Older Adults

For most older people, old age is a positive and rewarding period. However, as people age they are faced with new challenges that may affect their mental health such as:

Giving up work 

Physical jobs become more and more difficult as we grow old. Jobs that require good memory or concentration also become more of a challenge. To many people (often men) work is central to life. When work has to stop, people can sometimes feel rejected, worthless and question their purpose. This can lead to low mood and anxiety. Loss of income can lead to financial or housing problems.

Bereavement 

Older people frequently witness the death of their friends and older members of their family including their spouse and siblings. For some, repeated grief can be difficult to cope with. Older people can become lonely and isolated as a result.

Fear of death 

As we age we become more aware of our own mortality. Many people fear death. They may fear the way in which they may die, specifically in pain, all alone or without dignity. They may worry about the welfare of those they will leave behind.

Sleep 

Older people commonly have problems sleeping. If this problem is ongoing it can lead to tiredness, irritability and difficulty concentrating.

Physical health 

As we age we begin to experience more physical health problems like arthritis, pain, falls, heart or lung disease.

Increase in mental health problems

The most common psychiatric disorders in older adults are depression and anxiety. Dementia, delirium and substance misuse are common too.

• Delirium is common in older adults so presume that any older adult with new onset confusion or odd behaviour has delirium until proven otherwise
• Screen older adults for depression especially if they attend a clinic regularly for other complaints
• Check for signs of dementia by asking patient and their family if they have noticed memory problems or trouble doing things for themselves
• Perform a physical health check on the elderly and manage or refer for treatment as necessary
• Address psychosocial stressors that are particularly relevant to the person, respecting their need for autonomy
• Manage sensory deficits (such as low vision or poor hearing) with appropriate devices (e.g. magnifying glass, hearing aids)
• Assess and manage risks:
• Suicide
• Neglect
• Risk from others (e.g. abusive family)
• Self-harm in an older adult should be considered to be with suicidal intent until proven otherwise
• Refer if needed. Review regularly

Most conditions present similarly and are managed largely the same as in younger adults but be alert to the following:

More likely to show:

• Cognitive impairment (“pseudodementia”)
• Psychomotor agitation or retardation
• Poor appetite and weight loss
• Poor concentration
• Generalised anxiety
• Excessive concerns about physical health

When psychotic, older adults are particularly likely to have false, fixed ideas that they are physically unwell (in extreme cases believing they are dead), in financial ruin, or feel guilty.

Remember that older adults are at high risk for completed suicide.

• Reducing social and sensory isolation is important (hearing aids and glasses)
• Remind the patient they are unwell and that their illness is treatable.

• Support carers

• Start medication (Fluoxetine 20mg OD, usual max dose 40mg) slowly and at a lower dose. Drugs take longer to work (6-8 weeks) so increase slowly.

• Try to avoid tricyclics (Amitriptyline) as they can cause anticholinergic side effects such as delirium, dizziness or confusion in older people.

• Electroconvulsive therapy (ECT) is very effective for severe depression, so consider referring to a specialist service any older person with severe depression with suicidal ideation, and those who have stopped eating or drinking or have failed to respond to medication.

Less likely to be clearly elated in mood, although the patient generally has grandiose ideation. More likely to be irritable with a labile mood.

Antipsychotics are effective but Haloperidol (usual max dose 5mg daily) must be used with caution in elderly people with vascular risk factors because of increased risk of stroke. Use atypical/newer antipsychotics if available, such as: Risperidone (usual max dose 2mg).

Older people with psychosis may have illnesses that have continued from their early life, such as schizophrenia. A first presentation of psychosis in older people is reasonably common in people who have dementia or may simply be a late onset psychotic illness.

As for mania above, use atypical/newer antipsychotics if available, such as Risperidone. Only use drugs in combination with a social intervention to reduce isolation.

• Use lower doses of medications (usually 50% of general adult dose)

• Increase doses very slowly (usually twice as slowly as in general adults)

• Anticipate increased risk of drug interactions as older people are often on more drugs – do not treat one side-effect with another drug

• Sedating drugs (Diazepam) may result in drowsiness, confusion, falls and delirium

• Tricyclic antidepressants (Amitriptyline) are more likely to cause confusion, anticholinergic side-effects (dry mouth/eyes/constipation) and low blood pressure with dizziness on standing

• Antipsychotics more likely to be associated with parkinsonism (stiffness, slowness and tremor) and increased risk of cerebrovascular accident (stroke)

• Keep therapy simple; that is, once daily administration whenever possible.