MENTAL HEALTH
PSYCHIATRY AND THE Older Adult
David Casey, MD
G
eriatric psychiatry is a subspecialty
which deals with mental condi-
tions commonly encountered in
older adults. The management of
older patients involves a number
of intersecting perspectives. The effects of the
aging process itself are important, including
losses in the special senses such as vision and
hearing, reductions in physical strength, balance and mobility, and
reduced function of vital organ systems. Age-related medical illness
such as diabetes, cardiovascular disease, and neurological disorders
are also to be considered. Many older patients have complex effects
of a number of overlapping conditions.
The effects of psychiatric disorders may be bidirectional with
mental conditions also affecting physical health. Many elders con-
sume a large number of medications which may impact health in
negative as well as positive ways and produce untoward interactions.
Aging induces change in both pharmacokinetics and pharmacody-
namics. Certain syndromes are especially common in older adults,
particularly cognitive loss, weight loss, sleep disturbances and fall-
ing. In evaluating elders, the social context of the patient is of vital
importance. Where and how the person lives, and with whom, is
often as important as the medical conditions being managed. The
patient’s role in the family and how the family interacts with their
care is also of interest.
14
LOUISVILLE MEDICINE
Transportation, finances and access to a pharmacy are all im-
portant considerations. The role of important social programs such
as Medicare, Medicaid and Social Security, as well as less commonly
accessed agencies such as Adult Protective Services or Guardianship
Services are important in treating older adults, and crucial for the
physician to understand. The geriatric psychiatrist must understand
the legalities of concepts such powers of attorney, guardianship,
conservatorship, living wills and the like. Occasionally, the concept
of competence is also a factor in providing care. The psychiatrist
may be asked to weigh in on the patient’s capacity to make a will
or make medical decisions for themselves.
The context of care, including such factors as retirement, grand-
parenting and the “empty nest” are of importance. Especially in
cases of cognitive impairment, the referral for care is more likely
to come from family or others rather than the patients themselves.
Another consideration is the patient’s degree of dependency on
others and how the patient’s needs are met, as well as how the pa-
tient accepts the aging process and a more dependent role. The use
of technology in modern medical practice (such as the electronic
health record and communication by a closed email system or
portal) may be a difficult adjustment for the current generation
of older adults, who have widely varying degrees of access and
comfort with digital devices. The skills of the geriatric psychiatrist
are best utilized in the management of the so-called “frail elderly,”
a group overlapping with the “old-old,” that is, patients usually over