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CHAPTER 15: PSYCHOLOGIC CONCERNS

Overview

Anxiety

Depression

Alcohol Abuse

Drug Dependency


Overview

Your mental health will significantly influence your level of function and social activities, and even the course of medical illness. Over 25 percent of older people have significant mental illness and more than 90 percent of institutionalized elderly people have some psychologic problems.

    Psychiatric illnesses can occur on their own or as coexisting with other medical problems. Because elderly people often have a number of illnesses, it is important to monitor the interactions between physical and psychologic conditions and their treatments. If you are experiencing emotional suffering, you should seek help; most psychologic problems are treatable and can be relieved with appropriate therapy.

Anxiety

Anxiety is a common experience in later life. While anxiety can be specifically associated with panic attacks, phobias, and other psychiatric conditions, most anxiety is called generalized anxiety disorder (GAD). Anxiety can be a signal of problems that a person has difficulty managing with his usual coping strategies. It may signal that a person has inner psychological conflicts of which she may not be aware. It may also indicate concerns about life's circumstances. Many older people may become anxious because of several simultaneous problems such as physical illness, personal loss, psychological distress, and environmental stress.

Symptoms of Anxiety

The essential feature of a generalized anxiety disorder is unrealistic or excessive anxiety and worry about multiple problems in one's life. This may include worrying about misfortune to children and grandchildren, finances, or physical health. Obviously, if there is only one area of worry, or when the worry may be realistic, this is not a generalized anxiety disorder but a normal reaction to an unpredictable situation.

    Anxiety influences our physical and psychological states; the signs fall into three categories. The first is tense muscles, which lead to shaking and trembling, muscle restlessness, and easy tiring. The second category is increased nervous system activity indicated by such things as shortness of breath, rapid heart rate, sweating, dry mouth, dizziness, nausea and diarrhea, flushes or chills, frequent urination, or difficulty swallowing. The third category involves being excessively vigilant, feeling keyed up or on edge, having exaggerated responses to startling phenomena, having difficulty concentrating, trouble falling asleep or staying asleep, or feeling irritable.

    In a community survey of people 55 years or older, over 15 percent of men and 20 percent of women suffered such significant anxiety symptoms to be candidates for some form of treatment. Anxiety is generally inversely related to physical health: As health status deteriorates, anxiety increases.

Causes of Anxiety

In older people, symptoms of anxiety are not as clearly defined as they are in younger people--this makes it more difficult to determine if a person requires clinical attention. Clinically significant anxiety is more likely to occur concurrently with states of depression, in dementia, or as a consequence of physical illness or drug treatment. However, in some cases it may be impossible to distinguish between anxiety and normally appropriate worry and concern about the present or future.

    Anxiety can be one symptom of several medical disorders in later life including heart disease, lung disease, thyroid and other endocrine problems, neurologic illnesses, psychologic illnesses, dietary problems (such as excess caffeine intake or vitamin B12 deficiency), and drug-related disorders, including medication side effects and symptoms of withdrawal from alcohol or drugs.

Table 17. Differential Features of Anxiety and Depression

DEPRESSION ANXIETY
Persistent mood problems Episodic mood problems
Severe in the morning Progressive worsening during the day
Slow movement hurts Normal movement hurts
Excessive guilt Panic attacks
Suicidal thoughts Phobic symptoms
Family history No family history
Source: Adapted from Avant RF. Anxiety and depression: determining the predominant disorders. Family Practice Recertification. 1984;6(3 suppl):24. Reprinted with permission.

    In older adults, symptoms of anxiety and depression tend to accompany each other; this may make it difficult to determine which disorder is dominant. Both of these conditions may cause older people to complain, seek help, or talk about their physical symptoms or lack of memory. Table 17 shows useful features to help determine whether anxiety or depression is the major disorder.

    Generalized anxiety can be confused with panic disorders. People with panic disorders--a sudden state of extreme and uncontrollable hyperarousal--are usually convinced that they will die or lose control. Older people who have a history of panic attacks are most likely to experience these, as it is very uncommon for panic attacks to occur for the first time in late life. Some people develop a form of anticipatory anxiety, which is a constant fear of recurrent panic attacks. One coping mechanism to avoid panic attacks is to remain home, which leads to extreme avoidance behavior called agoraphobia (from the Greek, agora, "meaning gregarious").

    Anxiety may accompany an obsessive-compulsive disorder, which does not commonly develop in the elderly but often persists into old age from an onset earlier in life. Obsessions are persistent ideas, thoughts, impulses, or images that one may experience, at least initially, as being intrusive or senseless. Compulsions are repetitive, purposeful, and intentional behaviors that are sometimes performed in response to an obsession or in a stereotypical fashion. The goal of this compulsive behavior is to avoid discomfort and anxiety. An example is repetitive hand washing.

    Anxiety is a regular feature of delirium and may also be present in dementing illnesses. It needs to be distinguished from agitation in these conditions, since elderly people with either delirium or dementia often appear apprehensive, fearful, and may have indications of anxiety. Anxiety can exist simultaneously with agitation, but agitation is distinguished by the presence of physical motor restlessness. This excessive purposeless movement characterizes agitation in contrast with the inner subjective apprehension that defines anxiety.

Treatment of Anxiety Disorders

Approaches that do not rely on medications may be ideal for anxiety in the older adult. These approaches include reducing the stimulus that produces the anxiety and counseling and relaxation techniques. These techniques are usually quite effective and older people benefit from them in the same ways that younger people do.

