In older adults, as in younger people, poor mental health undermines general health, quality of life, and overall functioning. Given the dearth of specialty-trained geriatric psychiatrists and geriatricians, it is crucial for all clinicians to have skills in the diagnosis and management of common mental health conditions affecting older adults.
Lifelong Learning in Clinical Excellence | August 28, 2018 | 3 min read
By Susan Lehmann, MD, Johns Hopkins Medicine
With the aging of the Baby Boomer generation, demographics in the US are rapidly changing. Currently, about 16% of the US population is over age 65, and by 2030, it is estimated that adults over age 65 will comprise 1/5 of the US population.
The Institute of Medicine reports that 14-20% of older adults have significant mental health concerns. Given the dearth of specialty-trained geriatric psychiatrists and geriatricians, it is crucial for all clinicians to have skills in the diagnosis and management of common mental health conditions affecting older adults. Core knowledge useful to all clinicians caring for older adults falls into six areas, which are highlighted below:
1.) Normal Aging
Knowing which changes are normal with aging in the areas of cognitive functioning and personality is essential to recognizing cognitive impairment.
There are normal and expected changes in sleep, vision, and glomerular filtration rate with age. Similarly, there are age-related decrements in psychomotor speed and ability to multi-task that are considered normal with age and, by themselves, are not harbingers of further impairment. Vocabulary is not only preserved with aging, but may continue to strengthen. Core personality traits tend to be stable over the adult lifetime, and any marked changes in personality are often signs of mood illness or cognitive disease.
2.) Mental Health Assessment
Ageism is ubiquitous in society and not surprisingly, in medical settings, too. Avoid stereotyped assumptions about the older patient’s concerns.
Allow for time with the older patient by him/herself but solicit family input, especially if cognitive impairment is present. Respectful communication with older adults should include accommodation for sensory impairment.
Polypharmacy is rampant among older patients and can cause confusion, cognitive impairment, and falls.
Carefully review all prescription and over-the-counter medications with an eye toward eliminating duplicative or unnecessary medications. Older adults are especially vulnerable to adverse cognitive effects from medications with anticholinergic actions. More benzodiazepines are prescribed for older adults than any other age group, and often are continued for extended periods without adequate reason. Periodically asking patients to bring their actual medication bottles to medical appointments can reveal inadvertent administration errors or misunderstanding on the part of the patient.
While depression is never considered a normal part of aging, about 25% of older adults suffer from significant depression or depressive symptoms that impairs their social and emotional functioning.
Untreated or undertreated depression also causes medical morbidity and increases risks for health complications of surgery, extended hospital stays, and poorer recovery in rehab settings. Suicide rates continue to be high in older adults, and for Caucasian men, suicide rates climb dramatically after age 65, and are highest after age 85. While initial doses of antidepressant medications should be lower for older adults compared with younger adults, in most cases, the final doses needed for effective treatment will be quite similar.
Rates of dementia increase steadily with age, affecting about 5% of all adults over age 65, rising to about 30% of adults in their mid 80’s and over 50% of adults in their 90’s. Alzheimer disease is the most common type, affecting 2/3 of all patients with dementia.
Yet, many cases of dementia are missed in primary care settings, especially when clinicians do not utilize standard cognitive assessment tools or rely on the patient’s own assessment about his/her memory. Neuropsychiatric symptoms such as depression, anxiety, agitation, wandering, and insomnia occur in over 90% of patients with dementia and are a significant cause of caregiver stress. Effective management of dementia requires frequent review of factors impacting safe judgment and independent living as well as supportive guidance to patients and their families as cognitive and functional changes progress over time.
While delirium can occur in patients of all ages, it is highly prevalent in hospitalized older adults and is a cause of morbidity as well as mortality.
Older adults with dementia are particularly vulnerable to developing delirium. Use of a standardized assessment tool can be helpful in recognizing delirium, especially the hypoactive type. Delirium should always be considered a medical emergency in hospitalized older patients and should prompt a thorough and rapid evaluation of all possible medical and pharmacologic causes.
In older adults, as in younger people, poor mental health undermines general health, quality of life, and overall functioning, and increases general medical costs. These six areas, while not comprehensive, describe content areas of essential knowledge for all clinicians who care for older adults. As we begin to face the rising tide of seniors in our population, the time has come for these six essential areas of geriatric psychiatry to be standardized components of the educational curriculum of all future healthcare providers.