Geriatric psychological disorders

Type of psychology: Biological bases of human behavior; Clinical; Counseling; Developmental; Family; Geriatric; Psychopathology; Psychotherapy

In 2013 the population of people in the U.S. older than 65 was 14%, an increase from 11% thirty years ago. This number is expected to soar to 20%, or 90 million people, within the next thirty years. The sheer amount of resources that will be spent on the care of older persons makes it imperative for those in the medical industry to find effective, efficient, and holistic mechanisms to support the mental and psychological health of aged persons. There can be some optimism as the majority of mental health disorders that older persons face can be prevented or delayed with simple and straightforward lifestyle changes.

Introduction

The diagnosis and treatment of mental health problems in older persons is more difficult than that of young people for three reasons. First, there is a greater number of elderly people than ever before. The result is more cases of certain disorders that previously went unnoticed in the elderly. Second, the lack of previous data on these disorders makes effectively treating them more difficult. Care must be taken to account for physical differences in the aged body and mind. Diagnostic tools and treatments that are used for young people may not be appropriate for older patients. Third, many mental health problems in older persons stem from physical problems. Psychologists and caregivers may face a “chicken and egg problem” when diagnosing mental health disorders in older persons. That is, did mental decline begin first or did physical impairment lead to cognitive impairment? In addition, mental health disorders may change over time symptomatically or may not emerge until one is of advanced age. Care must be taken to properly diagnose and treat the root cause of a mental health disorder in an elderly person.

Dementia, depression, and anxiety: The big three

Older people may suffer from the same psychological disorders as younger people. However, there are several conditions that normally do not begin until old age. The most common of these is dementia, but older persons may also develop depression and/or anxiety. A survey of U.S. nursing home residents revealed that a staggering 89% suffered from dementia or the behavioral and psychological symptoms associated with dementia, 36% showed signs of depression, and 12% suffered from anxiety disorders.

Alzheimer’s and dementia

Dementia is the most common mental disorder affecting older persons, and it negatively impacts memory, thinking, and reasoning abilities. Simple chores such as driving from one place to another are affected. The behavioral and psychological symptoms of dementia include non-cognitive aspects such as agitation, sleep disturbances, elation, and hallucinations.

Alzheimer’s disease is the most common cause of dementia in older persons. It involves the slow and irreversible degeneration of brain tissue due to structural abnormalities or the loss of connections between nerve cells. Initial stages may go undetected but as the disease progresses cognitive function gradually declines and worsens to the point of interfering with one’s ability to function normally. Those who suffer from the disease ultimately become completely incapable of caring for themselves. Death typically occurs three to 10 years after initial diagnosis.

Changes in the blood supply to the brain may also cause dementia. This is known as vascular dementia and is sometimes the result of one or more strokes that block arteries and reduce blood flow to parts of the brain. Vascular dementia can also be the result of chronically damaged brain blood vessels. Much like other blood vessels in the body, brain blood vessels may be damaged from high blood pressure, diabetes, hardening of the arteries, or the wear and tear associated with aging. Older persons sometimes experience dementia-like symptoms without suffering from the disease for other medical reasons including chronic alcoholism, brain tumors or infections, vitamin deficiency, and thyroid, kidney, or liver disorders.

There is no known cure for Alzheimer’s disease or dementia. Symptoms, however, can be managed with medicines that increase neuronal activity in the brain. Behavioral and psychological symptoms of the disease can be treated with prescriptions for sleep disturbances, depressed mood, anxiety/restlessness, and hallucinations.

Delirium

Delirium is a temporary condition similar to dementia that causes patients to be disoriented and inattentive and experience an overall cognitive dysfunction. Side effects from certain medications, physical immobility, malnutrition, sleep deprivation, and chronic conditions such as renal disease, stroke, and hearing or vision loss all increase one’s risk for developing delirium. Many delirium cases can be prevented altogether with adequate nutrition, hydration, and rest and by maintaining a patient’s orientation to surroundings. Physical restraints should be avoided if an episode does occur and the patient should not experience frequent changes in rooms or staff. Sleep is an important factor in treating delirium patients; a quiet, low-light setting should be provided at night.

