When and How to Care for Adults as Elders
Pediatricians like to say that ill children are not just miniature adults, but members of a special population. So pediatricians typically tailor their treatments for the developmental, physiological, and social experience of each child they examine.
Geriatricians and geropsychiatrists have similarly adapted medical and psychiatric treatments for older adults. As each of us ages, we enter new developmental stages and experience physiological changes and altered social patterns. These changes affect our functional ability. Whatever their age, when patients’ functional status becomes geriatric and they become more dependent upon others, we favor treating an adult as an elder. You can see the difference a geriatric approach makes from our experience with a recent patient.
Florence was admitted with a straightforward story: suicidal in the setting of a recurrent depressive episode. A 55-year-old, thrice-divorced, retired seamstress, Florence was first diagnosed with bipolar disorder three decades ago and had experienced suicidality several times. So the suicide note she had placed next to a supply of emptied medication bottles seemed like a clear indication for a crisis hospitalization.
During an admission interview, the story grew complicated. Florence appeared older than her stated age, needed assistance to ambulate, and exhibited deficits in long-term memory and executive functioning. While she denied symptoms of mania and depression, she admitted her intentional ingestion, saying, “I did not take enough pills to die; I took enough of my pills to get out of her house.” Florence’s act of self-harm was a way out of her living situation.
Even though she was younger than the age typically regarded as geriatric, Florence was disabled by arthritis, bipolar disorder, and congestive heart failure. She had lived in an assisted living facility several states away for the past few years. Six months before hospitalization, she could no longer afford the facility, so she moved across the country and into her adult daughter’s home. Suddenly living together after years of estrangement, the two fought daily, the daughter externalizing her anger and Florence internalizing her shame.
When evaluating adults who have, or may have, a mental illness, we have come to expect complicated stories. Patients like Florence present with a combination of mental illness, cognitive ability concerns, character structure issues, substance and medication use, medical illness, family dynamics, and socioeconomic factors. Florence needed an acute hospitalization, but also changes in her medication regimen, individual therapy, a cognitive evaluation, family counseling, and increased social services.
The geriatric approach took a little longer, but it was necessary to understand Florence’s story.
First, we had to educate Florence and her daughter about what to expect as Florence aged. In family meetings, Florence’s daughter admitted that she did not understand her mother’s mental illness, but resented the ways it had taken Florence out of her life when her mother was young, but forced her back into her life as her mother aged. The daughter ultimately benefitted from attending a support group for family members, while Florence met with the staff psychologist to discuss the aging process.
Second, we made several psychosocial interventions for Florence. After assessing her gait and functional ability, we assessed her cognition and behavior and eventually recommended a nursing home placement. Florence and her daughter elected to go home together, with home health services, while awaiting a bed in an area nursing home.
Third, in an acute hospitalization, we selected a depression-focused psychotherapeutic approach called problem-solving therapy (PST). PST is an evidence-based psychotherapy that teaches suffering people how to solve their daily problems, decrease stress, and utilize these skills when problems arise.
Fourth, as people age, pharmacokinetic and pharmacodynamics changes occur. As muscle mass decreases and peripheral fat stores increase, lipophilic drugs remain in the body longer. Decreased renal clearance and hepatic blood flow combine to slow the clearance of medications. For older adults, the result is that in many older patients, drugs exert greater therapeutic and adverse effects at lower doses than expected. With Florence, we reviewed every medication prescribed to her, eliminated several, and optimized dosing and time of administration while educating Florence and her daughter about the safe administration and storage of prescription medications.
Coordinating or providing all these services can overwhelm even an experienced geropsychiatrist. To untangle a story like Florence’s, it helps to begin with a shift in thinking. Florence is not just another adult with bipolar disorder; she is an elder adult. When treating an elder like Florence, we try to engage the life story of a patient, consider how each treatment affects functional status, care for the patient and her caregivers, and recommend simple, pragmatic treatments. We learned the process of caring for our elders from people like Florence. ■
