By 2030, an estimated 15 million older people will be suffering from some form of psychiatric illness. As the first of the baby boom generation reaches age 65 in 2011, nurses will be charged with caring for an increasing number of elderly psychiatric patients.¹ The need to understand neuropsychiatric illness in geriatric patients is essential.

Elderly psychiatric patients who develop medical conditions such as heart disease, diabetes, and cancer may lack the ability to cope with or behaviorally manage their illnesses. Older individuals with no history of psychiatric illness may develop symptoms of depression and anxiety in response to chronic or acute major medical problems. Like medical illnesses, environmental stresses can also negatively affect the mental health of older adults. Limited finances and lack of interpersonal support can create emotional distress² and exacerbate an existing mental illness.²

Part 1 of this two-part series explored the normal aging process. This module looks at four general psychiatric conditions common in older adults.

Anxiety disorders

Anxiety disorders are the most common psychiatric illnesses in adults. While incidences of panic and obsessive-compulsive disorders are lower in elderly populations, phobias are more common.¹ Phobic disorders involve marked and persistent fears that are excessive and unreasonable and interfere with functioning. Examples of phobias include fear of flying, social situations, heights, water, and closed spaces.³

Additionally, anxiety may develop secondary to a medical condition. Medical problems not only make a person aware of his or her mortality, but they also create limited mobility and dependence on others, factors that are likely to create anxiety in the patient who is uncomfortable with his or her dependency needs.² Anxiety about physical health and body integrity goes hand in hand with increased incidence of health problems that often accompany aging.

Most elderly patients diagnosed with anxiety disorders receive psychopharmacologic treatment.⁴ Anxiolytic benzodiazepines (Valium, Ativan, Klonopin) are most frequently prescribed and are often continued over extended periods despite clinical research that suggests limiting them to short-term use.⁴,⁵ Benzodiazepines have been associated with memory loss and hip fractures.⁴ These drugs are habit-forming, and dependency and withdrawal may occur. Buspirone, a non-habit-forming antianxiety medication, may be an acceptable alternative to benzodiazepines.⁴ Other nonaddictive alternatives are antidepressive medications that have antianxiety properties, such as paroxetine (Paxil) and venlafaxine (Effexor). They often are prescribed to elderly patients with anxiety and are particularly useful for those who have anxious depression.⁵

Psychological treatments are effective adjuncts or alternatives to medication. Psychotherapy and relaxation techniques can be beneficial in alleviating anxiety symptoms. The anxious individual needs an avenue to verbalize fears, which serves to discharge, clarify, and contain emotions. The therapist helps the patient become aware of the underlying source of his or her anxiety and familiarizes the patient with techniques that foster relaxation and help the patient confront, rather than avoid, the anxiety-producing situation.²

For those with medical problems, supportive in-home care can be instrumental in minimizing a patient’s anxiety. Knowing that someone is present gives the patient a sense of safety and diminishes feelings of alienation.²

Cognitive impairment

A diagnosis of dementia always includes memory impairment, plus one of the following four conditions: aphasia (language disturbance), apraxia (disturbance in carrying out motor activities), agnosia (disturbance in object recognition), or disturbance in executive functioning (problems in planning, organizing, sequencing, and abstracting).³ Both short- and long-term memory are affected. Dementia significantly interferes with work and social activities and marks a decline from previous levels of functioning.³ Alzheimer’s disease (AD) is the most common form of dementia. It is characterized by an insidious onset with progressive deterioration over time. The average life expectancy after a diagnosis of AD is eight years. Beta-amyloid, a sticky substance found in the brains of Alzheimer’s patients, seems to be the culprit in the widespread death of neurons. An AD diagnosis is made when all other causes are excluded. Neuropsychological testing and neurological examination, CT scan, MRI, and more recently, positron emission tomography aid in diagnosis. Major changes found on these diagnostic tests are in the hippocampus, the region of the brain involved in consolidating memories.⁶ If Alzheimer’s symptoms occur before age 65, the diagnosis is early onset. Early onset is rare and highly correlated to genetics. Late onset is also believed to be influenced by genes but in a less clear-cut way. Researchers have been actively looking for genetic markers that put people at risk for AD. Most promising is the apolipoprotein E (ApoE) gene. Eighty percent of Americans with AD inherited the ApoE gene from at least one parent. However, many who carry this gene never acquire the illness.⁷

