Our society continues to age, and it is estimated that by 2030 there will be more than 75 million Americans over the age of 65. The population of older adults (60 YO+) is growing faster than any other age group. According to Institute of Medicine, 1 in 5 older adults will experience at least one mental health or substance use disorder. Worldwide, mental health issues are a greater cause of disability than Alzheimer’s and dementias by far.
Psychosis in older adults is relatively common and may be related to late-onset schizophrenia, mood disorders, delirium, or dementia. Neurological or medical issues may also manifest as psychosis. Psychosis in Alzheimer’s has a prevalence rate of greater than 41%. With Lewy Body Dementia the prevalence rate of hallucinations is 78% and 25% for delusions. Proper diagnosis is crucial to determine appropriate treatment. Antipsychotics are not recommended if the underlying diagnosis is dementia. These powerful medications must also be administered with caution in older adults as older adults are more sensitive to the side effects of antipsychotics.
Mood disorders and anxiety are also common as older adults deal with other medical issues, the loss of friends and spouses, poor quality of life, and diminishing capacity. It is important to remember that depression is not an inevitable part of aging. 80% of depression in older adults is treatable. However, we also know that depression is frequently either untreated or undertreated in older adults. 40% of the nursing home population has clinically significant symptoms of depression. Mental health issues that are not addressed are one of the drivers of institutionalization in this population.
Depression in homebound older adults is greater than the general population of older adults and ranges from 13% to 48%. We also know that 78% of that group is not getting proper treatment. This group is at higher risk for both medical and mental health issues. Depression in older adults is also more likely to be accompanied with psychotic features.
Anxiety disorders are also prevalent in the population of older adults and we often see increased disability, a poor quality of life, and cognitive impairment. As with mood disorders, anxiety disorders are untreated or undertreated. It is also typical to see mood disorders and anxiety disorders to co-occur.
Older adults are also prone to phobias. In this population one of the most common phobias is a fear of falling. It is important to remember that to be classified as a phobia and not a general fear, it must impair daily functioning. The prevalence of this specific phobia increases with age as does impairment when the phobia leads to social withdrawal and avoidance of daily activities.
Hoarding is another disorder we often see in the older population. With the publication of the DSM 5, hoarding became a distinct disorder. It is defined as “persistent difficulty discarding or parting with possessions, regardless of their actual value”. At its extreme, hoarding increases the risk of falls and generally decreases the safety of the living environment. Because older adults are more likely to live in subsidized housing, this becomes a major issue with property managers. Again, we frequently see co-occurring disorders such as anxiety, mood disorders, dementia, and/or physical illnesses.
Far more alarming is the suicide rate for older adults. Adults over 65 have the highest rate of suicide across all age groups. Men over the age of 75 have a suicide rate that is double that of any other age group. Suicide risk increases dramatically for men over 50 and women over 70. In addition to mental health issues, physical illnesses and other stressors of aging increase the risk of suicide. In one study, 37% reported that they felt like a burden to others and 15% felt that others would be better off without them. These are easily recognized as risk factors for suicide.
The more disabling conditions in older adults are delirium and dementia. Delirium is reversible where dementia is not. Delirium is typically the result of medical causes which are easily treated. Dementia is “an acquired impairment of mental function”. Dementia often sees impairment in at least three areas of cognition and mental activity. Dementia is a common symptom of Alzheimer’s disease, cortical Lewy Body disease, and other degeneration of the brain.
It is vital that these issues be identified early so that we may encourage appropriate treatment. Timely and appropriate treatment can dramatically improve the quality of life for older adults. One of the more important parts of treatment for this population is psychoeducation. Psychoeducation should clearly differentiate between the symptoms of mental disorders and physical disorders. One of the goals must also be to address stigma and misinformation. Psychoeducation can be key to getting good treatment adherence.