There are a number of clinical issues involved in treating seniors with new and lifelong mental illnesses. A loved one may develop one of these conditions as they age, or they may have received a diagnosis long ago and remained stable on the same psychiatric medication for decades. In the latter case, however, their treatment plan may need to be adjusted as their body processes these drugs differently, new conditions develop and other medications are added to the mix.
Furthermore, it can be especially challenging for doctors to distinguish the symptoms of new or worsening mental illness from conditions like dementia or medication interactions. This is especially true for primary care physicians and psychiatrists who have not received geriatric training.
According to the World Health Organization, approximately 15 percent of adults age 60 and over suffer from a mental disorder. To address the combined issues of aging and mental health, I consulted Connie M. Ward, PhD, a Licensed Psychologist who is in private practice at A New Start Counseling Center in Fayetteville, Georgia. Dr. Ward addresses some common questions and concerns regarding aging and mental health below.
What is your definition of mental illness?
Mental illness is very misunderstood in this country. It is denied, demonized, stigmatized, mocked, stereotyped, minimized, marginalized, judged, feared, blamed, danced around and rationalized in the media, public safety protocols, schools, and conversations with family and friends. Mental illness is not a sign of weakness, a character flaw, a lack of faith, a curse or a moral failing.
Rather, it is a condition that impacts an individual’s thinking, feeling or mood and may affect their ability to relate effectively with others and function on a daily basis. Furthermore, individuals may experience the same diagnoses very differently because of their different life experiences.
The diagnosis and treatment of a mental disorder becomes more complicated in an aging population because of the prevalence of multiple chronic conditions, multiple medications being prescribed by multiple doctors, possible drug interactions, social isolation, limited mobility, and increased emergency room (ER) visits with poorly articulated somatic or physical complaints and typically poor follow up.
What causes mental illness?
A mental condition is not the result of one particular event. Rather, it is due to multiple interlinking causes such as genetics or family history of mental illness, the environment, and an individual’s lifestyle choices. Susceptibility increases for those who are exposed to things like prolonged stress from a job, home life or caretaking role, as well as exposure to emotional, physical or sexual trauma, or being a victim of crime. Biochemical processes, basic brain structure and nutrition also play a significant role.
Researchers are finding that genetic and environmental factors, frequently in interaction with one another, are risk factors, especially when it comes to anxiety disorders. For anxiety disorders, factors include shyness or behavioral inhibition in childhood, being female, having few economic resources, being divorced or widowed, exposure to stressful life events in childhood and adulthood, anxiety disorders in close biological relatives and parental history of mental disorders.
Which conditions are most prevalent today?
The top major mental illnesses are:
- Attention-deficit/hyperactivity disorder (ADHD)
- Anxiety disorders
- Bipolar disorder
- Borderline personality disorders
- Major depressive disorders
- Dissociative disorders
- Eating disorders
- Obsessive compulsive disorders
- Post-traumatic stress disorder (PTSD)
- Schizoaffective disorders
What are the most common treatments and therapies for mental illness?
The most commonly used therapies consist of psychotherapy, cognitive behavioral therapy (CBT), self-help or support groups, stress-management techniques, and medications like antidepressants.
Family caregivers are often concerned with the challenging trifecta of aging, depression and serious illnesses like dementia. Could you please explain more about depression and treatments?
Depression and anxiety are two of the most commonly occurring mental disorders. But this does not consist of just having "the blues,” like the emotions we feel when grieving the loss of a loved one or nervousness before a big event. These are true medical conditions that are treatable, like diabetes or hypertension.
Some sadness and apprehension about the future are normal reactions for ill and aging individuals, but not in excess. If these feelings are interfering with their daily ability to function, relax and find enjoyment in life, then this is a problem that should be discussed with their physician. In older adults, depression often co-occurs with other serious illnesses, such as heart disease, stroke, diabetes, cancer, dementia, Parkinson's disease, and changes in mobility and independence.
Various social and economic difficulties may also be present, and health care professionals may mistakenly conclude that depression is a normal consequence of all these problems. This is an attitude that is often shared by the patients themselves and may cause them to avoid or delay seeking treatment.
Unfortunately, we find that older adults who are suffering from mood disorders also tend to complain of psychosomatic symptoms, such as persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment. These complaints are most often presented by seniors in emergency rooms and can baffle some of the most experienced doctors. Depression is a widely under-recognized and undertreated medical illness, and older adults specifically are at an increased risk for experiencing it, especially in more complex and unusual manifestations. Depression can and should be treated when it co-occurs with other illnesses. Untreated depression can actually delay a patient’s recovery or worsen the outcome of these other illnesses.
Treatments can vary widely depending on the patient. The solution could be as simple as opting for palliative care to improve their quality of life, adjusting prescription medications to minimize bothersome symptoms, prescribing an antidepressant, switching to a different antidepressant or adjusting their current dosages.
Medications may not always be the answer, though. Seniors can be very stubborn, and their dignity is extremely important to them. Even if they are feeling their best, they may shoot down the idea of changes that could improve their quality of life, such as in-home care, adult day care, independent living, etc. If a loved one is becoming increasingly depressed and withdrawn, they may dig their heels in about these choices even more. However, a bit of gentle encouragement from family members could help them to move outside of their comfort zone in order to engage in healthy, stimulating activities that can really improve their mood and quality of life. In other cases, the exact opposite is true. An elder may not be mentally or emotionally capable of making positive changes in their life or truly enjoying activities without the help of some therapy or medication beforehand. Each individual is different.
