Mental Illness in Older Adults
With a rapidly aging population, prescribers and non-prescribers alike will no doubt be seeing more elderly patients as more and more baby boomers approach retirement. Currently in the United States, those 65 years of age and older make up 13 percent of the total population, but account for 30 percent of all prescriptions written.
An important starting point is the recognition that most mental health syndromes improve with age. Surveys regarding quality of life issues such as happiness and contentment in older adults consistently yield higher scores when compared to people in their midlife years and young adulthood. The obvious exception here would be the neurocognitive disorders which must be controlled for in any quality studies or surveys.
When psychiatric illness does emerge in late life though, the potential ramifications can be significant. So when an elderly individual begins alluding to appetite or sleep problems or is speaking of feeling depressed, we must pay attention.
A viable indicator for when an older person may benefit from more focused psychiatric attention is their ability to thrive. This includes an assessment of activities of daily living – specifically, are they physically mobile, are they able to keep up with daily chores such as getting to the grocery store, managing their finances and safely able to operate an automobile? And if the person is being treated for certain physical disorders, it’s essential that this treatment not be segregated from the psychiatric help, because the two may very well be joined together. For example, an elderly woman who complains of feeling listless and dysphoric may very well be experiencing depression, but that depression may be influenced by her history of congestive heart failure and a recent hip replacement. As such, overall infirmity is an important consideration.
When it comes to mood disorders in the elderly, what’s most significant is their capacity to experience pleasure. When this waxes and wanes, instead of describing themselves as depressed, they’ll allude to an increasing lack of interest in seeing their children or grandchildren or even other longtime companions. This is often fueled by a growing lack of patience with others and can influence an increased tendency to socially isolate.
Medicating psychiatric concerns in older adults should be approached with reasonable caution. The time-honored adage of “start low and go slow” takes on much significance when the various psychotropic medication classes are employed. As a general rule, the starting dose should be at least 50 percent of that typically employed in younger, psychiatrically-disordered individuals. And although an older adult may very well need and benefit from higher dosing, beginning medication treatment in this fashion can give rise to intolerable side effects and may exacerbate drug-drug interactions eventually leading to resistance to future use and non-compliance. Also, liver and kidney function slows, adding yet another possible complication.
All of the antidepressants that are routinely prescribed in younger age groups are applicable in the elderly. Older, cyclic antidepressants such as Elavil should be avoided, especially in those with memory and cognitive decline. For sleep problems, trazodone use at 50mg or less remains a safe option because of the general absence of anticholinergic effects such as dry mouth, blurred vision, constipation, and memory problems.
Benzodiazepines should be used judiciously because of the risk of falls.
Antipsychotics are currently the most significantly debated medication class when it comes to their use in the elderly. When to use them and in what particular setting has become a hot button issue. Many states vigorously enforce and even prohibit their use in nursing home patients, complicating the conundrum as to how to best pharmacologically manage very agitated older folks residing in these facilities. When utilized, the newer, second-generation agents are preferred.
It’s worth noting that there is good data supporting the use of cognitive-behavioral therapies in conjunction with medication to relieve psychiatric symptoms in this population group. Seniors are usually cooperative and willing to work with more than one discipline. Getting and keeping them connected with more than one treatment professional is the major obstacle, particularly if they’re living alone.
Interventions to promote successful aging include an emphasis on physical activity to maintain strength and endurance and reduce the risk of falls. Nutritional strategies include caloric restriction to promote weight loss and increase mobility or the use of supplements to enhance weight gain in those who have lost interest in eating. Also, reducing social isolation through group activities and embracing a sense of spirituality can help considerably.
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.