first National Policy Summit on Elder Abuse, held in Washington, D.C., in December, 2001, numerous mental health issues of older individuals were considered a priority for future resource development. In 2000, the Task Force on Destigmatization was established by the Mental Health Program of the World Health Organization/European Regional Office (WHO/EURO) to address this problem in Europe. Research has demonstrated that depression, anxiety and other mental health concerns can lead to an increase in dependence upon others for assistance with daily living, and increased reliance upon the health care system. Such conditions may exacerbate self-neglecting tendencies, and may increase the older individual's vulnerability to abuse, neglect and exploitation by others. When caregivers, paid or unpaid, suffer from poor mental health, they may demonstrate poor judgment, become neglectful and even abusive of their care recipients. Furthermore, some disorders, such as depression, remain significantly under-diagnosed by health care professionals. Several studies suggest that when it is observed by physicians, older patients are not as likely to be referred for specialized services as younger patients. Untreated mental illness in the elderly has been linked to suicidal and suicidal-homicidal behaviors, inadequate care, poor quality of life, and appears to complicate recovery from other medical conditions. Barriers to mental health, medical and social services arise when impaired elders and / or their caregivers are unwilling or unable to seek available resources. A times, they face ageism and other forms of discrimination when they attempt to access services. Service gaps are apparent, particularly when attempting to find resources for elders who are dually diagnosed, who demonstrate violent behaviors due to dementia or other organic conditions, or who have chronic problems versus acute conditions warranting emergency services.

The following references highlight many of the complexities that become evident when elders experience mental illness, directly or indirectly.

Most of these reference materials may be obtained through your local university and community libraries or interlibrary loan services. Some must be ordered directly through the publisher or production company. When available, contact and pricing information is included with the abstract. Increasingly, many resources are available online, and the web addresses are also included.* If you have difficulty obtaining any of these materials, please contact the CANE office for assistance. CANE is a service of the National Center on Elder Abuse (NCEA) which is supported by a grant from the Administration on Aging.

(*Like the mysterious staircases at Hogwart's Academy, web addresses may change without notice. If an address provided is no longer accurate, we recommend using a generic search engine, such as Google, to find a current link. If you cannot locate the online publication, contact the CANE offices for assistance.)

2004

P5582-25
American Psychological Association (APA)
Guidelines for Psychological Practice with Older Adults
American Psychologist; Vol. 59 (4), 236-260; May-June 2004.
Journal article (scholarship)
Due to shifting demographics, the need for psychological services for older Americans has increased significantly. Sixty-nine per cent of psychologists recently surveyed throughout the country indicated that while they provided therapy for older clients, only 30 per cent had any graduate coursework in gerontological issues, and less than 20 per cent had any supervised internship in this area. Seventy per cent of the respondents indicated that they wanted training in geropsychology. This paper publishes the guidelines developed by the American Psychological Association (APA) for clinicians treating older adults. It is designed to allow practitioners to evaluate their qualifications to assist senior clients. The 20 guidelines are categorized into these topics: attitudes; general knowledge about adult development, aging and older adults; clinical issues; assessment; intervention, consultation, and other provisions; and education. Ageist stereotypes and counter transference that interfere with clinical objectivity are addressed, along with the need to understand the impact of collective social and psychological influences present during the client's lifetime. Equally important is the need for clinicians to stay informed about health-related aspects of aging, including physical, psychological, cognitive and behavioral changes that may typically accompany the aging process versus those that are indicators of illness. Pharmacological issues area also described. A great deal of attention is given to the special ethical and legal issues that often accompany the treatment of older clients, such as autonomy, competency, and confidentiality.


P5585-2
Barclay, L.
Primary Care Intervention Reduces Suicidal Ideation in Older Patients with Depression
Medscape Medical News; March 2, 2004.
Online article
This brief online medical update summarizes recent findings on the Prevention of Suicide in Primary Care Elderly (PROSPECT) trial (first published in the Journal of the American Medical Association/JAMA, March, 2004). In addition to a first line trial of a selective serotonin reuptake inhibitor (citalopram or Celexa), patients either received the "usual care" or were referred to a depression care manager, a master's level clinician, for interpersonal counseling. Results indicate that for those patients referred to the depression care manager, the rate of suicidal ideation decreased from 29.5 per cent to 16.4 pent. In the control group, the decrease was only 3 per cent (from 20.1 per cent to 17.1 per cent). At eight months, resolution had occurred in 70.7 per cent of the intervention group and in 43.9 per cent of the usual care group. (Note: This article is available online only at http://www.medscape.com/viewarticle/470842 .
A no fee registration is required.)

P5601-8
Boyle, V. et al.
Recognition and Management of Depression in Skilled-Nursing and Long-Term Care Settings - Evolving Targets for Quality Improvement
American Journal of Geriatric Psychiatry; Vol. 12 (3), 288-295; May-June 2004.
Journal article (research)
This research evaluates the effectiveness of Michigan's Quality Improvement Organization (MPRO) in the recognition and management of depression among nursing home residents. The Minimum Data Sets (MDS) and medical records of 818 residents from 14 sites involved in the MPRO project were analyzed for evidence of depression, regardless of diagnosis. Three-hundred and thirteen had depressive symptoms by day 14 of their admission, and 68 per cent of this group had been admitted with a diagnosis of depression. Ninety-one per cent of those admitted with a depression diagnosis were already receiving treatment (medication or therapy). Only 34 per cent of the 53 residents who were being treated for depression after a 60 day stay exhibited improvement. Of those who did not show improvement, only 41 per cent had had a change in medication, adjustment of dosage, augmentation, and documented evidence of reassessment. While detection of depression appears to have improved, the management and monitoring of the condition continues to require attention. Researchers recommend supplementing the administration of the MDS with the Geriatric Depression Scale (GDS).

P5503-7
Brown, L., Bongar, B. & Cleary, K.
A Profile of Psychologists' Views of Critical Risk Factors for Completed Suicide in Older Adults
Professional Psychology: Research and Practice; Vol. 35 (1), 90-96; 2004.
Journal article (research)
This article presents the results of a survey of psychologists regarding their perceptions of risk factors for suicide among their older clients. Complicating the issue of suicidal risk is the presence of indirect self-destructive behaviors (ISDBs), which include noncompliance with medical treatment, refusal of food and liquids, and risk-taking behaviors. A random sample of the American Psychological Association yielded 321 completed surveys (representing a 47 per cent usable response rate) rating 36 risk factors associated with suicide in older adults as either critical, moderate or low. Seventeen of the risk factors were rated as the most critical, including history of suicide attempts, severe hopelessness, seriousness of previous suicide attempts, and acute suicidal ideation. Eighteen factors were rated as moderate and one (scratching excessively) was rated as low. Consensus was achieved for 31 risk factors. The need for direct and specific assessment regarding suicidal ideation and the presence of severe hopelessness are among the clinical recommendations generated by this research.

P5586-11
Bruce, M. et al.
Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients - A Randomized Controlled Trial
JAMA / Journal of the American Medical Association; Vol. 291 (9), 1081-1091; March 3 2004.
Journal article (research)
Noting that older adults who commit suicide are likely to have seen their primary care physician within months of their deaths, the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study examines the impact of primary care based interventions designed to reduce suicide risk factors in elders, specifically depressive symptoms and suicidal ideation. In this randomized controlled trial, elders were screened for depression in 20 primary care settings throughout the New York city, Philadelphia, and Pittsburgh areas. The final sample included 598 participants who received either the intervention (which was first line treatment with citalopram and, for those declining medication, interpersonal psychotherapy with a depression care manager) or the usual care. Outcome measurements included assessment for suicidal ideation and depression severity at baseline and then at four, eight and twelve month intervals. Despite random assignment and equivalent rates of depression at baseline, the intervention group had a higher suicidal ideation rate (29.5 per cent) than the comparison group (20.1 per cent). However, the intervention group experienced a greater reduction in suicidal ideation (12.9 per cent) than the comparison group (3 per cent) at the four month interval. Resolution of symptoms was greater and quicker for those receiving the intervention; at eight months the intervention group resolution rate was 70.7 per cent compared to 43.9 per cent of the usual care group. Researchers point out that despite the limitations, this study included participants that are typically excluded from such trials, including patients with mild cognitive impairment and co-morbid medical conditions, and therefore suggests that the findings may have greater relevance to actual practice.