What kinds of issues can arise when a loved one who has been treated for long-term mental illness gets older and their condition becomes more complex?
So many different things can occur to affect their mental and physical health. It is important to realize that both of these aspects of wellbeing influence each other. If, for example, a senior receives a serious medical diagnosis or their spouse passes away, this can cause deep distress and exacerbate symptoms of an existing or underlying mental condition.
Furthermore, if an aging loved one has taken been taking psychiatric drugs for many years without issue, the physical changes that occur normally as the body ages can slowly cause new problems. For example, a senior’s body metabolizes drugs differently and is less capable of dealing with side effects.
The vast majority of prescription and over-the-counter drugs use carefully titrated dosages that are primarily intended for healthy, middle-aged individuals that are of average weight and have normal liver and kidney function. Of course, manufacturers thoroughly research these drugs and create warnings and limitations for their use in specific populations, but physicians commonly try to apply a generalized remedy to as large a portion of the population as possible.
A physician with specialized geriatric training can be a real asset to your loved one’s health care team, especially if they are taking multiple medications and/or experiencing symptoms of mental illness. This could be a general geriatrician, a geriatric psychiatrist or a geriatric pharmacologist. These professionals specialize in the care and treatment of seniors and can help to titrate medications, address “unusual” symptoms, and identify conditions that present differently in younger people.
How you can help an older loved one who suffers from mental illness?
Try approaching their care with these tips in mind:
- Help organize a digital or printed medical information for your loved one. It should include their name, DOB, list of current medications, dosages, and responses, a list of all vitamins, supplements and herbs and dosages, a list of all physicians and specialists, their addresses and contact numbers, and a list of conditions being treated. Make a copy for yourself to keep on file and bring an updated version with you to all appointments.
- Help your loved one prepare for doctor’s appointments by discussing their adherence to medication routines, problems or missed dosages, and any side effects they may be experiencing. Use this conversation to develop a list of questions for the doctor. Role play can help your loved one be more comfortable talking with the doctor.
- Offer to accompany them to their appointments. Come with a pad and pen and make detailed notes. With your loved one’s permission, ask for clarification of any information or medical terminology that is not familiar.
- If a new medication is offered, encourage a discussion with the doctor about how well current drugs are working, how a new option might work to improve their symptoms, the benefits and side effects of each option, the risk for serious side effects based on their medical history, and the costs of each. Some medications may also require lifestyle changes such as no alcohol or avoiding certain foods, so be sure to discuss this aspect as well.
- Help your loved one to remind their doctor of any other alternative therapies, medications, vitamins, and supplements they are taking and how these may affect their treatment.
- Ask how their current or any new medication should be stopped. Some drugs can’t be discontinued abruptly and must be tapered off slowly under a doctor’s supervision.
- Conduct research on any diagnoses and conditions and obtain reputable information from websites such as the American Psychological Association and the Centers for Disease Control. Mental illness is made worse by denial and refusal to get and use factual information.
- Avoid passing around lore about an acquaintance who went to a counselor once and didn’t get any help or who took medication and it didn’t work. Each diagnosis presents differently in each individual, partly due to genetics and personal experiences.
- Offer to sit down with your love one and help them make a plan to take their medications daily as prescribed, keep up with refilling medications and paying for them, and recognize changes in formulations of the medication (such as going from brand name to generic or from one producer to another). This may also include charting side effects and learning when to call the doctor.
- At least once a year, you and your loved one should make an appointment with their pharmacist to review all their medications, vitamins and supplements. I suggest taking them all in a bag (known as a brown bag check-up). Sometimes the sheer volume of medications sparks more interest in uncovering duplicates, possible harmful drug interactions, and medications prescribed to counter side effects that could instead be handled by alternative lifestyle changes. It is also a good time to have the pharmacist ask your love one how they are taking the medication to check accuracy.
- Going to only one pharmacy, where all their prescriptions are on file, can cut down on bad drug reactions, duplicate prescriptions from different specialists, doctor shopping and allergic reactions.
- Monitor your loved ones’ numerous reports of somatic complaints and any ER visits for these symptoms.
- Encourage your loved one to seek the right kind of social support. Social isolation increases the risk of depression, and having a good support network is crucial to the mental health of older adults.
- Urge your loved one to exercise within their abilities as an effective, drug-free and low-cost treatment for depression and other mental disorders.
- Help your loved one to seek and maintain treatment. Many older adults see an improvement in their symptoms when treated with antidepressant drugs, psychotherapy or a combination of both. Mental illness does not go away; it only gets worse if left untreated.
- Watch for increased alcohol consumption which may impact the effectiveness of any medication.
- Monitor antibiotic use, which can also impact effectiveness of psychiatric medications, especially antidepressants.
- Keep an eye on their overall mood and take immediate action if they begin experiencing serious side effects or mood changes such as suicidal thoughts, mania, or hallucinations. If you have worked with their doctor to learn about their condition and medications, you should be well aware of any warning signs to look for.
Thank you, Dr. Ward, for this eye-opening information. Family caregivers of loved one with mental illness experience many unique challenges. Proper education and attentiveness to detail can help us all become better caregivers for the people we love.