There are several clinical issues involved in treating seniors with new and chronic 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 the aging 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 medication interactions or health conditions like dementia that affect cognitive function, mood and/or behavior. This is especially true for primary care physicians and psychiatrists who have not received geriatric training.
According to the 2017 National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration (SAMHSA), 13.8 percent of U.S. adults aged 50 and older live with a mental, behavioral or emotional disorder. To address the combined issues of aging and mental health, I consulted Connie M. Ward, Ph.D., a licensed psychologist in private practice at A New Start Counseling Center, Inc. in Fayetteville, Georgia.
The Stigma of Mental Illness in the Elderly
Sadly, mental illness is very misunderstood in the United States.
“It is denied, demonized, stigmatized, mocked, stereotyped, minimized, marginalized, judged, feared, danced around and rationalized in the media, public safety protocols, schools, and conversations with family and friends,” Dr. Ward notes. She stresses that mental illness is not a sign of weakness, a character flaw, a lack of faith, a curse or a moral failing. Mental conditions impact an individual’s thinking, feeling or mood and may affect their ability to relate effectively with others and function on a daily basis.
According to Dr. Ward, the diagnosis and treatment of a mental disorder is much more complicated for older adults. Symptoms of mental health issues like depression or lapses in memory are often dismissed as “normal” aspects of getting older, but these assumptions prevent seniors from getting the care they need.
Even when new behavioral symptoms present and are acted on, the prevalence of multiple chronic conditions, multiple medications often being prescribed by multiple doctors and drug interactions can make it difficult for skilled physicians to properly diagnose and treat seniors with mental disorders. Additionally, inadequate support systems, social isolation, limited mobility, and increased emergency room (ER) visits with typically poor follow up decrease the likelihood that a senior will be willing or able to adhere to recommendations for treatment.
What Causes Mental Illness?
A mental health condition is not the result of one particular event, Dr. Ward says. 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 their 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 in mental health outcomes.
What Mental Health Issues Are Common in the Elderly Population?
According to the World Health Organization, the most common mental and neurological disorders among people aged 60 and older are dementia and depression, which affect approximately 5 and 7 percent of the world’s older population, respectively. Anxiety disorders affect approximately 3.8 percent of seniors worldwide.
The following mental health issues may be less common among the elderly, but they are still of concern since they can profoundly affect interpersonal relationships and overall quality of life.
- Bipolar disorder
- Personality disorders (e.g., borderline personality disorder, narcissistic personality disorder)
- Dissociative disorders
- Obsessive compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Schizoaffective disorder
- Substance abuse disorders
- Eating disorders
Treatments and Therapies for Mental Health Issues in Elderly Patients
The most used therapies consist of psychotherapy (talk therapy), cognitive behavioral therapy (CBT), self-help or support groups, stress-management techniques, and psychiatric medications like antidepressants.
“Since each person is unique, it’s important to understand that treatments can vary considerably,” adds Dr. Ward. “People may experience the same mental condition very differently because of their unique circumstances. Settling on a correct diagnosis and course of treatment can take some time and trial and error.”
Furthermore, one’s mental health can change over time. New and/or worsening physical health conditions, financial strain, loss and many other factors can have profound effects on a senior’s moods and ability to cope.
The Connection Between Aging, Depression and Chronic Illness
Depression and anxiety are two of the most commonly occurring mental disorders, but this does not consist of just having “the blues” or excessive nervousness. “Like diabetes or hypertension, these are true medical conditions that are treatable,” Dr. Ward stresses.
Some sadness and apprehension about the future are normal reactions for ill and aging individuals, but not in excess. In older adults, depression often co-occurs with other serious illnesses, such as heart disease, stroke, diabetes, cancer, Alzheimer’s disease and other types of dementia, Parkinson’s disease, and changes in mobility and independence. If these feelings are interfering with a loved one’s ability to function, relax and find enjoyment in life, then this is a serious problem that should be discussed with their physician.
Older adults who are suffering from mood disorders also tend to complain of psychosomatic symptoms, such as persistent aches or pains, cramps, or digestive problems that do not get better, even with treatment. According to Dr. Ward, 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,” she admits, “and older adults specifically are at an increased risk for experiencing it, especially in more complex and unusual manifestations.” Untreated depression can actually delay a patient’s recovery or worsen the outcome of their other health conditions.
Treatments can vary widely depending on the patient. The solution could be as simple as opting for palliative care to manage physical symptoms and improve quality of life, adjusting prescription medications to minimize bothersome side effects, prescribing an antidepressant, switching to a different antidepressant or adjusting current dosages.
