As the population of older adults continues to increase, so will the number of geriatric patients with mental health disorders. One estimate predicts that the number of geriatric patients with mental illness will increase by 275% from 4 million in 1970 to 15 million in 2030.68 Emergency medicine providers need to feel comforTable identifying and managing common mental health disorders in geriatric patients. A recent meta-analysis revealed that the mental health disorders with the highest estimated prevalence rates among geriatric patients were major depression and alcohol use disorders.69 Significant research remains to be done in the field of geriatric psychiatry. The next sections will give a short overview of what is currently known regarding several mental health disorders found in older patients including depression, bipolar disorder, schizophrenia, and eating disorders.
Although the prevalence of major depressive disorder among community-dwelling older adults is low (1.4% to 4.4%), the proportion of patients with symptoms of depression below the threshold of major depressive disorder can be quite high, with most studies reporting around 8% to 16%.7,70,71 Older patients with overt and subclinical depression can benefit from treatment.72
Depression in the geriatric population is associated with chronic medical illness, disability, increased use of health services, and poor health outcomes.7,72,73 Risk factors associated with development of depression in older adults include lack of social support, living alone, being unmarried, cognitive impairment, bereavement, and lower socioeconomic status.7,73
Depression presents differently in older adults compared to younger age groups. Older adults with depression frequently report loss of appetite or sexual interest, rather than crying spells, feeling sad, or feeling like life is a failure.7 They are more likely to be irriTable and withdrawn than appear sad.74 Older patients may also present with somatic or cognitive complaints when they are actually suffering from depression, which can make the diagnosis difficult.7 Caregivers and patients themselves may attribute depressive symptoms to normal aging, again making the diagnosis difficult.7 Comorbid anxiety is common with depression, and generalized anxiety disorder is frequently seen in the elderly population, with a reported lifetime prevalence of 15% in older adults.75
There are several screening tests for depression currently available to practitioners. Many are lengthy and would be difficult to use in the ED setting. The Patient Health Questionnaire-2 and Patient Health Questionnaire-9 are two- and nine-item self-administered questionnaires that have been developed to screen for depression based on Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria.76 The Patient Health Questionnaire-9 assesses nine features of depression: anhedonia, depressed mood, trouble sleeping, feeling tired, change in appetite, guilt or worthlessness, trouble concentrating, feeling slowed down or restless, and suicidal thoughts. The Patient Health Questionnaire-2 has two questions addressing anhedonia and low mood.76 See Table 288-5 for the Patient Health Questionnaire-2.77 Both questionnaires can easily be located and have been found to be comparable to longer scales used to screen for depression with more evidence supporting the use of the Patient Health Questionnaire-9.78 Several sources recommend starting with the Patient Health Questionnaire-2 and, if positive, then administering the Patient Health Questionnaire-9. It is important to find a screening test that you are familiar with and use it to screen for depression.
TABLE 288-5Patient Health Questionnaire-2 ||Download (.pdf) TABLE 288-5 Patient Health Questionnaire-2
Scores range from 0 to 6. A score of 3 or greater indicates the need for further screening.
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless?
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Have you often been bothered by little interest or pleasure in doing things?
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Screening for suicide is vital in the assessment of geriatric patients with depression.79 People >65 years old have the highest rates of completed suicide of any age group.80
Older adults may give fewer warning signs of suicidal intent, and they are more successful in attempting suicide.81 Depression is the largest risk factor for suicide. Other risk factors include perceived poor health status, poor sleep quality, alcohol abuse, absence of a confidant, physical illness, functional decline, and presence of a firearm.79
Treatment combines both nonpharmacologic and pharmacologic interventions.7 It is unlikely that new medications will be started in the ED for depression in geriatric patients, but recognizing depressive symptoms and assuring that the patient has appropriate follow-up are important. Review antidepressant doses, side effects, and drug interactions, as ED visits may be precipitated by symptoms from side effects or interactions. Selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors are some of the most frequently prescribed and effective antidepressants, but they can be associated with serotonin syndrome.7
Substance abuse is relatively common in the geriatric population and may increase with the baby-boomer cohort.82 One estimate is that the number of older adults who will need substance abuse treatment is expected to increase from 1.7 million in 2000–2001 to 4.4 million in 2020.82 Although the vast majority of substance abuse in the elderly is related to alcohol and prescription medications, there are reports of increased illicit drug use as well, highlighting the need to ask all patients about drug use.83
Alcohol abuse in geriatric patients specifically is frequent. In a cross-sectional study of 12,000 geriatric primary care patients, 15% of patients were felt to be at risk for, or were affected by, problem drinking.84 Other community surveys estimate the prevalence of at-risk or problem drinking to be between 1% and 15%.85,86,87 The current recommendation is that older adults consume no more than one standard drink per day or seven standard drinks per week.88 Alcohol-related problems, such as falls, confusion, and malnutrition, may be attributed to normal aging, and thus alcohol abuse may be missed.88 Physiologic changes from advancing age may also change alcohol tolerance, increasing risk for complications.88 If at-risk drinking is identified, refer the patient to an inpatient or outpatient treatment facility. Also, if the plan is to admit a patient with known alcohol or substance abuse, notify the admitting physician so plans can be made to mitigate withdrawal.
