History

The evaluation of the older adult with a possible mental disorder begins, as does any medical evaluation, with a careful history. If the patient is accompanied by family members, it is helpful to meet with them also to facilitate obtaining a complete history and database. The history should focus on a thorough assessment of the reason for the appointment, including a careful determination of when symptoms first appeared, how they have progressed over time, and accompanying features. In addition, the complete history should include the following:

Mental status examination

The heart of the psychiatric evaluation is the mental status examination, the here-and-now data gathering equivalent of the physical examination. It allows a systematic examination of the major aspects of the patient’s mental state. Depending on the nature of the presenting complaint and the cooperativeness of the patient, certain areas of the mental status examination may be emphasized, whereas others may be only touched on briefly. The complete mental status examination, however, always includes attention to the following areas:

Anxiety disorders

Anxiety is feelings of tension and distress that are distinct from sadness and that usually lack a stressful stimulus of such severity as to explain the feeling. It often has both somatic (physical) and psychological components. Generalized anxiety disorder is a condition marked by excessive worry and anxiety persisting for six months or more. It is accompanied by signs and symptoms of motor tension, including muscle aches or soreness, a feeling of restlessness, a feeling of shakiness, and reports of easy fatigability. In addition, there are feelings of being on edge, having difficulty concentrating and falling asleep, and being unusually irritable. At least three of these additional symptoms of motor tension must be present along with the subjective distress of constant worry to make the diagnosis of generalized anxiety disorder. Generalized anxiety disorder should be distinguished from a patient’s report of feeling “anxious.” The new development of a complaint of “anxiety” in an older person is most commonly caused by major depression. Generalized anxiety disorder, on the other hand, is usually lifelong, not episodic, and associated with the somatic and psychological accompanying symptoms previously described. Panic disorder is diagnosed when the patient reports discrete episodes (attacks) of intense fear and somatic anxiety symptoms that are both unprovoked and unexpected. The associated somatic symptoms include palpitations, sweating, trembling, shortness of breath, chest discomfort, lightheadedness, and abdominal distress. It is common for panic attacks to occur repeatedly in certain circumstances (e.g., in a grocery store). Specific phobias are clearly delineated fears of objects or situations that a person realizes are unrealistic but can nevertheless not resist. They sometimes occur in concert with panic attacks.

The anxiety disorders are among the most common psychologic problems identified in mental health surveys. Nonpharmacologic and pharmacologic therapies are usually used. Desensitization (gradually exposing the patient to the source of distress) coupled with relaxation in often effective. The most effective pharmacologic therapy is the use of antidepressants. There is no evidence that one antidepressant is better than another. Selective serotonin reuptake inhibitors (SSRIs), such as citalopram, sertraline, and fluoxetine, and selective noradrenergic/serotoninergic uptake inhibitors (SNRIs) such as venlafaxine and duloxetine, are effective for treating anxiety disorders. SSRIs are better tolerated with fewer side effects than tricyclic antidepressants.

Benzodiazepine compounds are also effective for anxiety disorders but, because of their addictive potential and side effects, are generally not prescribed as a first-line therapy. Short-acting benzodiazepines (e.g., alprazolam) have more abuse and addiction liability than longer-acting compounds (e.g., clonazepam), but the longer-acting compounds are more likely to accumulate and lead to sedation, functional impairment, and drowsiness. Buspirone is nonaddicting but appears to be less effective in the treatment of anxiety than benzodiazepine or antidepressants. If symptoms are severe and immediate results are desirable, the clinician may choose to initiate treatment with both an antidepressant and benzodiazepine and taper the benzodiazepine several weeks after the antidepressant begins to work.

Mixed anxiety and depression

Symptoms of anxiety and depression frequently co-occur. The clinician should make an effort to determine which is primary and to focus treatment on that set of symptoms. In our experience, depression is more frequently the primary disorder, but this is controversial. Features in the history suggesting that depression is primary include a history of episodic (prior) depressive episodes, a family history of depressive episodes, diurnal mood variation (i.e., a tendency for symptoms to be worse in the morning), self-blame, guilt, difficulty staying asleep in contrast to falling asleep, hopelessness, and mental somatization. Although anxiety disorders can begin de novo in late life, it is much more common for a depressive episode to appear for the first time in an older person. Because antidepressants are effective in both anxiety disorders and major depression, they should be the first-line treatment when the clinician is unsure which is primary.