    Doctors sometimes prescribe antianxiety drugs when a person's symptoms interfere with the ability to function or if they aggravate another illness. This is often encountered in older people who are facing a crisis such as the stress of hospitalization, grief, or a change in living circumstances. Sometimes antianxiety medications are useful for people who have a long-standing psychiatric illness that has responded to these medications in the past. The group of drugs most commonly used are called benzodiazepines. They are classified according to their chemical properties, but there is no evidence to suggest that one benzodiazepine is better than any other. The ones that do not linger long or accumulate quickly in the body are usually preferred. These short-acting compounds provide flexible dosing, but it is important to remember that rebound anxiety can result from their use.

    Rebound anxiety occurs after the effects of the medication have worn off, and it can be more intense than the original anxiety. This rebound anxiety may occur because the medication replaces and increases the amount of certain anxiety-restraining substances ordinarily produced in the body, which signals the body's production to slow down. Consequently, when the medication wears off, there is a complete deficit of the anxiety-restraining substances and anxiety rebounds with a vengeance. Regardless of the choice of antianxiety drugs, their use in older people must be very carefully monitored.

    Because our central nervous system becomes more sensitive to the effects of anxiety-reducing drugs with age, older people are more likely to exhibit side effects at doses that are generally nontoxic in younger adults. Any coexisting physical or emotional illness can further predispose the elderly person to increased drug toxicity. For example, any central nervous system disorder, such as stroke, Parkinson's disease, or dementia, may increase one's sensitivity to these drugs.

    Another potential source of increased toxicity of anxiety-reducing drugs in older people is the interaction with other medications that the person may be taking. Medications with sedating properties may especially increase the central nervous system toxicity of anxiety-reducing drugs.

    Generally, four side effects of anxiety-reducing drugs--sedation, clumsiness and staggering, mood difficulties, and impaired thinking--may occur in older people at much lower doses than those given to younger adults. These effects are increased by alcohol use or concurrent use of other medications affecting the central nervous system, and are often worse at night. Specific symptoms of toxicity include a staggering gait, difficulty speaking, uncoordination and unsteadiness, slowed reactions, and diminished accuracy of various motor tasks. The thinking impairment caused by anxiety-reducing drugs is characterized by difficulty remembering, increased forgetfulness, and decreased attention. This cognitive impairment may resemble the early stages of a dementing illness, and some older people who take these drugs for a long time seem to be losing their memories because of this commonly overlooked side effect. Generally, the cognitive impairment is reversible, however, and discontinuing the drug usually results in improved memory, attention, and concentration.

Depression

Depression refers to a variety of disorders that are grouped together by symptoms, genetic predisposition, environmental triggers, and responses to treatment. Mild depressive symptoms, however, should be distinguished from a more severe depression because the causes, outlook, and treatment are very different.

    Older people frequently experience temporary changes in their moods, usually as a result of some identifiable stress or loss. These changes respond to support when they are mild and, given time, generally get better on their own without any further intervention. However, when compared with the same symptoms in younger people, depression in older people is more likely to result from a medical condition or some dementing illness. Medical problems can aggravate the normal fluctuations in mood, leading to significant disruption of a person's ability to function socially as well as in other productive activity. Mood changes in older people can also be the first symptom of an illness, such as Alzheimer's disease or thyroid disease.

    In contrast to the temporary and common fluctuations in mood, severe depression (called major depression) is relatively uncommon in people who are over 60. In a community survey, over 25 percent of older adults reported symptoms of depression although only 1 percent had major depression. Major depression is more often seen in the hospital and in long-term care settings where it may be seen in 10 to 15 percent of older people. However, just because severe depressive episodes in elderly people are less common than in younger people, this does not diminish their importance. Suicide rates in older white men are higher than those of any age, sex, or racial group in the United States. These severe depressive disorders usually occur spontaneously and are not caused by or related to medical or social problems.

    Frequently, major depression is seen in dementing disorders such as Alzheimer's disease, dementia caused by multiple strokes, and Parkinson's disease. Among older people who have dementing illness, between 20 and 40 percent also have a major depression. Depression may be commonly seen in the early stages of a dementing illness, although transient and even severe mood swings are seen in the later stages as well.

Table 18. Diagnostic Criteria and Characteristics of Depressive Disorders

   DURATION SYMPTOMS HEREDITARY
PREDISPOSITION
RESPONSE TO
SOMATIC
INTERVENTIONS
Major depression 2 weeks or more Significant symptoms
Subtypes:
Melancholia
Seasonal pattern
Psychosis
Recurrent depression
Yes
(particularly
melancholia)
Yes (particularly
melancholia,
psychosis, and
seasonal pattern)
Dysthymia 2 years or more Less prominent
depressive symptoms
Probable Probable
May be secondary to
a physical disorder
(e.g., diabetes)
Adjustment disorder Onset within 3
months of stressor
and duration
no longer than 6
months
Maladaptive response or
overreaction to stress that
does not persist
None None
Source: Compiled from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3d ed (rev). Washington, DC: American Psychiatric Association; 1987:213; 329. Reprinted with permission.

The categories of mood disorders are shown in Table 18.

Types of Depression in Later Life

Major Depression. Among these disorders, major depression has several distinct characteristics. At least five of the following symptoms must be present on a day-to-day basis for at least two weeks to warrant the diagnosis, and at least one of the symptoms must be depressed mood or loss of interest or pleasure.