P5600-8
Fenton, J. et al.
Some Predictors of Psychiatric Consultation in Nursing Home Residents
American Journal of Geriatric Psychiatry; Vol. 12 (3), 297-304; May-June 2004.
Journal article (research)
Several studies have found that the prevalence of psychiatric disorders among nursing home residents exceeds 70 per cent, yet fewer than ten per cent of nursing home residents receive explicit mental health interventions. The purpose of this research was to document the number of psychiatric consultations requested for a diverse nursing home population and to identify demographic, clinical and facility characteristics associated with the consultations. Fifty-nine facilities throughout Maryland were randomly selected and new admission residents from September 1992 through August 1995 were eligible. Two-thousand and fifteen residents were evaluated for depression, dementia, cognitive deficits and agitation. Residents, their caregivers, or significant others were interviewed, and medical records were examined to determine whether or not a psychiatric consult had been ordered within the first 90 days of admission. Only 20 per cent of the sample had been referred for consultation. Behaviors that were associated with referrals included agitation, verbal abuse, wandering, manic/destructive acts and anxiety. However, depression in retarded and psychotic patients did not trigger a consultation. Researchers suggest that the mental health needs of the quietly depressed or developmentally disabled resident may be overlooked, and encourage care staff to be aware of such symptoms as social withdrawal or lethargy.

P5502-17
Gretarsdottir, E., Woodruff-Borden, J., Meeks, S. & Depp, C.
Social Anxiety in Older Adults: Phenomenology, Prevalence, and Measurement
Behaviour Research and Therapy; Vol. 42 (4), 459-475; 2004.
Journal article (research)
This article addresses the phenomenon of social anxiety among the elderly. A convenience sample of 283 adults (aged 60-94) and 318 young and middle-aged adults were assessed. Participants completed the Social Phobia and Anxiety Inventory (SPAI), the State-Trait Anxiety Inventory (STAI), the Beck Anxiety Inventory (BAI), the Geriatric Depression Scale (GDS), the Center for Epidemiological Studies Depression Scale (CES-D), and a health scale modified from the one developed by Belloc, Breslow and Hochstim (1971). Eighteen per cent of the older sample appeared to demonstrate social anxiety, which is slightly less than the prevalence demonstrated by younger participants (24.7 per cent). The profile of those experiencing social anxiety was similar despite the age of the participant. The SPAI appears to be a valid instrument in measuring social anxiety among the elderly; however, 65 of the original 348 respondents were excluded due to missing data on questionnaires. Researchers suggest that the tool may need to be shortened to increase its usefulness within this population.

P5504-4
Hammond, M.
Doctors' and Nurses' Observations on the Geriatric Depression Rating Scale
Age and Ageing; Vol. 33 (2), 189-192; 2004.
Journal article (research)
In this study, 20 junior doctors and 25 nurses from the Royal Liverpool University Hospital were interviewed regarding their use of the Geriatric Depression Rating Scale (GDS) as a screening tool for older patients. Only ten per cent of the participants felt that the GDS was an appropriate tool to routinely use. One criticism of the tool was that it inhibited rapport with the patient. While physicians wanted a more formal method for assessment and documentation, nurses expressed the desire for a more therapeutic environment in which to assess depression. (U.K./England)

P5569-7
Langa, K. et al.
Extent and Cost of Informal Caregiving for Older Americans with Symptoms of Depression
American Journal of Psychiatry; Vol. 161 (5), 857-863; May 2004.
Journal article (research)
The purpose of this study was to develop a national estimate of the additional time and costs associated with informal caregiving for older, community-dwelling Americans demonstrating symptoms of depression. Based on data from the 1993 Asset and Health Dynamics Among the Oldest Old Study (AHEAD, n=6,649), 44 per cent of the participants indicated that they had experienced one to three depressive symptoms within the past week, and 18 per cent indicated that they had experience four to eight symptoms. After adjusting for differences in health profile, sociodemographics and caregiver networks, it was estimated that respondents with no depressive symptoms received an additional 2.9 hours of assistance weekly, while those with moderate symptoms received 4.3 hours per week, and those with more frequent symptoms required 6 hours weekly. This results in an estimated additional $9.1 billion cost for informal caregiving in the U.S. annually. The study appears to support the assumptions that depressive symptoms are extremely common, associated with higher levels of disability and an increased need for informal caregiving. Women were more likely to report depressive symptoms, and appear at greater risk of having unmet care needs, in part due to financial conditions and to the increased likelihood of living alone.


P5521-10
Minardi, H. & Blanchard, M.
Older People with Depression: Pilot Study
Journal of Advanced Nursing; Vol. 46 (1), 23-32; 2004.
Journal article (research)
This quasi-experimental, cross-sectional pilot study was designed to examine the level of depression among elders attending a London Age Concern day center while considering the association between depression and perceptions of disability, loneliness, social support, life satisfaction, and satisfaction with social support system. A convenience sample of 24 participants, regular attendees of the center with no known psychiatric or dementia diagnosis, were assessed using the computerized Geriatric Mental Status (GMS) examination, along with the London Handicap Scale, the Loneliness subscale of the GMS, the Short-Form Social Support Questionnaire (SSQ6) and the Satisfaction with Life Scale (SWLS). Ten of the participants (41.7 per cent) were identified as depressed, and one as having anxiety. All but one individual was identified as having more minor presentations of a variety of psychiatric disorders and cognitive deficits. The prevalence of depression appeared higher than in previous community studies. Loneliness appeared positively associated with depression, life satisfaction appeared negatively associated, and perceptions of disability and loneliness appeared positively associated with depression. However, disability and social support did not appear associated with depression.

P5584-5
Staff - Brown University Geriatric Psychopharmacology Update
Depression in the Elderly: Exploring the Link with Physical Symptoms
Brown University Geriatric Psychopharmacology Update; Vol. 8 (4), 1-3; April 2004.
Conference presentation (summary)
Research suggests that depressed elders do not respond as well as younger patients to selective serotonin reuptake inhibitors (SSRIs), the traditional treatment. It is also noted that depression in older patients is often accompanied by symptoms of pain. This article summarizes the lectures of physicians Steven Roose, P. Murali Doraiswamy, and J. Craig Nelson, presented at the American Association for Geriatric Psychiatry (AAGP) conference in February, 2004. Presenters discussed research that suggest dual action agents and drug combinations that address both pain and depression are more effective interventions in producing remission of depressive symptoms than treatment with SSRIs alone.

P5473-8
Stek, M. et al.
Prevalence, Correlates and Recognition of Depression in the Oldest Old: the Leiden 85-Plus Study
Journal of Affective Disorders; Vol. 78 (3), 193-200; 2004.
Journal article (research)
Little research regarding the prevalence of depression in the oldest old (aged 85 and over) has been conducted, in part because of the difficulties of studying depression in the presence of multiple physical and psychiatric diseases. This study assessed depression in a sample of 599 of the 705 residents of the Netherlands, born between 1912 and 1914, who were participating in the Leiden 85-plus health study. Researchers used the 15-item Geriatric Depression Scale (GDS-S) and also the Mini Mental Status Exam (MMSE). Demographic, health-related and functional correlates were also analyzed. The prevalence rate of depressive symptomotology was 15.4 per cent. Depression was correlated with loneliness, impaired cognition, impaired daily functioning, self-described poor health, poor mobility and being institutionalized. Although 90 per cent of the depressed participants had been seen by their physicians during the past year, only 25 per cent of these individuals were identified as depressed by their doctor, and only one participant had been prescribed antidepressant medication. The prevalence rate is compared with findings from other oldest old studies.

P5518-22
U.S. Senate Special Committee on Aging
Judicial Responses to the Growing Incidence of Crime Among Elders with Dementia and Mental Illness - testimony of Max Rothman, Ex. Dir., Center on Aging, Florida International University (from Crime without Criminals? Seniors, Dementia and the Aftermath)
Washington, D.C.; March 22, 2004.
Senate hearing
In this U.S. Senate Special Committee on Aging hearing, the executive director of Florida International University's Center on Aging provides an overview of the judicial response to court proceedings effecting elders with dementia and mental illness. He reports that both the volume and complexity of cases involving such seniors is increasing, and that little research has been conducted in this area. The concept of therapeutic jurisprudence (TJ), the philosophy that the law itself can act as a therapeutic or anti-therapeutic agent, is discussed. Specialized problem-solving courts (such as drug courts, mental health courts, domestic violence courts, community courts, family courts, etc.) are practical applications of TJ. While many of these courts deal with non-violent violations, their role in early detection and intervention can be a vital tool in assisting elderly victims and perpetrators suffering from dementia and/or mental illness. In terms of trial court performance standards, the following are among the nine promising components for effective service coordination: recognition of the importance of court-based service coordination; judicial and court leadership; case-level service coordinators; creative use of available resources; active court monitoring of compliance with court orders; and training to address interagency/multidisciplinary collaboration. The Elder Justice Centers in Florida (Hillsborough and Palm Beach Counties) are also highlighted as models for judicial response and case studies are provided. (Note: The transcripts from this hearing are accessible online at: http://aging.senate.gov/index.cfm?Fuseaction=Hearings.Detail&HearingID=42)

P5500-8
Wetherell, J. et al.
Quality of Life in Geriatric Generalized Anxiety Disorder: A Preliminary Investigation
Journal of Psychiatric Research; Vol. 38 (3), 305-312; 2004.
Journal article (research)
Generalized anxiety disorder (GAD) is currently defined as a condition lasting six months or longer, wherein an individual experiences difficult to control, excessive worrying most of the time. It is usually accompanied by sleep disturbance, irritability and impaired concentration among other symptoms. In this study, researchers assessed the impact of GAD upon health-related quality of life of older adults. Seventy-five older individuals (median age 68) presenting with GAD (including 39 who had a co-morbid psychiatric diagnosis) were interviewed and completed the Medical Outcomes Study short form, the Beck Anxiety Inventory, and the Beck Depression Inventory. Results were compared with 32 participants who were not reporting any current psychiatric symptoms. GAD patients with and without co-morbid psychiatric symptoms did not differ on any quality of life variable, however, both groups experiencing GAD reported a poorer quality of life for all domains, including the physical health-related domains. When compared with national norms, older individuals experiencing GAD reported an overall quality of life worse than patients who recently experienced myocardial infarction or type II diabetes.

