Family history is an important aspect of the evaluation for mental illness. Many mental illnesses are known to have a genetic component. Major depression and occasionally schizophrenia or bipolar disorder can present initially in middle or later life. These conditions are more common in people with a family history of psychiatric disorders. Obtaining a thorough family history helps with making an accurate diagnosis. Assessing family history of drug and alcohol use is also an important component.

Social history  is also important. In older age, as health declines and as death and losses of family members increase, situational grief, depression, and the sometimes serious problem of pathological grief all become more common. Moving from home, loss of a key caregiver (even if it is a paid worker), loss of a body part, or loss of function and independence can be major stressors. Be alert to depression as a diagnosis when patients’ mental status or mood and affect change. Sometimes you will have to probe gently but persistently to learn what has happened to cause a depressive episode. Depression can be differentiated from a normal grief reaction by the severity of symptoms and the length of time they persist. In addition, assessing an individual’s history of witnessing or experiencing traumatic events is crucial. Trauma reactions can be related to long-standing psychiatric symptoms including full-blown post-traumatic stress disorder as well as depression, anxiety, and other psychiatric symptoms. Trauma reactions are by no means limited to people who have served in the military. A simple question that can be used to assess trauma is “In your life, have you ever had any experience that was extremely frightening, horrible, or upsetting?” Current symptoms and functional problems related to past traumatic experiences should be assessed further in the event of a positive response.

Because psychiatric services and resources for home-limited patients are sometimes limited, the home care providers may find themselves working out probable psychiatric diagnoses on their own. Table 7.1 offers some general guidelines to help navigate this complex field.

Hallucinations are common in severe mental illnesses, but they also accompany other conditions and are not necessarily diagnostic of a primary psychosis. Auditory hallucinations that are related to a primary psychiatric disorder are often experienced as voices talking or whispering. These may or may not be intelligible or recognizable to the individual. Often the content is very upsetting and disturbing. Auditory hallucinations such as hearing a song playing may be more likely to be related to neurological conditions. Some types of hallucinations are normative such as hearing the voice of a deceased relative after the person’s death. Visual hallucinations can reflect drug side effects, Lewy body dementia, and delirium due to medical illness; some are unique and specific such as seeing cats in patients with late stage Parkinson’s disease who take dopaminergic medication. Paranoia and delusions occur in primary psychotic disorders like schizophrenia but are also common in dementia and delirium. Major depressive disorder can be associated with psychosis. Rapid intervention is indicated in the case of psychotic depression. Do not forget to consider Charles Bonnet syndrome: visual hallucinations in patients with severe visual loss who otherwise lack psychiatric diagnoses; this is common in the elderly population.

Providers should be alert to the possibility of suicidal ideation in patients with psychiatric disorders. Older white males have a high rate of suicide. Depression, bipolar disorder, substance abuse disorders, and schizophrenia are all associated with higher rates of suicide. Do not be afraid to specifically assess suicidal thoughts. A good introductory question is “Do you ever feel like life is not worth living?” A positive response should elicit a more in depth assessment of the quality of the thoughts and whether the patient has had any specific thoughts or plans to harm him or herself. Patients will need further psychiatric evaluation and stabilization if they do have specific suicidal thoughts.

Consider both physical health problems and mental health conditions in your differential diagnosis and assessment (see Table 7.2). Medical problems can simulate mental health disorders and vice versa; and in a given case, symptoms and signs that suggest medical illness and those that indicate psychiatric illness often intermingle. Delusions and hallucinations may be from medications, delirium, encephalopathy, or from dementias like Lewy body disease rather than primary thought disorders and psychoses. Weight loss, sleep cycle changes, and cognitive function changes often indicate depression in older patients. Fatigue, lethargy, and anhedonia can be related to anemia, hypothyroidism, sleep apnea, or diabetes. Somatic complaints that seem “organic” such as abdominal pain or chest pain may resolve when patients are treated for depression. Chronic pain can also lead to psychiatric symptoms such as depression and anxiety. Persons with sleep complaints may be screened for sleep apnea or restless legs syndrome. Narcolepsy is rare but should be considered if there is excessive, overwhelming sleepiness during the day and may respond to psychostimulant medication. Neurosyphilis is rare in advanced old age but is a treatable cause of neuropsychiatric disease in middle-aged adults.