  • Depressed mood
  • Loss of interest or pleasure
  • Significant weight change or change in appetite
  • Sleeping difficulty
  • Severe restlessness or agitation or significant slowing of movement
  • Decreased energy, fatigue easily
  • Feelings of worthlessness or excessive guilt
  • Decreased ability to think or concentrate
  • Recurrent thoughts of death or suicide

    Melancholia: If a person has symptoms that meet the criteria for major depression, it is useful to consider if the person suffers from melancholia. The term melancholia as used clinically refers to the type of depression that is most responsive to medication. At least five of the following nine symptoms must be present on a day-to-day basis.

  • Loss of interest or pleasure in most activities
  • Lack of reaction to pleasurable stimuli
  • Variation during the day with the depression being worse in the morning
  • Early-morning wakening
  • Slow movements or severe agitation
  • Significant weight loss
  • No change in the personality before the onset of the depression
  • A previous history of a major depression with good recovery
  • A previous good response to treatment for the depressive episode

    Psychotic Depression: Another type of major depression is that which is characterized by the presence of psychotic symptoms. These psychotic symptoms usually occur late in the course of the disease, following a significant period of depression. The psychotic symptoms may be delusions or hallucinations that have a depressive (nihilistic) quality or tone. Psychotic depression occurs relatively more frequently in the later stages of life.

    Seasonal Depression: People with a seasonal pattern of depression often report a relationship of their depression to a distinct two-month period of the year (usually the winter), with the occurrence of at least three episodes of the illness in three separate years. Although seasonal variation in mood is common in late life, it occurs relatively less frequently in older people than in younger ones.

Dysthymia. Another depressive condition is called dysthymia. It is seen in about 2 percent of older people and is distinguished from major depressions by less severe symptoms than those associated with major depression and by having symptoms that last at least two years. Two or more of the following criteria need to be met.

  • Poor appetite or overeating
  • Change in sleep pattern
  • Low energy or fatigue
  • Low self-esteem
  • Poor ability to concentrate or difficulty in making decisions
  • Feelings of hopelessness

    Dysthymia may occur either by itself or with another psychiatric or medical disorder. When it starts in late life, dysthymia may derive from a loss of self-esteem. The degree to which a person experiences this loss depends upon a number of complex factors, including social expectations, individual personality characteristics, and specific life events. When the personality characteristics make up lifelong patterns that interfere with an individual's ability to function, they are called personality disorders. Sometimes dysthymia can occur because of personality disorders or other situations such as substance abuse or severe anxiety. However, a more common cause of dysthymia is having another serious medical illness with accompanying loss of function and independence.

Adjustment Disorders. Adjustment disorders with depressed mood may follow the onset of a sudden medical illness. In such a reaction, initially there is doubt, surprise, and wonder. Statements of denial or disbelief are common at this stage. Then there is an intense flooding of anxiety, which leads to feelings of confusion and the inability to solve the problem. The person may not be able to function very well, but over time the person begins to adjust, and if the underlying illness is corrected the dysthymia tends to resolve.

    Usually a depressive reaction to some stress is classified as an adjustment disorder when it is maladaptive, when there is an impairment in the level of functioning, when symptoms go far beyond what people would normally expect, or when the reaction occurs within three months of the onset of the stress. Clearly, there is room for subjective interpretation as to what is an adjustment disorder and what is a normal reaction to a specific stress. In elderly people, the four most common stresses are physical illness, reactions to the death of loved ones, retirement, and moving into an institutional setting. When the reaction to the death of a loved one is judged to be "normal," involving appropriate grief, psychiatrists call this "uncomplicated bereavement" rather than a psychiatric disorder.

Depression and Loss of Vitality. One type of depression that is not easy to describe with the existing classification system is the chronic depression that sometimes coexists with the loss of vitality and extreme weight loss. The symptoms of this disorder usually meet the criteria for a major depression, yet it is difficult to untangle the physical from the psychological symptoms. Nevertheless, this condition is of great importance, for older people who have loss of vitality combined with depression are at great risk for dying and may actually be committing a type of slow suicide. The treatment strategies that have been devised for this particular type of depression are less effective with the elderly; nonetheless, a thorough evaluation and aggressive treatment are usually worthwhile.

Manic-Depressive Illness. About 10 percent of all mood disorders in older people are caused by manic-depressive illness (also called bipolar mood disorder). Manic symptoms involve a distinct period of abnormally elevated, or irritable mood with accompanying euphoria, decreased need for sleep, distractibility, pressure to keep talking, and racing thoughts. People with a history of these episodes may need to take medication to keep them from recurring. Treatment with medication for depression alone may actually cause an episode of mania. In late life, manic episodes are less frequent than in the earlier stages of life and may also change in the way they are experienced. For example, the older adult with mania is less likely to feel euphoric and is more likely to feel irritable, agitated, and have sleep disturbance.

Other Causes of Depression in Later Life

When an older adult suffers from depression, one must consider as potential causes underlying medical illnesses, the side effects of medications, alcohol abuse, dementing illness, and other psychiatric conditions, such as hypochondriasis or a translation of anxiety into a physical symptom--a process known as a somatization disorder. While bodily complaints are often found in older people who suffer from depression, it is important to recognize that symptoms of depression often coincide with symptoms of physical illness. In addition, medications used to treat these illnesses can sometimes lead to depressive symptoms. In fact, many medical problems can lead to depressive symptoms. For example, stroke, congestive heart failure, and cancer can mimic a severe depression by causing weight loss, sleep disturbance, problems with concentrating, and low energy. People with Parkinson's disease may frequently have a number of symptoms suggestive of depression including lack of facial expression, slowed body movement, lack of spontaneity, decreased energy, and poor motivation. However, they may not report feeling depressed unless the Parkinson's disease has progressed to the middle or late stages. Abnormalities with the thyroid gland or other endocrine glands also produce depression. Changes in body chemistry, such as a low potassium in the blood, can also cause mood changes as well as disturbances in sleep, appetite, concentration, and energy. When these depressive symptoms result from physical illnesses, they are classified as "organic mood disorders." Other causes of organic mood disorders include nutritional deficiencies (such as vitamin B12 deficiency) and infections.