Depression

Depression is a mood disorder that causes persistent feelings of sadness and loss of interest in normal daily activities. For those who suffer from the disease it affects how they feel, think, and behave. Depression in older individuals is sometimes characterized by physical symptoms like agitation, hypochondriasis, and gastrointestinal malfunction. They may also experience confusion, social withdrawal, delusions, and hallucinations. The long-term prognosis is poor for older depressed persons because they tend to have higher relapse rates. Older individuals are also more likely to have concurrent medical problems that exacerbate their conditions such as cognitive impairment.

Older persons who have had a major surgery, heart attack or stroke, or hearing or vision loss are at increased risk for developing depression. Those who are isolated, have lost loved ones, and are lacking in a supportive social network are also more susceptible to depression. Women are more likely to become depressed than men in the general population, a difference that increases later in life because of the hormonal changes associated with aging. Psychotherapy and mood-improving medications are both effective in treating depression in older persons. Once the patient’s mood has improved subsequent lifestyle changes should be made to increase social contact and support. Some form of pharmacological maintenance is also in order because of the chronic nature of depression in older adults.

Anxiety

Anxiety is frequent and intense fear and worry about normal situations, sometimes including panic. The feelings of fear are difficult to control and are out of proportion to the actual danger. Generalized anxiety disorder is the most common anxiety disorder in older persons and is characterized by persistent, excessive, and unrealistic worry about everyday things. Like depression, older persons often develop anxiety because of a traumatic event such as developing an illness. Older persons also fear crime, further illness, and financial stress. Limited mobility is an important factor; many older persons have a fear of falling which can be so severe they avoid physical activities, leading to further disability. This interferes with daily activities such as shopping and bathing and reduces their overall quality of life. Once an older person has been diagnosed with anxiety, a prescription regimen, sessions with psychotherapist, or the combination of the two can be quite effective at treatment.

Dementia, depression, and anxiety are the most common psychological disorders in older persons and much of the mental health resources dedicated to the elderly are expended to address these issues. However, there are other mental health issues that persist from young and middle adulthood into old age or sometimes develop in old age.

Other mental health disorders

Alcohol and substance abuse. One-third of money spent on prescription drugs in the U.S. is from elderly patients, and many of these purchased drugs have the potential to be abused. In this category fall benzodiazepines, opiate analgesics, and medicines for pain and insomnia which, by misuse and overuse, can lead to substance abuse and addiction. It is estimated that 12–15% of older adults abuse prescription drugs. Alcoholism is another issue affecting aged persons; by some estimates 11% of adults aged 50–64 years and 6.7% of adults older than 65 report alcohol abuse or dependence. These statistics indicate that alcohol and substance abuse are the fourth most common mental health issue for older adults following dementia, depression, and anxiety.

Most alcohol and prescription drug abusers begin abuse prior to age 65. These are considered early onset abusers and comprise two-thirds of the population of elderly persons that are alcoholic. Because of the extended period of abuse, these individuals tend to have greater physical and psychiatric problems. It is challenging to diagnose late onset abusers because they do not fit the profile of younger abusers and their symptoms are often attributed to other causes.

Substance abuse in the aged increases the possibility of other mental health conditions like cognitive impairment. Psychotherapy and/or various medicines proven to work in younger populations are viable treatment options.

Bipolar disorder.Bipolar disorder, also known as manic depression, is a chronic, debilitating condition characterized by major shifts in mood and energy levels. In manic states patients may feel constantly overjoyed, need very little sleep, and have rapid flights of ideas. In depressive states patients feel sad and hopeless, experience changes in appetite and sleep, and have suicidal thoughts. Bipolar disorder is commonly diagnosed in young people and is highly treatable using mood-stabilizing drugs. Without medical treatment, however, those with the disease have trouble carrying out their normal daily activities. Until recently it was believed that bipolar disorder “burnt out” in older adults whose symptoms often appear to go into remission. However, symptoms may present differently in older patients who experience agitation and irritability during a manic phase rather than feeling “high” or on top of the world.

Some patients do not develop bipolar disorder until late in life. This is far less common but in fact 10% of patients are diagnosed with the disorder after age 50. Diagnosing bipolar disorder in older persons is difficult as symptoms may be confused with other possible disorders. Once diagnosed, aged sufferers of bipolar disorder can also benefit from mood-stabilizing drugs.

