#39040: Psychiatric Treatment Options in the Older Adult

Dementia is a general term for difficulties with cognitive functioning, including impairment in executive functioning (e.g., balancing a checkbook), memory loss, poor judgment, impulsivity, getting lost in familiar places, and taking longer than usual to complete daily tasks. Although the likelihood of developing dementia increases as one ages, it is not considered a normal part of aging. Dementia is further categorized by type and severity. Alzheimer disease is one of the most common forms of dementia, with an estimated 6.5 million individuals 65 years of age and older in the United States affected [6]. Other types of dementia include frontotemporal dementia, vascular dementia, and dementia with Lewy bodies. It has been suggested that the total number of Americans with some form of dementia could rise to 14 million by 2040 [7].

Behavioral and psychological symptoms of dementia (BPSD) can be challenging for patients and caregivers and can include psychosis, anxiety, agitation, depression, wandering, and apathy [8]. Patients with BPSD are more likely to experience delusions than hallucinations, and the more commonly experienced delusions revolve around theft from the home and intruders within the home [8]. The specific symptoms experienced by the patient with BPSD may vary by different types of dementia; for instance, dementia with Lewy bodies has a higher incidence of hallucinations, while vascular depression has a higher incidence of depression and anxiety [9]. The patient with BPSD may try to leave the home, often requiring caregivers to be home with the patient full-time. Caregivers of patients with dementia may experience financial stress associated with decreased employment or leaving their job to provide care. Caregiver financial strain is associated with higher levels of role overload among caregivers in general [10].

Much like dementia, older adults are at increased risk for depression, though this should not be considered a normal part of aging. In some cases, depression in older adults is dismissed by providers, brushed off as loneliness or grief—things that cannot be avoided. Risk factors for depression in the older adult include a history of depression, sensory losses, social losses, functional impairment, stressful life events, and increased dependence on others [11]. It is important to note that depression in the older adult can and should be treated. Although the overall symptom profile of depression is the same for older adults as for younger individuals, it is important to point out that older adults are more likely to display physical health-related symptoms when depressed. For example, the older adult is more likely to experience non-specific aches and pains or gastrointestinal distress associated with depression [12]. Furthermore, the older adult may struggle more with loneliness as they grow older. Not being close to family members, friends, or other supports can have a negative impact on the older adult as their functional capacity decreases.

When assessing an adult with possible social anxiety disorder, the National Collaborating Centre for Mental Health recommends that clinicians be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis, and autism.

(https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397 Last Accessed: January 24, 2025)

Level of Evidence: Expert Opinion/Consensus Statement

Anxiety disorders are thought to be more common in older adults than depression, with a prevalence rate of 7% to 14.2% for this population [12]. Anxiety can manifest differently in older individuals compared to younger populations due to various factors, including age-related changes, comorbidities, and life circumstances. Furthermore, the older patient may also experience lower self-confidence, reduced activity and movement, loss of friends/social supports, reduced financial and physical independence, and medical comorbidities, all of which can further fuel anxiety symptoms [16]. These factors culminate to the development of anxiety surrounding death among older adults; additionally, generalized anxiety disorder, anxiety related to a general medical condition, and agoraphobia are more likely to occur in late adulthood [12,17]. As individuals get older, they may experience death anxiety, or a heightened awareness and fear of death, whether conscious or unconscious. The mental health and quality of life of the older adult improves if death anxiety is addressed psychotherapeutically. Lower death anxiety is associated with higher levels of meaning in life [18]. Nurse psychotherapists can be very important in helping the older adult patient find meaning in life to mitigate the risk of depression and anxiety in late life [12].

Bipolar disorder in the older adult population encompasses both those who experience late onset of the disease and those who were diagnosed with bipolar disorder at a younger age (early-onset bipolar disorder). Some epidemiological studies use an age cutoff of 50 years of age to identify older adults with bipolar population, in part due to the shorter life expectancy of individuals with bipolar disorder [19].

As the population grows older, it stands to reason that the number of elderly patients with bipolar disorder will increase. Individuals with late-onset bipolar disorder are more likely to present with bipolar II disorder than bipolar I disorder and are more likely to have co-occurring neurologic disorders or cognitive decline. Most of the literature surrounding bipolar disorder focuses on adolescents and working-age adults rather than older adults, showing a gap in research and knowledge in this area. It is unclear if clinical guidelines focused on younger populations can be safely extrapolated to the older adult population due, in part, to the physical and metabolic changes that occur with age [20]. Due to the lack of available data on treatment recommendations for late- and early-onset bipolar disorder in older adults, experts recommend that treatment should be similar to that of a younger patient, keeping in mind the potential risk factors of common bipolar disorder treatments that may come with advanced age [19]. Safety and tolerability should be taken into account as much as efficacy when choosing a treatment option for the older adult with bipolar disorder [20]. Considerations for psychopharmacology in older adults will be discussed in detail later in this course.