    Depressive symptoms can also be prompted by prescribed medication. Drugs for high blood pressure head the list as the most frequent offenders. In addition, corticosteroids and other hormones such as estrogens can sometimes lead to depression. The medicines used to treat Parkinson's disease can also produce depression or manic symptoms. Any sedative medication can lead to depression.

    Alcohol abuse (see elsewhere in this section), also linked to mood disorders, may go undetected in older people. It should be suspected in any older person who develops a shake or tremor, bleeding in the skin, heartburn, bleeding from the intestines, or symptoms of alcohol withdrawal, such as increases in temperature, heart rate, blood pressure, and sweating.

    Dementing illness is most frequently associated with depression in late life. Some people, however, who are diagnosed as having a dementing disorder may be primarily depressed (independent of the dementia), because symptoms such as apathy, thinking difficulties, and withdrawal occur with both dementing illness and depression. In addition, some depressed people without dementing illness may appear demented. Up to half of patients with Alzheimer's disease may show depressive symptoms, although only 10 to 20 percent may have severe depressive episodes.

    Certain psychiatric conditions can resemble depression. Hypochondriasis is a preoccupation with the belief that one has a serious medical illness. It is quite different from the preoccupation with physical symptoms such as constipation, dizziness, and nausea that are sometimes noted in depressed older people. However, hypochondriasis may be difficult to distinguish from major depression; psychiatric consultation and evaluation may be the only means for distinguishing between these conditions. The person with hypochondriasis may be willing to entertain the fact she does not have a disease whereas a person with severe depression may have a psychotic delusion of a fixed and bizarre nature concerning the dread--but imaginary--disease. The person with depression also usually reports a history of depressive symptoms that have steadily gotten worse over time. The person with hypochondriasis usually has a history of other long-standing complaints that are not associated with any physical findings.

    The condition called somatization disorder applies to someone who has had a long history of physical complaints that began before the age of 30 and include at least 13 different symptoms. The early-age onset, the multiple-organ systems that are imagined to be or actually are affected, and the lack of any associated other symptoms help to differentiate older people with this disorder from those with other major psychiatric conditions. Again, this is a condition best identified and treated by a psychiatrist.

Evaluation of Depression

The older person who feels depressed or appears to be suffering from depression should consult a physician or a psychiatrist in order to explore the background of the current symptoms or manifestations. Generally, major depression is a disorder that recurs many times. If the person has had a previous episode, it is also important to note what previous treatment approaches have been successful. Typically, recurrent episodes of depression in an older person last about the same length of time, exhibit the same symptoms, and respond to similar treatments. Further helpful information is the presence of any mood disorders in other family members, any thoughts of suicide, and any substance abuse in the immediate family members. Since the presence of manic symptoms may indicate that the person has a manic-depressive condition, the family history should incorporate a review of symptoms of mania. It is also important to know how a depressive episode starts and how long it lasts. It is particularly important to review the contribution of any stresses, any previous episodes of feeling depressed, and the presence of any other symptoms. Another factor is the person's level of cognitive function before the episode of depression began in order to determine whether this depression may be the early manifestation of dementing illness. Sometimes depressive symptoms occur in conjunction with a previously established decline in mental function.

    It is usually helpful to watch for signs of depression while the person is responding to questions. For example, the person's speech may be slow and prolonged, he may have difficulty finding words, there may be a medical condition causing slurred speech, or some other speaking problem such as aphasia. It is also important to determine how the person's thoughts are organized to see if they make sense or reveal any unusual beliefs. Depressed people should also be asked whether they have had any thoughts of suicide. If they answer yes, supportive care should immediately be provided, including medical and psychiatric assistance.

    People with dementing illness usually try to hide it in an effort to answer questions correctly. In contrast, people who are depressed are often unconcerned about their performance. They may make little effort to answer questions correctly or try to curtail the interview process with "I don't know" answers. There are a number of sophisticated neurologic and psychologic tests to clarify the picture. Generally, CT scans or MRIs are not necessary for people with mild or moderate depression. However, these imaging studies may be helpful if the person's depression is severe and if hospitalization is required. Another laboratory test for depression is the sleep electroencephalogram (EEG). This test is accurate and reliable in differentiating those people with very severe depression from those who have no evidence of it and in distinguishing depression from dementing illness. The sleep EEG test is most effective when the person has been off all medications from seven to ten days. It is generally not necessary for mild or moderate depression, but it may be helpful in the case of the severely depressed older adult who has profound sleep problems and who does not respond to medication.

Treatment of Depression

Depression can be treated with psychotherapy, medication, and electroconvulsive therapy. Often, a combination of psychotherapy and medication has the best results.

    The branch of psychotherapy known as cognitive therapy emphasizes behavioral interventions such as daily or weekly activity schedules and graded task assignments that are designed to mold more adaptive levels of functioning. Negative statements such as "My life is not worth living" are examined and viewed as symptoms of the depressive process. Such statements are challenged and the depressed person is encouraged to adopt new ways of viewing life. Supportive psychotherapy is another approach to help the person deal with grief or feelings that might be contributing to the depression.

