Introduction
According to the American Psychological Association, by 2012 an estimated 20 percent of elderly Americans had some form of mental illness, although much of this illness goes undiagnosed and untreated because many of the elderly are reluctant to seek the professional help that might alleviate their conditions. Medicare benefits for conditions relating to mental illness are often less generous than those for physical disorders. Therefore, elderly people, especially those who are financially constrained, are unwilling and often unable to pay for the treatment that could offer them relief from the mental problems they are experiencing.
The elderly population in the United States is growing exponentially and is expected to continue that growth throughout the twenty-first century. According to the US Census Bureau, individuals sixty-five years of age and older made up more than 13 percent of the US population in 2012; that number is expected to increase to more than 20 percent by 2050, according to estimates by the US Department of Health and Human Services' Administration on Aging. Not only will the number of people aged sixty-five or older continue to grow, but also, with advanced medical breakthroughs, many of them are expected to survive for two or more additional decades, leading active lives and enjoying reasonably good health into their eighties or nineties. Nevertheless, it is anticipated that millions of these people will have some form of mental illness.
Common Mental Disorders
The most common mental disorder that affects elderly Americans is
dementia, with such accompanying conditions as delirium, depression, and psychosis. Many elderly individuals and their families overlook the symptoms of dementia, especially those that develop gradually. Often obvious symptoms are attributed to the normal aging process. Sometimes obvious symptoms are ignored by friends or family members in the hope that they will diminish or disappear. In the minds of many people, a degree of shame is still associated with any mental disorder, which leads them to deny even obvious symptoms.
Throughout history, many elderly individuals have exhibited eccentric behaviors and were forgetful. However, life expectancy was such that few people survived beyond their fiftieth year, and truly elderly people were seldom encountered. Their eccentricities could be shrugged off as being normal developments in the aging process. In medical circles, these behaviors were often identified as manifestations of senile psychosis.
In 1906, however, Alois Alzheimer, a German pathologist and neurologist, presented a case study of a fifty-seven-year-old woman, Auguste D., whose symptoms were classic symptoms of what has come to be called
Alzheimer’s disease. Following this patient’s death, Alzheimer studied samples excised from her brain and found amyloid plaques, or accumulations of dark protein, in the brain’s cortex and hippocampus. In his microscopic examinations of Augusta D.’s brain tissue, he found twisted tendrils of very fine fibers that he called neurofibrillary tangles. He concluded that these tangles were at the heart of this patient’s mental disorder.
Alzheimer’s disease, named after this pioneering physician, is the most prevalent type of dementia found in elderly patients. To date, the causes of this disease have not been identified definitively. It is known that those with Alzheimer’s often survive for five to twenty years following the onset of the disease and that their conditions usually become progressively worse. Many Alzheimer’s patients die from causes related to the disease.
Normal Aging Versus Dementia
Symptoms that suggest dementia may occur in elderly people who are not experiencing dementia as such. As the aging process accelerates in people over the age of sixty-five, most of them experience a decrease in their sensory abilities, with declines in vision, hearing, touch, taste, and smell. Also, many of the elderly use prescription drugs that may interact adversely with one another, causing severe behavioral changes. Physicians are well advised to obtain lists of all the medications, including over-the-counter drugs, taken by their patients.
Among the most significant behavioral changes observed among the elderly is a decrease in memory, both short-term and long-term. In people with Alzheimer’s disease, one of the first symptoms observed is a loss in short-term memory. Therefore, if older people show evidence that their short-term memory is failing, those who observe them might leap to the conclusion that they are in the early stages of Alzheimer’s. However, even some perfectly healthy people are forgetful. Absentmindedness occurs among people of all ages and may be the result of many factors other than dementia.
Another symptom of dementia is a tendency to respond to questions inappropriately or to give answers that do not make sense. Among the elderly, however, deficits in hearing can cause people to misconstrue questions. Therefore, if an elderly person answers questions inappropriately, it may suggest an auditory deficit rather than dementia.
Visual and auditory deficiencies can result in older people’s misinterpreting situations and reacting to them in ways that seem strange to those caring for them. Also, the elderly person in question might be living in a context quite different from the one that a caregiver perceives, so that conclusions reached based on the caregiver’s observations may be inaccurate. It is important to view the behaviors of the elderly realistically within the actual contexts in which they live and function.
Some behaviors that younger people exhibit may intensify as they age. This is often a normal part of aging. People who have typically been rigid and suspicious in their early years may find that such tendencies increase substantially as they age, but such an increase does not categorically indicate dementia. However, if such behaviors turn to unhealthy or obsessive paranoia, dementia may account for the change.
As the motor abilities of older people decrease, often as a result of factors such as arthritis or reduced blood flow to the brain, they may walk with difficulty and seem to be disoriented, even though they may be performing quite appropriately given the total context of the situation in which they find themselves. They may also become confused or lost in unfamiliar surroundings, but this is not a clear indication of dementia. However, if they cannot find their way in familiar surroundings, dementia may be suspected.
When dealing with the elderly, misdiagnoses of dementia are common. They must be regarded as questionable if they are based on information that has been obtained solely through observation. Neurological testing and sophisticated procedures such as magnetic resonance imaging (MRI) provide more reliable diagnoses.
Dementia
Dementia usually involves the loss of memory, particularly short-term memory, although in advanced cases, long-term memory may also be compromised. Those with dementia often have problems with language, most frequently being unable to bring forth the words they need to express themselves. This tendency may come and go as blood flow to the brain waxes and wanes.
