We are an aging society. By the year 2020, one in five Americans will be over the age of 65 years, compared to a little over one in eight today. The oldest of the old, those aged over 85 years, comprise an increasing proportion of the elderly, and present special challenges to health care providers. The clinical care of older adults relies on knowledge of normal aging and the common diseases of old age. This chapter focuses on these aspects of mental health and illness.

Although chronic and degenerative diseases impact quality of life, many older adults are active, engaged, and pleasure seeking. They remain curious and continue to learn throughout their lives. Temperament (i.e., energy, intensity, reactivity) remains stable, whereas personality (learned behavior patterns) undergoes refinement and change over time in most healthy adults. Predictable changes in intellect occur in most people as they age. Although judgment, knowledge, and verbal skills increase through the life span, mental functions that rely on memory and processing speed are adversely affected by aging.

Successful adaptation to old age is difficult to define and variably expressed. Signs of successful aging include acceptance of change, affectionate relationships with family and friends, and a positive view of one’s life story. Another indicator is the ability to find new sources of self-esteem independent of raising children, career, physical strength, or beauty. Factors that promote successful adaptation are luck (good genes, avoiding injury) and healthy behaviors including proper diet, adequate sleep, plenty of physical activity, and good stress management. Having enough money for basic needs as well as strong kinship and extended family bonds add extra protection from disease and despair, as do spirituality, having friends and confidants, and feeling valued by society. Opportunities to be productive and assist younger generations can provide a sense of connection to one’s community and a feeling of completeness.

Patients and families will often ask for advice on staying engaged and active. Many communities have senior centers, agencies, or programs that organize discussion groups, lectures, hobby groups, travel groups, book groups, adult education classes, and volunteer activities. Similar programs or groups can be created, even in the smallest communities, by forming book or knitting groups, foster grandparent services, or peer support programs. The local Area Agency on Aging may have information for specific resources and volunteer opportunities in your community.

Social conditions that contribute to demoralization in old age include highly mobile and rapidly changing communities, youth-oriented aesthetics, the deaths of friends and family members, and forced retirement. Physical conditions that limit function and increase isolation, such as urinary incontinence, chronic pain, gait and mobility problems, and hearing and vision loss also contribute to demoralization. Declining hygiene, poor nutrition, falls, alcohol abuse, social withdrawal, chaotic finances, and denial of severe health problems are clues that an older person is failing at home because of diminishing physical, emotional, or intellectual function. Recognizing these problems can be difficult. Health care practitioners may not detect problems if older patients are reclusive, try to look their best in the office, or avoid discussion of problems they face functioning at home. Often it is family members, friends, neighbors, and others who first recognize a person’s functional decline. Their impressions can be very helpful to clinicians, but sometimes the family needs to be specifically asked to investigate the well-being of the patient. In extreme cases, Adult Protective Services or a local Council on Aging may be asked to investigate a patient’s safety. The challenge is to obtain the needed information while abiding by Health Insurance Portability and Accountability Act (HIPAA) regulations, and obtaining the information while retaining the confidence of the patient. If time permits, a home visit may be especially revealing.

Older adults experience obstacles to obtaining medical care. Financial barriers to mental health care are compounded by the lesser coverage for mental compared to physical illness under the Medicare insurance program. This disparity is being phased out by 2014 under the Medicare Improvements for Patients and Providers Act (MIPPA). Older patients may also deliberately avoid seeking help, particularly for emotional and cognitive problems. Some seniors do not view emotional distress as something to discuss with physicians. They suffer silently or disguise their distress with physical symptoms or irritability and withdrawal from family, friends, or caregivers. Unfortunately, the prejudicial attitudes of physicians and mental health providers about mental and emotional problems in old age play into this silence and contribute to the under recognition and treatment of these disorders. Clinicians may be reluctant to prescribe treatment for problems viewed as inevitable parts of aging or they may simply consider treatment to be futile.

Providing medical care to older patients requires an understanding of normal changes in mental and emotional functioning in old age, and skill in determining when intervention is needed. Addressing the concerns of family and caregivers, accessing community services, and advising patients about end-of-life and long-term care options all require sensitivity and skill. Diagnosing mental disorders in older people is challenging as multiple clinical syndromes—including both mental and medical—often overlap. In the following sections, we will review an approach to geriatric conditions and highlight cases that illustrate how clinicians can effectively treat this population.

Considerations for Communicating with Older Patients

The Clinical Setting

Seeing older adults in a primary care practice can be challenging due to the special needs of this population. Adaptations to the office setting, such as larger, wheelchair-accessible rooms, can make it easier for patients to get in and out of the examination room. Loud noises, from the waiting room or adjoining rooms, can be distracting and can limit the provider’s ability to obtain a focused history. If possible, appointments should be made later in the day to allow older adults to arrange transportation. A more liberal “no-show” policy may need to be adopted as cancellations in this age group are not uncommon.

