Mental Health Concerns in the Elderly

What are they?
Mental health concerns specific to the elderly include dementia, delirium, psychosis, and depression. Generally, elderly patients are more sensitive to medications and their side effects. Women are especially susceptible to the side effects of various medications prescribed for mental health problems.

Many different kinds of dementia are known to occur in elderly patients, with Alzheimer's being the most prevalent type. Degeneration due to Alzheimer's dementia can last anywhere from 5 to 20 years. Although sometimes uncomplicated, dementia usually occurs with some or all of these symptoms:

  • Delirium
  • Delusions
  • Depressed mood
  • Behavioral disturbances
Memory loss, language difficulties, difficulty in carrying out motor functions, failure to identify objects, and disturbances in planning and organizing all characterize early stages of dementia. It is common for some of these symptoms to be confused with normal aging or depression. Many cases are not caught early because the growing deficiencies that the patient exhibit may be masked by the compensation of loved ones.

Sometimes medications are used to treat symptoms that are secondary to dementia, such as sleep disruption, depression, and aggressive behaviors. These medications are only treating the symptoms that arise out of the underlying dementia, and do not treat the dementia itself.

Elderly patients, and especially women, are extremely sensitive to things such as surgery and anesthesia, drug toxicity, and infections like urinary tract infections (especially in women). The symptoms of delirium are often misdiagnosed as relating to other conditions. Common symptoms include:

  • Sudden reduced ability to focus, sustain, or shift attention
  • Disturbed consciousness
  • Sudden onset of misperceptions
  • Impaired judgement
  • Increased or decreased motor activity
If the symptoms develop over a short period of time, fluctuate over the course of the day, or can be caused by a general medical condition, it is quite possible that the patient is suffering from delirium. A diagnosis of delirium can be made if the patient's EEG (electroencephalogram) findings show a slowing of activity in the brain.

In order to effectively treat delirium, the doctor needs to first identify the underlying cause. Haloperidol is commonly given to patients experiencing delirium to try to reduce the symptoms.

Psychosis is usually used as another term for schizophrenia or bipolar disorders. Schizophrenia is a group of mental disorders that involve disturbances of thinking, mood, and behavior. Bipolar disorders involve periods of depression followed by periods of mania. Mania can be accompanied by grandiosity, lack of sleep, and excessive activity. One well-known bipolar disorder is manic depression.

Of all patients with schizophrenia, only 3% experience their first symptoms in their sixties or after. However, women comprise a large portion of that 3%. The treatment of schizophrenia for elderly patients is largely the same as in other schizophrenic patients. Some of the minor differences are the necessity to treat depression that often results in elderly patients as a result of psychosis. Younger patients are less likely to become depressed as a direct result of schizophrenia.

Bipolar disorders occur in approximately 1% of the population. They can be easily confused with other thought disorders, so the patient needs to be carefully evaluated before treated. Elderly patients who are diagnosed with psychosis may also experience delirium or dementia, so these conditions must be treated in addition to the psychosis.

Depression is a common condition amongst elderly women. Research has shown that more than one third of all depressed patients seen by doctors will go untreated because they are not properly diagnosed. Therefore, it is very important to know the symptoms of depression so that a scenario of misdiagnosis or lack of diagnosis will not occur. Usually women will not complain directly of sadness. Rather, they will complain of a host of other, seemingly unrelated symptoms, which serve to attract their doctor's attention. Common symptoms can include, but are not limited to:

  • Disturbances in sleep, self-esteem, libido, appetite, interest, energy, concentration, memory, and movement
  • Feelings of guilt
  • Suicidal thoughts, plans, or attempts
  • Pain
Depression can be caused by several personal losses experienced in rapid sequence, which is often the case in the elderly. While the lifetime risk for major depression is only 7-12% in men, it is a whopping 20-25% in women. Why this is so is not clear. What is clear, however, is that certain medical conditions seem to be associated with depression. These conditions include, among others:

  • Alzheimer's disease
  • Cancer (including breast and ovarian)
  • Congestive heart failure
  • Diabetes
  • Parkinson's disease
  • Rheumatoid arthritis
  • Sexual dysfunction
The elderly are also commonly taking many more medications than younger people are. Some of these medications are known to be associated with depression. Following is a selected list of these medications:

  • Anticancer drugs
  • Anti-inflammatory drugs
  • Progesterone
Anti-depressants are used to treat depression, and they usually are fairly successful at improving the quality of life of the elderly patient. Psychotherapy is often used in combination with anti-depressants, which can include drugs in these classes:

  • Tricyclics such as imipramine, desipramine, amitryptyline, and nortriptyline
  • Heterocyclics
  • Selective serotonin reuptake inhibitors (SSRIs) such as Prozac
  • Monoamine oxidase inhibitors (MAOIs)
There are quite a few side effects to these medications, which the elderly population is more susceptible to. These side effects include:

  • Blurred vision
  • Dry mouth
  • Urinary retention
  • Confusion
  • Constipation
  • Drowsiness
  • Insomnia
  • Cardiac arrhythmia
  • Hypotension
  • Gastrointestinal distress
  • Weight fluctuations
  • Sexual dysfunction
Many, but not all, of the side effects can be overcome by changes in medication dosage or by substituting other drugs for the one causing the side effects.

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