However, Dr. Ward warns that psychiatric medications may not always be the answer. Modifications to a loved one’s daily routine or care plan might be beneficial, but seniors can be very stubborn when it comes to changes that appear to threaten their sense of dignity or control. They may shoot down ideas that could improve their quality of life, such as in-home care or adult day care. If a loved one is becoming increasingly depressed and withdrawn, they may dig their heels in about these choices even more.
“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 improve their mood and quality of life,” says Dr. Ward.
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,” she acknowledges. The most extreme cases require a legal guardian to be appointed to make care decisions on an incompetent senior’s behalf that will improve their physical and mental health.
Long-Term Treatments for Mental Illness
Mental health issues can be temporary or conditions that require lifelong treatment. Dr. Ward acknowledges that many people who have received long-term treatments for mental illness tend to face additional challenges as they get older and their overall health becomes more complex. She emphasizes the fact that aspects of physical and mental health 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 or physical condition.
Furthermore, an aging loved one may have taken a psychiatric drug for many years without issue, but the physical changes that occur normally with age can alter how the medication interacts with the body—and with other medications. The vast majority of prescription and over-the-counter drugs use carefully titrated dosages that are primarily intended for healthy, middle-age consumers who 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,” urges Dr. Ward, “especially if they are taking multiple medications and/or experiencing symptoms of mental illness.” This could be a geriatrician, a geriatric psychiatrist or a geriatric pharmacologist. These professionals specialize in the care and treatment of seniors and can help titrate medications, address rare or “unusual” symptoms, and identify conditions that present differently in older people.
How to Help a Senior With Mental Health Issues
Dr. Ward offers the following tips for helping a senior manage their behavioral health and ensuring they get the physical and mental care they need.
- Organize a digital or printed medical file for your loved one. It should include their name, date of birth, a list of current medications, dosages, and responses, a list of all vitamins, supplements and herbs with dosages, a list of all physicians and specialists, their contact information, and a list of conditions being treated. Make a back-up copy to keep on file and bring a current version to all of your loved one’s appointments.
- Prepare for doctor’s appointments by discussing the senior’s 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 exercises can help your loved one be more comfortable talking with the doctor.
- Offer to accompany your loved one to their appointments. Bring a notepad and pen for taking detailed notes. With their permission, ask for clarification of any information or medical terminology that is not familiar to you.
- If a new medication is offered, encourage a discussion with the doctor about how well current drugs are working, the risks, benefits and side effects of each option, and the costs of each. Some medications may require lifestyle changes, such as abstaining from alcohol or avoiding certain foods, so be sure to discuss this aspect as well.
- Help your loved one remind their doctor of any other alternative therapies, medications, vitamins and supplements they are taking and how these may affect their treatment.
- Ask how the senior’s current medications or any new drugs 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 and Prevention. Misinformation surrounding mental illness is perpetuated when people refuse to seek out and use factual information.
- Help your loved one make a plan to take their medications as prescribed, obtain refills, pay for their prescriptions, and recognize changes in formulations (such as going from brand name to generic or from one producer to another). This may also include charting side effects and learning when it’s important to call the doctor about adverse reactions.
- At least once a year, you and your loved one should make an appointment with their physician or pharmacist to review all their medications, vitamins and supplements. I suggest taking them all in a bag (known as a brown bag check-up). The appointment can reveal duplicate medications, drug interactions, and medications that are no longer needed or can be phased out. It is also a good time to have the pharmacist ask your loved one how they are taking their meds to verify compliance and accuracy.
- Use only one pharmacy. When one place has all a senior’s prescriptions on file, it helps to prevent drug interactions, duplicate prescriptions from different specialists, doctor shopping and allergic reactions.
- Record your loved one’s reports of somatic complaints and any ER visits for these symptoms. Bring ER paperwork to their doctor’s appointments or ask to have these records sent to their doctor directly.
- Encourage your loved one to seek the right kind of social support. Social isolation and feelings of loneliness increase the risk of depression for people of all ages. Having a solid support network is essential to the mental health of older adults.
- Urge them to exercise within their abilities. Physical activity is an effective, drug-free and low-cost treatment for depression, anxiety and other mood disorders.
- Keep an eye on your loved one’s 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 and how to react.
Keep in mind that the Substance Abuse and Mental Health Services Administration’s National Helpline is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders. Call 1-800-662-HELP (4357) or TTY: 1-800-487-4889 to receive referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information. If your loved one is experiencing a medical emergency or mental health crisis, call 911 immediately.