    The decision to use antidepressant medications may depend as much upon the person's condition and preferences as on the physician's treatment preferences. People who have major as well as less severe depressions usually respond to these drugs. Because of this, the use of antidepressant medications is determined by weighing the benefits and the risks of the treatment.

    All of the antidepressant drugs stay in the body a relatively long time (on the order of days to weeks), and therefore they tend to accumulate in the older person's body and can lead to side effects. Some of these medications may be stored in body fat. Since fat turnover in the body is slow, this means the elimination of antidepressants from the body may be even more prolonged. The risk of accumulation can be decreased by monitoring blood levels, but only a few antidepressants are able to be measured reliably in the blood. Desipramine and nortriptyline are two examples.

Table 19. Comparison of Side Effects in Antidepressant Drugs

   RELATIVE
ANTICHOLINERGIC
EFFECT
RELATIVE CAUSE
OF ORTHOSTATIC
HYPOTENSION
RELATIVE SEDATION
Amitriptyline High High High
Amoxapine Low Moderate Moderate
Bupropion Low Low Low
Clomipramine High High High
Desipramine Low Low Low
Doxepin Moderate-high High High
Fluoxetine Low Low Low
Imipramine Moderate Moderate Moderate
Maprotiline Low Low High
Nortriptyline Low Low Low
Trazodone Low Moderate High
Trimipramine Moderate High High
Source: Adapted from McDonald WM, Krishnan RR. Pharmacologic management of the symptoms of dementia. American Family Physician. 1990;42:126. Originally compiled from Pollack MH, Rosenbaum JF. Management of antidepressantinduced side effects; a practical guide for the clinician. Journal of Clinical Psychiatry. 1987;48:3-8, and Wise MG, Taylor SE. Anxiety and mood disorders in medically ill patients. Journal of Clinical Psychiatry. 1990;51(suppl):27-32. ©1987 and ©1990 by Physicians Postgraduate Press. Reprinted with permission.

    The three major side effects of antidepressant medications result from their ability to block various receptors in the nervous system for acetylcholine, adrenaline, and histamine (see Table 19). Anticholinergic effects (the blocking of acetylcholine receptors) can include dry mouth, difficulty urinating, constipation, impaired vision, and memory loss and confusion. Orthostatic hypotension (the blocking of adrenaline receptors) causes a drop in blood pressure when a person changes position. This puts extra stress on the heart. Thus, if the person has underlying heart disease, serious problems can result. The primary effect of blocking a histamine receptor is sedation. The more sedating antidepressants may initially appear to be the more effective ones. Their initial effectiveness may not be due to the antidepressant effect, which may take two to six weeks of treatment, but rather the effect of eliminating the insomnia, which is a common symptom of depression. Other potential side effects include weight gain, trembling, and various effects upon sexual performance, such as impaired erections, inhibition of orgasms, and decreased sex drive. Physicians sometimes obtain an electrocardiogram before prescribing an antidepressant medication. This is because certain kinds of antidepressants should not be used with some types of heart abnormalities.

    Antidepressants have become available with different range and degree of side effects. One medication called bupropion can cause nausea, insomnia, and agitation, but generally does not block acetylcholine, adrenaline, or histamine receptors. It can make a person more susceptible to having a seizure and must be used carefully by people with seizure disorders.

    Another new antidepressant, fluoxetine, stays in the body a long time. For example, half of it may linger for two days in an older person, and active components of the drug may stay in the body for weeks. Such a lingering presence is particularly worrisome when the drug is given to very old people. It may also cause weight loss and agitation; nonetheless, it is a useful compound and offers a real advantage because it is not sedating and does not block the cholinergic receptors.

    There are many other medication choices for people with depression. People with manic-depressive illness can be treated during a manic episode with lithium. In most cases, once the manic episode has resolved, people are put on lithium to keep new attacks from occurring. Blood levels of lithium can be measured.

    Electroconvulsive therapy (ECT) may be a very effective treatment for depression especially in situations where medication is ineffective, when there are life-threatening consequences to the depression, or when other treatments have failed. A thorough medical evaluation is essential before ECT is administered. In the case of a person with a known brain tumor, treatment with ECT is out of the question. Older people generally respond well to ECT, and medication can be given to help reduce the rate of subsequent depressive episodes.

    Frequently, family therapy is an effective addition to the treatment of the depressed older person. Families can unwittingly reinforce the depression because some family members may not recognize that their behavior is exacerbating the original depression of the older member. Moreover, a family's prejudice against mental illness may undermine the follow-up treatment by denying that the problem exists or that it is serious. The illness should be treated within a supportive and structured environment in which, for example, the older person is encouraged to eat, exercise, and engage in social activities. It is important to reemphasize that depression in elderly people is a devastating disorder with a high risk of suicide. Because of this, family and other caregivers need to join in a full supportive network as part of the treatment program. Family members, for example, need to be alerted to the possible side effects of medications, especially problems with falls, memory disturbances, and problems with driving. Older people suffering from depression should be carefully evaluated to determine their capacity to provide consent for various procedures.