Schizophrenia.Schizophrenia is a serious and chronic mental disorder that affects 1% of the adult population world-wide. The disorder manifests itself in delusions, auditory hallucinations, confused thinking, erratic behavior, and a pervasively abnormal interpretation of reality. Patients are normally diagnosed with a sub-type of the disorder in young adulthood although any diagnosis prior to age 45 is considered early or normal in onset.

A fascinating component of the disease is that in some cases it may develop later in life so that individuals who were previously symptom free are diagnosed between the ages of 45 and 65 (late onset) or with a very late onset schizophrenia-like psychosis (older than 65). Most that are diagnosed with the disorder in young adulthood are males who have otherwise structurally sound brain matter. In contrast, those diagnosed with very late onset schizophrenia-like psychosis are usually women who have marked brain structure abnormalities and progressive cognitive deterioration. Estrogen may play some protective role in preventing schizophrenia early in life, a protection that disappears after menopause is reached. Treatment-wise, newer, atypical antipsychotic medicines are recommended for older patients as they have fewer possible side effects that the elderly, who are especially susceptible, might experience.

Personality disorders.Personality disorders are characterized by rigid, unhealthy, and inaccurate patterns of thinking and behaving. Those with a personality disorder commonly have difficulty relating to people or functioning in normal situations. There are multiple sub-types of personality disorders; these usually begin in young adulthood and can change symptomatically with age. Generally speaking, extreme symptoms such as aggression decrease with age. However, some traits such as passive-aggressiveness, hypochondriasis, and depression increase with age. Like bipolar disorder it was commonly held that personality disorders declined with advanced age. However, it may simply be the case that those aspects of personality disorders that require a certain amount of energy, sexuality, and social interaction only appear to decrease when in fact they simply have fewer opportunities for expression in later life.

Healthcare workers can more accurately diagnose personality disorders when the more stable psychological factors are taken into greater consideration and when there is correspondingly less emphasis on the more dramatic features of particular disorders. Once diagnosed, some psychotherapeutic treatments that specifically focus on current behaviors and relationships are most effective for older adults.

Treatment for and prevention of behavioral health disorders in geriatric patients

When treating mental health disorders of any type in the elderly, extreme caution is advised. It is important for healthcare workers to use diagnostic tools that rule out other medical conditions such as stroke, brain abnormalities, or medicinal side effects. Pharmacological approaches to treat mental health disorders in older persons should be avoided at all costs as they can further compromise the patient’s mental state and make it difficult to monitor the patient’s condition. When medicine is prescribed appropriate dosages must be carefully managed as absorption and efficacy can be different for the aged. Furthermore, concurrent medicines may negatively interact with drugs used to treat psychological disorders. Generally speaking, older patients often require much smaller doses because of physical changes associated with aging that affect the metabolism of medicine in the body.

Many mental health disorders persist from young adulthood. However, the big three, dementia, depression, and anxiety, often begin with advanced age, and, thus, can largely be prevented. Certain lifestyle changes such as being mentally active while aging, having frequent social contact, and remaining physically active can significantly decrease an older person’s likelihood of developing one or more of the common disorders associated with aging. Returning to the chicken and egg problem, the number of older persons is increasing at an unprecedented rate, and the bulk of resources spent addressing these issues may be more wisely, and more effectively, spent in measures of prevention. While the aging process cannot be stopped there are actions that communities and individuals can take to help older persons maintain their health and independence.

Bibliography

Anxiety and Depression Association of America http://www.adaa.org/living-with-anxiety/older-adults.

Kennedy, G. (2008, January 1). Bipolar disorder in late life: Mania. Retrieved February 13, 2015, from Primary Psychiatry website: http://primarypsychiatry.com/bipolar-disorder-in-late-life-mania/

Mayo Clinic. http://www.mayoclinic.org/disease-conditions/dementia/basics/definition/con-20034399.

National Alliance on Mental Illness. http://www.nami.org/Template.cfm?Section=By‗Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=7515

National Institute on Aging. http://www.nia.nih.gov/alzheimers/topics/alxheimers-basics.