This is a special category. There are individuals in every community who have gradually separated themselves from society and keep to themselves. Some have mental illness and many have unusual ways of dressing, grooming, and keeping house. Often they hoard things and are not careful about personal hygiene or dress. Many hermits are cognitively intact and have no defined mental health disorder. Be careful to avoid labeling these unique individuals with dementia or mental illness until after you have thoroughly evaluated them. Some may have personality disorders as defined by the DSM-5 (Diagnosis and Statistical Manual, Edition 5). One of the more difficult dimensions in mental health is the category of personality disorders (10 of them in DSM-5) that share as common features. (1) Distorted thinking patterns; (2) problematic emotional responses; (3) over- or under-regulated impulse control; and (4) interpersonal difficulties. Among “cluster A” or the odd, eccentric clusters are: Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorders.

Dependency on or heavy misuse of alcohol, cocaine, and other chemical substances make it difficult to diagnose and treat mental illness. Often the chemical dependency must be addressed before progress can be made with depression, anxiety, or other mental illness; this usually requires the help of people who are specialized in the care of addiction disorders and psychiatric care resources. If you are on your own, be careful to address the substance abuse problems first and foremost. You may get more information if you ask patients specifically about commonly used names for street drugs and various alcoholic beverages. Performing comprehensive urine drug screen testing may also be indicated. Patients may abuse prescription drugs that they obtain from others or from their own prescriptions.

In the setting of concurrent mental illness and chronic medical conditions, a frequent challenge is management of controlled medications. Because of diversion and accidental deaths, this is a national focus. Many patients at home suffer from chronic pain or anxiety, for which opiates and other controlled medications are needed and should be prescribed. Careful documentation about diagnosis, about numbers of pills that are prescribed, pill counts, patient contracts related to controlled substances and in some cases regular use of urinary drug screens are all important. Keep track of current local and national regulations and remain compliant. Be alert; in the home you may find that drugs needed by older patients with pain are diverted and sold to pay for needs of other household members, which is a form of abuse and a crime. Providers must take care to be thorough in determining the appropriateness of medication use. Signed paper prescriptions are needed for each new and refilled prescription for Schedule II medications. Since our patients are not mobile, this can present problems between visits. In our practice, we have found local pharmacies that will send a driver to our office to pick up prescriptions for patients. In selected circumstances, providers must ultimately refuse to continue prescribing controlled medicines. This may be difficult, particularly when there is a genuinely painful condition and concern about elder abuse and neglect, yet the older patient refuses to leave the situation for what we would consider to be a safer alternative. Lock boxes and other strategies may allow the prescriber to continue providing medications that are truly indicated for the patient. For additional guidance on managing controlled substances prescriptions in home-based palliative care, please see Chap. 12: “Palliative Care.”

Managing conditions without medications is always a good initial goal. In some conditions, such as depression, there is evidence that cognitive behavioral therapy (CBT) is equivalent to or better than antidepressant medication in some cases. Many older individuals respond well to CBT. One of the problems in home care is finding a mobile resource for this kind of treatment, but when resources exist providers should offer them. This does not require a psychiatrist or a psychologist, but may be provided by a licensed clinical social worker (LCSW), licensed professional counselor (LPC), or advanced practice psychiatric nurse. Some episodes of depression are situational and transient and should not result in medication management. Improved socialization may help, as may reassurance and effective management of concurrent symptoms like pain that can lead to depression [5]. Another important intervention that has good research support is the use of relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery. These can be taught to patients in 10–15 min and can be very beneficial for managing pain, anxiety, and depression.