P5567-3
Staff - News-Medical
$9 Billion Cost of Depression in Senior Citizens
May 1 2004.
Online
According to a recent study on depression of seniors in America (conducted by the University of Michigan), if informal caregivers were paid wages commensurate with home health care aides, the cost to society would be an annual $9 billion. Those elders with many depressive symptoms required an average of six hours of unpaid caregiver assistance per week, while those with no symptoms typically require 2.9 hours. These costs are in addition to "formal costs" which include paid care, doctor visits, medications, etc. This cost estimate of informal care is second only to that of dementia, which is estimated at $18 billion annually. (Note: This article is available online at http://www.news-medical.net/view_article.asp?id=1105)


2003

P5122-8
Akaza, K. et al.
Elder Abuse and Neglect: Social Problems Revealed from 15 Autopsy Cases
Legal Medicine; Vol. 5 (1), 7-14; 2003.
Journal article (research)
This retrospective study examined cases of individuals aged 65 and older who died and were autopsied from 1990 through 2000 in the Department of Legal Medicine at the Gifu University School of Medicine in the prefecture of Gifu, Japan. The analysis revealed that in the sample of 125 cases, 15 deaths were attributed to elder abuse and neglect. Among the 13 domestic cases classified as abuse, the perpetrator was most often the victim's son. Eight of the perpetrators were unemployed, four had a history of mental illness, and two were alcoholics. Each case is briefly described. In seven cases, criminal investigations were initiated and three perpetrators were psychiatrically hospitalized.

P5432-12
Coon, D. et al.
Anger and Depression Management: Psychoeducational Skill Training Interventions for Women Caregivers of a Relative with Dementia (research)
The Gerontologist; Vol. 43 (5), 678-689; 2003.
Journal article (research)
The purpose of this study is to consider the effectiveness of two psychoeducational skill training interventions for caregivers of relatives experiencing dementia. One-hundred sixty-nine female caregivers aged 50 and over, were randomly assigned to either an anger management group, a depression management group, or the waiting list control group. Participants were assessed (for depressive symptoms and anger/hostility) three times: at intake, four months later (post intervention), and again three months later. Both the anger management and depression management interventions consisted of small group, workshop type sessions, which included lecture, skill practice, discussion and home work. Results indicate that the skill training was effective; participants with higher levels of anger appeared to benefit the most from the anger management intervention and those experiencing higher levels of depressive symptoms appeared to benefit the most from the depression management intervention, while the participants of both groups experienced reductions in anger and depression when compared to the control group. The study also focuses on the role of specific moderator variables (present at baseline) and mediator variables (those that are impacted by the intervention and, in turn, effect outcome variables). Self-efficacy appears to be a mediator that increased for participants of both psychoeducational groups. In order to maximize the skill training, pre-treatment assessments are important in prescribing appropriate interventions.

P5259-8
Dixon, C. & Richard, M.
Contemporary Issues Facing Aging Americans: Implications for Rehabilitation and Mental Health Counseling
Journal of Rehabilitation; Vol. 69 (2), 5-12; April-June 2003.
Journal article (scholarship)
In this article, intended for rehabilitation and mental health counselors, an overview of some of the most significant issues to impact the aging population are discussed. Financial concerns related to employment, retirement and long-term care, grandparenting, victimization and abuse, and mental illnesses are among those topics discussed. Program development is needed in the areas of advocacy, guardianship, case management, benefits planning, gerontology counseling, employment and training, and multicultural
competencies.

P5478-13
Fischer, L. et al.
Treatment of Elderly and Other Adult Patients for Depression in Primary Care
Journal of American Geriatric Society; Vol. 51 (11), 1554-1562; 2003.
Journal article (research)
The objective of this study was to consider whether depression in older patients was treated differently than depression in younger patients in the primary care setting. A baseline sample of 1,023 patients with a diagnosis of depression was divided into six age groups (under 35, 35-44, 45-54, 55-64, 65-74, and aged 75 and over). Participants were assessed just after their index visit and then three months later using the short form of the Center for Epidemiological Studies - Depression scale (CES-D), a 12-item health survey, a modified version of the CAGE for alcohol screening, and demographic items. Patients were also interviewed about which diagnostic questions were asked and what resources and referrals were identified by their physicians. Charts were audited for two specific pieces of information: whether the patient was assessed for suicide risk, and whether the patient was referred for mental health services (in addition to medication). Results indicate that while the severity of symptoms was relatively similar for all age groups, the care process revealed differences in interventions by physicians. Specifically, doctors were more likely to ask younger patients about suicidality, to explicitly address the depression, and to provide written information on depression. Physicians were three times more likely to refer young-adult patients to mental health specialists than old-old patients. Approximately 75 per cent of patients across all age groups were prescribed anti-depressants. (Note: This article is available online through Medscape at    http://www.medscape.com/viewarticle/463910?src=search)

P5414-9
Harris, T. et al.
Predictors of Depressive Symptoms in Older People - A Survey of Two General Practice Populations
Age and Ageing; Vol. 32 (5), 510-518; 2003.
Journal article (research)
While disability and lack of social support have already been established as predictors of depression among the elderly, socio-economic status (SES) & health locus of control have not. This study considers the factors of physical disability, social support, SES, and health locus of control in association with geriatric depression. Two group medical practices in Great Britain (one inner city, one suburban) provided the research settings. Surveys were mailed to all registered patients, aged 65 and older, who were not identified as either having a dementia diagnosis or a terminal illness. The response rate was 70.4 per cent with a final sample of 1,602 participants. In addition to answering questions regarding the above factors, participants also completed the Geriatric Depression Score 15 (GDS15). Unlike previous studies, the findings indicate that lower levels of SES were associated with higher rates of depression. Health locus of control also appears associated. (U.K./England)

P5232-7
Landesman, A.
Mahler's Developmental Theory - Training the Nurse to Treat Older Adults with Borderline Personality Disorder
Journal of Gerontological Nursing; p22-p28; February 2003.
Journal article (scholarship)
According to one researcher, adults with Borderline Personality Disorder (BPD) are at greater risk of morbidity and mortality secondary to neglect, increased risk of self-destructive behavior including drug abuse, and premature institutionalization. After presenting an overview of Mahler's developmental theory of BPD, the authors present a case study of an older nursing home resident who exhibits the characteristics of the disorder including interpersonal conflicts with staff and other residents that arise from demanding, abusive and splitting behaviors. The need for nurses, CNAs, physicians and other health care professionals to be aware of the dynamics of this mental health issue and to provide a unified and consistent care plan is essential for the resident's benefit and to diminish caregiver stress.

P5300-10
Lee, H. & Lyketsos, C.
Depression in Alzheimer's Disease: Heterogeneity and Related Issues
Biological Psychiatry; Vol. 54, 353-362; 2003.
Journal article (Literature review/Scholarship)
Research indicates that rates of "noncognitive mental disturbances" are three to four times greater in Alzheimer's disease (AD) patients than in patients without dementia. Depression, including major depression, is one of the most common conditions observed. Not only does it have a negative impact upon the quality of life of the patient and the patient's health, it also appears to increase caregiver depression and burden. This article briefly reviews the existing literature on depression in AD, including eight placebo-controlled studies of the efficacy of antidepressant therapy in AD patients. It presents a discussion of the difficulty in assessing depression accurately in the presence of dementia. The provisional diagnostic criteria for depression that was recently developed by the National Institute of Mental Health's Alzheimer's Disease Workgroup is also presented. Four subtypes of depression in AD are discussed: emotional reaction to cognitive decline; recurrence of earlier life depressive disorders; vascular diseases associated with AD causing depressive symptoms; and the neurodegenerative process of AD causing depressive symptoms. Future research areas are outlined, including the Cache County Dementia Progression Study, a longitudinal study that will examine, among other things, "...the phenomenology and natural history of incident cases or neuropsychiatric disorders including depression in AD..."

