Diagnosis Dilemma

Mental illness is often overlooked in aging populations

Back Article Sep 1, 2011 By Judith Horstman

Until about a year ago, 86-year-old Clair was living in her own home on the East Coast with her husband of 60 years. When her husband died suddenly, her daughter quickly moved Clair into a senior living complex in Sacramento to be near family.

But the double whammy of widowhood and a whirlwind move away from everyone she knew left Clair feeling confused and out of control. Isolated in her new small apartment, Clair (who asked not to be identified by her real name) began to have problems with depression, anxiety and memory. Her new doctor prescribed antidepressant and anti-anxiety medications and when there was no change, upped the dosage, increasing Clair’s confusion.

Finally, Clair’s daughter consulted Dr. Barbara Gillogly, a Sacramento psychotherapist specializing in aging and loss. Gillogly found Clair grieving her losses and needing someone other than her daughter to talk to about anger and grief. Gradually, her mood improved, her medications were decreased and Clair became less confused and happier –– and so did her family.

“She didn’t need a chemical intervention, but someone to hear her story, validate her feelings and help her maximize her natural strengths,” says Gillogly, who chairs the gerontology department at American River College. “She needed someone to reassure her that sadness over her many changes was normal and would pass.”

Depression, however, is not a normal part of aging.

While the majority of older adults are not depressed, they are more at risk for depression as they face major life changes and losses, including illnesses and the death of mates and friends. Depression rates for people 65 or older jump from less than 5 percent for those living independently to 13.5 percent for those who are homebound, requiring home health care.

All too often depression, dementia, anxiety and other mental illnesses are considered a normal part of aging, Gillogly says. Ironically, older folks often share this belief and don’t seek medical treatment because they think it won’t help.

It’s a mistaken belief, and it may prevent patients, their families and even doctors from checking into and treating the many conditions or situations that can contribute to what looks like mental illness, says Ladson Hinton, a psychiatrist and director of geriatric psychiatry at UC Davis, who has been researching late-life depression.

In many ways, Clair is among the lucky seniors with depression. First, she was fortunate that her condition was recognized: By some estimates, up to half the cases of depression in older adults go undiagnosed and untreated. And second, she eventually got the right combination of treatments. Doctors are giving out more drugs than patient time these days, and even psychiatrists have all but abandoned talk therapy.

However, even with the best of intentions, most primary care doctors are just not trained to cope with and recognize mental health issues, says Dr. Irving Hellman, a Sacramento geropsychologist who consults with agencies and individuals on elder care issues.

In fact, a study in the Journal of the American Geriatrics Society found primary care doctors spend little time discussing mental health issues with older patients and rarely refer them to a mental health specialist even if they show symptoms of severe depression. Even when a patient mentioned a mental health issue –– as 22 percent did in the study –– the discussion took only two minutes of the average 16-minute consultation.

Doctors may fail to detect mental health issues because older patients often have multiple physical conditions, Hinton says. “So they address the most acute diseases and conditions and don’t consider mental health issues as life threatening,” he says.

Yet ignoring mental illness and depression in the elderly can indeed be life threatening. Last year, the Centers for Disease Control and Prevention found that while people age 65 and older represent 13 percent of the U.S. population, they accounted for 16 percent of suicide deaths; men aged 75 and older made up more than 36 percent of those deaths. By comparison, the suicide rate in the overall population is 11 percent.

Several studies have found many older adults who commit suicide have visited a primary care physician very close to the time of the suicide — 20 percent on the same day and 40 percent within one week of the suicide.

Even without suicide, mental illness in the elderly causes much grief for the person and the family.

One of the most common misdiagnoses is dementia. Depression can mimic dementia, which has no cure as yet, as can many treatable physical conditions.

Hellman recalls an 87-year-old patient he called George (not his real name) who was an active participant in a senior care program. One day George showed up looking as though he hadn’t slept. Over the next few days he became lethargic, forgetful and increasingly confused. Did he have a stroke — or was this the onset of dementia?

Fortunately for George, he was in a center geared toward elder care. The staff looked for a more immediate cause and discovered an infection was causing the mental symptoms. “Once he was treated for a urinary tract infection, he was better in a matter of days,” Hellman says.

At the other end of the spectrum are elders such as Clair, who are being overmedicated or suffering from medication interactions or side effects. Many doctors aren’t aware of the different medications their elderly patients are taking, and when combined they can have toxic effects, Hinton says.

“Medicine has overemphasized medication and underemphasized nonpharmaceutical treatments such as psychotherapy and cognitive behavioral therapy,” Hinton says. Yet talk therapy is as effective as drugs, “and the best treatment is a combination of both, especially for older adults.”

Meanwhile, the first wave of the silver tsunami has hit. Boomers make up the largest demographic group. They are living longer, which means more health issues. Current projections estimate 50 percent of those who live to age 85 are expected to develop Alzheimer’s disease, the leading cause of dementia.

But finding a psychotherapist or counselor specializing in aging issues can be challenging. “A big problem is the lack of providers in the community for the elderly,” Hinton says. Very few psychiatrists do talk therapy anymore; their primary treatment is chemical. And most talk therapists specializing in aging issues aren’t covered by or don’t take Medicare.

“It’s very difficult to get doctors to go into family practice and even more so to specialize in geriatrics because of the lower income — in geriatrics especially — where services are reimbursed by Medicare,” Hellman says.

In fact, there’s a drastic shortage of health practitioners trained in treating all issues of aging. Few family practitioners are formally trained in geriatrics, and there is currently just one geriatrician for every 5,000 adults age 65 and older, according to the American Geriatrics Society. In 2030, it’s estimated that there will only be one geriatrician for every 7,665 older adults — a 50 percent decline.

“Mental health services for seniors has always been an area of need, and now there are even less services as the need grows,” says Dorian Kittrell, executive director of the Sacramento County Mental Health Treatment Center.

Hinton says: “To meet the mental health needs of our growing older adult population, we need to dramatically increase the number and availability of health care professionals with training and expertise in geriatric mental health care.”
The economy has only added to problems. Some referral and crisis services and hotlines that used to offer advice and referrals for elders are no longer in operation. However, Sacramento County sponsors Senior Link, a multilingual prevention program that provides supportive services for people 55 and older who are experiencing depression, isolation and similar issues (sacpros.org).

A primary care doctor should be able to give a referral to a counselor who specializes in issues of aging and loss. In a crisis, your best bet may be a hospital emergency room, usually covered by Medicare, or the Suicide Prevention Crisis Line at 1-800-273-TALK.

Transitions: Who Cares?
Transitions: Folly of Youth
Transitions: Road to Recovery


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