Patients with mental health disorders are better able to manage their symptoms when they are active and have something that brings meaning to their lives. This can be as simple as performing housework, spending time with family, and staying involved in a religious community. An important assessment question is “What do you spend your time doing?” Providers should be concerned when patients say they spend most of their time watching TV, sleeping, or sitting around. Physical activity and exercise are also important components of improving mental health. Even those who have mobility limitations can usually perform chair exercise or a stretching program. The importance of adequate sleep to mental and physical health cannot be overstated. Many patients who complain of difficulty sleeping will benefit from basic sleep hygiene interventions such as adhering to routine bedtime and wakeup times, increasing activity level during the day, removing TVs and electronics from the bedroom, avoiding any electronic devices for at least an hour before bedtime, and keeping the bedroom cool and dark.

Assuming that nonmedication strategies have failed, use of medications for mental illness is a key skill in home-based medical care. A comprehensive discussion is impractical but general guidelines follow.

First, follow this time-honored axiom in geriatrics: “start low and go slow… but go.” This means that caution should be taken with dosing but one should not under-treat. Some older patients do not improve until doses are raised to therapeutic ranges.

In depression, antidepressant medications are used as the first-line pharmacologic strategy. These include serotonin reuptake inhibitors (SRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and several atypical antidepressants such as bupropion and mirtazapine. Tricyclic antidepressants (TCAs) are still used in some cases; however, they have anticholinergic properties and should be used with caution in the elderly. Because of drug interactions and required diet restrictions, monoamine oxidase inhibitors (MAOIs) are used infrequently for treatment-resistant depression.

When selecting an antidepressant medication, be mindful of other symptoms that may benefit from that particular medication. For example, chronic neuropathic pain or migraine headaches may also respond to TCAs or SNRIs. Bupropion is also used for smoking cessation. Mirtazapine and TCAs may benefit those who have difficulty with insomnia. Mirtazapine may also increase appetite. Antidepressants that are commonly used in older patients include citalopram, mirtazapine, and sertraline. Side effect profiles and potential for drug interactions should be taken into consideration in medication selection. All antidepressants may increase the risk of falls, and elderly patients may be more susceptible to antidepressant-induced hyponatremia, particularly with serotonergic agents (SSRI, SNRI, other)—so check the sodium level routinely after starting these drugs.

Patients usually require at least a 4–6 week trial on a given antidepressant to determine benefit. Doses must be increased to a therapeutic range before concluding the drug is not effective. It is helpful to target and quantify the specific symptoms being treated and evaluate those systematically when deciding whether a medication is effective. While the patient’s subjective experience is important, simply asking patients if they feel “better” may provide an inaccurate assessment. Additionally, with major depression, research clearly indicates that a treatment period of 6–12 months or longer is usually needed. Early withdrawal of medication is not advisable unless there are side effects.

In active bipolar disorder, patients usually have a psychiatric care provider involved. If the nonpsychiatric home-based medical care provider is the only provider involved, continuing maintenance medications is important to prevent manic and depressive episodes. Commonly used now are the anticonvulsants like valproic acid, carbamazepine, and lamotrigine. Lithium is another effective mood stabilizer but may be less often preferred due to the side effects and a narrow therapeutic window. Second generation antipsychotics (SGAs) are also effective as mood stabilizers for patients with bipolar disorder. Do not let these medications expire, and do not let patients with known mania talk you out of continuing their drugs. Often patients with significant bipolar disorder are taking multiple medications, and in these cases trained psychiatric providers are an important part of the treatment team.

In disorders like schizophrenia and schizoaffective disorder, there is a subpopulation of older individuals whose psychiatric disease has stabilized and who are now able to function with less intensive psychiatric interventions. There may be chronic fixed delusions or hallucinations that are not particularly disturbing to the patient, and these can be managed by acknowledging the existence of symptoms, tracking them, and maintaining the patient on some medications to limit exacerbations. Nonpharmacological techniques such as distraction can also be very helpful. These patients can remain stable in the community for years without many changes to their regimen. If the problems are less stable or more complex, psychiatrically trained providers should be involved. Regular review for the development of tardive dyskinesia should be performed for any patient on long-term antipsychotic medication therapy.