Ashok J Bharucha, MD Discusses What You Should Know About Geriatric Psychiatry

Aging presents many challenges for everyone involved, from family members trying to keep up with changing needs to clinicians struggling to find effective treatments for worsening symptoms. Ashok J Bharucha, MD of Lackawanna County, PA, feels individuals and communities need to be more aware of the fact that these problems could indicate underlying physical and mental health issues, including depression or other mood disorders caused by changes in brain chemistry or circuitry due to age and/or illness.

This lack of understanding can lead to the neglect of a patient’s mental health, leaving them without the care they need. To understand how geriatric psychiatry came to be and why it has become so important today, the following needs to be taken into account.

What is Geriatric Psychiatry?

Geriatric Psychiatry is the branch of psychiatry that deals specifically with assessment, management and treatment of mental disorders of older adults. It is an offshoot of both neurology (for dementias) and general psychiatry (for other conditions), and practitioners are required to have extensive training in the diagnosis and management of both physical and mental health issues that affect older adults. Many academic medical centers offer fellowships in geriatric psychiatry, though vast majority of psychiatrists engage in standard (adult) psychiatric work without further specialization.

Ashok J Bharucha says that geriatrics has become one of the most relevant fields of modern medicine because the average age of the populations in developed countries is increasing; by 2050, 1/5th of people will be 65 or older. The World Health Organization estimates that 500 million people worldwide currently suffer from some form of age-related dementia.

The field remains in its infancy, with some maintaining that older adults are underrepresented in clinical studies and official diagnostic manuals. Although the DSM-V has moved towards a more unified approach to mental health issues, many psychiatrists prefer not to specialize or develop expertise in geriatric psychiatry.

What are the Benefits of Geriatric Psychiatry?

The aging population is one of the most vulnerable and medically underserved groups in society. Geriatric psychiatrists can address this need by providing expertise that other medical specialists may not have, such as comprehensive knowledge of both neurological and psychiatric conditions that affect older adults.

Geriatric Psychiatry encourages a team-based approach to care, which means hospital systems and primary care physicians can collaborate to provide the best possible care for their patients. It also allows specialists better access to subspecialists, optimizing the care of patients with complex ailments. This is especially important in areas where many geriatricians collaborate across medical disciplines, such as neurology, rehabilitation medicine, and various medical and surgical specialties.

Core Knowledge that a Geriatric Psychiatrist Should Have.

Currently, about 16% of the US population is over age 65, and by 2030 estimations indicate a rise to about 20%. Because the population demographics are changing, here are a few things Ashok J Bharucha feels that clinicians must understand about how mental health affects the elderly.

Normal Aging vs. Disorders

The normal aging process can contribute to changes in mood and cognition, but these are not necessarily pathologies that require treatment. Psychiatrists use the DSM-V to diagnose mental health disorders. Geriatric psychiatrists need to focus on disorders unique to the elderly; these include dementia, delirium, depression, and the less common psychotic disorders.

Psychopharmacology

Medications such as the Selective Serotonin Reuptake Inhibitors (SSRIs) that are used to treat anxiety and depression in younger populations may not be as robustly effective in older patients. Older adults are more sensitive to the side effects of the medication(s), may be more prone to drug-disease interactions, and vulnerable to cognitive impairment in some cases.

The elderly also have a higher risk of drug-drug interactions because they metabolize medications less effectively than younger individuals. Neuromodulation treatments such as electroconvulsive therapy (ECT) may present small but important cardiovascular risks, and result in transient (rarely, longer term) cognitive impairment.

Mental Health Assessment

Adults over age 65 may experience specific mental health issues, including delirium, dementia, or depression. Geriatric psychiatry requires psychiatrists to maintain a broad knowledge of the physical and cognitive conditions likely to cause mental health problems in older patients.

The elderly sometimes have difficulty communicating their symptoms because they don’t recognize when something is wrong. In addition, they are sometimes afraid to report their symptoms or do not recognize them as treatable conditions.

Depression

Geriatric psychiatrists must be able to not only understand how depression is experienced by older patients but also how it can co-occur with other medical conditions. Treating depression involves navigating the balance of risks and benefits of specific medications and treatments in the context of multiple co-existing medical problems and multiple medications.

While depression is not a normal part of aging, roughly 25% of older adults suffer from depressive symptoms. Risk factors for depression include living alone, poor health, chronic pain, and grief.

Delirium

Delirium is a mental state that occurs in about 15–20% of patients with dementia. It can also occur during periods of sleep deprivation or isolation. Ashok J Bharucha explains that delirium can present in several different forms. The hyperactive form involves agitation and restlessness. The hypoactive type may present as lethargy, somnolence, or mutism. Others present with a mix of both forms.

Delirium can be precipitated by a long list of medical perturbations such as infections, constipation, electrolyte imbalances, or anemia. Geriatric psychiatrists need to understand that delirium entails a range of underlying causes, as well as predisposing and precipitating factors. Treatments should be targeted at the cause of delirium.

Dementia

Patients with dementia experience a decline in memory and other cognitive abilities that impair their ability to carry out daily activities. Geriatric psychiatrists need to identify patients with undiagnosed dementia because it can easily lead to mistreatment or further decline in mental functions. Dementia symptoms include memory loss, changes in visuospatial skills, perceptual-motor skills, language abilities, and ability to problem-solve, especially in novel situations. Some forms of dementia present with prominent changes in personality, behavior, and lifelong habits, while others specifically target language and motor skills.

Understanding Geriatric Psychiatric Care

Geriatric psychiatry is the branch of psychiatry that applies psychiatric expertise to the care of people with mental health issues in later life. Geriatric psychiatrists should consider the effects of aging on mental functioning while also understanding how common disorders like depression, delirium, and dementia may manifest differently in older patients. Competent geriatric psychiatric care necessitates fluency in internal medicine (geriatrics), neurology, and psychiatry.