CHAPTER
1
Introduction
After a lifetime of seeking medical assistance only for emergencies, Pat, a 67-year-old woman, is belatedly establishing a primary care relationship at the request of her adult daughter Kate. Pat was recently hospitalized for an unintentional overdose of pain medications; while going through her mother’s home, Kate discovered that Pat was taking five different types of pain pills from four different doctors. Kate, who has accompanied her mother, wants you to help organize Pat’s care.
Kate tells you that a few years ago a neurologist diagnosed Pat with “mild memory problems.” Over the past year, she has had increasing trouble finding words and answering questions meaningfully. Pat is fairly independent—she can drive to familiar places, cook simple meals, and run errands without difficulty—but needs help when driving to new places and, as Kate has discovered, when taking medications.
Kate tells you all this before Pat says anything. When you ask Pat how she is doing and what today’s date is, she replies, “I’m fine.” She says nothing else. When you repeat your question about today’s date, Pat responds, “My daughter knows everything else. Why don’t you ask her what day it is.” While Pat glares at the wall, Kate starts to cry.
You feel frustrated as you open up Pat’s electronic health record. It includes a screen-long problem list, each problem associated with a medication or two, and 6 years’ worth of notes from her neurologist and three other subspecialists, who apparently have never communicated with each other. You have 15 minutes to organize this information, assess Pat’s mental health, reassure her daughter, and stifle your own feelings of being overwhelmed.
We too have felt overwhelmed when caring for older adults with uncharacterized needs who are receiving uncoordinated care. After many years, we learned to transform our frustrations into effective strategies; we offer this guide to share the lessons we have learned from our mentors and from our own experiences. We provide accessible strategies for assessing and addressing the mental health needs of older adults.
What Is in This Book
Many practitioners fear treating mental health issues in older people because of beliefs that special expertise is required; however, we believe that all practitioners can learn to feel confident about working with older people. Our goal is to help you build confidence in your ability to care for older patients with mental health needs and to nurture your interest in working with the people who make up this rapidly growing segment of the population. We describe how to perform a brief interview, recognize the main elements of the most common mental health disorders, reach an initial diagnosis, engage patients in treatment, work with other caregivers, and, if necessary, know when to refer patients for additional subspecialty mental health treatment.
Gaining confidence in caring for older patients comes from building relationships with them and their caregivers. Relationships develop through stories. To model this, we share stories drawn from our clinical experience so you can learn the following essential skills:
- Recognizing that the same chief complaint can result in different diagnoses (Chapter 3)
- Performing a 15- or 30-minute version of a diagnostic interview when you are considering different diagnostic possibilities (Chapters 5 and 6)
- Measuring and following the symptoms of a patient’s mental illness and psychosocial functioning (Chapters 10 and 11) as you decide between diagnoses
- Initiating psychosocial (Chapter 14), psychotherapeutic (Chapter 15), psychopharmacological (Chapter 16) treatment, and brain stimulation interventions (Chapter 17) once you have arrived at the best diagnosis
Each chapter focuses on the most common mental health disorders in older adults. We hope practitioners working outside behavioral health clinics and hospitals will grow confident in diagnosing and managing these disorders. To aid you, we have designed this book with easy-to-use tips, tables, and treatment guidelines tied to the DSM-5 diagnostic criteria sets (American Psychiatric Association 2013). We developed these diagnostic and treatment aids after working in various clinical roles, including consulting psychiatrist to geriatric medicine and primary care services, outpatient adult psychiatrist in an intake clinic, psychotherapist for adults struggling with aging, emergency psychiatrist, and inpatient psychiatrist. We have provided both psychotherapy and medication treatments for older people. We include a range of treatments because we understand that the way geriatric mental health conditions are treated varies widely by setting and access to mental health and social services. Despite our many years of working with older adults, we continue to be surprised by what we learn from our patients and their caregivers and still frequently consult colleagues and brainstorm new ideas for treatment. We remain humble each time we meet a new elder as a patient and are always eager to learn from her, her caregivers, and her other practitioners.