P5514-10
Leenaars, A.
Can a Theory of Suicide Predict All "Suicides" in the Elderly?
Crisis: International Journal of Suicide- and Crisis-Studies; Vol. 24 (1), 7-16; 2003.
Journal article (scholarship)
In this overview regarding suicide among the elderly, the author addresses the lack of research on personality factors that contribute to this phenomenon. He presents a description of the following eight factors: unbearable psychological pain; cognitive constriction (rigidity in thinking); indirect expression (ambivalence); inability to adjust; ego; interpersonal relations; rejection-aggression; and identification-egression (escape). The case of Sigmund Freud is discussed in order to highlight the concept of suicide versus "self-chosen death," and raises questions regarding the differences between suicide among those who are terminally ill and those who are not. Suicide notes are included along with protocol sentences intended to generate analysis of intrapsychic and interpersonal aspects of individual cases. The concept that suicide among the elderly is multidimensional, rooted in individualized personalities and circumstances, is important to the development of effective suicide prevention initiatives. (Canada)

P5572-4
Lima, C., Levav, I., Jacobsson, L. & Rutz, W.
Stigma and Discrimination Against Older People with Mental Disorders in Europe
International Journal of Geriatric Psychiatry; Vol. 18, 679-682; 2003.
Journal article (research)
The Task Force on Destigmatization, established by the Mental Health Program of the World Health Organization/European Regional Office (WHO/EURO) in 2000, was charged with the duty to investigate and address the impact of stigma and discrimination of older mentally ill Europeans. WHO mental health representatives from seventeen countries were surveyed regarding both health care professional activities (such as research and teaching) and the public's attitudes towards elders with mental disorders. Among the results, two-thirds of the fifteen countries that had conducted psychiatric epidemiological studies included the elderly in the samples; the sixteen countries that include an old age psychiatry residency modality allow ten per cent curriculum time for such; two-thirds of the surveyed countries had specialized services (as compared to 100 per cent for children); and stigma is perceived as greater towards elders with psychosis and depression (and their families) than towards patients with Alzheimer's disease.

P5593-8
Moutier, C., Wetherell, J. & Zisook, S.
Combined Psychotherapy and Pharmacotherapy for Late-Life Depression
Geriatric Times; Vol. IV (5); September/October 2003.
Online article (scholarship)
A combined treatment approach of both pharmacological and psychotherapeutic interventions is warranted to manage the medical, cognitive and psychosocial complications of late-life depression. This article discusses the unique characteristics of geriatric depression, including the symptoms of irritability, somatic complaints, social withdrawal, and sudden changes in functional level. Observing that depression is often unrecognized in the presence of other medical conditions, the authors provide recommendations for primary care physicians, such as maintaining a "high index of suspicion" in patients with medical illnesses known to have a high correlation with depression. The interactive nature of the relationship between depression and cognitive dysfunction is also discussed. The article provides links to tables describing the consensus of geriatric psychiatrists regarding the use of pharmacological interventions and therapy/counseling modalities. (Note: This article is available online only at http://www.geriatrictimes.com/g031014.html .)

P5576-3
National Institute of Mental Health (NIMH)
Older Adults: Depression and Suicide Facts
National Institute of Mental Health (NIMH), U.S. Department of Health and Human Services (DHHS)
NIH Publication No. 03-4593; Printed January 2001; Revised May 2003.
Agency report (online)
This National Institute of Mental Health (NIMH) fact sheet provides an overview of recent findings regarding geriatric depression and suicide. It is estimated that nearly 2 million of the 35 million Americans aged 65 and over have a depressive illness and an additional five million have a subsyndromal condition. Older Americans account for 18 per cent of suicide deaths, however, they comprise only 13 per cent of the population. Research indicates that nearly 75 per cent of all elders who commit suicide had seen their primary care physicians within the month preceding their deaths. The fact that depression often coincides with other serious illnesses contributes to the difficulty in assessing the condition. (Note: This fact sheet is available online at: http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm .)

P5362-9
Neil, W., Curran, S. & Wattis, J.
Antipsychotic Prescribing in Older People
Age and Ageing; Vol. 32 (5), 475-483; 2003.
Journal article (literature review)
In this article, the authors review the relevant (though scant) literature regarding the effectiveness of antipsychotic medication for older individuals. Research findings on the use of neuroleptics (including Risperidone, Haloperidol, Olazapine, and Clozapine) for dementia, delirium, anxiety, depression, bipolar affective disorder, and early and late onset schizophrenia are described. In general, atypical antipsychotics appear associated with less severe side effects and drug-drug interaction, which are pronounced in the older patient and should be a major consideration to the prescribing primary care physician or psychiatrist. Evidence-based research on the efficacy and limitations of these medications in older patients is needed. (England/U.K.)

P5594-14
Oishi, S. et al.
Impacting Late Life Depression: Integrating a Depression Intervention into Primary Care
Psychiatric Quarterly; Vol. 74 (1), 75-88; Spring 2003.
Journal article (research)
Despite a patient preference to have late life depression treated in the general practitioner's office, research indicates that treatment is often less successful in the primary care setting. While barriers to effective treatment have been identified, strategies targeting individual barriers have been ineffective. This article describes Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), an initiative designed to integrate mental health services into primary care health services delivery. The authors conducted focus groups and semi-structured interviews with IMPACT's Depression Clinical Specialists (DCS). Program interventions include psychiatric supervision, weekly team meetings (with the patient's physician, a consulting psychiatrist, and a liaison primary care physician/PCP), computerized patient tracking, and outcomes assessments. Details of protocols, training, environment, and interpersonal factors are described by the DCSs, along with the research features that will need to be "preserved" in collaborative care approaches in actual practice. In particular, the need to involve the patient as a collaborator in his/her own treatment is emphasized, along with a need to maintain simplicity in the treatment approach. Also, the role of the liaison PCP was noted as vital to the resolution of continuity of care issues.

P5461-3
Pals, J., Weinberg, A. & Tune, L.
Improving Psychiatric Consultation in Long-Term Care Facilities: Removing Barriers and Helping Residents
Annals of Long-Term Care; Vol. 11 (10), 42-44; October 2003.
Journal article (scholarship)
There are roughly 17,000 nursing homes in the U.S., with an estimated 1.7 million residents. Approximately one million are diagnosed with dementia and one-third of long-term care residents carry the diagnosis of depression. This article, based upon a presentation to the American Geriatrics Society in May 2003, addresses the need to understand the context of agitation or inappropriate behavior and the need to describe specifically the behavioral issues before being able to adequately treat the resident. Behavioral management and environmental changes should be attempted first, with psychotropic medications being prescribed only when these interventions fail. The importance of communication regarding treatment between the consulting psychiatrist and the attending physician or medical director, as well as communication between the prescribing doctor and the nursing home staff is stressed. The need for psychiatric input in treatment planning is also discussed.

P5422-28
Roy, K.
Sleeping Watchdogs of Personal Liberty: State Laws Disenfranchising the Elderly
Elder Law Journal; Vol. 11, p109; 2003.
Journal article (legal scholarship)
Generally, voting rates among the elderly are higher than those of other age groups, yet elders under guardianship are at risk for disenfranchisement. This note presents a detailed legal discussion of voting legislation throughout the U.S. that serves to disenfranchise the elderly. Eleven states specifically prohibit anyone under guardianship from voting due to presumed incompetence, and 44 states have either statutes or constitutional provisions that permit disenfranchisement. The article describes the history of such decisions and its current impact upon elderly voters. A number of guardianship processes are highlighted, such as that of Florida, which specifies that the judge must appoint an examining committee with experts in the disciplines of aging to determine competency. However, discrepancies in professionals' abilities to assess dementia are a critical concern. Recent trends indicate that greater emphasis is being placed upon functional ability and not merely diagnosis of mental illness and mental disability to determine competency. Carroll v. Cobb (New Jersey, 1976) and Doe v. Roe (Maine, 2001) are among the law suits presented.

P5589-5
Staff - Harvard Mental Health Letter
Depression in Old Age
Harvard Mental Health Letter; September 2003.
Journal article (scholarship)
This article provides an overview of some of the distinct ways in which depression is manifested in older patients. While elders are exposed to the same risk factors as younger individuals, they may also experience physical disability, chronic medical conditions, personal losses and bereavement, and possibly caregiver burden. The difficulty in identifying depression in the presence of dementia is considered, and the concept of pseudo-dementia, a depression "masquerading as dementia," is described. Effective medications suitable for this age group are discussed, along with nonpharmacological treatment options such as counseling and psychotherapy.

