Navigating Mental Health in the Elderly [Mental Health Awareness Series #3]

Apparently, doctoring octogenarians is pretty unpopular in the medical community. That means that there are very few medical experts in the field who specialize in the unique healthcare of those over 70.

How do I know this? In addition to spending my free time reading medical literature, I happen to be coordinating a study for some Hadassah doctors who are trying to figure out why geriatrics is such a poorly attended specialty among Israeli residents. In fact, in 2016, the Israeli Ministry of Health even offered special grants to interns if they chose specific needed areas of residency; geriatrics was one of the ten.

This lack isn’t only in Israel. In 2016, the American Geriatrics Society estimated that medical schools would have to train at least 6,250 additional geriatricians between now and 2030 to serve the growing rate of elderly in the United States. Needless to say, that isn’t happening. Even if, somehow, we were to create enough geriatricians to treat the elderly, we still haven’t included geriatric psychiatry in those numbers, those needed to treat the mental health of the elderly.

I’m asked often why one would need a specially trained practitioner to manage the health of a patient in her 80’s. A doctor is a doctor; a psychiatrist is a psychiatrist. Just treat the patient in front of you. I’ll give you an example.

I have a client, I’ll call her Sarah, who just celebrated her 92nd birthday. She has no hint of dementia, walks with a slight stoop, and begrudgingly, sometimes a walker. She had a bypass surgery in her 60’s, a slight bout of cured bladder cancer, nerve pain that wakes her up at night, and a previous diagnosis of mild depression and anxiety. If she were to see a regular psychiatrist, they may look at the previous diagnosis, notice the anxiety and prescribe a SSRI (Cipralex, Zoloft, etc..). However, recent research has demonstrated a clear connection between SSRI usage and irregular heartbeat, as well as increased falls, in elderly patients. Both of which are in Sarah’s medical background.  Not only that, but we also know that medicines metabolize more slowly in the elderly, meaning that the correct dosage for a 45-year-old woman is different for an 85-year-old woman, even if they are the same height/weight and medical background.

This is not to say that one psychiatrist couldn’t treat them both, but that the physician should have experience in working with the elderly and an understanding of the uniqueness of their health position.

We haven’t even touched on treating the aging mental health patient; those with a diagnosis of schizophrenia, bipolar disorder, and others who have spent a lifetime on antipsychotic medication. They may now respond differently to their medication or develop adverse physical effects that could cause physical harm. The recommendation seems to be to reduce antipsychotic medication dosage in the elderly, but there are no specific guidelines.

This is a small but significant group of patients. For example, I have a client who wants to bring over his older sister from the U.S. to live near him in Israel, now that his parents are deceased. His sister has managed schizophrenia but cannot live independently. She is 75 years old, has a heart condition and osteoporosis. She was diagnosed with this mental illness 60 years ago. Reasonably, he would need a geriatric psychiatrist, but those are difficult to locate in Israel. More importantly, he needs a psychiatrist who speaks English. I recommended that he start the dialogue with his kupah branch office about the need to recruit more English speaking psychiatrists and psychologists to his geographic area (Netanya). This is not a pipe dream but rather how we need to make change. Every English speaker in need of psychological services in English must approach their kupah, and if there isn’t an option in English, politely demand one. The government has put both law and money into developing mental health services through the kupot and as English speakers, we need to advocate for our health rights.

The take-home message today? If you, or your elderly loved one is over 65 and in need of mental health services, ask the following questions:

• Does the psychiatrist have experience treating geriatric patients?

• Do they only recommend medication, or will they also treat the patient therapeutically over time?

• Do they feel comfortable treating the patient in English?

If they answer no to all three, you’ll have to keep looking.