The definition of older adult has changed over the years. In the past, geriatric care was initiated when a patient turned 60 or 65. Today, we prefer to initiate a geriatric approach to medical care when it suits the patient. We determine whether an adult is functionally geriatric by considering the severity of medical and mental illness and functional status alongside her chronological age. A 55-year-old patient with progressive dementia secondary to severe traumatic brain injury would benefit from the approaches described in this guide and, if available, geriatric subspecialty care. In contrast, a primary care practitioner may care for a fairly healthy 75-year-old with mild depressive symptoms who functions independently.
Four Concepts That Define Geriatric Psychiatry
- Everyone has a story. We learn individual life stories from our patients and their caregivers, so we need to take the time to bond, laugh, and cry with them.
- Treatment must have functional benefit. We do not recommend tests or treatments that offer no benefit to a patient. We would not, for example, prescribe donepezil for a 95-year-old woman who has end-stage dementia resulting in poor functional status, even though the U.S. Food and Drug Administration has approved donepezil for dementia.
- Practitioners care for both the patient and her caregivers. As a patient functionally declines, she increasingly relies on caregivers to make appointments and follow treatment regimens. Therefore, if a caregiver is not implementing treatment recommendations, we work to ensure implementation or initiate other resources if she is having difficulty.
- Simple works best. We try to stop unnecessary medications before starting a new one. Similarly, we first introduce simple lifestyle changes such as asking our patients to walk 10 more minutes when they do their routine grocery shopping before we ask them to run a half-mile.
- Practitioners care for both the patient and her caregivers. As a patient functionally declines, she increasingly relies on caregivers to make appointments and follow treatment regimens. Therefore, if a caregiver is not implementing treatment recommendations, we work to ensure implementation or initiate other resources if she is having difficulty.
Behavioral and Mental Distress Seen in Older Adults
An older adult experiencing mental illness usually comes to a practitioner’s attention when the patient, a caregiver, or the practitioner identifies a distressing behavioral or mental symptom. Common examples of behavioral distress include sleep problems, physical complaints that cannot be explained entirely by medical illness, social isolation, and substance use. Common examples of mental distress include excessive worry, enduring sadness, declining cognitive ability, thoughts of suicide, and suspiciousness of others. Less common examples of distress include perceptual disturbances such as auditory and visual hallucinations, compulsive behaviors, and even homicidal thoughts.
DIFFERENCES BETWEEN MENTAL DISTRESS AND MENTAL ILLNESS
Imagine that while seeing Pat for the first time, you tell her, “Kate seems very concerned about you.” Pat replies, “I’m fine. I want to go home now.” You encourage her to stay and complete the visit so you can ask screening questions about appetite, mood, and sleep. Pat agrees, but then she folds her arms over her chest and answers “fine” to all questions. Kate catches your eye and says, unbidden, “Mom’s lost 10 pounds in the past 3 months. She watches TV in her bed all day and sleeps badly at night.” You share Kate’s concern that although Pat reports being fine, her memory symptoms have progressed from mental distress to mental illness.
Mental distress is often characterized by the 4 Ss: self-resolution of symptoms in a brief period of time (usually days to weeks), response to short-term supportive interventions alone (e.g., a couple of counseling sessions or a short-term support group), self-awareness of symptoms and their impact on functioning, and stable functioning. Usually, people with mental distress have no previous psychiatric history or recent psychiatric contact, no previous use of psychotropic medications, and a high level of functioning prior to the current episode.
Mental illness is usually characterized by the 4 Ps: the progression of symptoms if a person does not receive treatment, persistence and poor awareness of symptoms, and poor functioning due to these symptoms. Poor awareness of symptoms may be from anosognosia (a lack of awareness due to brain damage) and may indicate decreased motivation for successful participation in mental health treatment. A common example of anosognosia is a patient, like Pat, with major neurocognitive disorder who is not aware of her memory problem. An additional sign of mental illness may be that another person accompanies the patient to the visit, although patients who present alone may not be functioning independently. Although recurring symptoms suggest mental illness, neurocognitive disorders are distinct among the major mental illnesses because their first presentation usually occurs as an adult ages. If you cannot determine, after an initial interview, whether an older adult is experiencing distress or illness, you should explain that the diagnosis is not yet clear but that assistance is already available. You can follow a patient to see if her symptoms resolve on their own, initiate an intervention, and alter your approach as needed.
