5. CGA in Primary Care Settings: Psychological components

Mood

Depression in older people has a prevalence of 5-10 per cent in those aged over 65, but is frequently under-recognised.  It is associated with higher morbidity and poorer outcomes from physical illness.  Older people under-report symptoms of depression, and may attribute them to the effects of ageing.  Somatic symptoms are more common than in younger people with depression.

Assessing mood, looking for depression, requires close observation of expression and affect during the  conversation. Evidence of psychomotor retardation is often present in older people with depression but can be missed if there are other reasons for this such as Parkinson's Disease.  Likewise older people presenting with weight loss, poor sleep or increasing pain with stable physical issues could well have a depressive illness and this needs to be considered.

Simple screening questions which might help include:

• During the last month, have you often been bothered by feeling down, depressed or hopeless? 
• Do you ever sit and cry for no reason? 
• Do you worry about the future and what it might hold? 
• During the last month, have you often been bothered by having little interest or pleasure in doing things?
• Do you feel lonely?

However, people are often embarrassed to admit these things in front of others and it is usually more fruitful to ask these questions during the physical examination when perhaps family and carers are not in the room.

If indicated, it might be helpful to proceed to a more formal depression assessment – potential tools include the Geriatric Depression Score (see Further information, below). This is validated for older people with no, mild or moderate cognitive impairment.

Diagnosing depression in those with significant cognitive impairment is a diagnostic challenge, and specialist referral is usually required. Some symptoms of depression such as tiredness, weight loss and psychomotor retardation also occur in dementia.  A history of the symptoms from an informant may be helpful.

Older adults with depression are at higher risk of completed suicide than younger people, so specific enquiry into suicidal thoughts should always be made.  Risk factors for suicide in older people include:

• Older age, male gender.
• Social isolation and or bereavement.
• History of attempts and or evidence of planning.
• Chronic painful illness or disability.
• Drug or alcohol use.
• Sleep disorders.

Cognition

It is a useful approach to use the social aspects of the assessment conversation to judge whether or not there is a possible issue with cognitive dysfunction. It is important to have a low threshold of suspicion as many people with dementia have learned to cope with day to day social questions despite significant cognitive deterioration.

Often a simple screening question addressed to the patient and/or family and/or carers can be a useful introduction to the subject. One such question is: has the person been more forgetful in the last 12 months to the extent it has affected their daily life? For example, difficulty using the phone, managing shopping lists, using money, managing their medication, driving, etc.

The rate of decline is important to distinguish delirium from dementia.  Cognitive decline which is rapid and which has taken place over days to weeks as opposed to months or years is more likely to represent delirium. 

The progression (smooth or stepwise) may differentiate the type of dementia suspected.

If there are grounds for suspicion that dementia or mild cognitive impairment may be present, most older people are then happy to undertake a more formal assessment of their cognitive function. 

The GP-Cog test takes about 5 minutes to complete and includes an informant interview. 

Although the Hodkinson Abbreviated Mental Test Score (AMTS) is a useful and fast screening test, it was developed in hospital-based care and can miss executive dysfunction. It has never been validated for use in primary care.

More detailed assessment of cognition can be done with either the Mini Mental State Assessment (Folstein); however its use is subject to copyright. It also does not examine executive function in detail. The Montreal Cognitive Assessment, which is available free of charge after registration, has been developed to detect mild cognitive impairment in many conditions.