Depression in Elderly Care Recipients

Depression in Elderly Care Recipients
by Nick Zullo

Introduction

Depression . . so mysteriously painful and elusive . . . remains mysteriously in-comprehensible to those who have not experienced it in its extreme mood, although the . . . "blues" which people go through occasionally . . . are of such prevalence that they do give many individuals a hint of the illness in its catastrophic form.

This description is from William Styron's book, "Darkness Visible" (1990, p. 32). The book is a rare literary account of depression. It revealed to many their inability to fully imagine what they had not experienced; and instilled in others a willingness to fully express what they had. Styron "helped to unlock a closet from which many souls were eager to come out" (1990, p. 34).

He wanted to correct misunderstandings regarding this mental illness. Those misunderstandings included the affects of depression on the elderly. After his own recovery from depression in 1986, Styron learned of the suicide of the aged Italian chemist and humanist, Primo Levi, in 1987. Levi had survived internment by the Nazis at Auschwitz , completed an exemplary career, and was in late life admired by his colleagues. After his death, however, at a symposium on his life and works, scholars lamented the weakening of character in his old age due to what they perceived was his self-destruction.

Styron began to speak out, to write articles, and eventually, his book. His message was, "the pain of severe depression is unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne" (Styron, 1990, p. 33)

Prevalence of Elder Depression

Researchers estimate that 20% of community dwelling elders experience symptoms of depression, and the prevalence rate for depression in older women is twice that of men (Huisani, 2004, p. 295).

Late-life depression can have serious repercussions, increasing mortality and disability, higher health care utilization, and longer hospital stays. Yet 63 percent of older adults with a mental health disorder experience an unmet need for mental health services" (Huisani, p. 296).

While Americans are living longer, illness, disability, and injury will eventually happen with advanced age. According to the Administration on Aging, 53 per cent of persons age 65 and older have at least one disability and 33 per cent have a severe disability. Thus, over 7 million elderly persons require assistance with the activities of daily living, i.e., eating, dressing, bathing, getting in and out of bed, etc. All of this increases sharply for persons over 80 years of age.

Consequently, "an estimated 15 per cent of U.S. adults are providing special care for seriously ill or disabled relatives" (Dixon, 2003, p. 5). These family caregivers are simultaneously caring for their own children and often working outside the home as well. Over 22 million households are providing informal care to an elderly relative or friend. "Adults who are caught between caring for aging parents/relatives and raising children at the same time have been referred to as the sandwich generation" (Dixon, 2003, p. 6). To all of this, add the problem of elder depression in perhaps one in five of all family caregiving relationships.

Do families even know what they're dealing with? How do we completely care for what we don't fully understand? Sadly, there is a "what's the use" attitude regarding our elderly. Our society is youth oriented. Old age is just the end of life. The elderly are merely "invisible citizens" (Dixon, p. 5). Family members and caregivers could change such attitudes by influencing a more empathic notion of aging in the family system and in the society of increasing numbers of elderly around us. The needs of aging Americans should not be ignored. Margaret Kuhn, a founder of the "gray panthers" in 1971 and advocate of the rights of elderly persons until her death in 1995, stated well that "aging is a life-spanning process of growth and development from birth to death.

Old age is an integral part of the whole, bringing fulfillment and self-actualization. She regarded aging as a triumph, a result of strength and survivorship" (Dixon, 2003, p. 5). Caregivers may benefit from perceiving every elderly person as a hero or heroine, just as every infant is perceived as precious or adorable.

The elderly themselves "ignore the blackness that has overcome them" (Morris, 2004, p. 281) because it is hard for them to move away from beliefs borne of their time when depression was judged to be a weakness and a result of flawed character. Moreover, they may think a person should just be able to handle it themselves. Family members may have to re-train their own perspectives, and view depression for what it is instead of excusing, avoiding, or putting up with indicators such as antisocial or grumpy behavior, unexplainable weight loss, or sleeping at odd hours. Depression is not normal at any age. Do not overlook possible depression because of other illnesses, medications, or grieving. These issues which seem like the problem could also be the depression triggers.