Mood disorders

Mood disorders are the most frequently clinically diagnosed and the most treatable psychiatric disorders in older people.[5, 6] They encompass a spectrum of disorders ranging from adjustment disorder (in which an identified psychosocial stressor provokes a mild depressive reaction that impairs functioning) to psychotic major depression with hallucinations and/or delusions to mania.

Major depression is characterized by a persistent diminution in three spheres of functioning: (a) mood, (b) vital sense (a sense of one’s well-being and energy), and (c) attitude toward oneself (self-confidence). Depressed patients tend to have a more negative self-assessment than is usual for them, may be self-blaming, or can have excessive feelings of guilt, regret, or worthlessness. Patients with major depression experience loss of energy, disturbed sleep (usually insomnia and early morning awakening), diminished appetite and weight loss, difficulty thinking and concentrating, and a loss of interest and pleasure in activities that were once enjoyed. Ruminant thoughts of death and suicidal thoughts may occur during the course of a major depression. Elderly patients who are depressed often complain of physical rather than psychologic distress. Up to a third of older people who suffer from major depression do not describe their mood as depressed. Rather, they focus on feelings of weakness, lack of energy, and lack of motivation. Somatic complaints, including headaches, gastrointestinal disturbances, and body aches, are common. Occasionally, hallucinations and delusions occur. Such hallucinations and delusions tend to have a depressive theme and are consistent with low mood (e.g., the persecutory delusion that one deserves punishment; the delusion that one has no money, clothes, or insurance; and the delusion that one has a terrible illness that doctors cannot find).

Major depression can first occur at any point in the life span. It may occur as a single episode, but recurrence is common. The causation of major depression is complex, involving genetic, neurochemical, and psychologic factors. Although genetic transmission is poorly understood, it is clear that affective (mood) disorders tend to run in families and that there is a higher prevalence of affective disorders among the first-degree relatives of depressed individuals. The neurochemistry of depression is an active area of research focusing on abnormalities in adrenergic and serotonergic neurotransmitters in the brain. Many commonly prescribed medications, including steroids, reserpine, methyldopa, antiparkinsonian drugs, and β-adrenergic blockers, can cause depression. Depression is especially common in diseases of the brain. For example, 30%–60% of poststroke patients have a clinically significant episode of depression within six months to two years of the stroke. The incidence of poststroke depression has been found to be greatest among patients with strokes affecting the left anterior cerebral hemisphere.[7] Although major depression can occur in the absence of any precipitating event, psychologic issues such as recent loss (i.e., job, independence, social supports) and chronic medical illness play a contributing role in many cases.[8] Regardless of whether psychological factors provoke a depressive episode, they clearly can affect its course and outcomes. Supportive psychotherapy is an important part of the treatment of depression in conjunction with appropriate pharmacotherapy.

The psychopharmacologic treatment of major depression has advanced considerably in recent years, and many effective antidepressant medications are available. Tricyclic antidepressants are older drugs with well-established efficacy. Older persons do best when given antidepressant drugs with the least anticholinergic activity. Therefore, nortriptyline and desipramine are favored for older people. SSRIs, including fluoxetine, sertraline, and citalopram, are well tolerated by older patients. They have minimal anticholinergic effects and are not associated with blood pressure and heart rate changes. However, SSRIs can impair sleep even when taken in the morning. If this occurs, adding trazodone at bedtime can improve sleep. Nausea, another common side effect, may be dose related. Monoamine oxidase inhibitors can be given to older patients if prescribed cautiously. They may be indicated for difficult cases when other medications have failed.

Other antidepressants include buproprion, which has mild central nervous system-activating effects, minimal anticholinergic effects, and few cardiovascular side effects, but a higher risk of inducing seizures at higher doses; venlafaxine and duloxetine, which inhibit both norepinephrine and serotonin reuptake and have a side effect profile similar to those of the SSRI agents except that they can increase blood pressure; and mirtazapine, which has norandrogenic and serotonergic pharmacologic properties, is sedating, and stimulates appetite.

All antidepressants must be taken for a minimum of six to eight weeks at appropriate dosages before efficacy can be determined. To prevent relapse, they should be prescribed for a minimum of 6–12 months once the right dose and therapeutic response have been achieved.

Another effective treatment for serious depression is electroconvulsive therapy (ECT).[9, 10] ECT may be the first-line treatment of choice if the patient cannot eat or is refusing to eat and is at risk for dehydration. It may be used as a second-line treatment after one or two antidepressant trials have failed to improve symptoms adequately. There is no age limit to ECT, although several medical conditions are relative contraindications that must be evaluated case by case. Those include brain tumor, recent myocardial infarction, coronary artery disease, hypertensive cardiovascular disease, bronchopulmonary disease, and venous thrombosis. The only absolute contraindication for ECT is increased intracranial pressure, since ECT causes a rise in cerebrospinal fluid pressure that may lead to herniation. Relapse of major depression after ECT is high, and therefore it must be followed by maintenance antidepressant treatment.