Mild cognitive impairment is a condition that often proceeds AD, and it is characterized by serious memory problems noticeable to others as well as to the individual. Memory impairment is evident on neuropsychololgical testing when age and education level are controlled for. Normal overall intellectual capacity is relatively intact in mild cognitive impairment, and there is adequate daily functioning. Problems appear in complex matters, such as handling money. Many experts view mild cognitive impairment as a prelude to AD. In order to track impairment, neuropsychological testing and brain scans are recommended every six months for patients with mild cognitive impairment.⁸

Vascular dementia (multi-infarct dementia), the second most common form of dementia, typically occurs at an earlier age than AD. Onset is generally abrupt, rather than the slow progression of AD, and changes in functioning are rapid. The deficit pattern is referred to as “patchy,” occurring in a stepwise manner. Deficits depend on the area of the brain affected. There must be evidence of cerebral vascular disease for the diagnosis of vascular dementia to be made. Focal neurological signs are indicators of vascular damage. They may include gait abnormality, exaggerated or deep tendon reflexes, or weakness of an extremity.³

Dementia also can result from medical conditions such as HIV, Parkinson’s disease, and Huntington's chorea. Pick’s disease is a progressive form of dementia that creates atrophy to the frontal and temporal lobes. It is more common in women and occurs between ages 40 and 60. Creutzfeldt-Jakob disease is a rapidly progressive dementia related to the agent prion that causes bovine spongiform encephalopathy, referred to as “mad cow disease.”⁶

Prolonged use of alcohol, hypnotics, or anxiolytics in large amounts may result in dementia. Substance-induced dementia is diagnosed when cognitive deficits persist beyond the usual time frame for intoxication or withdrawal.³

Dementia, delirium, or depression?

Dementia must be distinguished from depression and delirium, which have similar features. Delirium involves altered consciousness, most notably disturbance of attention. As in dementia, there is a change in cognition. However, in delirium onset develops over a short time and fluctuates during the course of the day. Unlike dementia, symptoms of delirium are reversible.³ In the elderly, delirium may be the result of stroke, concussion, dehydration, hypoglycemia, electrolyte imbalance, hypoxia, sleep deprivation, or malignancy. Delirium can result from less likely causes, such as severe constipation. It also may be superimposed on dementia. Depression can also be mistaken for dementia in older adults because symptoms often include poor concentration and mild memory impairment. These symptoms typically have a gradual onset and are reversible if treated.⁹  

Antipsychotic medications are considered for delusions and agitation seen in patients with dementia and should be used only after behavioral and environmental interventions have failed to alleviate symptoms.² Behavioral interventions may include providing structure, routine, lowering environmental stimulation, and identifying hearing or vision problems. Correcting vision with proper eyeglasses prescriptions and improving hearing with hearing aids will allow the individual to be more aware of his or her surroundings and reduce distortions that contribute to an altered sense of reality.²

Late-life depression

Rates of depression are no higher for the elderly than for young adults. The problem lies in low detection and treatment rates of older depressed adults. Undertreatment may stem from the myth that the elderly do not benefit from mental health interventions. Older patients may not recognize that their symptoms are due to depression, and therefore do not seek treatment for depression per se. Elderly depressed patients who recognize their depressive state may not know how to access treatment.¹⁰ Shame may prevent some older depressed people from getting help, particularly if they equate depression with weakness.

Major depression is diagnosed when five or more depressive symptoms persist over a two-week period. At least one of the symptoms must be either depressed mood or loss of interest or pleasure.³ Other symptoms include a change in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, poor concentration or indecisiveness, and recurrent thoughts of death or suicidal ideations with the intention or a plan to end one’s life.³ For a patient to be diagnosed with major depression, the episode must mark a change in usual functioning.³

Dysthymia, another form of depression, is milder but longer term. To meet diagnostic criteria for dysthymia, depressed mood must continue for at least two years.³ A dysthymic patient is depressed most of the day more often than not. Additionally, at least two of the following symptoms must be present to make the diagnosis: appetite disruption, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions, or feelings of hopelessness.³ Dysthymia and depressive symptoms that do not meet full diagnostic criteria for a disorder are associated with risk of developing major depression.¹⁰