For the elderly, compounded losses of spouse, siblings, and friends cause tremendous changes and affect emotional well-being. Elderly women live longer and suffer greater effects of loss and are more often widowed. 57 per cent of women over age 65 are not married ( Dixon, 2003, p.6). Although the majority of older persons are alone due to death, divorce is increasingly becoming a factor. Women alone are more likely than men to live in poverty, on limited income, and with limited social activity (Dixon, p. 6). This increased isolation and its causes are a cause of depression.

Loss of physical functioning and independence is associated with depression. Furthermore, research has shown "depression in old age to be an independent risk factor for disability, similarly, disability was found to be a risk factor for depression" (Lenze, 2001, p. 113). Disability restricts activity due to impairment. Restricted activity means reduced social interaction, reduced sense of impact and value as a person, and increased dependence in order to get through the day. Help with the activities of daily living (ADL's) becomes necessary, as mentioned above, feeding oneself, dressing, bathing, toileting, and mobility. IADL's are less basic tasks for independent living, including food preparation, cleaning, and paying bills. They may be physical activities, but they are considered mental activities as well.

It is the mental component of physical disability that distinguishes it from physical impairment and makes it a broader concept. This is important to note because physical disability has been shown to improve with treatment for depression, presumably due to the mental component.

Quality of life, a still broader concept than physical disability, includes the physical, social, role position in family and community, and life satisfaction elements. "Depression affects quality of life" (Lenze, p.114), life at the core. Quality of life in one's final year should be equal to that in one's first. In both of those years, it is the people around us that make all the difference.

Depression is associated with vision impairment. Sight is probably considered the most valuable of all the five senses. "In a sample of 1,000 elderly people with severe visual impairment, the most depressed subjects with the least socialization and highest mortality rate were those in whom visual impairment had been neglected or not sufficiently corrected" (Cantor, 1999, p. 339). A common reaction to vision loss is depression. Self-sufficiency and self-esteem are diminished. The visually impaired person mourns the loss of the sighted self. In some cases, suicide is the result.

As high as "40 percent of people with dementia also suffer from depression" (Morris, 2004, p. 284). Depression may be mistaken for dementia and left untreated, but depression is often coupled with dementia. If an elderly person is suffering from depression, regardless of what else is happening, it should be treated. Even when coupled with dementia, if depression is treated, it could help with some of the confusion (Morris, p. 285).

The elderly are at higher risk for suicide than any other segment of the population. "Older suicide victims are (also) more likely to have suffered from depressive illness" (Yeates, 2001, p. 32).

Connected factors include illness, a history of suicidal behavior, feelings of hopelessness, a quiet personality, and physical impairment. Research indicates that treatment for depression will reduce the risk of suicide in the elderly.

So, when depression is suspected, how do family caregivers approach the subject? Enlightened family members realize it is not a mood, but a medical illness. They note their elderly parent or relative's loss, fear, boredom, worry, loneliness, stress, genetics, personality, low self-esteem, poor coping skills, medications, illness, poor diet, and/or move to an institution all play a causal role in the on set of late-life depression.

On top of that, they are leery that suggesting to an elderly parent that he or she has a mental health problem may cause a furious reaction. They will want to make it clear that this is a biological and medical issue that can be treated. It does not relate to personal determination or strength of character, and his or her life is too valuable not to get help. The "D" word does not have to be invoked. Tell him or her this "thing" can be dealt with, and it will mean you can remain independent in life. Failing to act may mean dependence, illness, and disability.

Diagnosing Elder Depression

Major depression is diagnosed in the Diagnostic and Statistical Manual, Fourth Edition, Text Revised (DSM-IV-RV) when the older adult, for a 2-week period, exhibits five or more of the following symptoms including at least one of the two major symptoms:

Two major symptoms:

depressed mood (feelings of sadness or emptiness)
lack of interest.

The other diverse additional symptoms include:

significant decrease or increase in appetite
insomnia or hypersomnia
psycho-motor agitation or slow down (observable by others)
fatigue or loss of energy
feelings of worthlessness or inappropriate guilt
diminished ability to concentrate or make decisions
recurrent thoughts of death or suicidal ideation (2002, p. 356).

Melancholic features are more common in the elderly. "The essential features of a Major Depressive Episode, With Melancholic Features, is the loss of interest or pleasure in all, or almost all, activities or a lack of reactivity to usually pleasurable stimuli" (DSM-IV-RT, 2002, 419).