Risk of Suicide

Whenever an older person suffers from a severe depressive disorder, the risk for suicide must be carefully evaluated. Among the risk factors to be considered are suicidal thoughts, a history of previous suicide attempts, whether the person has any other psychiatric disease, and most important, the severity of the depressive disorder. As mentioned earlier, suicide is more prevalent among white men who live alone. Alcohol abuse or drug dependency increases the suicide risk. Furthermore, when older adults suffer from long-term, painful, or potentially life-threatening medical conditions, the risk of their suicide increases. After assessing the risk of suicide, physicians generally determine whether hospitalization is necessary. If it is, every effort should be made to have the person admitted to the hospital for a period of observation and treatment despite the usual protests on the part of the individual. When family members, physicians, and any others involved in the situation are cooperative and honest in apprising each other of the potential risk of suicide, the older person will generally agree to the hospitalization. In extreme circumstances, however, some older people may need to be hospitalized against their will for a brief period.

    If the physician determines that hospitalization is not necessary, everyone should be warned of the potential risk and means for committing suicide. Weapons in the home, for example, should be made inaccessible to the older adult. The older person who is suicidally depressed should be under constant supervision. However, the family members should not be placed under too great a burden of responsibility for preventing the suicide. If there is any question in this regard, hospitalization should be considered as the best preventive option.

    Usually suicide is a risk for a relatively short period. Because of this, rapid intervention is often successful in alleviating the risk danger during that period. Afterward, successful treatment of the depression generally improves the outlook and lowers the risk of suicide. Nevertheless, in some cases the risk may be recurring and the older adult may continue to be at risk for suicide over months and even years. This prolonged risk is usually associated with a partially resolved depressive disorder or, more especially, with frequent recurrent episodes of depression.

Alcohol Abuse

Alcohol dependency is often thought to be a problem of young people, but community surveys suggest that about 5 percent of Americans over age 65 have significant drinking problems. Older men are four times more likely than women to abuse alcohol. About a decade ago, a large community survey of the prevalence of mental disorders in the United States revealed that alcohol abuse was the third most commonly diagnosed mental illness (after dementia and anxiety disorders) in men over age 65. Moreover, the survey found that abuse and dependence on alcohol or some other drug were the most common psychiatric diagnoses of men in their sixties. Other studies have found that alcohol plays a role in about a third of suicides in elderly people.

    The terms "alcohol abuse" and "alcohol dependency" are frequently misinterpreted. Alcohol abuse includes a pattern of alcohol use that is demonstrated by at least one of the following: continued use of alcohol despite social, occupational, psychologic, or physical problems that are caused or worsened by continued use, and recurrent use in situations in which it is physically hazardous, such as driving. These problems must have been present for at least a month or have occurred repeatedly over a long period of time.

    Alcohol dependency includes at least three of the following:

  • The taking of alcohol in large amounts or over a longer period of time than intended
  • The persistent desire or unsuccessful efforts to cut down
  • A great deal of time spent in activities that are necessary for obtaining alcohol or for recovering from its effects
  • Frequent intoxication or withdrawal symptoms when the user is expected to fulfill major role obligations or when alcohol use is physically hazardous
  • The giving up or reduction of activities because of alcohol use
  • Continued alcohol use despite social, psychologic, or physical problems caused or exacerbated by it
  • Marked tolerance to alcohol
  • Characteristic withdrawal symptoms
  • The frequent taking of alcohol to relieve or avoid withdrawal symptoms

    As with alcohol abuse, the symptoms must have persisted for at least a month or recurred repeatedly over a long period of time.

Alcohol and Aging

Although the chemical breakdown of alcohol in the body does not appear to change with aging, other changes that are associated with aging may increase the concentration of alcohol in the blood. These include changes in the liver, decreased lean muscle mass, and a decreased amount of body water. Decreased body water results in a higher concentration of alcohol for each amount consumed since alcohol quickly distributes in this water compartment. After drinking the same amount of alcohol, an average 60-year-old person's blood alcohol level is 20 percent higher than that of a 20-year-old, and a 90-year-old person's blood alcohol level is approximately 50 percent higher than that of a 20-year-old. The nervous system in older people also seems more sensitive to alcohol. In addition, people with dementia illnesses seem especially sensitive to the effects of alcohol.

Signs and Symptoms of Alcoholism

Alcoholism often goes undiscovered in older people. Medical problems, psychosocial problems, and the use of medications may obscure the signs of alcoholism. In addition, symptoms such as confusion, falls, and physical problems may be inappropriately attributed to aging. Some older people may have confusion or severe hearing impairment, making it difficult to question them about their alcohol abuse. The stigma associated with having an alcohol problem, especially in an older person, may prevent some health professionals from asking if such a problem exists.

    Patterns of alcohol dependence in older people have generally been divided into the categories of "early onset," which occurs before the age of 60, and "late onset," which occurs after the age of 60. In one-half to three-quarters of older people with alcohol problems, the pattern is that of early onset; these people generally have a family history of alcoholism, are less well adjusted, and may have had alcohol-related legal problems. Late-onset alcohol abuse is thought by some to be due to the stresses and losses associated with aging. People in this category point to life events as the cause for their drinking more often than do those who have had an early onset of a drinking problem. However, early retirement, premature health problems, and other life stresses can be caused by alcohol abuse. People with late-onset alcohol dependence may respond more favorably to treatment.

    Questionnaires and screening approaches increase the detection of alcohol-related problems. A doctor may ask four key questions: "Have you ever felt you ought to slow down on your drinking?" "Have you ever felt annoyed by criticism of your drinking?" "Have you ever felt guilty or bad about drinking?" "Have you ever felt the need for an eye-opener in the morning to steady your nerves?" Two or more positive answers should raise the suspicion of alcohol abuse. A positive response to even one question should prompt further inquiry.