Depression can erode physical health and well-being. Studies reveal that depression can precipitate or amplify physical symptoms such as pain. It can interfere with immunity, nutrition, and mobility.¹¹ A depressed patient may avoid eating because of a lack of energy or interest or lack of pleasure from the activity. In turn, nutritional status deteriorates, and the elderly person becomes vulnerable to other illnesses. Absence of interest is likely to cause diminished physical activity, which negatively affects health and mobility. A growing body of research links depression to impaired immunity.¹⁰ This is of considerable importance for the elderly because the immune response becomes less efficient with age — both under- and over-reacting. Recovery from illness such as a viral infection is extended when depression co-exists. Likewise, wound healing may be compromised if a patient is depressed. Even the risk of cancer increases.¹¹ The link between depression and heart attack fatality is striking. Depressed patients are five times more likely than other patients to die after a heart attack.¹² Risk of death in nursing home residents with depression is 60% higher than for nondepressed patients.¹¹

Depressive disorders must be distinguished from normal grief reactions. Losses occur at high rates in later life, including the loss of physical abilities and social roles as well as the death of family members and friends. Grief is the process of coming to terms with loss.² A person who is grieving has depressive symptoms, but symptoms are typically less extreme than in major depression, and unlike dysthymia, remit over time.³ Some elderly patients use alcohol to cope with loss or stress. Unfortunately, alcohol problems in older adults are too often overlooked.¹

Bipolar disorder typically manifests in the early 20s but sometimes first appears after age 50. Minimal research exists on bipolar and the elderly. Contrary to what was once believed, bipolar illness does not “burn out” with age. Five to ten percent of elderly patients referred for mental health treatment are bipolar. Little is known about the long-term course of this disorder.¹³ Bipolar disorders are a collection of depressive illnesses marked by cycles of persistent depressive episodes alternating with periods of mania or hypomania.³ Mania is the psyche’s way of masking underlying emotional pain. During manic episodes, the patient experiences euphoric mood, rapid thoughts and speech, hyperactivity, sleep disruption, poor judgment, and sometimes delusions of grandiosity.³

The initial step toward treatment of mood disorders is identifying depressive symptoms. Primary care is typically the first setting in which the elderly depressed patient presents. Simple in-office screening tools designed to measure depression in older adults such as the Geriatric Depression Screen (GDS), which takes about 8-10 minutes to administer can help uncover symptoms.⁹ If depression is identified, suicidality must be assessed. Alarmingly, the highest rate of suicide in Americans is among those 65 and older.^10,14 Older Caucasian males are at considerable risk.¹⁰ (See sidebar for other risk factors.) A frequently cited study reveals that most older adults who commit suicide visited their physician within a few weeks of their death.¹⁴ Treatment studies show psychological interventions as well as medication to be effective in reducing recurrent depression in the elderly.¹⁰

Newer antidepressants have fewer adverse effects and are less lethal in overdose than the older tricyclics.² The advent of selective serotonin reuptake inhibitors has encouraged the pharmacological treatment of depression¹⁰ and undoubtedly underlies the shift of treatment of uncomplicated depression from psychiatry to primary care, but the value of psychotherapy must not be minimized,¹⁰ and care must be taken when prescribing antidepressants to the elderly. Decreased liver functioning associated with aging makes metabolization less efficient, creating more free-active drug available. As a result, antidepressants are typically prescribed to older patients in smaller doses (30% to 50% less than for younger adults).² The elderly also are likely to be more sensitive to adverse effects.¹

If severe depression does not respond to trials of medications from different antidepressant classes and to psychotherapy over a reasonable amount of time, electroconvulsive treatment may be indicated.¹⁰

Both lithium carbonate and certain antiepileptic medications are used to treat bipolar disorder. Lithium is typically the first line of treatment. Lithium is broken down by the kidneys, so regular renal studies and lithium levels must be obtained in addition to baseline and regular ECG, thyroid studies, and electrolyte levels. This is critical for older patients since aging can negatively affect kidney functioning. In cases in which kidney functioning is less than optimal or lithium adverse effects cannot be tolerated, antiepileptic medications such as carbamazepine (Tegretol) or valproate (Depakote) may be used because they are metabolized in the liver. Liver function tests, platelet count, PT, and INR should be obtained before starting valproic acid and at regular intervals ordered by the treating clinician. The following laboratory tests should be performed before starting carbamazepine and should be monitored regularly: urinalysis, BUN, liver function, CBC, platelet and reticulocyte counts. and iron levels.²