Even when something good happens, the depressed mood is unchanged. Additionally, at least three of the following symptoms occur:

there is a distinct quality of the depressed mood ("different from the sadness experienced during bereavement or a non-melancholic depressive episode" (p. 419)
depression is worse in the morning
there is early morning awakening
psychomotor slow-down or agitation
significant anorexia or weight loss
excessive or inappropriate guilt.

The diagnostic work-up for late-life depression comes from the elderly person's presentation of symptoms and comparisons with known causes (etiology). Basically, the diagnosis is made on the basis of present and past history, including history from a family member, along with nutritional status, functional status, medications, screening for cognitive functioning, and augmented with some specific laboratory tests (Blazer, 2003, p. 249). Vascular depression (due to vascular lesions on the brain) is a subject of growing research, is more common with late-life depression, may be more clinically evident, and may involve additional biological testing, including magnetic resonance imaging scanning (p. 253).

As mentioned, screening is helpful in diagnosing late-life depression. A widely used instrument for this purpose is the standardized screening scale known as the Geriatric Screening Scale (GDS). When an elderly person is hospitalized, transferred to a temporary care facility, or commencing home health care, screening may be appropriate. For instance, hospitalizations occurring due to a heart condition, complications associated with diabetes, falls, fractures, strokes, or malnutrition, make understandable the statistically higher prevalence of major depression associated with hospitalization for medical or surgical services (Blazer, 2003, 251). Additionally, "screening in primary care is critical. Not only is the frequency of depression high, but suicidal ideation is high as well" (p. 254).

The first line of diagnostic awareness is the family. Many symptoms of depression such as fatigue, apathy, weight loss, confusion, and change in appetite could easily be seen as incidental to a current medical condition for which primary care, hospitalization, or home health is sought. Say, for instance, the elderly family member has had a stroke, and its changed him or her completely. It may occur to a perceptive family member that the symptoms are pieces of a treatable depressive episode.

Without such astute family care and perceptiveness in another case, an elderly patient, perhaps reeling in despair, fails to follow the prescribed treatments for his heart disease or arthritis, fails to take care of himself properly, fails to show up for his doctor appointments, and ultimately fails in the process of recovery. Both the physical illness and the mental illness continue to get worse (Morris, 2004, 282).

Self neglect is common and harmful. When elderly people are depressed, they may not take care of themselves. Without counseling and medication for depression, this treatable condition left untreated will compound the risk of stroke and heart disease, "reduce a person's ability to recover from surgery, infection, and illness. Depression causes confusion and exacerbates dementia. It reduces a person's incentive to care for himself, and lowers his energy level" (Morris, 2004, p. 282). Some elderly persons will self-medicate with alcohol or drugs.

Untreated depression could cause "irreversible brain damage" (p. 282), and could lead to suicide. Know the signs of depression, including withdrawal, apathy, crying, hopelessness, changes in weight or sleep habits, and vague physical complaints.

Consider carefully the following:

It is noteworthy that the elderly may not talk about sadness or anxiety, but rather, about the physical manifestations of an upset stomach, backache, headache, sleepless nights, fatigue, or memory loss.
In addition to working with the doctor to find an elderly loved one's biological symptoms, screen for depression.
Ask the doctor point blank. If the issue of depression is not taken seriously, get a second opinion or confer with a counselor with geriatric experience.
Even if a major depressive episode is not diagnosable, mild depression may sort itself out in time. Why not get help through counseling, support, and medical treatment to help the process?
Patients and families should be careful, however, that doctor-prescribed antidepressants are truly necessary in comparison with their side effects (Morris, p. 283).

An example of a caregiver being on one's toes occurred recently when a home care case manager recently received a call on his mobile phone from an elderly husband, who has been caring for his wife in their home for many years. His voice was calm, but pleading. His wife had suffered a number of strokes, is paraplegic, has a sunny disposition, some apparent cognitive impairment, able to feed herself, speech impaired, incontinent, and completely non-ambulatory.

She has recently begun to receive hospice care. He has been her sole caregiver for years, but is recently experiencing weakness, a loss of energy, with increased symptoms of painful arthritis, lack of appetite, significant loss of weight, and complains of his recent inability to cook, come up with something to make, or to clean up the kitchen. In requesting a home caregiver to assist him for a few hours each day,

he himself stated a "woman's touch" is needed in his kitchen and maybe it would "get me better psychologically."

