Is it dementia, a psychotic break or a UTI? Has pain medication use become an addiction? Is that a normal amount of sleep or an indication of depression?
Identifying and treating behavioral health and substance abuse issues is made all the more challenging by the host of comorbid conditions that often accompanies elderly patients. Michael Genovese, MD, JD, chief medical officer for Nashville-headquartered Acadia Healthcare, shared insights on addressing special considerations in the geriatric population.
Michael Genovese, MD, JD
Genovese, a clinical psychiatrist and addiction specialist, said onset of behavioral health conditions and substance use disorder can occur at any point in a person's life. The goal, he continued, is to recognize behavioral changes and to intervene to improve quality of life ... no matter what a patient's stage in life.
Diagnosis
"We have to be really careful with diagnosis. There are a lot of things in the geriatric population that can mimic psychiatric symptoms but have a medical etiology," said Genovese. "It's absolutely essential you provide a thorough physical exam so you can rule out an underlying medical condition. One of the things I always ask medical students is, 'What's the first thing you should think of when an elderly patient presents with delirium?'" The answer, he continued, is to check for a urinary tract infection.
While physical health issues might mimic behavioral health conditions, Genovese said it's equally important not fall into the opposite trap of thinking new psychiatric symptoms won't arise as someone ages. Just because a patient hasn't exhibited signs of depression in the first seven decades of life doesn't mean they might not in their eighth decade.
"Age does not confer immunity to depression," said Genovese. "It's important to observe and also to listen. If an older patient tells you they feel sad or depressed, it's important not to dismiss that."
Genovese said the most common disorders among geriatric patients are anxiety disorders, mood disorders including major depression, suicidal ideation, destructive anger, bipolar disorder and failure to thrive.
Alcoholism and prescription drug abuse are other issues providers should consider. "Substance use disorders do not discriminate based on age," Genovese pointed out. "Alcohol Use Disorder is a chronic, progressive disease," he continued, noting those who were able to maintain some sort of functionality when younger find it increasingly difficult to do so with age. For others, abuse begins in later years. "People can get started because they're trying to numb the emotional pain they didn't have before," he said of the grief that comes from losing a spouse, child, friends and independence.
Clear communication, he added, is critically important for both older patients and their caregiver support systems. Because older patients are more likely to sustain falls or have illnesses that lead to pain medication prescriptions, there is a heightened possibility for abuse ... even if it's accidental.
Genovese shared the story of a woman prescribed an opioid with a label that said, 'use three times a day as needed for pain." Trying to be a good patient, she took the medicine three times a day, every day, until she became addicted. "We see a lot more iatrogenic addiction in older patients," he added.
Comorbidities & Treatment
"The complexity of geriatric patients can differ from that of younger patients," said Genovese. "Older patients often present with complex medical comorbidities with the constellation of issues ranging from diabetes to heart conditions and stroke."
Because of that, he continued, "The pharmacology can be a lot more complex." For example, Genovese noted, lithium is widely used in treating bipolar disorder but would not be a viable option for an older patient with renal disease. Similarly, geriatric patients are often on a blood thinner, which impacts prescription decisions for treating a number of mental health disorders.
Genovese said close supervision is required, particularly on the front end, when an elderly patient starts a new regimen. "They need daily medical monitoring while receiving behavioral health treatment, so it's much more staff intensive," he said.
Marveling at the myriad conditions primary care providers manage, Genovese said it's always good to know when to call in reinforcements. "When they start to feel this might be beyond their purview for managing disease, really good doctors have a really low threshold for requesting consultation. Collaboration is key in medicine."
For some patients, the solution is an acute care admission to a facility like Acadia's TrustPoint Hospital in Murfreesboro, which has a senior psychiatric unit. With a typical stay of 10-14 days, patients are evaluated, begin a treatment regimen and are closely monitored. Once stabilized, patients return to the care of their community provider and hopefully to a prior level of function.
"You certainly don't want to dismiss how they feel, but you really want to observe functioning as a hallmark of treatment," said Genovese. Just as psychiatric disorders can occur at any age, so too can help and healing.
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