Depression is common in older patients and can often coexist and/or be confused with dementia and delirium. Additionally, screening for depression can be challenging because standard clinical assessments have diminished sensitivity and specificity in older patients. The provider needs to incorporate validated screening instruments, nonverbal communication and clinical judgment in order to identify the symptoms of depression in older patients.
Depression Screening. The patient health questionnaire-2 is a two-item depression screen that has been demonstrated to be valid in older adults. The patient health questionnaire-2 asks the patient if they have been bothered by "little interest or pleasure in doing things" or "feeling down, depressed, or hopeless" in the last 2 weeks. If a patient answers 'yes' to either question, then further assessment for depression is warranted. While a positive patient health questionnaire-2 necessitates further interview and assessment, this brief depression screen has a time and efficiency advantage over many other depression screening instruments.
Depression Assessment. In the older population, the 15-item short form of the Geriatric Depression Scale (GDS) is one of the most frequently-used assessments. The GDS utilizes 15 yes/no questions to identify symptoms of depression. Yesavage lists the questions in the GDS and the scoring format for the scale. A positive response on 11 or more items is considered indicative of moderate to severe depression, on six to ten items is considered to be indicative of mild depression and on five or less is considered not depressed.
While alcohol use generally declines in older patients, older age also changes the ability to metabolize alcohol due to comorbidities, medications and changes in body composition changes. Thus, older patients can become intoxicated on fewer drinks. Complications of intoxication are more prevalent in older patients including: fractures, depression, cognitive impairment and delirium. In addition, alcohol use is viewed differentially generationally. Thus, the assessment of alcohol usage should be performed in all patients.
Alcohol Screening. In general, alcohol-screening instruments have decreased sensitivity and specificity in the older patient. However, screening still plays an important role in the assessment of alcohol use. The single alcohol screening question is: 'When was the last time you had more than X drinks in one day?', where X = 5 in men and 4 in women. A response of <3 months has 85% sensitivity and 70% specificity for an alcohol problem compared with the alcohol use disorders identification test.[50,51] Unfortunately, the validation study was performed primarily in younger patients. Further studies found increased sensitivity and specificity when combined with a question about alcohol frequency such as "when you consume alcohol, how many days per week do you have a drink containing alcohol?"; a positive response is more than three. The two combined questions have a sensitivity of 97% and a specificity of 88% compared with the alcohol use disorders identification test.
Alcohol Assessment. An alcohol assessment that has been validated in older patients is the short Michigan alcohol screening test (geriatric version). Like the GDS, it consists of yes/no questions with a positive screen occurring when the patient answers 'yes' to two or more questions. When compared with the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders, the short Michigan alcohol screening test (geriatric version), has a sensitivity of 85% and specificity of 93% for an alcohol problem.[54,55] The short Michigan alcohol screening test (geriatric version) is available online and includes questions related to underestimating how much one drinks; skipping meals due to drinking; drinking to relax, forget one's problems or reduce shakiness or loneliness; forgetting events due to drinking; drinking after experiencing a loss; making rules to manage one's drinking; or having a doctor or nurse concerned about one's drinking.
Aging Health. 2013;9(6):579-591. © 2013 Future Medicine Ltd.