He went on, "I used to keep the kitchen clean as a whistle, but now I'm a piler (just pile things up)."

He concluded, "All of a sudden, I've gone downhill."

He is specific about needing a caregiver who not only can lift and transfer his wife, but one who is, in his words, an independent "self-starter," because he plans to sleep during the day while the caregiver cares for his wife on what he calls her "BM days."

In the perception of this case manager, there are potentially two patients here, not merely the disabled wife. Diagnosis and treatment for depression seemed appropriate in the case of the loving husband, on whom his wife is nearly completely dependent. "Health care providers should identify depression so that patients may receive adequate treatment and enjoy better outcomes" (Weeks, 2003, p. 133).

The Geriatric Depression Scale (GDS was developed by J.A. Yesavage and colleagues twenty years ago for this purpose. This reliable 30-item self report instrument was reduced to 15 items a few years later. It has been translated into numerous languages and is used world-wide. Despite the availability of this reliable tool, many elderly are still not screened for depression during interaction with elder care workers. It may be that the instrument still takes too much time or that its questions are perceived as too negative for the circumstances.

In response to this concern, a study was conducted by S. K. Weeks and colleagues of three other instruments that attempt to shorten the screening process, but are still sensitive, specific, and reliable screens for depression. The most reliable was adopted into a new version of a shortened, two-tiered test that asks 5 questions. If the elderly patient scores 0-1 on the GDS-5, the elderly patient is classified as "not depressed" and no further questions are asked. If the patient scores 2 or more on the GDS-5, questioning continues with the remaining 10 questions and the patient is classified as "suggesting depressed" with a score of 5-9 on the full GDS-5/15.

A score above 9 usually indicates depression. With these results on the Geriatric Depression Scale, the elderly patient can receive further clinical investigation for symptoms of depression. In this study, 40 per cent of the 816 elderly patients screened indicated possible depression on the first 5 questions, and 17 per cent indicated possible depression on the entire 15 question scale (Weeks, 2003, p. 136). Utilization of these questions by family members as they interact with their elderly loved ones could assist families in detecting and responding to symptoms of depression in a way and in a time when it can make a difference in the lives of the elderly.

The questions (Weeks, 2003, p. 138) are as follows:

Table 1. The GDS-5/15 Geriatric Depression Scale
A score above 9 usually indicates depression. Circle each answer. Each answer indicated by an asterick (*) counts as 1 point
Section I
1. Are you basically satisfied with your life?	YES	NO*
2. Do you often get bored?	YES*	NO
3. Do you often feel Helpless?	YES*	NO
4. Do you prefer to stay home rather than going out and doing new things?	YES*	NO
5. Do you feel pretty worthless the way you are now?	YES*	NO
calculate your score in the box below
Score from first five questions =
if a score of 2 or more above, please continue with remaining 10 questions, otherwise depression may not be a problem :
Section II
6. Have you dropped many of your activities and interests?	YES*	NO
7. Do you feel that your life is empty?	YES*	NO
8. Are you in good spirits most of the time?	YES	NO*
9. Are you afraid that something bad is going to happen to you?	YES*	NO
10. Do you feel happy most of the time?	YES	NO*
11. Do you feel you have more problems with memory than most?	YES*	NO
12. Do you think it is wonderful to be alive now?	YES	NO*
13. Do you feel full of energy?	YES	NO*
14. Do you feel your situation is hopeless?	YES*	NO
15. Do you think that most people are better off than you are?	YES*	NO
calculate below the totals from both section one and section two
Score from all fifteen questions =

Treatment for Elder Depression

The outcome of family involvement both to support a process of self screening for depression as well as a process of open, objective, adult-to-adult communication on a subject of relevance in the lives of the elderly is not only conducive to healthy family relationships, but will lead to more screenings, diagnosis, and treatment for elder depression. The use of the shortened Geriatric Depression Scale is a more caring approach because it is more efficient and less negative. Fostering the discovery and diagnosis of depression will prolong the quality of life of the elderly and sustain their independence. That is, if the process leads to effective treatment.

In order for treatment through counseling to become more acceptable, families and caregivers will have to overcome a significant obstacle. "Family physicians consider medications for depression . . . effective for older patients . . . but are less optimistic about the effectiveness of (counseling). Because of this, they may be reluctant to recommend (counseling) to their depressed older patients" (Landreville, 2001, p. 285). Family members and caregivers who have seen the benefits of counseling among the elderly they care for may find it useful to inform others of the effectiveness and acceptability of counseling for elder depression.

