With the mental health of older Americans, it’s important to understand the distinctions between dementia and mental illness, what their personality changes might be signaling and the role medication plays in diagnoses.
I could hear the low drone of the TV in the background, and the scent of baking biscuits still lingered in the air. It had been a hectic afternoon, not unusual in the psychiatric group home where I cared for a dozen people – each with different diagnoses, challenges and personalities. Evenings were my favorite time of day when most of my residents would go relax on the back porch and soak in the night air. As I finished washing the last of the day’s dishes, an angry voice broke the silence, “Stop it, just stop it!” I dried my hands and hurried outside before the situation could escalate.
The scene I found was all too familiar; Renee was glaring angrily at Jason who looked near to tears. I gave Jason an encouraging smile and a reassuring touch on the shoulder as I steered Renee inside. Even though Jason and Renee were polite to each other during the day, this scenario had played out almost every night of late. As the evening wore on, Renee became more and more agitated, pacing the halls and muttering to herself.
Diagnosing Mental Illness in Seniors
Prior to her personality changes, recent hospitalization and move to the group home, Renee had been a seamstress and a stay-at-home mom. She was a doting grandmother, who was active in her community, and who at age 60, seemed to be aging well. Then, she began to show signs of confusion, aggressiveness and other socially inappropriate behavior, which prompted her daughter to make an appointment with her mother’s doctor. The doctor referred her to a neurologist who diagnosed her with possible Alzheimer’s disease and started her on medication for dementia since the symptoms displayed seemed to match. The medication didn’t help, and Renee continued to spiral downward, eventually trying to take her own life.
We talked to Dr. Bruce Shapiro, Clinical Professor of Psychiatry at Columbia University of Physicians and Surgeons, about how mental illness gets diagnosed in seniors since the erratic behavior, confusion and memory loss symptoms are similar to those found with dementia. “These are very serious issues in seniors and it is often overlooked that the rate of suicide is higher in the senior years than in any other age group,” explains Dr. Shapiro. “The psychologist attempts to clarify whether there are symptoms of psychosis, dementia, anxiety, depression or bipolar disorder. In reviewing these areas it is often helpful for the psychologist to speak with involved family members who may have observations of difficulties that the individual does not see. In this way, along with a thorough mental status examination and possible psychological testing, and careful review of history, current symptoms and other factors impacting the elderly individual, will lead the psychologist to a diagnosis which will form the basis for treatment.”
Late Onset Bipolar
While at the state hospital she was given a complete physical, neurological and mental examination by a geriatric psychiatrist who changed her medication to a mood stabilizer. Her symptoms gradually improved and she was diagnosed with late onset bipolar disorder.
Renee is an unusual case among bipolar patients since most people with this disorder get diagnosed in early adulthood. “Late-onset bipolar disorder occurs infrequently,” says Dr. Shapiro. “The majority of bipolar disorders have their onset in the late teens and early adult years. It is estimated that only about 10% of individuals who have a bipolar disorder will have an onset after age 50, and that 5% will have an onset of the disorder after age 60.”
Diagnosing late onset bipolar is a difficult task as symptoms such as agitation, manic behavior, delusions and depression can be caused by dementia, stroke, medication interactions and even thyroid problems. Because so few people, even clinicians, are aware of late onset bipolar disorder, patients are often misdiagnosed and not medicated appropriately.
Dr. Shapiro says, “When assessing mental disorders in the elderly it is important to clarify if, in fact, the illness had its onset in the senior years or whether what is being seen is a recurrence of a disorder that had its onset earlier in life. When bipolar disorders are seen in seniors they are most often due to the recurrence of bipolar episodes which began earlier in life. That being said there are relatively uncommon geriatric onset bipolar disorders or disorders which have symptoms similar to bipolar illness (such as an episode of psychotic mania) which later turns out to be a manifestation of a more global illness, such as dementia. It is also noted that, not uncommonly, individuals with dementia will have significant psychiatric symptoms, such as agitation, combativeness, delusions or hallucinations, particularly as their disease progresses.”
In Renee’s case, her bipolar symptoms were aggravated by changing light in the evening, a characteristic common in both bipolar disorder and dementia. A complete neuropsychiatric consultation should include the following:
Mental status examinations
Neuroimaging such as MRI or CAT scan
Thorough social, developmental and physical history
Complete medication and supplement review
Mental Health and Medication
Bipolar disorder in the elderly usually follows the same course as the disease does in those who are younger, and similar treatments are used. However, some common mood stabilizers, like lithium, must be used cautiously in the elderly as their kidneys cannot clear the drug efficiently and constant monitoring is needed to prevent lithium toxicity which can be fatal.
“The metabolism in seniors differs from that of a younger individual,” explains Dr. Shapiro. “There are often changes in liver and kidney function in this age group. These changes will often make the senior more sensitive to medications and many medications must be given with 1/3 to 1/2 reduction of the usual adult dosage in the elderly. As well, the elderly may be more susceptible to sedating medications or to interaction of medications causing sedation and other side effects.”
Also, according to Dr. Gary J. Kennedy, Director of Geriatric Psychiatry at Montefiore Medical Center, anti-epileptic drugs provide a much safer initial treatment option, with Depakote usually being the first choice.
Medication and Assisted Living
With behavioral similarities between dementia and mental illness, it looks to be a potential challenge for assisted living communities. However, Dr. Shapiro explains that assisted living communities have a low chance in dealing with changes in personality or erratic behavior. “The likelihood of such changes correlates with age, and particularly correlates with the onset of dementia. Erratic behavior, particularly involving agitation, is commonly seen in individuals whose dementia has progressed, and these individuals may have to move from the assisted living setting to the more acute dementia care setting.”
He further shares that, “Most assisted living facilities have a physician, psychiatrist or psychologist whom they can call to address these difficulties. There are medications which can be very effective in helping to deal with behavioral changes, and striking the balance between helping to normalize behavior while not sedating the patient is key here. Seniors who take mood stabilizing medications may have behavioral or personality changes, particularly if they experience changes in the blood levels of their mood stabilizing medication. This is generally addressed with blood level testing and medication dosage adjustments.”
Proper Diagnosis Brings Happy Ending
Shortly after the latest incident with Jason, I scheduled Renee for a follow-up with her geriatric psychiatrist who adjusted her medication and referred her to a bipolar support group. It took a few months, but gradually her outbursts calmed and our evenings became peaceful again.
I bumped into Renee at the mall a few years ago. She had improved enough to be able to move out of the psychiatric group home, and she now has an apartment that she shares with her sister. She is once again the sweet, doting, active grandmother she was before. Renee’s family was also able to continue celebrating her contributions while keeping her healthy.
Posted On 19 May 2014
By : Angel Ridout