P5597-11
U.S. Department of Health and Human Services (DHSS), National Council on the Aging, (NCOA), Administration on Aging (AoA), Substance Abuse and Mental Health Services Administration (SAMHSA)
Get Connected! Linking Older Adults with Medication, Alcohol, and Mental Health Resources
U.S. Department of Health and Human Services (DHSS), Administration on Aging (AoA), Substance Abuse and Mental Health Services Administration (SAMHSA); 2003.
Tool kit
This tool kit is designed to help providers in aging services address issues related to medication misuse, substance abuse and emotional problems among older people. It includes fact sheets, a video, consumer brochures, training guides and curricula, and a services resource guide. To order, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Clearinghouse for Alcohol and Drug information at 1-800-729-6686 or email info@health.org .

P5602-00
U.S. Senate Special Committee on Aging
Senior Depression: Life-Saving Mental Health Treatments for Older Americans
Washington, D.C.; July 28 2003.
Senate hearing
This U.S. Senate Special Committee on Aging presented testimony from family members, individuals and mental health experts regarding the profound effect of depression, suicide and mental illness upon older individuals. Statements were made by Diana Waugh, Hickmah Gardiner, Donna Cohen, Ph.D., Dr. Ira Katz, and Jane Pearson, Ph.D. (Note: Testimony from this hearing can be accessed online at http://aging.senate.gov/index.)

P5587-3
U.S. Senate Special Committee on Aging
Senior Depression: Life-Saving Mental Health Treatments for Older Americans
Statement by Jane L. Pearson, Ph.D: NIMH Research on Geriatric Depression and Suicide
Washington, D.C.; July 28 2003
Senate hearing
Since 1996, the National Institute of Mental Health (NIMH) has dramatically increased efforts to research the disturbing trend of high rates of elder suicide in America. In her statement before the U.S. Senate Special Committee on Aging, Jane Pearson of the NIMH Research Consortium reported upon such initiatives as the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study, which focuses on a collaborative care approach to late life depression. In addition, she discusses research designed to prevent depression among patients with significant medical conditions. (Note: This statement can be accessed online at www.hhs.gov/asl/testify/t030728.html .)

P5390-5
U.S. Senate Special Committee on Aging
Senior Depression: Life-Saving Mental Health Treatments for Older Americans
Depression and Violent Deaths in Older Americans: An Emergent Public Mental Health Challenge.
Statement of Donna Cohen, Ph.D. Professor, Dept. of Aging and Mental Health
Washington, D.C.; July 28 2003.
Senate hearing
In her statement before the U.S. Senate Special Committee on Aging hearing entitled "New Treatments for Depression Among the Elderly," Professor Cohen reports that although treatable, depression remains undetected in 80 per cent of the older population. She emphasized three key points in her address: depression, prevalent in nearly half of all Alzheimer's patients, is often unrecognized in acute care and long-term care settings; depression in caregivers, often undetected, puts both caregivers and patients at risk for decline in health, poor care, abuse and violence; depression can be lethal and may result in suicide, homicide and homicide-suicide. It is estimated that between 500 and 900 older homicide-suicides occur in the U.S. annually. (Note: This statement is available online at http://aging.senate.gov/hearing_detail.cfm?id=271693&)

P5595-10
Unutzer, J. et al.
Collaborative Care Management of Late-Life Depression in the Primary Care Setting - A Randomized Controlled Trial
JAMA/Journal of the American Medical Association; Vol. 288 (22), 2836-2845; December 2003.
Journal article (research)
This randomized controlled trial was designed to evaluate the effectiveness of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) management program. Project IMPACT provides an integrative care model for the treatment of geriatric depression. A sample of 1,801 patients aged 60 and over, participated throughout eighteen primary care clinics across five states (July 1999-Autust 2001). Seventeen per cent of the participants were diagnosed with major depression, 30 per cent were diagnosed with dysthymic disorder, and 53 per cent were diagnosed with both. Nine-hundred and six patients were randomly assigned to the IMPACT intervention and the remaining 895 were assigned to usual care. Components of the IMPACT intervention include one year's access to a depression care manager (under the supervision of a psychiatrist and a liaison primary care physician), psychoeducation, anti-depressant medication and brief psychotherapy (Problem Solving Treatment in Primary Care or PST-PC). Outcomes were assessed at three, six and twelve month intervals. Of the major findings, patients enrolled in the IMPACT intervention were more likely to access medication and therapy, and at the twelve month assessment, 45 per cent of the intervention patients had experienced at least a 50 per cent reduction in depressive symptoms as compared to nineteen per cent in the usual care group. The annual cost of the IMPACT intervention per patient was estimated at $553.00.

P5590-15
Watson, L. & Pignone, M.
Screening Accuracy for Late-Life Depression in Primary Care: A Systematic Review
Journal of Family Practice; Vol. 52 (12), 956-964; December 2003.
Journal article (research)
The purpose of this literature survey is to review the accuracy of depression screening instruments for use with older adults in the primary care setting. Among the nine assessment tools surveyed, the Geriatric Depression Scale (GDS), the Center for Epidemiological Studies Depression Scale (CES-D), and the SelfCARE (D) are identified as both sensitive and specific and appropriate for use in this setting. The CES-D and Cornell Scale for Depression in Dementia (CSDD) appear accurate for identifying depression in dementia patients with an average Mini-Mental Status Exam (MMSE) score of 19, although more research is needed in this area. Tables include summaries of studies reviewed.


2002

P5596-11
Bartels, S. et al.
Suicidal and Death Ideation in Older Primary Care Patients with Depression, Anxiety, and At-Risk Alcohol Use
American Journal of Geriatric Psychiatry; Vol. 10 (4), 417-427; July-August 2002.
Journal article (research)
This article discusses the risk factors associated with suicidal and death ideation based upon data from the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe) study, which was designed to compare the integrative approach of mental health and substance abuse service delivery to the referral approach. The sample consisted of 2,240 primary care patients aged 65 and over who screened positive for a mental health disorder, suicidal ideation or at-risk drinking, who were not already receiving mental health or substance abuse services. Suicidal ideation was assessed by the five Paykel suicide questions. Subjects were categorized as having no ideation, death ideation, or suicidal ideation. Overall, one-third of the participants experienced either death or suicidal ideation. Based on the findings, researchers suggest that geriatric patients at greatest risk of suicidal ideation are those with moderate-to-severe depression, co-occurring depression and anxiety, those who are socially isolated, aged 65-74, and white or Asian. Although death ideation was associated with a higher incidence of co-morbid medical conditions and higher rates of health care service use (including ER visits and in-patient hospitalizations), no health care service usage patterns were observed to identify which primary care patients may be experiencing suicidal ideation. Researchers failed to find an association between at-risk alcohol use and suicidal ideation.

P5266-4
Fabacher, D. et al.
Validation of a Brief Screening Tool to Detect Depression in Elderly ED Patients
American Journal of Emergency Medicine; Vol. 20 (2), 99-102; 2002.
Journal article (research)
Research indicates that although depression among elders leads to higher rates of functional decline, morbidity and mortality, it is often undiagnosed by physicians. The purpose of this article is to assess the validity of a brief screening tool, the ED-DSI (developed by the authors) by comparing it with the 30 question Geriatric Depression Scale (GDS). During a six-month period in 1999, 103 medically and mentally stable emergency room patients aged 65 and older participated in the study. Forty-nine per cent scored positively for depression on the three-item ED-DSI, and 32 per cent screened positively on the GDS. Results emphasize the need for screening ED elderly patients for depression, and suggest that the ED-DSI is useful tool, easily administered.

P5565-9
Mays, W.
Elder Abuse and Mental Health
Journal of Elder Abuse & Neglect; Vol. 14 (4), 21-29; 2002.
At the first National Policy Summit on Elder Abuse (December, 2001, Washington, D.C.), mental health needs of older individuals were considered a priority. This article provides an overview of issues faced by the mentally ill aged, including the historically poor integration of mental health and adult protective services (APS), minimal consumer involvement, minimal specialized psychiatric evaluation, and Medicare and Medicaid limitations. It also describes recent initiatives such as the New Freedom Commission on Mental Health's Subcommittee on Older Americans, the Older Adult Consumer Mental Health Alliance, the National Coalition on Mental Health and Aging, and the federally mandated Preadmission Screening and Resident Review (PASARR or PASSR) that are providing opportunity for enhanced service delivery. The article contains contact information and web addresses for many of these initiatives.