Thought disorders

A variety of psychotic disorders may be seen in older people. Schizophrenia is typically a lifelong illness that can be treated but not cured. Although symptoms of schizophrenia persist throughout the lifespan, there is evidence that they may diminish with age. Minimal scientific information exists on schizophrenia relative to aging and older adults. Most studies in this area have excluded those over the age of 50. It’s known that schizophrenia is associated with a reduced life expectancy. This is in part due to lifestyle factors associated with this illness such as increased incidence of tobacco use and the long-term use of antipsychotic medication, and their accompanying adverse effects, such as weight gain and diabetes.¹⁵

For a diagnosis of schizophrenia, at least two of the following symptoms must be present: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, an inability to speak [alogia], and avolition). Only one criterion is required if delusions are bizarre or hallucinations are severe. There also must be marked problems functioning in social and occupational situations. For a diagnosis of schizophrenia, the disturbance must continue for at least six months.³ Maintenance with antipsychotic medication is likely indicated throughout life.¹⁵ As the schizophrenic patient ages, symptoms do tend to lessen, and lower antipsychotic medication doses can be used.¹ Although a rare occurrence, schizophrenia may first manifest in later life, in which case it is called late-onset schizophrenia. Technically, the term late-onset is used when diagnosis is made after age 45. Presentation is more likely to include paranoid delusions and hallucinations and less likely to include disorganized and negative symptoms.³ These patients are generally responsive to antipsychotic medications in lower doses. When onset occurs after age 60, there are usually associated sensory deficits, such as hearing loss. Hearing loss creates a situation in which a patient can misperceive information, making some people prone to delusions and confusion.²

Delusional disorder involves nonbizarre delusions. (An example of a “nonbizarre” delusion would be a person with the false belief that he or she is under surveillance by the police. An example of a “bizarre” delusion would be that one’s bodily organs have been removed and replaced with someone else’s organs.) Other than the delusion, thinking is normal. Hallucinations rarely occur. These patients usually do not respond well to antipsychotic medications.^2,15

With antipsychotic medications in the elderly, extrapyramidal adverse effects occur in higher rates than in younger patients. (Extrapyramidal adverse effects refer to medication-induced Parkinson’s syndrome, with symptoms of muscle rigidity, difficulty walking, and extreme slowness of movement (bradykinesia). Sedation, anticholinergic effects, orthostatic hypotension, and cardiac problems are also possible adverse effects. The lowest effective dose should be used to minimize adverse effects.²

When caring for patients with dementia, the nurse can provide interventions that maximize independent functioning while anticipating interventions that address inevitable decline. Education and support for the family and others caring for the patient are vital. Be aware that caring for patients with dementia can be extremely taxing. Nurses need to recognize signs of being physically and emotionally overwhelmed in both themselves and in the caregivers of their patients and ensure that the necessary respite is taken.

Monitoring responses to treatment is an important nursing function in any setting. Nurses can evaluate and communicate patient responses to medications as well as any adverse reactions. Good record keeping is essential, particularly when nursing care is on a 24-hour basis.

Nurses can tailor behavioral and environmental treatment plans to the patient and setting. Creative interventions can help orient patients to reality. When cognitive impairment is an issue, patient photographs from a younger age may be placed on room doors.² Individual treatment plans should be developed that provide structure and activity. Simple interventions should not be overlooked, such as ensuring that an anxious patient has a place to pace or providing nursing staff with time to listen to an anxious patient’s concerns.

Delusional thinking may be minimized when nurses work to enhance patient trust and safety. Referral for evaluation and treatment for vision and hearing problems is important because sensory impairment contributes to disorientation and disturbed behaviors in patients who have dementia and thought disorders. Nurses are typically in an ideal position to notice sensory decline.

For the patient with chronic mental illness, strategies that ensure that medication is taken at designated times — and in proper dosages — can help prevent relapse of psychiatric conditions. The nurse can help mobilize the family to become involved. Research has shown the positive impact of family-based interventions on younger adult patients with schizophrenia, and the impact is likely to be similar for older patients.²

Nurses in any setting in which elderly patients receive care need to be vigilant about identifying symptoms of depression. A depression checklist may be used as an assessment tool. Depression must be taken just as seriously in the elderly as in the rest of the population. Considerable research has been done on depression in the elderly. Studies are also needed on other functional disorders and geriatric psychiatric nursing.