Lithium is considered the criterion standard of bipolar disorder treatment, particularly for the control of mania. Lithium is also known for its narrow therapeutic index for the treatment of mania, with blood levels typically needing to fall between 0.8 mEq/L and 1.2 mEq/L to be effective. In addition to the potential for damage to the thyroid and kidneys with long-term use, lithium can reach toxic levels in the blood. Early signs of lithium toxicity include tremor, sedation, and confusion, all of which can be missed in older adult patients. At higher lithium levels, patients can experience delirium, seizures, and coma [21]. Because of these risks, blood levels of lithium should be monitored periodically. There is some evidence that older patients may respond well to "subtherapeutic" serum levels of lithium, and signs of toxicity may occur at levels less than 1.2 mEq/L in older adults [20,21].

People of all age groups can have schizophrenia, with onset most commonly occurring in those around 20 years of age; late-onset schizophrenia develops after 45 years of age. The prevalence of schizophrenia in older adults is projected to double and reach 1.1 million people in the United States by 2025 [22]. It is suggested that healthcare costs will be significantly impacted with the increasing number of older adult patients with schizophrenia [23]. Still, the life expectancy of an individual with schizophrenia is lower than the national average by about 10 years.

Characteristics of schizophrenia in older adults can vary widely from younger individuals diagnosed with the disorder [24]. This may be due to a combination of a different symptom profile among those with late-onset schizophrenia and significant symptom reduction among those with early-onset disease who have reached older adulthood. Older adults with schizophrenia are also more likely to have acquired medical comorbidities that complicate the clinical picture. It has been noted that individuals with late-onset schizophrenia have better premorbid functioning than those who develop the disorder earlier in life [23]. Those who develop schizophrenia later in life tend to have fewer negative symptoms and less severe neurocognitive impairments [23].

There are risks associated with the treatments for schizophrenia that are exclusive to the older adult population, particularly related to drug reactions and interactions.

Older adults experience post-traumatic stress disorder (PTSD) at rates lower than younger populations. It has been suggested that older adults are less likely to be assessed or diagnosed with PTSD due to a lack of research on this demographic. However, this appears to be changing [12]. It has been noted that the prevalence of PTSD in individuals older than 60 years of age ranges from 1.5% to 4.0%; this is lower than the lifetime prevalence of all adults (8.0%) [25]. This raises the question: Do older adults have less trauma, or is this population less treatment-seeking? Experts have suggested that older adults may be less likely to recognize symptoms as trauma-related and may also be less likely to seek care; conversely, clinicians may be less likely to assess for trauma-related disorders in this population [26].

The diagnosis of PTSD was first introduced to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980; individuals who experienced an onset of symptoms before this time may have received a different diagnosis or have not been diagnosed at all, leading to gaps in identification and treatment that persist into older age [26]. It is reasonable to assume that older adults have lived through global and personal events that could create and elicit trauma-related symptoms.

The psychiatric treatment-seeking views of older adults are marked by stigma and a perception of personal responsibility over psychiatric symptoms linked to a lack of psychiatric treatment-seeking [27]. Research indicates that older veterans with PTSD are more likely to endorse somatic complaints (e.g., headache, memory problems, gastrointestinal distress) than PTSD-related symptoms (e.g., hypervigilance, increased startle response) in comparison to their younger counterparts [25].

Alcohol use among older adults has increased over time, and an increase in substance use in general has been noted in the "baby boomer" generation (defined as those born between 1946 and 1964) [12]. Age-related changes to pharmacokinetics in older adults, including slowed metabolism of substances, can place this population at greater risk of adverse outcomes related to substance use and misuse.

Alcohol can cause difficulties with cognition, increase the risk of falls, and contribute to potentially dangerous alcohol-drug interactions for the older adult [28]. Careful assessment is required in this group, as changes can be mistakenly attributed to normal age-related changes, other chronic diseases, and/or dementia. When identified, this group requires individualized treatment that considers the impact of advanced age. One study attempted to reduce risky drinking among older male veterans presenting to primary care. It was found that integrated care behavioral health models were more effective at reducing risk drinking than no alcohol-use specific treatment referral at all; there were differences in the changes in risky drinking patterns depending on the treatment facility/location [28]. In one literature review, all studies examined found correlations between alcohol use and cognitive decline and dementia in older adults [29]. Nurses should consider increasing rates of substance use disorder among the older adult population and screen for substance misuse in all patient populations.