    Sleep problems can be a sign of alcohol misuse or abuse. With aging, the time that it takes to fall asleep increases, and alcohol may be used in an effort to induce sleep. Initially, alcohol may help one get to sleep, but overall it worsens sleep problems by decreasing the amount of restful sleep, which in turn increases anxiety and irritability. Alcohol abuse also decreases the deep levels of sleep and causes early awakenings, which can result in sluggishness and lethargy during the day.

Drug Interactions with Alcohol

Another major problem associated with alcoholism in older people is the increased likelihood and danger of drug-alcohol interactions. With age there is a decrease in the chemical processing of certain drugs in the liver, and this results in the drugs lasting for a longer time in the body. For some of these medicines the ingestion of alcohol increases this effect. On the other hand, there are some drugs whose effects are diminished in the person who abuses alcohol, such as drugs used for seizure disorders, anticoagulants (blood thinners), and some of the oral medications used to treat diabetes mellitus. Alcohol also unpredictably strengthens the effects of sedatives, which can compromise motor skills and alertness. Frequent use of alcohol can cause bleeding in the intestines; this risk can be especially increased if the person is taking arthritis medications or aspirin.

Complications of Alcohol Abuse

Alcohol can affect every part of the nervous system either directly or indirectly by depleting nutrients, especially B vitamins. Prolonged alcohol dependence can cause significant problems, including confusion, clumsiness, muscle problems, liver disease, coma, and degeneration of the brain and spinal cord. Some experts estimate that 5 to 10 percent of cases of dementia are caused by alcohol abuse.

    People who abuse alcohol may have additional psychiatric problems such as anxiety disorders, depression, memory difficulties, and the abuse of medications. At times alcohol is used by older people for self-medication to ease both the emotional pain of psychiatric and physical illness. Tobacco dependence also tends to occur with alcohol abuse and dependence, further compromising the health of the alcoholic older adult. People who use sedatives or pain relievers seem especially predisposed to develop alcohol dependence.

    Alcohol abuse can interfere with treatment for other problems. If a person with a physical illness does not respond to treatment, or if adverse drug reactions appear to be present, alcohol abuse or dependence should be considered as a possible contributing factor. On the other hand, the presence of a psychiatric condition or cognitive impairment does not seem to affect the chance of treating alcoholism.

    Severe withdrawal symptoms occur as frequently in older people as in younger people. Approximately 5 percent of older alcoholic individuals experience withdrawal delirium also called delirium tremens, or DTs. This severe form of alcohol withdrawal is a medical emergency; older people have a higher risk of death than younger people and may take longer to complete the withdrawal process.

Treatment Principles of Alcoholism

Clearly prevention is the most effective treatment of alcohol abuse. The effectiveness of personal concern and advice and education on the effects of alcohol is well documented. People may be asked to keep a diary on their drinking patterns. In addition, they may respond to information on the particular effects of alcohol on their body's organs and systems. People with long-standing alcohol problems usually require more aggressive treatments.

    Thankfully, it is not the case that older alcoholics must hit rock-bottom before they will agree to treatment. When an alcohol problem is identified, people important in the person's life need to be instructed by experienced counselors in ways to strengthen the person's motivation to begin treatment. Group confrontation can also be taught to air the problem of alcoholism. Older persons with alcohol problems who are confronted in a supportive way are more likely to enter into treatment programs and to remain abstinent for longer periods than those who are confronted antagonistically or not confronted at all. Family members can be given support and training by experienced counselors to help them deal with the alcohol abuser's behavior and to decrease behaviors of their own that might encourage and enable alcohol intake. Sometimes well-intended family members inadvertently find ways to allow and even ensure that the person's addiction to alcohol continues.

    People with a long history of alcohol use should take multivitamins daily and a doctor may want to prescribe thiamine as soon as possible. People with very poor nutrition, mental impairment, or nervous system problems may need to have their vitamin B12 level checked to make sure they are not deficient in this critical nutrient. Occasionally, vitamin K supplementation may be necessary for people with bleeding problems.

    Many people report symptoms of depression while they are off alcohol. Usually these symptoms get better after they have participated in treatment programs for three to four weeks. Antidepressant medications are sometimes useful and are given after about four weeks of abstinence.

Treatment of Alcohol Withdrawal

The amount of time from the last drink to the onset of typical symptoms of alcohol withdrawal is similar across the life cycle, usually 24 to 36 hours. These withdrawal symptoms include shakiness, agitation, sweating, hallucinations, or seizures. Doctors use many types of medications to help address these withdrawal symptoms. Older people must be monitored continually for signs and symptoms of alcohol withdrawal as these medications are adjusted. Sometimes giving an older person magnesium can be helpful in treating withdrawal symptoms and in some cases allows for the decreased use of other medications. People with severe agitation, hallucinations, or paranoia may need stronger antipsychotic medication, usually haloperidol. It must be stressed that the treatment of alcohol withdrawal is a serious medical emergency and should not be undertaken without the supervision of a physician.

Alcohol Rehabilitation

The rehabilitation programs for alcohol and other drug dependence use many strategies. Individual therapy can help break down the person's denial that an alcohol problem exists and can focus on other specific problems, such as grief or difficulty in adapting to retirement. In addition, group therapy provides education on alcoholism, additional assistance in breaking down denial, and development of alternative coping mechanisms. Groups also provide emotional support and can give a person a sense of belonging and renewed self-respect.