In fact, the elderly prefer counseling as a treatment for depression over medication alone, according to Landreville (2001, p. 285). This study included elderly patients of family medicine clinics. This confirmed the findings of other similar studies, that counseling is "considered by older adults as more acceptable than anti-depressant medications for the treatment of geriatric depression" (Landreville, 2001, p. 290).

The Landreville (2001, p. 287) study employed the following kinds of cognitive therapy in counseling:

situations causing increased depressive feelings were identified and discussed
the counselor would help the elderly client to discover whether his or her interpretations of these situations were overly negative or unrealistic

Through counseling, the elderly client would learn to interpret these situations less negatively and more realistically. This cognitive approach involved weekly meetings with the counselor. Additionally, a cognitive biblio therapy approach included readings and learning exercises done at home by the elderly client and weekly telephone discussions with the care provider.

Group therapy has been used extensively in treating the elderly for decades. It is cost effective and has been successful at countering the challenges faced by the elderly. As previously noted, the elderly are dealing with chronic and acute illness, functional incapacity, loss of spouse and friends, and activity restrictions. This causes or increases depression, and leads to social isolation, lowered self-worth, less social support, diminished social skills, and withdrawal. Group therapy counters this with social interaction, mutual support, and "reciprocal validation" (Huisani, 2004, p. 295).

A variety of group therapy approaches are helpful. These include:

Cognitive behavioral therapy, similar to that in the individual counseling sessions described previously. Elderly clients are taught the connection between thoughts, feelings, and behaviors. In a group setting, elderly clients are able to assist one another in identifying and changing thoughts and behaviors that just don't work. Feedback and suggestions in the group setting motivate change.
Reminiscent therapy is effective in the group setting. The elderly can discuss past events, positive or negative. Group members get to know each other on a deeper level, and develop cohesion as a group recognizing the universality of their experience. They feel supported in their grieving and affirmed in their abilities and accomplishments.
Supportive therapy has as its main task in the group setting the objective of helping the elderly to deal with "late-life stress" (Huisani, 2004, 297). The supportive group helps elderly members face current challenges. The group is a resource team, helps to solve problems, and gives present meaningful peer encouragement to the elderly in their day-to-day lives.

Groups typically experience a process of "jelling" quickly. Positive experiences of the participants is the primary reason. A "family atmosphere" is perceived. "For example, if any member were not at the meeting close to the staring time, one of them would leave to check on that person" (Huisani, 2004, p. 300). Members sometimes played cards after the group session. Complaining about doctors became rare. During reminiscence, members felt free to discuss difficult situations that they somehow managed through. They became optimistic about the challenges of aging that lie yet ahead.

A successful program on behalf of the elderly population in the Wasatch Front is the Valley Mental Health Masters Program, an intensive outpatient program for the depressed elderly in our community. Transportation and lunch are provided. The elderly clientele receive help with issues such as: loneliness, loss, poor concentration, loss of interest, poor sleep, sadness, irritability, physical limitations, excessive worrying, fatigue, and poor appetite. Short-term treatment is emphasized to get the elderly and their families stabilized and functioning. The modality focus is on group therapy (see vmh.com).

Depression is one of the most common emotional and psychological disorders found in the elderly and affects relational problems, but the subject of depression and marital relations has been ignored in marriage and family counseling. Although with the growth of the elderly population is changing that. Marital therapy has been successful in treating depression in younger and middle-aged couples and should be applied in treating the increasing numbers of elderly couples.

Previously, the effects of depression on physical and social functioning have been discussed. Depression also affects marital functioning. Depression has been viewed as a result of marital distress, but ought to be considered as a precursor to marriage difficulties as well, particularly in the elderly, for whom "marital distress is an antecedent, concomitant, and consequence of depression" (Sandberg, 1999, p. 393).

"For mature couples, just as for their younger counterparts, marital distress and depression are highly related" (Sandberg, p. 404). Wives' depression is more strongly tied to marital quality. Many studies show this. Feelings of emotional closeness for wives is more highly related than husbands to marital distress. Wives' level of depression results from dissatisfaction in the relationship. This leads to further negative interaction, thus, increasing the husbands' level of depressive symptoms. "This pattern would provide one possible explanation for the finding that wives' level of depression is significantly associated with both partners' perception of marital quality" (Sandberg, p. 405).