One of the most devastating symptoms of dementia, one usually suggestive of Alzheimer’s disease, is an inability to recognize the people and objects with which patients have been most familiar. Individuals may be unable to recognize their spouses. Patients may touch objects, such as hammers or screwdrivers, but be unable to determine how they function. They also may be unable to attach names to such objects.
People with dementia often have difficulty carrying out the motor functions that most people take for granted, but this is not a categorical indication of dementia because physical incapacities such as the joint pain that accompanies arthritis may severely limit the motor skills of those with this condition. Adverse drug interactions may also account for a decline in motor skills.
Delirium
Delirium
is an acute state of mental confusion marked by difficulty in focusing, sustaining thoughts, and shifting attention. Patients may misconstrue the statements and actions of others, often reacting to them with great suspicion. Those experiencing delirium may have difficulty sleeping and may be physically disturbed and restless, resulting in dramatic swings in their moods.
The judgment of such people is often impaired, and efforts to alter such misjudgments may elicit anger from them. They may also experience either significantly increased or decreased motor activity. If these symptoms manifest themselves suddenly or fluctuate over short periods of time, the person may be experiencing delirium.
A reliable diagnosis of delirium can be made by having an electroencephalogram (EEG) performed on the patient. If an EEG reveals a marked decrease in cerebral activity, delirium is likely to be the cause. When such a diagnosis is made, the condition may be treated with medications that can reduce the symptoms.
Manifestations of Psychosis
Various forms of
psychosis may afflict the elderly. The most common occur in the elderly with schizophrenia or bipolar disorder. Among elderly patients diagnosed with schizophrenia or bipolar disorder, many may also have delirium or dementia.
Schizophrenia
, a chronic brain disorder, is characterized by hallucinations and delusional thinking or behavior. Although schizophrenia is rare among people over the age of sixty-five, it can be a very disturbing and potentially dangerous condition. Most people with schizophrenia develop it in the second or third decade of life, but some are first diagnosed between the ages of forty and sixty-five, and others are diagnosed after reaching the age of sixty-five. Late-onset schizophrenia-like psychosis is more common in women and is characterized by paranoia, brain structure abnormalities, and cognitive deterioration. A family history of schizophrenia and a history of early childhood problems are usually absent. Schizophrenia differs from Alzheimer’s disease in that hallucinations tend to be auditory rather than visual, delusions tend toward the bizarre, and patients usually recognize their caregivers. Elderly people who have schizophrenia are usually treated with antipsychotic medications. Psychosocial treatment such as cognitive behavior therapy and social skills training can also be helpful.
Bipolar disorder causes significant and often sudden mood swings in which patients fluctuate from the depressive state to the manic state, which sometimes reaches psychosis. Manic periods are characterized by heightened mood (irritability or euphoria), grandiosity, decreased sleep, and, in severe cases, a loss of touch with reality. Depression is a universal condition and is perfectly normal in most people, particularly if it has an identifiable cause such as loss of a job or financial difficulties. In such cases, once the cause is removed or controlled, the depression usually moderates. However, those with bipolar disorder, like the clinically depressed, are depressed for no apparent reason. They experience down moods that may be so pervasive that they can lead to such drastic outcomes as suicide, which is a major cause of death among those over the age of sixty-five. Bipolar disorder is most commonly treated with mood-stabilizing drugs such as lithium.
Clinical Depression
The elderly are more subject to
depression than is the general population, partly because they are at a point in their lives when their spouses and close friends are dying, leaving the survivors feeling isolated and hopeless. This factor is combined with the physical deterioration that is part of aging. The diagnosis of severe, or clinical, depression is sometimes difficult because many people will not admit that they are depressed. Men experiencing deep depression may view such feelings as unmanly. Women who fight depression are often less skillful than men at masking their depression. Those dealing with them must understand various nuances that may suggest the condition.
Among these nuances, one of the most common is hypochondria. People who are basically healthy and organically sound may experience imaginary ills that are, to them, quite real. Overworked physicians may simply dismiss such patients because they cannot find anything wrong with them. A sensitive physician, however, will probe deeply enough to find the real cause of the patient’s hypochondria and will avoid treating it medicinally until the basic causes have been uncovered.
Various behaviors provide the clues that signal a patient’s depression. Among the most common of these are severe declines in self-image, often accompanied by dramatic decreases or increases in appetite; loss of interest in sex; difficulty in concentrating; loss of memory; reduction of motor skills; and significant declines in energy levels. People entering a depressive state may experience substantial gains or losses in weight. The clinically depressed may have seemingly unjustified feelings of guilt. They may experience physical manifestations such as a tightness in the chest or unexplained difficulty in breathing. They may also harbor thoughts of suicide and may have gone so far as to plan or to have attempted suicide.
Depression in the elderly can be treated with medications, but also can be dealt with successfully in many cases by making changes in lifestyle, such as becoming more actively involved socially. Seeing films and plays with friends and then discussing what they have seen or playing board games or card games can be a useful therapy for some elderly people. Many older people benefit greatly from participating in book clubs.
Nutrition and exercise are also major components in maintaining the mental health of the elderly, who should eat three well-balanced meals a day and consume at least five portions of fresh vegetables and fruits daily. The elderly should limit their intake of alcohol and refrain from smoking. Regular activities such as walking, cycling, swimming, water aerobics, or yoga can help restore flexibility to aging joints and, if engaged in judiciously, can prolong one’s active life. Exercise and proper nutrition often do more to control depression than any medication can.
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