Bipolar disorder is a lifelong recurrent disorder characterized by one of more manic episodes. There is often at least one prior episode of major depression. Recurrence can take the form of either mania or depression. Whereas most patients with bipolar disorder have their first episode of illness before age 50, late-onset mood disorder does occur.[11] Most patients with late-onset mania have had at least one episode of major depression, often 10–15 years earlier. There is a tendency for patients with late-onset bipolar disorder to have a lower incidence of positive family history of mood disorders. In addition, a number of studies of late-onset mania reveal a high rate of secondary mania, in which there is an association between onset of mania and known brain injury, especially affecting the right side of the brain, or another medical problem such as thyrotoxicosis or hypercortisolemia.

Patients having a manic episode usually have little need for sleep, are talkative, and may have loose associations in their speech. Hyperactivity, hypersexuality, overspending, and involvement in foolish or unwise endeavors are frequently seen. Patients usually have an inflated self-esteem and increased sense of well-being but may also be irritable and demanding to those around them. Frank grandiose delusions may develop, such as believing oneself to be chosen by God for a special mission.

The mainstay of treatment for mania is lithium pharmacotherapy, sometimes in combination with lose-dose antipsychotic medication. For patients who cannot tolerate lithium because of sensitivity to side effects or impaired renal function, divalproex sodium and carbamazepine are alternative mood-stabilizing agents. Although many patients enjoy long periods of remission, it is typical for episodes of illness to become more frequent with age. In addition, complicated clinical conditions such as mixed episodes, in which symptoms of mania and depression coexist, and rapid cycling, in which four or more mood episodes occur within 12 months, may develop. Because of the high recurrence rate, patients with bipolar disorder often require lifelong pharmacologic treatment and regular psychiatric monitoring.

Chronic depression is a persistent depressive condition lasting two years or longer and marked by a persistently low mood more days than not and at least two of the following: appetite change, insomnia, low energy, low self-esteem, poor concentration or difficulty making decisions, and hopelessness. It may be a milder depressive disorder than major depression in severity of individual symptoms, but the chronicity of the depressive symptoms can be disabling and demoralizing to the patient and may contribute to lowering functional capacities.[12] In addition, some patients with dysthymic disorder go on to develop a major depressive episode. In older people, dysthymic disorder often develops in the setting of physical disability, multiple medical problems, isolation, and loneliness. Many patients with a dysthymic disorder respond to treatment with an antidepressant. Supportive psychotherapy is a vital component of treatment, the goals being to increase social contacts and activity level and to improve self-esteem and outlook through an empathic therapeutic relationship.

Grief is not a mental disorder, and depressive symptoms are considered to be part of the normal bereavement process. Although persons vary in their response to losing a loved one, there are common predictable phases to grieving.[13] The initial response, which lasts several days, is characterized by shock, disbelief, and emotional numbing. This is often followed by prominent emotions, including anger and frustration, that evolve into periods of fluctuating despair, mourning, and wishing to be with the deceased. During the first three to six months following the death of a loved one, insomnia is common, as are frequent episodes of tearfulness, anxiety, and a loss of interest or pleasure in activities once enjoyed. Usually the intensity of symptoms begins to remit after the first 6–12 months; strong feelings of loss and mourning continue for one to two years, longer for some people. In addition, intense emotional feelings tend to return on the anniversary of the loved one’s death and birthday and at holiday times. Transient hallucinations or a sense of presence of the deceased are common early in grief and normal.

It is unclear at what point a bereaved person should be referred for professional help or counseling. The support of family, friends, and clergy is sufficient to help most bereaved persons through the grieving process. Widow and widower support groups can also be helpful in readjusting to life without a spouse and increasing social contacts. When the bereaved person is overwhelmed by grief and unable to begin to return to usual activities or if grief is complicated by panic attacks, delusions, or suicidal thoughts, referral for psychiatric evaluation is indicated. Grief may trigger a full major depressive episode. Although sadness, disruption of sleep, and loss of motivation and interest may be part of an uncomplicated grief syndrome, feelings of guilt, worthlessness, and hopelessness are not part of grief and should signal concern that a major depression has developed and should be treated as outlined earlier.