    Involvement in Alcoholics Anonymous (AA), a worldwide group of recovering alcohol abusers who assist others in their recovery, is effective for many older people. About a third of the people in Alcoholics Anonymous are 50 and older. Family members or others who have unknowingly fostered the older person's alcohol abuse or at least denied that there was a problem, sometimes referred to as enablers, also need to be brought into the treatment process. Involvement in groups like Al-Anon (a companion group to Alcoholics Anonymous) can help these family members and others to recognize and change their harmful patterns of behavior. Al-Anon also offers relief and support to family members or others who have suffered with stress, strain, or victimization caused by a person with alcohol or drug dependency. Community resources such as senior citizens groups, visiting nurses, church groups, halfway houses, as well as opportunities for volunteer work should all be utilized. Some life care and retirement communities have developed support groups for people with alcohol problems.

    The outlook for recovery from alcoholism in elderly people is generally good since older people who have this problem are more likely than younger people to remain in treatment and to maintain sobriety.

Drug Dependency

Drug abuse, which can be found in people of almost any age, gender, race, nationality, and socioeconomic class can be a major problem for elderly people. Those in this age group take on average 4 over-the-counter drugs daily; those who have a chronic disease may take 10 to 15 drugs daily. Those who are 65 and older are at increased risk for dangerous drug-alcohol interactions. Of the 100 drugs most frequently prescribed, over half interact with alcohol.

    The frequency of drug addiction in older people is not known. Some people have a twofold diagnosis: a major psychiatric illness and drug addiction. Some older people may have lifelong histories of addictive behavior whereas others may have only recently developed a drug problem.

    The drugs most likely abused by the older person are benzodiazepines, oral narcotics, and barbiturates. However, all other drugs, whether legal or illegal, have also been reportedly abused by older people including stimulants, cocaine, marijuana, hallucinogens, and intravenous narcotics.

Symptoms of Drug Abuse

Older people who are addicted to medication rarely complain about it. Instead, they may complain about anxiety (which may be related to tolerance or withdrawal symptoms), memory loss, depressed mood, agitation, falls, changes in blood pressure, pain in the upper abdomen, fatigue, sleep disturbance, appetite and weight loss, weakness, and confusion. Drug-seeking behavior is quite common among addictive individuals and some are quite clever at "doctor shopping"--a strategy that enables them to get several copies of the same prescriptions from different doctors and to fill the prescriptions at different pharmacies. Addiction to more than one drug is extremely common.

    Several psychological symptoms are typical of drug addiction: denial, minimalization, rationalization, defocusing, and enabling. Generally, addicted individuals deny that they are addicted. Sometimes the denial is extreme to the degree that the person may not admit to taking any addictive drugs. In less extreme circumstances, the person might minimize the amount of drug taken or the effects of drug use on their behavior and life. In rationalization, addicted people try to find reasons other than the addiction for their use of the offending compounds. A common rationalization used by older adults addicted to prescription drugs involves blaming the physician for prescribing the medication. People with medication addiction also try to focus the discussion away from their addiction and onto anything else in their life such as marital conflicts or significant medical illness. Enabling relates to the families and others close to the addicted person. People who enable an addicted individual unconsciously support the addictive behavior. "Enabling persons" may also demonstrate the symptoms of denial and rationalization, and attempt to focus the discussion away from the addiction. (See also the section on alcohol abuse.)

    Drug tolerance is a phenomenon to watch out for. Tolerance refers to the need of an increased dosage over time in order to maintain the same control of symptoms. The body adapts to each level of dosage and loses its sensitivity to the effects of the medication. The body can develop tolerance to many kinds of drugs, and some of these can become addicting. This is particularly true of antianxiety drugs and sleeping pills. When increasing dosage leads to addiction, any attempt at abrupt cessation of the medication will lead to withdrawal symptoms. While such symptoms vary with different drugs, they can be severe and can include tremor, sweating, hyperthermia, delirium, convulsions, and cardiac crises. Because of these potentially life-threatening dangers, drug withdrawal must always be monitored closely by a physician.

Treatment of Drug Addiction

Drug addiction is a disease and should be treated as such. Symptoms of other conditions need to be treated after the person is detoxified and frequently they diminish spontaneously. The two phases of treatment are detoxification and rehabilitation. Detoxification should begin the moment the decision is made to start treatment. This process usually requires an in-hospital stay where constant supervision can prevent the person from "sneaking" in drugs. Detoxification of the older adult can never proceed rapidly, and in some addicted individuals it may take eight to ten weeks to complete treatment. Rehabilitation should usually take place within the context of a program such as that of Alcoholics Anonymous (AA), even if the addiction is not related to alcohol. Addicts should start attending daily AA meetings as soon as their physical condition warrants it. As discussed in the section on alcohol addiction, family members should also be counseled regarding the process of addiction, and a discussion of their roles as enablers should be part of the treatment. Even if a person addicted to many drugs has not abused alcohol, attendance at an AA meeting is usually better than attendance at a Narcotics Anonymous (NA) meeting because the older person is more likely to be able to relate to people who attend AA than to the younger people who attend NA.

    All addictive medicines must be stopped once detoxification is complete, regardless of the person's complaints of anxiety, inability to sleep, or pain. If the person experiences pain that is severe enough to warrant treatment with narcotics, such as after an acute injury or after surgery, narcotics are given under controlled circumstances and usually only in the hospital.

    Once the inpatient treatment is complete, the older person with an addiction should always be considered to be recovering but never fully recovered. To prevent a relapse, it is necessary to attend AA meetings every day for one year and then to attend them frequently thereafter. Following all 12 steps of the AA program is important, from the first step in which people admit they are addicts and can explain why, to making contacts at AA meetings, to becoming a sponsor. All of the steps are integral parts of successful treatment.




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