Spotting the difference: mental health issues in older patients

Tom MacLaren is a Teaching Fellow and James Warner is a Consultant Psychiatrist and Chair of the Faculty of Old Age, Medical Royal College of Psychiatrists. Here they discuss mental health issues that can affect older patients.

We are all living longer and much emphasis is now placed on the need to identify and treat dementia in older patients.

While these efforts are helpful and important, we must remember that while dementia is a big issue, more than nine in every ten older people do not have dementia.

There are around 10 million people over the age of 65 in the UK. At any given time, 10% of them will have mental health symptoms of some sort due to conditions other than dementia. Depression, often linked to loneliness and isolation, and anxiety are prevalent and increased frailty can make accessing care more difficult.

Impact on patients and hospitals

Up to 60% of older patients on hospital wards have, or will develop, a mental illness ¬– principally dementia, delirium or depression. Left untreated, these symptoms can slow recovery, leading to an increased length of stay and overall bed occupancy. A recent initiative to strengthen the provision of liaison psychiatry for older adults by providing intensive, proactive multidisciplinary care throughout the acute hospital care pathway has sought to address this issue.

What are the symptoms of depression in older people?

In primary care, loneliness may take the form of a lingering handshake, depression or anxiety manifesting as physical pain or complaints about noisy neighbours.

The hallmarks of depression in younger people – such as tearfulness, low mood and psychomotor poverty – may be absent in older people. Agitation, lack of interest and pleasure in daily activities, reduced energy and poor concentration/memory may be the presenting features in this age group. One in three people also experience a disturbed sleep, reduced appetite or weight loss.

For older people, many of whom have multiple physical conditions, recognising depression is a challenge. The cost of undiagnosed depression can be high with poorer outcomes in the primary and secondary prevention of many conditions, including myocardial infarction, stroke and Parkinson’s disease where depression rates may exceed 20%.

How can you spot anxiety in older people?

Anxiety symptoms can occur alone but are often concurrent with depression, especially in older people. Anxious older patients may book frequent appointments at their GP surgery and attend their local emergency department. Look out for the fidgeting patient with a plethora of physical complaints who finds it difficult to take in what you say.

Physical symptoms, including feelings of muscle tension, tingling and numbness, shaking and sweating, may all arise from anxiety. Panic attacks involving intense fear, rapid heartbeat and breathing can lead to panic disorder and a reduced quality of life. Identifying and treating older people with anxiety will improve quality of life and reduce demand on A&E and primary care services.

Schizophrenia in older people

We must also keep in mind that older people can be affected by schizophrenia – a serious condition that carries a lifetime suicide rate of 5%.

Older people with schizophrenia may not receive help because they tend to be isolated, have no close family, and may not exhibit behavioural complications that often trigger help for younger people. Patients may miss appointments in primary care, become dishevelled, stop speaking to their neighbours or looking after their home.

Untreated, schizophrenia has wide implications for health and wellbeing, shortening a person’s lifespan by 20 years on average.

Recognising conditions early is key

Our growing older population has a high, and increasing, risk of poor mental health. Societal trends and cuts in social funding, leading to greater isolation, are likely to make the situation worse.
Many illnesses are treatable but more focus on prevention and early recognition is needed. It is important as doctors we take the time to spot the signs and understand the issues underpinning illness, treat effectively and liaise with social services/voluntary organisations to address social and environmental triggers. Old age psychiatry services are there to help in complex and risky situations .

The GMC has guidance, resources and signposts to help doctors deal with issues related to the care of older people. Find more at Better Care for Older People

References

  1.  Parsonage M, Fossey M. Economic evaluation of a liaison psychiatry service. Centre for Mental Health, November 2011.
  2. Tadros G, Salama R, Mustafa N, Pannell R, Balloo S. The Rapid Assessment Interface and Discharge Liaison Team, City Hospital Birmingham: Evaluation Report December 2009 – September 2010. Publisher, 2011.
  3.  Prince M, et al. Prevalence of depressive symptoms and syndromes in later life in ten European countries: The SHARE study. British Journal of Psychiatry 2007; 191: 393-401.
  4.  Williams R. Why Should I Be Concerned About Depression After a Heart Attack? Circulation 2011; 123: e639-e640 doi: 10.1161/CIRCULATIONAHA.110.017285.
  5.  Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology November 2010; 24(4_supplement): 81–90.
  6.  Laursen TM, Munk-Olsen T, Vestergaard M. Life expectancy and cardiovascular mortality in persons with schizophrenia. Current Opinion in Psychiatry March 2012; 25(2): 83–8.
Dr. Tom MacLaren is  Specialty Trainee 5 in Psychiatry, Teaching Fellow,  CNWL and Honorary Clinical Lecturer, Imperial College London.

Dr. Tom MacLaren is Specialty Trainee 5 in Psychiatry, Teaching Fellow, CNWL and Honorary Clinical Lecturer, Imperial College London.

Dr James Warner is a Consultant Psychiatrist and Chair of the Faculty of Old Age, Medical Royal College of Psychiatrists.

Dr James Warner is a Consultant Psychiatrist and Chair of the Faculty of Old Age, Medical Royal College of Psychiatrists.

One response to “Spotting the difference: mental health issues in older patients

  1. Pingback: Good continuity of care: four top tips for junior doctors | General Medical Council·

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