Bipolar disorder is a spectrum of illness that affects an individual's ability to regulate mood. There are four types: type I, which requires a manic episode for the diagnosis; type II, which requires one or more depressive episodes and a hypomanic episode; cyclothymia (cycling moods that do not meet criteria for depression or mania); and bipolar not otherwise specified.89 Research regarding bipolar disorder in older adults is limited. The prevalence of bipolar disease in older adults is reported to be approximately 0.08% to 0.5%.89 Given this low rate, older adults who present with new-onset mania require a complete medical evaluation before a new diagnosis of bipolar disorder should be made. Even though the prevalence rate of older adults in the community with bipolar disorder is low, one study found that 17% of patients >60 years old presenting to a psychiatric ED carried a diagnosis of bipolar disorder.90 There are some differences between younger and older patients with bipolar disorder. Older people with bipolar disorder are more likely to be female. Late-onset bipolar disorder (onset between age 30 and 50 years) is associated with fewer genetic associations and more neurologic illnesses.91 The frequency of psychotic features is essentially the same in young and old patients with bipolar disorder.91 Older patients with bipolar disorder can have either early- or late-onset disease.
The treatment and adverse effects of treatment of bipolar disorder have implications in the elderly. One of the most customary treatments for bipolar disorder is lithium, which is a mood stabilizer.92,93 Older patients can demonstrate beneficial effects at lower serum levels of lithium than younger patients. The renal clearance of lithium decreases with age, increasing the elimination half-life and predisposing to lithium toxicity.94 Neurotoxicity can develop at serum levels that are therapeutic in younger adults.94 Frequently reported side effects of lithium include tremor, muscle twitches, GI symptoms, and CNS effects such as sedation.94 Many common medications interact with lithium, including thiazide diuretics, nonsteroidal anti-inflammatory agents, and angiotensin-converting enzyme inhibitors, which can increase serum lithium concentrations and the risk of toxicity.94 An older patient taking lithium can display signs of toxicity even if the level is in the therapeutic window. See chapter 181, "Lithium," for further details of toxicity and treatment. Three anticonvulsants have also been approved to treat bipolar disorder: valproate, carbamazepine, and lamotrigine. The literature regarding their use in older adults is sparse.89
Several disorders, such as schizophrenia, psychosis associated with dementias, and more acute processes such as delirium, can present with symptoms of psychosis (hallucinations and delusions) in geriatric patients. This section provides a brief discussion of schizophrenia in older adults (please see earlier discussion regarding delirium and behavioral disturbances in dementia).
The estimated prevalence rate of schizophrenia in geriatric patients ranges from 0.1% to 0.5%.95,96,97 The majority of patients with schizophrenia develop the disease in the second or third decade of life (considered early-onset schizophrenia), meaning that most geriatric patients with schizophrenia have had the disorder since they were much younger.98 There are two other groups of patients with schizophrenia: late-onset schizophrenia (>40 years old) and very-late-onset schizophrenia-like psychosis (>60 years old).98 Individuals with late-onset schizophrenia have many of the same attributes as patients with early-onset schizophrenia, but late-onset patients have fewer problems with learning, abstraction, and flexibility.99 The diagnosis of very-late-onset schizophrenia-like psychosis is rare, but patients >60 years old can develop a late-life primary psychosis disorder.98 Very-late-onset patients tend to have a lack of negative symptoms, greater risk of tardive dyskinesia, and evidence of a neurodegenerative process rather than a neurodevelopmental process.98
Schizophrenia in geriatric patients represents complexity in the psychiatric, medical, and social realms. Nonadherence to medical therapy is common.100 Mortality secondary to cardiovascular disease is more than twice as common as in the general population, likely due to high rates of smoking, diabetes mellitus, hypertension, and obesity in schizophrenic patients. Older patients with schizophrenia typically have a sedentary lifestyle and poor diet.100 Atypical antipsychotics used for treatment increase the risk of metabolic syndrome and weight gain, which in turn increase the risk of cardiovascular diseases.101 The use of typical antipsychotics is limited because the risk of tardive dyskinesia is elevated in geriatric patients.102 One study noted that the cumulative annual incidence of tardive dyskinesia in patients >45 years old treated with low-dose typical antipsychotics was 26%, which is five to six times greater than in younger patients.102 Antipsychotic medications should be carefully selected and doses titrated upward slowly with close monitoring for side effects. Older patients with schizophrenia can also benefit from adjunctive psychosocial interventions. For example, Functional Adaptation Skills Training, a group therapy targeting everyday life skills, improves the functional adaptation of older patients with schizophrenia.103,104,105
There is little information regarding eating disorders such as anorexia nervosa and bulimia nervosa in older adults. One recent study examined women >50 years old for the presence of eating disorders and found that about 13% reported some form of core current eating disorder symptoms. Current binge eating, and purging in the absence of binge eating, were the most common symptoms.106 Approximately 71% of women in the study were currently trying to lose weight.106 Another review identified 48 cases of eating disorders in adults >50 years old. In this article, 88% were female and 60% were >65 years old. The most frequent diagnosis was anorexia nervosa (81% of cases).107 Of the 48 cases, 79% had the onset of eating disorders later in life.107 Importantly, this study identified a strong connection between eating disorders and other psychiatric conditions (60% of cases), with major depression being the most important. Eating disorders were often preceded by a stressful event, such as widowhood, bereavement, and marriage difficulties.107 Of the 48 patients reviewed, 21% of the patients died from complications of the eating disorder.107
Diagnosis is difficult and is made by excluding any physical or medical cause of unexplained weight loss. Eating disorders in older patients are treated similarly to those in any other age group, with a combination of cognitive-behavioral treatment and pharmacotherapy.107
Acknowledgments: Special thanks to members of the Academy of Geriatric Emergency Medicine, Dr. Timothy Platts-Mills, and Dr. Debra Bynum for their contributions to this chapter.