Dan G. Blazer, PhD, MD
Vice Chair, Department of Psychiatry and Behavioral Sciences, Vice Chair, Academic Development, Duke University
Dr. Blazer has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Apart from the obvious problems like memory disorders and dementia, what should we know about psychiatric issues in the elderly?
Dr. Blazer: One thing to begin with is to recognize that in general surveys of happiness, contentment, and well-being, older persons for the most part score higher than people in midlife and certainly in earlier young adulthood. So most conditions, other than the neurocognitive disorders, are actually less frequent in the elderly. You may see what people call “burnout” as individuals get into late life, in which depressive disorders, substance use disorders, manic disorders, and others, decline over time. But it doesn’t mean that they are less important. For example, the suicide rate was higher among older persons than in any other age group throughout the 20th century.
TCPR: Are there special considerations when evaluating older adults with psychiatric disorders?
Dr. Blazer: Yes. Psychiatric disorders in late life occur in individuals who are generally more vulnerable, either in terms of their cognitive capacity or their physical health. So the consequences of a psychiatric disorder in late life can be very significant. We must be very careful not to discount symptoms: when an older person begins to complain of sleep or appetite problems or begins to look depressed, that is something that really deserves attention.
TCPR: So what symptoms or psychiatric complaints should we be looking for to determine which patients need more aggressive psychiatric help?
Dr. Blazer: A good marker for understanding older persons is not the diagnosis of a specific illness, but rather the function of the individual. How much is the person getting up and walking around? Can the person take care of his or her daily needs, such as keeping up with the checkbook, buying groceries, or driving? Really looking at the spectrum of what the older person is capable of doing will tell us more than simply focusing on a diagnosis. Furthermore, it is important not to separate the psychiatric help from treatment for the physical disorders, because they are comingled. For example, say an elderly man is tired, he has lethargy, is down, and is having difficulty sleeping. He may very well be suffering from depression, but that depression also may be superimposed on chronic obstructive pulmonary disease. Finally, a very important part of geriatric medicine is the understanding of frailty and failure to thrive. Older people can sometimes pass a threshold beyond which they will not eat, they seem to be depressed, they are very lethargic, and if you don’t turn that around, the result is continuing decline and possibly death. Depression and cognitive difficulties can certainly be a part of that; but importantly, we can’t say we are going to deal with these symptoms and not be concerned about the others.
TCPR: Tell us about mood disorders in the geriatric population.
Dr. Blazer: One thing to keep in mind is that older persons often will not use the term “depressed,” but the good news is that they are usually very cooperative and willing to work with the psychiatrist once they get to you. The most significant symptom is anhedonia. A typical thing a depressed older person will say is, “I love my grandkids. I used to really enjoy them coming over to the house. I still care a lot about them, but I just can’t get excited to know that they are coming, and sometimes am glad that they are ready to go when they go,” Or they will say, “I eat because I need to eat.” So their interest in food will decline and they might report weight loss. Sleep problems are also very common. Older persons, in general, have sleep problems anyway, but what we see with depressed older persons is that they will awaken frequently, and they realize that they have awakened frequently.
TCPR: What are some of the methods and principles we should keep in mind when treating this population?
Dr. Blazer: There is a fairly substantial literature supporting the combination of one of the more “educationally-oriented” or cognitively-oriented psychotherapies along with medication use as the best way to treat these individuals, both in relieving their initial symptoms and in preventing the recurrence of symptoms. With medications, you want to start low and go slow in your dosage. This is a reasonable rule of thumb for someone who is maybe 75 years of age and older. For example, if you are using a drug like paroxetine where your usual dosage might be 20 mg, you might want to start with 5 mg, try that for a while and then work up gradually to your target dose. Generally they will need and often will tolerate a regular dose of the medication, but you don’t want to start them on that initially because of the potential for side effects, which will undermine your ability to treat them. All of the medications that we use earlier in life can be effective in later life.
TCPR: So any antidepressant that is effective for depression in the young is good for the elderly as well?