P5579-8
National Institute of Mental Health Aging Research Consortium (NIMH)
Late-Life Mental Illness Research at the National Institute of Mental Health: An Analysis of Fiscal Year 2000 Grants, Contracts, and Intramural Research Program Projects
National Institute of Mental Health Aging Research Consortium, U.S. Department of Health and Human Services; 2002.
Agency report (online)
This report reviews the types of research initiatives conducted by the National Institute of Mental Health (NIMH) that addressed aging issues during fiscal year 2000. The three greatest concentrations were dementia (comprising 29 per cent of all aging research), general aging (23 per cent), and depression (23 per cent). Studies also focused on schizophrenia, suicide and anxiety. (Note: For more information on this report, contact NIMH at nimhinfo@nih.gov .)

P5773-26
Old Age Psychiatry of the World Psychiatric Association and the World Health Organization
Reducing Stigma and Discrimination Against Older People with Mental Disorders Geneva, Switzerland; 2002.
Technical consensus paper
The World Health Organization and the World Psychiatric Association collaborated with other NGOs to produce this technical consensus statement, which promotes discussion aimed at reducing the stigmatization of older people with mental illness. The authors point out that to date, attention to the concept of stigmatization regarding the mentally ill was directed towards younger individuals. Older individuals experiencing mental illness are likely to be dually stigmatized, as both older and mentally ill people are routinely marginalized in society. Causes of this discrimination are discussed, including ignorance, fear, drive for conformity, internalization, cultural influences, social and economic instability, a lack (or perceived lack) of preventative strategies and interventions, and gender biases. Consequences include negative attitudes such as prejudice, ageism, damaging self-beliefs, secrecy and distortions regarding costs of care and treatment. Such discrimination is not only directed at the mentally ill but at their families and mental health professionals as well. Negative attitudes impact upon quality of health care, and at times, undermine the credibility of elders when describing instances of abuse and mistreatment. One section of the paper addresses specific stigmas attached to depression, dementia, delirium, psychosis, anxiety, substance abuse, personality disorders, and learning disabilities. Recommendations for future action are outlined for policy makers, NGOs, professionals, families and informal caregivers, the public, elders with mental illness, the media and the corporate sectors. (Note: This paper is available online at http://www.who.int/mental_health/media/en/499.pdf)

P5268-19
Ron, P.
Depression and Suicide Among Community Elderly
Journal of Gerontological Social Work; Vol. 38 (3), 53-71; 2002
Journal article (research)
This study was designed to examine how demographic factors, such as family status, gender, etc., impact upon an elder's sense of hopelessness and helplessness, which leads to depression. The sample of 316 elders was drawn from five senior centers around Haifa, Israel. The participants revealed their gender, age, family status, level of religiosity, previous suicide attempts, country of birth, and whether he or she was a Holocaust survivor. They were administered the following tools: the Beck Depression Inventory (BDI); the Beck Hopelessness Scale (BHS); and the Scale for Suicidal Ideation (SSI). Of the findings, females appeared significantly more depressed than males, widowed participants indicated higher levels of suicidal ideation than married participants, and age appeared to have the greatest impact upon levels of hopelessness.

N4797-9
Sable, J., Dunn, L. & Zisook, S.
Late-life Depression - How to Identify Its Symptoms and Provide Effective Treatment
Geriatrics; Vol. 57 (2), 18-35; February 2002.
Journal article (scholarship)
Depression in older patients can be as functionally and physically disabling as many chronic medical conditions, and it remains underdiagnosed and undertreated. This detailed article provides an overview of the identification and treatment of depression in geriatric patients. It addresses the differentiation between depression and co-morbid
physical conditions, the presentation of nonspecific depression in older patients as it may differ from that in younger individuals, the course and prognosis of late life-depression, and integrated treatment approaches. Tables include a guideline on diagnosis, medical conditions that are associated with depression, and descriptions of tricyclic and SSRI
anti-depressants for geriatric patients. (Note: This article can be accessed online at http://www.geri.com/geriatrics/data/articlestandard/geriatrics/072002/9472/article.pdf .)


2001

L4517-4
Carson, V.
Depression as a Complicating Factor for Home Care Patients
CARING Magazine; 30-33; January 2001.
Journal article (scholarship)
This article discusses the importance of assessing and addressing depression in the home care patient. The author notes that elements of depression often accompany serious medical conditions and observes that untreated depression may not only endanger the patient but also can complicate an illness by medication non-compliance, decline in daily functioning, increased confusion and cognitive functioning. An overview for identifying symptoms and a graduated list of interventions is provided. The author recommends using the OASIS screening as a starting point for assessment. In addition to enhancing a patient's well being, the accurate diagnosis of depression can provide a better clinical outcome at a reduced cost.

P5771-15
Chang, V. & Greene, R.
Study of Service Delivery by Community Mental Health Centers as Perceived by Adult Protective Services Investigators
Journal of Abuse & Neglect of the Elderly; Vol. 13 (3), 25-39; 2001.
Journal article (research)
Noting the need for coordination of intervention between adult protective services (APS) and mental health services, researchers designed this qualitative study to evaluate the perceptions that Indiana APS investigators held regarding their interactions with the state's Community Mental Health Centers (CMHCs). Thirty-three of the state's 34 investigators participated in the interview process which addressed topics such as the problems and frustrations perceived when referring to CMHCs, procedural issues, quality of working relationships, needed improvements, and service gaps. In particular, diagnostic issues (mental illness versus dementia or other medical conditions, such as traumatic brain injury) posed barriers to evaluation and psychiatric hospitalization of endangered adults. Other issues included problems in sharing information due to perceived conflicts with confidentiality on the part of the mental health clinicians, and limited placement options, especially for clients demonstrating aggressive behaviors related to dementia. Investigators identified a number of strengths, including effective working relationships and increased understanding regarding information sharing on behalf of endangered clients. Increased dialogue and interdisciplinary team approaches were among the recommended interventions to enhance service delivery.

N4868-15
Cohen, C., Sokolovsky, J. & Crane, M.
Aging, Homelessness, and the Law
International Journal of Law and Psychiatry; Vol. 24 (2-3), 167-181; 2001.
Legal scholarship
Although the aging homeless are relatively invisible in the media and throughout the literature, it is estimated that 20 per cent of the U.S. homeless and 33 per cent of London's homeless are aged fifty and over. This article explores the link between the law, aging, and the homeless. The historical evolution of homelessness in Western civilization is traced as the moral economy of charity gave way to the criminalization of this vulnerable group, and then to a modification of criminalization. Perspectives are offered as to how current laws in Great Britain and the U.S. affect the aging homeless, and how the law may be used to address the problem. The compounding factor of mental illness is also considered.

L4534-4
Fried Ellen, E.
Detecting and Treating Geriatric Depression
Geriatric Times; Vol. II (3); May/June 2001.
Based on the fact that the depressed elderly are more likely to seek help from their primary care physicians than mental health professionals, this article provides the physician with guidelines for assessment and treatment of this underdiagnosed condition. The importance of family input, a thorough history and a detailed medication evaluation is emphasized, as well as the reciprocal impact of depression and various illnesses. (Note: This article is available online only at http://www.geriatrictimes.com/g010506.html .)

N4891-9
Malphurs, J., Eisdorfer, C. & Cohen, D.
A Comparison of Antecedents of Homicide-Suicide and Suicide in Older Married Men
American Journal of Geriatric Psychiatry; Vol. 9 (1); 49-57; Winter 2001.
Journal article (research)
This study, part of ongoing retrospective research examining the phenomenon of homicide-suicide in older people, compares characteristics of older perpetrators of homicide-suicide with characteristics of those who committed suicide alone. Records from various counties in Florida (from 1988-1994) of twenty-seven men who perpetrated spousal homicide-suicide were compared with those of thirty-six married males who committed suicide. Suicide victims typically appeared to have significantly more disease than the homicide-suicide perpetrators, while approximately half of the homicide-suicide perpetrators were providing caregiving as compared to 17 per cent of the men who committed suicide. Depression appeared to be significant among both groups, though none of the perpetrators tested positive for anti-depressants. The researchers emphasize the need for health professionals' sensitivity to the presence of depression as a preventative measure.

N4584-8
Nagatomo I., Akasaki, Y., Tominaga, M. et al.
Abnormal Behavior of Residents in a Long-Term Care Facility and the Associated Stress of Care Staff Members
Archives of Gerontology and Geriatrics; Vol. 33, p203-p210; 2001.
Journal article (research)
This study focuses on the relationship between abnormal behavior and depression among Japanese special nursing home residents, and the impact these factors have upon staff. In this research, 99 residents of a Kagoshima Prefecture special nursing home were rated by their caregivers for abnormal behaviors (with the Dementia Behavior Disturbance scale), cognitive abilities, depression (by using the Cornell Scale for Depression in Dementia) and ability to perform activities of daily living (ADL). Caregivers were also assessed for stress and burnout. The results show a correlation between behavioral difficulties and depression. The researchers postulate that assessment and treatment for depression among this population may decrease behavioral problems that impact negatively upon their care, and on the stress level of caregivers.

