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Issues for Seniors with Mental Illness Need Special Consideration

America's baby boomers are aging and dealing with all the medical problems normally associated with the elderly.  But it is important to know that it is never normal to be depressed, anxious, or to have psychotic symptoms no matter how old someone is.  Contrary to some widely held opinions, it is also important to know that it is not dangerous to prescribe psychotropic medications to elderly patients who have treatable psychiatric disorders.  Therefore, treatment should not simply be avoided because someone is over the age of 65.  However, it is important that care be taken that the doctor is given all of the proper information to make the right treatment choice and that all effects and reactions to the medications be monitored carefully.

Studies show that 13 to 27% of all adults over the age of 65 living in the community suffer from symptoms of depression. Another 20 to 25% of elderly adults who are being treated for a medical condition in the hospital suffer from symptoms of depression. Furthermore, the prevalence of depressive symptoms in the nursing home residing elderly has been estimated to be 30 to 40% and may even be as high as 50%.

Several studies have shown that the combination of anti-depressant medication and talk psychotherapy is superior to either alone in the treatment of depression in the elderly, particularly in the prevention of relapse of symptoms.

Anxiety has been found to be a significant factor in determining the prognosis, length of illness and the response time to anti-depressants in major psychiatric disorders in the elderly, such as depression.  In addition, symptoms of anxiety have been associated with suicide, which has its highest prevalence in the elderly.  Again, the use of certain anti-depressant medications, in combination with support and talk psychotherapy, has been found to bring about a positive response in approximately 90% of the elderly anxious patients studied.

The prevalence of psychoses has been found to be approximately 6-10% of the elderly population.  Anti-psychotic medication or mood stabilizer medication treatment (depending on the cause of the psychotic symptoms) is often indispensable in treatment of elderly psychotic patients.  Also, low doses of anti-psychotic medications are very effective in calming agitated patients with dementia and in eliminating the symptoms of delusions and hallucinations that sometimes accompany dementia.

In spite of these staggering statistics and the multiple studies demonstrating the benefit of psychotropic medications, these medications have been significantly underutilized in the elderly population.

One reason for this may be the misconception that the above symptoms are "normal" in the elderly.  However, it should be noted that depression, psychosis, and anxiety disorders are never normal, no matter a person's age.

Another reason that elderly patients may not be prescribed the psychotropic medications that they may need is that doctors fear the potential side-effects and, therefore, avoid prescribing such medications at all.

Let's look at this very real risk for medication side-effects in the elderly.

Elderly adults generally experience increased side-effects to medications at doses that are generally therapeutic for younger adults.  The reason for this is that the pharmokinetics (that is, how well the body absorbs the medication, how it distributes the medication throughout the organs, how well it transforms that medication into the chemicals that the body then utilizes, and how well the body eliminates the medication) tend to change with age.  In addition, the response of the body to the medication changes due to co-existing medical conditions, changes in hormonal balance, and general changes in chemical make-up of the body as one ages.

It is often quite necessary to treat an elderly patient with psychotropic medication (often in conjunction with talk psychotherapy).  Yet, there is the risk of an adverse reaction as a result of adding yet another medication to the long list of medications often already taken by elderly patients.  So what can be done?

First of all, careful diagnosis must be made.  Whenever an elderly person develops a psychiatric symptom, the first consideration must be whether or not a medical problem exists.  Often the symptoms of a medical problem in the elderly patient can mimic a psychiatric disorder, such as depression or anxiety, or may even cause psychotic symptoms, such as delusions or hallucinations.  Also, an adverse reaction to another medication taken by the patient should be considered as a possible cause of the symptoms.  Additionally, symptoms of psychiatric disorders in the elderly are not the same as for younger adults.  For example, depression in an elderly person may appear as anxiety.  When the depression is treated, the anxiety then often resolves on its own.

Evaluation for other medical problems must also be made.  Although the medical problem may not be the cause of the symptoms, an elderly person is more likely to have a condition that will interfere with the action of a psychotropic medication.

To reduce the potential for drug interactions, the doctor should identify the potential variables that put a person at risk, such as their diet, whether or not they smoke, alcohol use, and chronic conditions.  In addition, they must have a thorough drug history of the patient and they must take care that the patient or caregiver has a clear understanding of the potential interactions and the necessary regimen for taking the medication.

It is, therefore, very important that the patient, or their caregiver, give the doctor a thorough list of symptoms experienced by the patient, a complete list of all known conditions that the patient currently has or has had in the past, the patient's history with regard to reactions to various medications, a complete list of all medications currently taken by the patient, and an honest and complete understanding of the patient's life-style, with regard to diet, smoking, and alcohol use.  Finally, it is very important that the patient, or the caregiver, stick to the regimen prescribed by the doctor and that they notify the doctor of any unusual or undesirable side-effects or reactions.  In general, it is usually necessary to start the elderly patient at a lower dose of the medication than what is usually given to younger adults and to obtain blood levels of the drug more frequently.