Dr. Blazer: Yes. For people who are very old, and have a lot of lethargy and apathy, sometimes a very low dose of methylphenidate can be effective, too. I mean about 5 mg once or twice a day, and never after 2 o’clock in the afternoon. The best treatment is a combination of medications and behaviorally-oriented, educational psychotherapy.
TCPR: Which types of therapy work best?
Dr. Blazer: Interpersonal therapy and cognitive behavioral therapies are effective sometimes on their own in treating older persons. If you have an older person who really cannot take a medication, perhaps for medical reasons or for significant side effects, then certainly it is worth a trial of cognitive behavioral therapy. If the depression is moderate to severe, and if it does not respond to medications, then I recommend thinking about brain stimulation techniques. Of course ECT has been around for the longest and it can be very effective in treating older persons. And the memory problems that were the bane of ECT for many years are less worrisome now when nondominant treatments are used and when you really monitor these individuals very carefully. There are some other brain stimulation techniques that have been used on depression in the elderly: transmagnetic stimulation is one example.
TCPR: What can you say about the use of benzodiazepines, anticholinergics, and antipsychotics, given the potential risks of these drugs in the geriatric population?
Dr. Blazer: Let’s take the benzodiazepines first: older persons are more likely to experience adverse effects with benzodiazepines than are people who are younger, all other things being equal. On the other hand, older persons, in my view, are less likely to become addicted or abuse them. So benzodiazepines can be used judiciously. I would recommend the short-acting benzodiazepines like lorazepam, for example, or alprazolam, as opposed to some of the longer acting ones. There is no reason that the benzodiazepines are absolutely contraindicated in older persons, but you should be careful of potential for falls in patients taking these.
TCPR: And the anticholinergics?
Dr. Blazer: You generally want to avoid anticholinergics, especially in older persons who have memory difficulties. At one time a low dose of amitriptyline was used to help older people sleep. A better option now is a very low dose of trazodone, as low as 25 mg, which might give you the same effect without the problem of the anticholinergic effects.
TCPR: And finally, the antipsychotics?
Dr. Blazer: Physicians have hotly debated the topic in geriatric psychiatry, specifically the use of antipsychotics in nursing home populations. On the one hand, there has been a recent drive to reduce the regularity of nursing home patients taking these. On the other hand, there are older persons who are very agitated who cannot be managed pharmacologically without an antipsychotic medication. In this case, the new generation drugs are generally preferred, as patients can tolerate using those drugs for a long time, and sometimes you can rotate on and off.
TCPR: Earlier you mentioned burnout of certain conditions. Is mania one of these? Does it wane with age?
Dr. Blazer: Mania is somewhat less prevalent in old age, and even individuals who have had significant and frequent episodes of mania when they were younger might have less frequent or no manic episodes at all when they get into late life. What is important to recognize, though, is that mania can present in different ways in older persons. What we tend to see is more agitation and irritability than what we typically think of as mania, where the person is joyous, euphoric, and full of energy. Sometimes mania can even be misinterpreted as depression. In such cases, as in younger patients, the person may be put on an antidepressant that might exacerbate the mania. So I think recognizing how mania presents is very important. Mania certainly can present with psychotic episodes; in fact, it probably is more likely to present with psychotic symptoms later in life than it is earlier in life.
TCPR: What ways can people age happily?
Dr. Blazer: A number of things have come out over the years, both from our research and the research from many others, to suggest that physical health is a key predictor of better aging, so exercise and watching one’s diet are major factors. Cognitively, we’ve found that it’s important to remain involved in interesting and useful things. When older adults keep involved with other people and with interesting ideas—through social interaction, reading, even going on Facebook—this can help greatly. In addition to that, studies show that individuals who endorse some form of spiritual well-being actually do better physically and emotionally.
TCPR: Thank you, Dr. Blazer.
Measuring Function in the Elderly
Katz Index of Independence in Activities of Daily Living (ADL)
The Rosow-Breslau Functional Health Scale
Older Americans Resources and Services (OARS) Activities of Daily Living (ADL) Scale