Geriatric Psychiatry

Old age is not a disease. It is a phase of the life cycle characterized by its own developmental issues, many of which are concerned with loss of physical agility and mental acuity, friends and loved ones, and status and power. At the same time, old age is associated with the accumulation of wisdom and the opportunity to pass that on to future generations, one of the tasks that informs Erik Erikson’s view of healthy old age as a time of integrity and not a time of despair. In contrast to this group of the well-old, there are the sick-old, persons with mental or physical disorders, or both, that impair their ability to function or even survive. This group is the concern of geriatric psychiatry, which deals with preventing, diagnosing, and treating psychological disorders in older adults. The American Board of Psychiatry and Neurology established geropsychiatry (from the Greek geros [“old age”] and iatros [“physical”]) as a subspecialty in 1991, and today geriatric psychiatry is one of the fastest growing fields in psychiatry.

Prevalence data for mental disorders in elderly persons vary widely, but a conservatively estimated 25 percent have significant psychiatric symptoms. The number of mentally ill elderly persons was estimated to be about 9 million in the year 2005. That figure is expected to rise to 20 million by the middle of the century.

STRESSORS

High-ranking stresses of aging include acute and chronic medical illnesses, the concomitant use of therapeutic drugs, and the complicating drug-drug and drug-disease interactions. Thus, geriatric psychiatrists must be able to recognize the physical and mental ills of their patients, as well as have skills in the social sciences, knowledge of the health care delivery system, and information about the availability of financial and social supports, especially nursing homes. Moreover, self-assessment of health is associated with income. The loss of one’s job, including voluntary and involuntary retirement, carries with it the loss of financial resources, social status, and much of the person’s social network; the loss of contemporaries through death, illness, and migration brings both psychological deprivation of an intimate love object and a void that usually remains unfilled; forming new relationships that result in marriage is difficult in old age. In part, because of their greater life expectancy, older women are more likely to live alone than older men. Physical limitations and the loss of friends are frequently associated with restricted mobility, which leads to further social isolation and increased difficulty in pursuing the tasks of daily living, such as procuring food and clothing and maintaining one’s shelter. Often, homes are lost because of financial strains and the inability to perform home upkeep. Many middle class widows, for example, have had to move from the five- to ten-room family homes that they occupied for most of their lives to one-half of a room in a residential extended-care facility for the elderly. In addition to losing most of their worldly possessions and social support, they also lose their privacy and their sense of self-worth.

Poverty in the Aged

A strong correlation exists between poverty and increased rates of mental and physical illness in the elderly. For workers 65 years and older, the median earned income in 2005 was $15,000. Although the overall rate of poverty is relatively low, it remains high for women, minorities, the less well educated, and those older than 80 years. Of Americans 65 years or older, 28 percent had incomes of less than $10,000 in 2005, whereas 10 percent had incomes of $50,000 or more. Earnings from work continue to be an important source of income for older Americans, especially those younger than age 70 years. Although a trend was seen toward earlier retirement from about 1960 to 1985, over the last 20 years more Americans have continued to work at older ages. In 2005, median earnings for individuals of age 55 to 61 years who worked were $34,000, whereas median earned income for workers of age 62 to 64 years was $27,000.

PSYCHIATRIC EXAMINATION OF THE OLDER PATIENT

Psychiatric history taking and the mental status examination of older adults follow the same format as those of younger adults; however, because of the high prevalence of cognitive disorders in older persons, psychiatrists must determine whether a patient understands the nature and purpose of the examination. When a patient is cognitively impaired, an independent history should be obtained from a family member or caretaker. The patient still should be seen alone—even in cases of clear evidence of impairment—to preserve the privacy of the doctor-patient relationship and to elicit any suicidal thoughts or paranoid ideation, which may not be voiced in the presence of a relative or nurse.

When approaching the examination of the older patient, it is important to remember that older adults differ markedly from one another. The approach to examining the older patient must take into account whether the person is a healthy 75-year-old who recently retired from a second career or a frail 96-year-old who just lost his or her only surviving relative with the death of a 75-year-old caregiving daughter.

Psychiatric History

A complete psychiatric history includes preliminary identification (name, age, sex, marital status), chief complaint, history of the present
illness, history of previous illnesses, personal history, and family history. A review of medications (including over-the-counter medications) that the patient is using or has used in the recent past is also important.

Patients older than age 65 years often have subjective complaints of minor memory impairments, such as forgetting persons’ names and misplacing objects. Minor cognitive problems also can occur because of anxiety in the interview situation. These age-associated memory impairments are of no significance; the term benign senescent forgetfulness has been used to describe them.

Mental Status Examination

The mental status examination offers a cross-sectional view of how a patient thinks, feels, and behaves during the examination. With older adults, a psychiatrist may not be able to rely on a single examination to answer all of the diagnostic questions. Repeat mental status examinations may be needed because of fluctuating changes in the patient’s family.

Functional Assessment.

Patients older than 65 years of age should be evaluated for their capacity to maintain independence and to perform the activities of daily life, which include toileting, preparing meals, dressing, grooming, and eating. The degree of functional competence in their everyday behaviors is an important consideration in formulating a treatment plan for these patients.

MEMORY.

Memory usually is evaluated in terms of immediate, recent, and remote memory. Immediate retention and recall are tested by giving the patient six digits to repeat forward and backward. The examiner should record the result of the patient’s capacity to remember. Persons with unimpaired memory usually can recall six digits forward and five or six digits backward. The clinician should be aware that the ability to do well on digit-span tests is impaired in extremely anxious patients. Remote memory can be tested by asking for the patient’s place and date of birth, the patient’s mother’s name before she was married, and names and birthdays of the patient’s children.

In cognitive disorders, recent memory deteriorates first. Recent memory assessment can be approached in several ways. Some examiners give the patient the names of three items early in the interview and ask for recall later. Others prefer to tell a brief story and ask the patient to repeat it verbatim. Memory of the recent past also can be tested by asking for the patient’s place of residence, including the street number; the method of transportation to the hospital; and some current events. If the patient has a memory deficit, such as amnesia, careful testing should be performed to determine whether it is retrograde amnesia (loss of memory before an event) or anterograde amnesia (loss of memory after the event). Retention and recall also can be tested by having the patient retell a simple story. Patients who confabulate make up new material in retelling the story.

Medical History.

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