It is common knowledge that as individuals age, total body water content decreases, muscle mass decreases, body fat increases, and function of several organ systems (e.g., hepatic, renal) decrease. These age-related changes can contribute to differences in drug absorption, distribution, metabolism, and excretion. However, nurses should consider (on an individual basis as much as possible) to what extent these body systems have and will change. For example, glomerular filtration rate (GFR) can decrease with age, and this is considered a normal part of aging [87]. Further, some degree of decreased liver function is expected as hepatic size and blood flow decrease with age. Despite some degree of decreased function, enzyme induction of the CYP450 system can remain relatively unchanged in the older adult; others may experience a decrease of up to 30% of enzyme action [88]. Genetics may play a greater role in aging and in pharmacokinetics and drug metabolism in older adults than is generally appreciated [89]. Although decreases in hepatic and renal function are highly variable from patient to patient, an overall decrease in both hepatic and renal function is expected and should be part of prescribing decisions and drug monitoring in this group.

As a patient ages, they are increasingly likely to accrue medical comorbidities. The NCOA has reported that 80% of adults 65 years of age and older have at least one chronic condition, while 68% have two or more [5]. Medical concerns to be particularly watchful of in older adults include dehydration, hyponatremia, and impaired renal function. Some of the most common medical comorbidities in older patients include hypertension, type 2 diabetes, osteoarthritis, coronary artery disease, and hyperlipidemia—all of which often require at least one medication for control [5].

More medical conditions tend to lead to more medications, and older adults are particularly susceptible to polypharmacy. In a scoping review, researchers found that the most current clinical practice guidelines fail to offer guidance on safe prescribing practices for the patient with multimorbidity; most guidelines focus guidance on a single condition only [15]. Safe prescribing practices when caring for older adults with psychiatric disorders rely on knowledge of patient medical comorbidities, accurate medication reconciliation, and knowledge of any over-the-counter, vitamin, supplement, or herbal preparations the patient may be taking. Co-administration of drugs that act on the same or similar receptors are increase the risk of pharmacodynamic drug interactions, including serotonin syndrome, anticholinergic intoxication, seizures, and QTc prolongation.

The Beers criteria were first developed in 1991 by Mark Beers, MD, and colleagues and have since transitioned to the American Geriatric Society (AGS) [31]. The purpose of the Beers criteria is to identify medications that may pose a higher risk to older adults; these risks include drug-drug interactions, increased risk of side effects, increased risk when used with certain medical comorbidities, and dosing adjustments required for the physiological changes that occur with aging [31]. The Beers criteria aim to assist prescribers in making pharmacologic decisions in the best interest of the patient while acknowledging risks and potentially seeking alternatives to the medications on the list. The list serves to identify specific potentially inappropriate medications, with the goal of decreasing exposure to these drugs in older patients. The AGS released the most recent update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults in 2023 [31]. The Beers criteria is intended for use by prescribers, though a strong case can be made for its importance to nurses who administer medications and spend more time observing the patient. The list is also not intended to be punitive or as a replacement for clinical judgment by providers.

The treatment plan for the older adult experiencing unacceptable side effects of psychopharmacology should include the practice of deprescribing or tapering and/or discontinuing medications that have been deemed to be more harmful than helpful. Some have proposed a distinction between the terms polypharmacy and medication overload [49]. As noted, polypharmacy is defined as taking five or more medications, which may or may not be associated with adverse effects. Conversely, medication overload describes cases of multiple medications (with no clear quantification as to number of medications) being prescribed to the patient in which the harms outweigh the benefits [49]. Some groups have called for a national strategy to address the issue of medication overload and thus improve the quality of life of older adults. In many cases, older adults can benefit significantly from deprescribing to mitigate problematic and life-altering side effects.

Patients with behavioral and psychological symptoms of dementia are at heightened risk for psychiatric medication-related risks and side effects associated with the antipsychotic medications. The American Psychiatric Association (APA) guidelines suggest deprescribing antipsychotic medications to older patients with dementia after three months [50]. There is a lack of consensus of the dosing recommendations for older adults with dementia, and higher antipsychotic dosages have been associated with worse discontinuation syndromes among these patients [51]. The APA recommend limiting doses to maximums of 50 mg of quetiapine, 1.75 mg of olanzapine, and 0.5 mg of risperidone in those with dementia [51].

