Caring for the aging mind

Although the couple are now in their 80s and have been together much of their lives, he had suddenly begun to change, turning against his wife, accusing her of having an extramarital affair with their grandson’s friend. And he had been hitting her.

"His grandson’s friend is 18 or 19, which doesn’t make sense, but to this patient it was real," said geriatric psychiatrist Dr. Dan Tanahashi. "She couldn’t understand why her husband was acting this way."

As painful as that scenario sounds, it’s not uncommon, said Tanahashi, one of Hawai‘i’s few geriatric psychiatrists. As the effects of age-related dementia begin, they may show up as paranoid delusions that require treatment with antipsychotic medication, as well as psychotherapy.

It’s one of the reasons a psychiatric unit dedicated specifically to the specialized problems of seniors is now operating at Wahiawa General Hospital.

"Their needs and issues are really different from the younger generation," said Judy Brasel, director of the new unit. "It scares the seniors to be around the general psychiatric population, so they don’t want to go there. And their issues are very specific. If they’re sitting in a group with someone who is a drug abuser, their issues . . . are very different."

In its first few months, the 10-bed Senior Behavioral Health Care Unit at Wahiawa has averaged six to seven patients a day, but is often full as the staff works to unravel the profound problems that strike a portion of the population whose emotional needs are complex and often ignored.

The unit’s work is complicated by the stigma still attached to mental illness - especially among those in the older generation - and the shame and embarrassment they feel about seeking help of this kind, said Tanahashi, medical director of the unit.

But he hopes that families will get the message that these issues are not a cause for shame, and the problems associated with age-related dementia are often solvable, he said.

For many, the senior years may be ones filled with overwhelming depression, along with a gradual loss of cognitive balance. For some, the loss is so profound that suicide is a danger.

"A lot of them have no friends, they’ve all died off," Brasel said. "Or they’ve lost their spouses. Or they’ve lost some of their children, and that’s very difficult. They can be plunged into a deep depression, and we see this over and over again. Not the least of this is because of their medical issues."

As well, Tanahashi said, a person’s ability to cope with stress diminishes with age.

While much of society’s focus is on suicide rates among teenagers, the elderly are at far greater risk, according to studies published in the last decade. In 1994, the National Center for Health Statistics reported that while people over 65 made up 12.5 percent of the population, they accounted for 20 percent of the suicides. The same high rates have been reported in England, Japan, New Zealand and Canada.

Studies have also shown that certain signs predict a risk of suicide: When an elderly person becomes overly preoccupied with death, has lost interest in usual activities, begins giving away beloved possessions and saying goodbye to people, and perhaps stockpiling pills, attention needs to be paid.

Psychiatric problems among the elderly generally fall into three categories: depression, dementia and delirium.

Depression

While the reasons for mental disturbance late in life are often unclear, physical problems can be at the root of some. For instance, some medications for high blood pressure - beta blockers, for instance - can be a risk for depression.

Contributing factors of depression might also include a vitamin B12 deficiency, folic acid deficiency or an imbalance in thyroid hormone, Tanahashi said.

Meanwhile, something as seemingly simple as a bladder infection may be the cause of depression. As a result, part of the approach at the new unit is to provide a complete physical assessment.

"Certain medical illnesses such as end-stage renal disease, or a stroke - any insult to the brain - are also risk factors for depression," Tanahashi said. "Also, if someone is an active substance abuser, or actively drinking."

Although depression is one of the most common psychological ailments of aging, it may not always be easily identified, because it can take the form of complaints about chronic pain, chronic headache, chronic backache. As a result, the elderly may be treated for pain and not depression.

The signs of depression can also show up as loss of appetite, loss of interest in normal activities, little energy and trouble sleeping. "They feel hopeless, helpless and worthless," Brasel said, "and their family is at its wit’s end and doesn’t know what to do. We had one lady who wouldn’t even talk to her family. But with medication and therapy, she is doing much better and is going to be able to return home."

"If antipsychotic drugs, group and individual therapy fail, the last treatment resort is electro-shock therapy, which has come back into use strictly controlled, safer and more effective form than before.

Dementia

Dementia is the gradual onset of confusion and forgetfulness as cognitive functions begin to diminish in aging brains. This may also be accompanied by delusions, such as those suffered by the elderly man who imagined his wife having an affair. There may also be hallucinations as the person "sees" ghosts from the past, or hears voices.

"Some elderly people, because of paranoid delusions or hallucinations, don’t sleep at all," Tanahashi said. "They will keep the family up at night, so the family can’t go to work. Or the patient might be constantly pacing. Or constantly saying, ‘Oh, there’s someone outside. We have to make sure they don’t break into the house.’"

Delusional people require special handling, and the unit’s job is often to help families understand and cope. "When they have delusions, you can’t deny it or challenge them," he said. "Don’t ever say, ‘What are you talking about!’ Try and distract them instead, or say ‘Don’t worry, we’ll get the police to chase the intruders away.’"

"If the patient becomes physically threatening or assaultive, you need to seek help."

In teaching the wife how to deal with her husband’s delusions, Tanahashi suggested distraction or changing the topic of conversation. Antipsychotic drugs also helped to control his delusional behavior.

Delirium

In contrast to dementia, delirium shows up rapidly and is generally caused by a medical condition. It, too, can cause hallucinations, as well as fits of screaming. It may be characterized by a total reversal of sleep patterns that have the elderly person roaming the house all night and sleeping all day.

Delirium may be caused by infections, or even common over-the- counter sleeping medicines such as Benadryl. Treating the medical problem often ends the episode of delirium.

With baby boomers aging, the needs for these services, and such units, will only increase, Tanahashi said. "The number of elderly with dementia is going to double in the next 20 years."

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