The Elderly Patient
EVALUATION OF THE ELDERLY
Assess each patient carefully: Mental decline is not normal for the aged.
Always carefully evaluate physical condition. An impaired physical state can markedly alter the psychiatric evaluation. Make sure the patient can hear and see. Check for deficiency states (iron, folate, vitamins B12 and D, calcium, serum proteins).
Interview technique: Be respectful, use surname, sit near, speak slowly and clearly, allow time for answers, be friendly and personal, pat and hug, be supportive and issue oriented, ask direct questions if appropriate, keep interview short.
Collect history, do mental status: Perhaps in more than one interview.
Identify premorbid personality: Defense mechanisms and coping styles (e.g., independent vs. passive-dependent, rigid vs. flexible, use of denial).
Assess the major risk factors:
Loss: Of spouse, friends, physical health, job, status, independence, etc.
Poverty: Many elderly are poor; some are victims of crime.
Social isolation: Impaired mobility, few friends, etc.
Medications: Particularly steroids, antihypertensives, anticholinergics, L-dopa.
Sensory deprivation: Poor hearing, vision, etc.
Sickness: Chronic illness, chronic pain, forced inactivity, alcohol abuse, etc.
Fears: Of being dependent, of being alone, of being helpless.
See family: Assess their strengths, dynamics, support for the patient, hidden agendas.
COMMON PSYCHIATRIC DISORDERS
Fluctuating confusion, cognition, and consciousness, of acute onset with lucid intervals; it is common among the elderly and commonly overlooked or mistaken for psychosis or depression (due to agitation or lethargy). May be the primary presentation of:
CNS: Cerebral infarction (embolic or thrombotic), transient ischemic attacks (TIAs), neoplasms, infection.
Circulation: Myocardial infarction (MI; often without pain), arrhythmia, congestive heart failure (CHF), anemia.
Lungs: Pneumonia (without fever or leukocytosis), pulmonary embolism (PE; without chest pain, dyspnea, tachycardia).
Medication: Multiple drugs, anticholinergics, benzodiazepines, bupropion, narcotics.
Metabolic: Diabetes, liver failure, hyper- or hypothyroidism, electrolyte abnormalities.
Psychogenic: Strange surroundings, stress, restraints.
Infections: Most kinds, any severe and acute disease.
Other: Alcohol abuse, prescription drug misuse, dehydration, fecal impaction, “silent” appendicitis, urinary retention, urinary tract infections (UTIs), eye or ear disease, surgery (e.g., cardiac).
Treat the underlying disease process, if possible. Keep patient in a lighted room and with familiar surroundings and people. Restrain only if absolutely essential. If needed, use small doses of major tranquilizers (e.g., haloperidol, 0.5 to 1.0 mg p.o. or i.m., b.i.d. PRN; quetiapine, 25 mg p.o. b.i.d.). Mild delirium may continue (unnoticed?) for months after the acute episode.
Dementia (see Chapter 6)
Most elderly have unimpaired intellectual functioning. Dementia (30% of those 80 years old) is not “just a result of aging”; it needs an explanation. Dementia often is seen first with agitation, anxiety, depression, somatic complaints, or a combination of these. Always do a mental-status examination on elderly patients with these complaints, but remember that it can also be mimicked by depression, serious physical conditions, alcoholism, and malnutrition. Dementia in the elderly frequently occurs with, is confused with, and is made worse by depression or delirium. Treat the depressed and/or
agitated demented patient with low-dose atypical neuroleptics (e.g., quetiapine, olanzapine) initially, but consider an early switch to SSRIs, lithium, or anticonvulsants. Marked memory loss may be unrecognized by the patient but is of major concern to the family, who ultimately insist on evaluation and treatment for it. Recent medication includes the cholinergic agonists such as donepezil, rivastigmine, and galantamine; enhance one of these with the possible addition of memantine (a glutamate blocker).
agitated demented patient with low-dose atypical neuroleptics (e.g., quetiapine, olanzapine) initially, but consider an early switch to SSRIs, lithium, or anticonvulsants. Marked memory loss may be unrecognized by the patient but is of major concern to the family, who ultimately insist on evaluation and treatment for it. Recent medication includes the cholinergic agonists such as donepezil, rivastigmine, and galantamine; enhance one of these with the possible addition of memantine (a glutamate blocker).
Most patients with a progressive and nonreversible form of dementia can be maintained at home until the late stages of the disease process. The decision to institutionalize depends not only on what facilities are available locally (some may be very good) but also on the realistic strengths and limits of the family. Once the cause and prognosis of the dementia is determined, the physician may most profitably spend his time helping the family draw limits, handle guilt, and adjust.
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