FREQUENCY OF BEHAVIORS AND MENTAL DISORDERS
In 2010, about 5.6–8 million older adults had a mental health or substance use disorder (Institute of Medicine 2012). The prevalence of these disorders, however, varies widely by setting. For example, delirium is usually diagnosed in a hospital rather than a community setting, making the prevalence in hospitals much higher. The higher the level of care a patient requires, the higher the overall prevalence of mental health disorders. In the United States, about 11% of older adults have Alzheimer’s disease (the most common type of major neurocognitive disorder), whereas 30% of home health patients and nearly 50% of patients in a long-term-care facility have major neurocognitive disorder (Alzheimer’s and other types) (Alzheimer’s Association 2015a; Harris-Kojetin et al. 2016). Similarly, whereas less than 25% of patients in adult day service centers and residential care communities have depression, nearly half of all patients in long-term-care settings are depressed (Harris-Kojetin et al. 2013).
Among older adults who were living in the community, less than 6% reported having a depressive disorder (major depressive disorder or dysthymic disorder) or an anxiety disorder (panic disorder, social phobia, or generalized anxiety disorder) (Institute of Medicine 2012). About 2% reported having posttraumatic stress disorder or a substance use disorder, and less than 1% reported having bipolar disorder, schizophrenia, or obsessive-compulsive disorder (Institute of Medicine 2012).
USE OF A DIAGNOSTIC INTERVIEW TO DISTINGUISH BETWEEN MENTAL DISTRESS AND MENTAL ILLNESS
The gold standard for diagnosis of psychiatric disorders is the clinical interview; one of its major purposes is to distinguish between mental distress and mental illness. As you interview someone, remember the 4 Ss and 4 Ps. Specifically, ask about the progression and persistence of symptoms and the impairment of functioning secondary to these symptoms. Questions such as “How long has this been going on?” and “Have you had symptoms similar to this at any other time in your life?” can clarify whether you are dealing with a brief episode of the blues, a first depressive episode, or recurrent major depressive disorder. Assessing function is so essential to diagnosis and treatment that we discuss it in detail in Chapter 11. In brief, you should be sure to assess a patient’s social functioning, instrumental activities of daily living, and activities of daily living. Finally, all practitioners should be alert to red flags for mental illness that may necessitate consultation with a general psychiatrist or, if possible, a geriatric psychiatrist (Table 1–1). In some cases, red flags may require referral to the emergency department for urgent assessment and psychiatric admission.
Previous inpatient psychiatric hospitalizations |
High risk for suicide |
Previous suicide attempts, especially those resulting in medical hospitalization |
Ready access to firearms or other weapons and presence of mental health symptoms |
Symptoms of mania or psychosis |
Previous treatment with psychotropic medication, electroconvulsive therapy, or other neurostimulation treatments |
One commonly held belief is that the diagnostic interview is completed on the first visit. We believe that the diagnostic mental health interview is a tool to be used at every visit, just like a stethoscope. With the interview, you can assess a patient’s well-being while reassessing the validity of a diagnosis. Although the strongest evidence for a correct diagnosis is usually a positive response to treatment, you should always remember that the relationship between treatment and improvement can be a coincidence. With each patient encounter, you should perform a portion of the diagnostic interview to collect additional information to confirm your diagnosis, add a diagnosis to your differential, or exclude a diagnosis. To avoid premature conclusions, you can repeat portions of the diagnostic interview as you learn more about a patient.
Therapeutic Alliance: The Key to Accurate Diagnosis and Successful Treatment
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
