Peace of Mind Never Gets Old

Mental-health treatment isn't just for the young

He doesn't want to go out anymore, has trouble sleeping, gets confused easily, and is always complaining about his aches and pains. Many people would simply shrug off this man's behavior as symptomatic of old age. But chances are good that he's depressed or suffering from some other psychological disorder. Left untreated, as mental-health problems too often are in the elderly, he might feel he has nothing to live for. With proper medical attention, however, he can very likely find enjoyment in his final years.

"I don't buy that anyone is too old to be treated" for emotional problems, says Dr. Stephen Bartels, a geriatric psychiatrist and associate professor of psychiatry at Dartmouth-Hitchcock Medical Center in Hanover, N.H. Treatment also makes economic sense: Research has shown repeatedly that psychological problems can lead to physical decline. "You're going to end up with higher health-care costs in the long run if you don't address mental disorders," he says.

Ignoring mental illness has other dire consequences: People over 65 have the highest suicide rates of any age group. Granted, older people have more to make them despondent. Their careers end, friends and spouses die, and they often have to cope with disabling physical problems such as arthritis and heart disease. Many are also forced to move into nursing facilities or accept caretakers in their home.

RESILIENCE. Although these are distressing circumstances, they don't mean an older person has to be miserable. "You can't just say: `She's got four illnesses and lives in a nursing home. Wouldn't you be depressed?' because she can feel better with treatment," says Dr. Mark Kunik, a geriatric psychiatrist at Baylor College of Medicine in Houston. Indeed, the elderly are amazingly resilient. "Once they commit to therapy, they are outstanding patients," says Dr. George Grossberg, director of geriatric psychiatry at St. Louis University School of Medicine.

Older adults suffer from depression and anxiety more than any other psychological disorders. Signs of depression include loss of appetite, lethargy, insomnia, social withdrawal, memory loss, and an inability to concentrate. Anxiety manifests itself as restlessness, rapid heartbeat, excessive worrying, a fixation on physical ailments, and feelings of fear and foreboding. The elderly are also prone to adjustment disorders, triggered by life-changing events such as the death of a spouse. Dementia, usually related to Alzheimer's disease, is another problem. Unlike other woes, however, it's irreversible. Still, since depression and anxiety are often mistaken for dementia, you might as well treat them first and see if things improve.

Getting treatment requires finding a doctor who will not summarily dismiss the problem as an inevitable consequence of old age (table). A good primary-care physician who works with older patients is the first line of defense. You can also seek out a specialist, such as a geriatric psychiatrist or geropsychologist, who is adept at diagnosing and treating mental disorders in the elderly.

Among the first things these experts look for are possible physical and pharmacological causes of mental problems. The culprit could be an illness such as diabetes, a thyroid disorder, or cardiovascular disease, which can profoundly affect brain function. Drugs also frequently provoke symptoms of psychological distress in the elderly. "Even seemingly benign, over-the-counter pain and cold medications can make older people terribly confused and agitated," says Grossberg.

That's because the number of chemical receptors in the brain that regulate emotion and thinking declines with age. The remaining receptors then become incredibly sensitive to drugs' side effects, says Grossberg. Also, older kidneys and livers process medications less efficiently. So the drugs can accumulate to undesirable levels, disrupting mental processes and even causing psychotic behaviors such as paranoia and hallucinations. "Overmedicating is a common problem that is often overlooked," says Baylor's Kunik. To avoid that, elders typically should take a fraction of the standard adult dosage of most medications.

Geriatric experts are sensitive to many older people's resistance to seeing a "shrink." "The elderly often view mental illness as a social stigma or something that gets you locked up in an institution," says Grossberg. "I always address this up front and assure them they are not crazy and they can always quit coming to see me if they want to." Family and friends can help smooth the way by avoiding terms such as psychiatrist and psychologist. Instead, they can suggest seeing a doctor who specializes in helping people with low energy or diminished appetite or some other physical manifestation of the psychological problem.

STRATEGIES. If the difficulty is emotional, mental-health specialists most often recommend cognitive behavioral therapy. "There isn't a lot of talking about their mothers," explains geropsychologist Dolores Gallagher-Thompson, director of the Older Adult Family Center at the Veterans Administration in Palo Alto, Calif. "We give them strategies to help them cope with their situation."

Through role-playing and discussion, patients learn how to stop negative thought patterns. In addition, therapists suggest activities, such as volunteer jobs, that give them a greater sense of control and general happiness. Gallagher-Thompson adds that geriatric mental-health specialists conduct sessions with an understanding of older people's limitations. They present material more slowly, since older minds don't process information as rapidly as they once did. They are also careful to speak louder or use larger visual material to accommodate seniors who have lost hearing or eyesight.

For people who do not respond to the cognitive behavioral approach alone or refuse therapy, antidepressants such as Prozac and Zoloft may relieve their symptoms. Studies indicate elders react just as well to drug treatment as younger adults. But older people need far lower doses, and their doctors must be wary of possible interactions with other drugs. "A lot of seniors take several medications already, so prescribing a new drug that won't interfere or cause more problems can be a bit tricky," says Grossberg.

Treating mentally distressed elders requires a certain amount of finesse. But with the right clinician, a willing patient can regain some youthful hope and happiness.

By Kate Murphy

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