N4640-9
Steketee, G., Frost, R. & Kim, H.
Hoarding by Elderly People
Health and Social Work; Vol. 26 (3), 176-184; August 2001.
Journal article (research)
Although compulsive hoarding has been publicized in recent years, little research has been conducted regarding this behavior in the elderly. This study was designed to observe how compulsive hoarding is manifested in the elderly, and to explore its impact upon functioning, as well as any relationship it may have with cognitive deficits and physical and psychological conditions. Thirty-six providers of home services to the elderly and eight public health officials were interviewed regarding 42 cases of reported compulsive hoarding. Researchers hypothesized that information-processing and memory deficits would be present in compulsive hoarders. Findings did not support this; however, 44 per cent of the hoarders appeared to have a mental illness, and nearly two-thirds demonstrated difficulty with self-care. For more than 80 per cent of the hoarders, the clutter posed a physical threat to their safety.

P5566-8
Teresi, J. et al.
Prevalence of Depression and Depression Recognition in Nursing Homes
Social Psychiatry and Psychiatric Epidemiology; Vol. 36 (12), 613-620; 2001.
Journal article (research)
This research was intended to assess the prevalence of depression among nursing home residents as well as the recognition of depression within this population by the nursing and social service staff. Three-hundred and nineteen residents from six downstate New York institutions were assessed for depression, initially by psychiatrists using the DSM-III R criteria, and then by staff (nurses, nurses aides and social workers). According to the psychiatric assessments, testable residents demonstrated a 44.2 per cent rate of significant depressive symptomotology (major depressive disorders, minor depressive disorders and probable and possible depression). Rates of recognition for social workers were 19.7 per cent, 29 per cent for nurses, and 32 per cent for aides. Following the use of the Depression Recognition Scale, staff recognition increased to between 47 and 55 per cent. Also presented is a discussion of prevalence of depression according to cognitive functioning levels and age subgroups.

P5591-126
U.S. Department of Health and Human Services (DHHS) and the Administration on Aging (AoA)
Older Adults and Mental Health: Issues and Opportunities
U.S. Department of Health and Human Services (DHHS) and the Administration on Aging (AoA)
Agency report
This report was written as a companion document to "Mental Health: Report of the Surgeon General" and is intended to focus on community-based services designed for a wide variety of elders. In addition to outlining the challenges of service delivery for those with severe mental illnesses and those experiencing acute stress, it also describes the need for psycho-educational programs for mentally healthy individuals. Chapters are organized around the following topics: community mental health services; primary and long-term care; supportive services and health promotion; Medicaid and Medicare financing of mental health services; and challenges in mental health and aging. Initiatives that address these challenges are highlighted throughout the report, and include such programs as the Preadmission Screening Resident Review (PASSR), the Eden Alternative, the Geriatric Mental Health Care Training Project, adult day services (ADS), the Alert and Alive program, outreach efforts such as the Gatekeeper Program, peer counseling programs, caregiver programs and respite care. Appendices include a summary of Chapter 5 of Mental Health: Report of the Surgeon General" and a resource listing. (Note: This report is accessible online at http://www.globalaging.org/health/us/mental.pdf .)

P5045-10
Williamson, G., Shaffer, D. and The Family Relationships in Late Life Project
Relationship Quality and Potentially Harmful Behaviors by Spousal Caregivers: How We Were Then, How We Are Now
Psychology and Aging; Vol. 16 (2), 217-226; 2001.
Journal article (research)
This research explores the hypothesis that the quality of a relationship before the need for caregiving arises impacts later caregiving behaviors. In particular, the authors consider the impact of the degree to which relationships were perceived as communal (partners concerned about or attentive to each others needs) and to the degree that the caregivers perceive the current relationship as rewarding. One-hundred and forty-four spousal caregivers were interviewed regarding their past relationship, the amount of assistance provided, the relationship rewards, caregiver depression, and potentially harmful behaviors. Results suggest that caregivers who were involved in highly communal relationships were less likely to become depressed, and in turn, less likely to treat care recipients in potentially harmful ways, since they are currently experiencing rewarding relationships.

N4708-4
Zylstra, R. & Steitz, J.
Physician and Public Knowledge of Depression Among Older Adults
Gerontology & Geriatrics Education; Vol. 21 (3), 13-20; 2001.
This article explores differences in perceptions of depression among older adults between the general public and physicians. The study compares a group of 52 non-geriatric physicians to a public group of 235 adults in the 1999 Zylstra and Steitz study. The accuracy of the physicians' perceptions was greater (80 per cent compared to 44 per cent); however, results also indicate that physicians may incorrectly expect depression to be a normal part of the aging process. Similarly, they may mistakenly perceive that lower levels of depression do not warrant, and would not respond to, psychopharmacology.


2000

L4432-8
Cohen, D.
Homicide-Suicide in Older People
Psychiatric Times; Vol. XVII (1); January 2000.
Online journal article (scholarship)
This article provides an overview of homicide-suicides in the older population. There is discussion of incidence rates, clinical characteristics and perpetrator profiles. Three subtypes of homicide-suicides are identified: dependent-protective, aggressive and symbiotic. The author stresses the importance of detection of depression in caregivers as well as patients as a preventative step. (Note: This article is available online only at http://www.psychiatrictimes.com/p000149.html .)

L4536-7
Cohen, D.
Caregiver Stress Increases Risk of Homicide-Suicide
Geriatric Times; Vol. I (4); November/December 2000.
Online journal article (scholarship)
This article explores the impact that depression and caregiver stress has on the incidence of homicide-suicides. The myth that most homicide-suicides are mercy killings is disputed with statistical evidence that indicates that perpetrators are often acting unilaterally and out of desperation. Pointing out that most homicide-suicides are planned in advance, and that most caregiver/perpetrators are involved with the victim's physician, the author offers strategies for assessment and intervention that can be employed by the health care professional to aid in risk identification. (Note: This article is available online only at http://www.geriatrictimes.com/g001225.html .)

N4616-5
Eisdorfer, C. & Cohen, D.
Homicide-Suicides in Older Persons: Acts of Violence Against Women
October 18, 2000
Roundtable discussion background paper
In this paper, prepared for the Medical Forensic Issues Concerning Abuse and Neglect roundtable discussion, the authors review their findings on homicide-suicides (H-S) among the 55 and older age group. The research presented indicates that most older women are unaware victims, not willing partners in a death pact. They discuss the subtypes of H-S; half can be categorized as dependent-protective subtype, one-third can be categorized as aggressive subtype wherein there is a history of physical and/or verbal conflict, and twenty percent can be categorized as the symbiotic subtype. A common risk factor is undetected, untreated depression in the perpetrator and therefore the authors urge all health care professionals, particularly primary care physicians, to be alert to indicators of depression in caregivers as well as patients.

P5073-10
Frost, R., for The Hoarding of Animals Research Consortium
People Who Hoard Animals
Psychiatric Times; Vol. XVII (4); April 2000.
Online journal article (scholarship)
This clinical discussion reviews the scant research available on the psychiatric and psychological theories regarding animal hoarding and explores a number of proposed theories. The most recent research, from the Hoarding of Animal Research Consortium (HARC), appears to support earlier findings that hoarders tend to be female, older and typically hoard objects as well as animals. Delusional disorders, dementia, addiction, zoophilia, attachment disorder and obsessive-compulsive disorder are among the models discussed. Multi-faceted treatment approaches are warranted and should be tailored to the specific needs of the individual. (Note: This article is available online only at http://www.psychiatrictimes.com/p000425.html .)

N4632-5
Knowlton, L.
Treating Suicidal Elders
Geriatric Times; Vol. I (3); September/October 2000.
Online journal article (scholarship)
This article outlines the highlights of Dr.Yeates Conwell's lecture on suicide among the elderly. He reports that adults over seventy are at the greatest risk for suicide of any age group in America. Suicide rates have increased in this age group since the 1980's and attempts tend to be more lethal, most likely due to the increased frailty and social isolation of this population. Among other concepts, he discusses the ageist notion that suicide among the elderly is more "acceptable" than suicide among younger people, that bereavement intensifies other factors of depression, and that the strongest risk factor appears to be a history of psychiatric illness. Prevention involves education for risk identification (particularly in the primary care setting) and outreach programs. (Note: This article is available online only at http://www.geriatrictimes.com/g001010.html .)