Hardiness is a new but significant area of study, not only as a mediating factor for the elderly on the effects of mental illness, but also as a buffer to the negative effects of depression on marriage. Just as social support ameliorates depression, so does hardiness.

Hardiness is a combination of personality features that function as an internal buffer, resource, or strength when stressful circumstances arise. Hardy people are less likely to become physically ill when dealing with extreme stress. "Hardy people feel they can control or influence the events of their experience, feel involved or committed to the activities of their lives, and see change as an exciting challenge to further development" (Sandberg, 1999, p. 406). A lack of autonomy or control may be the opposite of hardiness, and adversely emotional or psychological well-being.

Hardiness as a mediator of grief, stress, and physical illness, whether largely genetic in origin or learned in the family system of origin, and it is collateral for counseling. It should be assessed and fostered in the lives of the elderly in counseling.

Restatement:

Cognitive therapy is known to be effective in treating depression, and could be employed as a means of identifying and re-framing negative thinking that decreases hardiness.
Behavior-based marital counseling could help through problem-solving and communication training.
Life review and reminiscent therapy could also help with helping the elderly clients in restorying past events. Sustaining hardiness in counseling may stave off the need to treat more severe depressive issues later.

Conclusion

The exchange of assistance between aging parents and adult children will always be a key factor in the well-being of the depressed elderly. Feedback and encouragement through that exchange may motivate elderly family members to overcome the reluctance of their generation to seek help for depressive symptoms. Counseling can make all the difference, and the gateway may be a caring family member or elder care professional whose changed vision sees afresh the present worth of an old soul, and acts to foster that elderly person's quality of life now because its never too late.

Bear in mind, however, the potential psychological costs of providing assistance to depressed elderly loved ones who do not want to feel dependent on their adult children because they reject any notion of role reversal and because above all they do not want to be a burden. While the "receipt of assistance from (adult) children is critical to the quality of life of many older persons" (Lee, 1995, p. 823), research has shown its relational effect on elderly depression.

Practitioners and caregivers should temper concerns for the elderly with objectivity and respect. . The keys, or what needs to change in the adult children, are "filial maturity," working out "parent-child" issues of the past, and then firmly recognizing "that aging parents are adults, who need and should have input on decisions that directly affect their lives . . .

(Having thus changed, caring adult children) are more clear regarding decisions about when to provide care, when to let the (aging) parent maintain the autonomy they still need and when to (assist them in pursuing counseling intervention for suspected depression). This is filial maturity" (Sherrell, 2001, p. 383). Indeed, filial maturity of family caregivers and enlightenment on the part of elder care professionals are key combatants against the insurgence of elder depression.

References

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Dixon , C., Michael, R., & Rollins, C. (2003). Contemporary Issues Facing Aging Americans: Implications for Rehabilitation and Mental Health Counseling. Journal of Rehabilitation, Alexandria , 69, 2, 5.

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Lee, G. R., Netzer, J. K., & Coward, R. T. (1995). Depression Among Older Parents: The Role of Intergenerational Exchange. Journal of Marriage and the Family, 57, 3, 823.

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Morris, V. (2004) . How to Care for Aging Parents, New Edition. New York : Workman Publishing, Pages 280-289.

Sandberg, J. & Harper, J. (1999) Depression in Mature Marriages: Impact and Implications for Marital Therapy. Journal of Marital and Family Therapy, 25, 3, 393-407.

Sherrell, K., Buckwalter, K., & Morhardt, D. (2001). Negotiating Family Relationships: Dementia Care as a Midlife Developmental Task. Families in Society, 82, 4, 383-393.

Styron, W. (1990). Darkness Visible: A Memoir of Madness. New York : Random House, pages 7 and 33.

Weeks, S. K., McGann, P. E., Michaels, T. K., & Penninx, B. W. (2003). Comparing Various Short-Form Geriatric Depression Scales Leads to the GDS-5/15. Journal of Nursing Scholarship, Indianapolis , Second Quarter, 35, 2, 133.

Yeates, C. (2001). Suicide in Later Life: A Review and Recommendations for Prevention. Suicide and Life - Threatening Behavior, New York , 31, 32-48.