Louisville Medicine Volume 66, Issue 7 | Page 16

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