N4603-3
Lindbloom, E.
How Can We Identify The Physical And Psychological Markers of Abuse and Neglect?
October 18, 2000
Roundtable discussion background paper
In this paper, prepared for the Medical Forensic Issues Concerning Abuse and Neglect roundtable discussion, the author, a physician and professor of family medicine, outlines his approach to treating elderly patients and their caregivers while observing for markers of abuse. He indicates that frailty, cognitive impairment, depression, substance abuse are risk factors for victims, while mental illness, behavioral issues and legal issues, as well as substance abuse issues, are risk factors for perpetrators. Also considered are complexities regarding the responsibilities of the caregiver versus the rights of the elder who suffers from some degree of dementia. (Note: This entire report is available online at http://www.ojp.usdoj.gov/nij/topics/crime/elder-abuse/roundtable/short-papers.htm .)

P5334-210
Papadopoulos, A. & LaFontaine, J.
Elder Abuse: Therapeutic Perspectives in Practice
Winslow Press Ltd., Oxon, U.K.; 2000.
Book
This book, written by two clinical psychologists, is intended to assist counselors and other clinicians who are working with older individuals and their families. The first part provides an overview of elder abuse as a societal problem, and the second part addresses the psychological dynamics of elder abuse and its impact upon older individuals. Therapeutic interventions, such as the ABC diary used for assessing the problem, and treatment modalities, such as cognitive therapy, individual, couple and family counseling, are outlined. In part three, relationships within families where abuse is present are considered. Dependency, transgenerational violence and intrapersonal factors (such as mental illness and/or substance abuse problems) that contribute to and sustain abusive environments are examined. Systemic approaches of intervention are explored. Part four discusses abuse within institutional settings. Staff, resident and facility characteristics that present risk factors are identified. Part five concludes with a discussion of professional issues such as factors affecting therapeutic objectivity and interagency and multidisciplinary team work. (Note: This book is not available through CANE.)

N4581-9
Rogers, A. & Barusch, A.
Mental Health Service Utilization Among Frail, Low-Income Elders: Perceptions of Home Service Providers and Elders in the Community
Journal of Gerontological Social Work; Vol. 34 (2), 23-38; 2000.
Journal article (research)
Although research suggests that as many as one in three frail elderly patients suffer from some form of depression, the condition remains underdiagnosed. This article reports on the study of seventy-nine frail, low-income participants of The Alternatives Program (TAP) in Salt Lake County. These clients receive social support services in order to maintain independent residence. Participants were screened for depression using the Center for Epidemiologic Studies Depression Scale (CES-D). In addition to finding 29 per cent of the participants demonstrating symptoms of depression, the analysis compared the participant's perception of their depressive symptoms with that of his or her case manager. Only 31 per cent of those who screened positive for depression received counseling. Possible reasons for poor detection are discussed.

P5506-66
Schonfeld, L., VandeWeerd, C. & Berko, L.
The Relationship Between Elder Mistreatment and Depression
Funded by the Department of Elder Affairs; published by the University of South Florida, Louis de la Parte Florida Mental Health Institute, Tampa, FL; September 2000.
Agency report
The purpose of this project, sponsored by the Florida Department of Elder Affairs (DOEA), was to explore the link between depression and elder abuse and neglect. The first section of this report provides a review of the three waves of elder abuse research. The following section presents the results of a key informant survey of law enforcement agencies in selected Florida counties to identify what information is collected regarding substance abuse, depression and elder abuse. In the final section, records from the Florida Department of Children and Families were examined for information regarding mental health issues in elder abuse cases. In general, information regarding the mental health and substance abuse issues of elder victims was poorly documented. Recommendations of the study include the need for the DOEA to begin coding and tracking mental health data on both the Client Information Registration and Tracking System (CIRTS) and the Comprehensive Assessment and Review for Long Term Care Services (CARES) in order to provide appropriate services and support to elders. Further, the DOEA should provide training in elder abuse identification to those professionals who may be likely to serve as sentinels (such as law enforcement, protective service workers, health care professionals, social workers, case managers, and in-home service providers), and to develop a depression assessment protocol for elders being served. Also, data collected by the Florida Abuse Hotline Information System should collect uniform information regarding mental health and substance abuse issues of service users. (Note: This report, available as a loan item, must be obtained through the Louis de la Parte Florida Mental Health Institute. For more information, please contact 813/974-4471.)

1999

K4212-8
Brownell, P., Berman, J., and Salamone, A.
Mental Health and Criminal Justice Issues Among Perpetrators of Elder Abuse
Journal of Elder Abuse & Neglect; Vol. 11 (4), 81-94; 1999.
This article reports the findings of a survey by the New York City Department for the Aging (DFTA) of older victims of reported domestic abuse seeking assistance from the DFTA Elderly Crime Victims Resource Center. Results support recent research suggesting that perpetrator pathology or impairment appears a stronger predicator of elder abuse than victim characteristics. Impaired and unimpaired abusers are compared on the basis of age, employment, living arrangements, and history of involvement with the criminal justice system.

P5592-72
U.S. Department of Health and Human Services (DHHS)
Mental Health: A Report of the Surgeon General - Chapter 5
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; Rockville, MD; 1999.
Agency report
This chapter from "Mental Health: Report of the Surgeon General," (DHHS, 1999) provides an overview of issues related to the mental health of older adults. The first segment presents information on normal developmental processes associated with aging, including the development of adaptive qualities that allow most older individuals to handle the challenges of this life stage. The following section addresses mental illness as it impacts upon elders in terms of assessment and diagnosis, prevention, and treatment. Depression, Alzheimer's dementia, anxiety, schizophrenia and substance abuse are topics examined. The chapter concludes with a review of resources beyond traditional treatment options for this population, including self-help groups, community-based supports, and consumer advocacy. (Note: This chapter, along with the entire report, can be accessed online from the Table of Contents page at: http://www.surgeongeneral.gov/library/mentalhealth/toc.html .)


1998

M98
Wisconsin Coalition Against Sexual Assault (WCASA)
Widening the Circle: Sexual Assault/Abuse and People with Disabilities
Wisconsin Coalition Against Sexual Assault, Madison, WI; 1998.
Manual/video
As quoted from the introduction, "This manual...is structured to assist sexual assault service provider agencies, human services personnel and others to widen the circle of our communities to include all of us who are vulnerable to being victims/survivors of sexual violence..." The manual (which is accompanied by a video) covers such topics as increasing service accessibility for people with developmental, physical, psychiatric and cognitive disabilities and the elderly, and promoting awareness of these services to these populations. The manual provides many practical guidelines, including the "Disability Etiquette," which instructs service providers in terminology and communication skills that are person-centered and facilitative. Various case scenarios of "hands off," "hands on," and "harmful genital practices" are used to illustrate different types of sexual abuse that include stranger or acquaintance sexual assault, caregiver sexual assault, incest and intimate partner violence. Guidelines for responding to disclosure, investigating allegations made by individuals with cognitive and communicative limitations, and interviewing guidelines are outlined. In addition, the manual provides an overview on developmental disabilities (such as mental retardation, autism, cerebral palsy, brain injury), mental illnesses (including schizophrenia and bi-polar mood disorder), physical and/or sensory disabilities (including mobility impairment, visual impairment, speech and hearing impairment, and a range of other conditions). Assisting older survivors of childhood sexual assault, counseling interventions (including a section on dealing with suicidality as a result of victimization and/or post traumatic stress disorder), programming considerations and working with guardians are among the other topics addressed. Other contributors include Joanne Berman, Eileen Dombo, Roy Froemming, Dianne Greenley, Leslie Myers, and Christine White. (Note: This manual is available only through WCASA, 123 E. Main St., 2nd floor, Madison, WI, 53703, voice/TTY 608 257-1516; web site: http://www.wcasa.org . Price: $30.00 WCASA members/$40.00 non-members.)

1997

P5018-7
Thomas, N.
Hoarding: Eccentricity or Pathology: When to Intervene?
Journal of Gerontological Social Work; Vol. 29 (1), 45-56; 1997.
Journal article (scholarship)
This article provides an overview of hoarding behaviors as they relate to the elderly. The author, a seasoned geriatric social worker, provides case scenarios illustrating varying degrees of hoarding behaviors in which competency and dangerousness require assessment. Interventions are then tailored to the degree of dysfunction and receptivity of the client. Relationships between such behaviors and mental illnesses and dementias are discussed. Establishing an alliance with the client is considered essential in beginning the process of change, which is likely to be slow.

1995

L4398-18
Longres, J.
Self-Neglect Among the Elderly
Journal of Elder Abuse & Neglect; Vol. 7 (1), 69-86; 1995.
Journal article (research)
This study examines the differences between cases of self-neglect and cases of maltreatment by others. These cases were collected by combining three years of data from the Wisconsin Elder Abuse Reporting System with in-depth interviews from elder abuse investigators. It was found that certain living arrangements were associated with the type of maltreatment. Also associated were mental illness, substance abuse problems and dementia. Data also suggested that family context may have a significant role in maltreatment. The impact of these findings on policy, program development and practice is also discussed.