Patient Interview

Clinicians should inquire early in the interview whether they are being heard and understood. Projecting one’s voice and speaking distinctly are helpful for many older persons, but clinicians should not assume this is necessary and shout at all patients just because they are very old. Speaking slower facilitates communication much better than speaking louder. Assistive devices, such as portable amplification (e.g., Pocket Talker^®), can be invaluable in obtaining useful information. Active listening methods, such as maintaining eye contact, nodding, and paraphrasing the patient’s questions and statements should be used (see Chapter 1). Attention to the light source is important; be certain not to sit or stand with your back to the window or light fixture so patients will be able to see your face. Shorter, more frequent visits for patients with many symptoms or greater need to talk will reduce the physician’s frustration, improve communication, and better meet the patient’s emotional needs for contact with the physician. One of the true pleasures of caring for older patients is hearing their life stories, but time constraints may mandate that this occur over several visits.

Family and Caregiver Interview

Most frail older patients should be accompanied by a family member or caregiver so that the clinician can obtain a complete view of the problem. If this is not possible, a phone conversation with family, once permission from the patient is obtained, can be just as illuminating. Patients with dementia may not be aware of their memory impairment and can actively deny they have any problem. They may also have limited insight into functional decline in their own activities of daily living (ADLs), depressive symptoms, or paranoid thinking. Delusional thoughts may seem perfectly logical until the family or caregiver is consulted (sometimes, of course, the patient is correct—abuse and exploitation must be ruled out). Family consultation must be pursued with sensitivity to the patient’s feelings, and may need to occur outside the examination room (with permission from the patient) to avoid alienating the patient. It is during these separate interviews that clinicians can obtain more candid reports of impaired ADLs, psychiatric symptoms, and memory problems.

Assessment

History

When assessing older adults, clinicians should pay particular attention to recent changes in function and a review of the most common geriatric syndromes. These include cognitive impairment, falls, urinary incontinence, hearing loss, vision loss, malnutrition, frailty, and mood disorders. Careful medication reconciliation is one of the hallmarks of a geriatric assessment. Polypharmacy and medication interactions are common. Many medications can result in behavioral side effects, and many medications for mental health conditions can cause serious medical adverse events. Increasingly, vitamins, homeopathic medications, and over-the-counter therapies are being used, further complicating the picture. Alcohol use is often overlooked in this population, but abuse is not uncommon, and the results can be devastating. A careful assessment of alcohol intake is key. A useful acronym we have developed for a geriatric review of systems (MOMS AND DADS) is presented in Table 14-1.

Physical Assessment

Though a complete physical examination is always informative, there are certain elements that are especially important in older adults. General appearance and hygiene can help determine whether the patient is well cared for or able to take care of him or herself appropriately. Weight measurements are useful in assessing nutritional status. Orthostatic blood pressure measurements can help determine a patient’s risk of dizziness and falls, and are particularly important to monitor if new medication is being considered. The oral examination, often overlooked in younger adult patients, can be critical in this population, as poor dentition or ill-fitting dentures can contribute to weight loss and frailty. A careful neurologic examination can pick up conditions such as Parkinson disease and Lewy Body Dementia. Gait and balance, which can be evaluated with tools like the Get Up and Go or the Tinetti Gait and Balance, should be assessed to determine fall risk. Evidence of abuse, such as suspicious bruises or injuries, or evidence of neglect should prompt an adult protective services referral through the local Area Agency on Aging or as directed by the regulations applying to your jurisdiction.

Mental and Cognitive Status Examinations

An important component of geriatric assessment is using validated tests to examine cognition and mood. Orientation, short-term memory, problem-solving ability, judgment, insight, initiative, executive function, mood, and affect are all components of a broad cognitive assessment.

The Geriatric Depression Scale (GDS) is a standardized mood rating scale that can be administered by the clinician or the patient himself or herself. The answers are “yes” or “no” rather than a five-point scale, which allows for use in an ill or cognitively impaired population. The original is a 30-question version, but a shorter 15-question version has been validated and can be a more efficient tool.

The Folstein Mini-Mental State Exam (MMSE) is the most widely used tool to assess cognition. It is a 30-point scale that can be used to screen for dementia, as well as assess severity, and monitor response to treatment. The MMSE has been translated into 10 foreign languages, making it the most useful for diverse populations; however, the MMSE is copyrighted and copies must be ordered through the company that holds the intellectual property.