Deprescription of antipsychotics in the older adults with behavioral and psychological symptoms of dementia did not experience worsened symptoms following discontinuation of the antipsychotic medication [52,53].

Nursing and advanced practice nursing care of the older adult extends beyond the patient with psychiatric diagnoses, as potentially inappropriate medications could be prescribed off-label for a variety of reasons. For example, quetiapine may be prescribed in low doses for insomnia in psychiatry and primary care practice. Tricyclic antidepressants (which may prolong the QTc interval) may be used for a combination of insomnia, chronic pain, and nocturia. Anticholinergic medications (e.g., benztropine) may be prescribed alongside antipsychotic medications without evidence of movement-related side effects. A combination of the Screening Tool of Older Person's Potentially inappropriate Prescriptions and the Screening Tool of Alert doctors to the Right Treatment (STOPP/START) can be used to detect prescribing omissions and potentially inappropriate medications in this population [54].

In one qualitative study, most patients did not think they were taking an inappropriate number of medications but were open to the idea of deprescription [55]. A strong therapeutic alliance is necessary in helping the patient to understand the risks associated with medication overload. Factors that contribute to a positive attitude of older adults toward deprescribing include trust in the healthcare provider, adverse effects on quality of life from current medications, prospect of follow-up and monitoring, and alternative treatment options [55].

It is important to remember that polypharmacy may be necessary, particularly for patients with chronic conditions. It is up to the nurse to consider each patient situation on a case-by-case basis.

Frailty is a condition commonly observed in older adults, characterized by the cumulative decline in multiple physiological systems over a lifetime [57]. This change disrupts the body's homeostasis and increases vulnerability to minor insults. Frailty in older adults is associated with an elevated risk of falls, delirium, and varying degrees of disability [57]. Medical comorbidities, decreased immune response, and social and psychological vulnerabilities further complicate the healing process for older adults, making it more challenging for them to recover from illnesses [58].

Pain and depression often coexist in older adults, with each condition often exacerbating the other. Research has supported a correlation between depression and chronic pain, as well as between depression and sleep disturbances; sleep and physical activity level are mitigating factors [59]. Chronic pain can have adverse effects on older adults, not only in terms of physical well-being but also socially and emotionally. Another study involving Chinese nursing home residents reported that 46% experienced mild-to-severe pain and 20.7% exhibited symptoms of depression [60]. Monitoring nursing home residents with pain is essential, as they may experience lower levels of social support and self-rated health and are more likely to exhibit higher levels of depression compared with those with stronger perceived social support or better self-rated health [60]. Chronic pain can also contribute to functional impairments in certain patients.

The COVID-19 pandemic was associated with uncertainty and anxiety, particularly for the older population, who were at higher risk due to medical comorbidities and frailty [58]. Older individuals face an increased risk of developing severe COVID-19 or medical complications associated with infection. During the first waves, older adults had a three times higher risk of death from secondary pneumonia compared with the general population [58]. Social distancing measures, implemented to control the spread of the virus, posed additional challenges for older adults, who often already are experiencing loneliness and disconnection [58]. Moreover, those living in long term-care facilities often experienced complete isolation, leading to limited physical interactions with others.

During the early peak of the pandemic, older adults experienced prolonged periods of isolation, which exacerbated existing mental health symptoms or resulted in the development of new mental health disorders in some patients [61]. In one study, increased stress, anxiety, depression, and PTSD symptoms were noted across different age groups during the initial and subsequent waves of COVID-19. Interestingly, older adults demonstrated more adaptive and relaxed coping strategies compared with younger participants [61]. The lower likelihood of developing PTSD-related symptoms in older adults is consistent with their generally lower rates of PTSD [26].

In addition to physical symptoms, those with chronic conditions may experience psychological and emotional manifestations that may result from the physical symptoms of and treatments for the disease. Because the diagnosis process can be protracted for many chronic illnesses, individuals who receive the diagnosis may be relieved to finally have a name for the condition that afflicts them; the chronic nature of the condition may not be of immediate importance. Initially, the individual may be more focused on treating the symptoms rather than the realization that there is no cure. Individuals with chronic illness often face the uncertainty of the disease process, including the unpredictability of disease flares and remissions. Thus, living with a chronic disease can be overwhelming for patients, marked by uncertainty and the potential loss of function secondary to the disease process.

The psychological impacts of chronic disease can be variable, affecting family life, work, sexual activity, social activities, finances, and day-to-day living [62]. The diagnosis may impact one's current lifestyle and result in a need for changes in that lifestyle pattern. It may affect the ability to maintain employment status, alter financial stability, and create a potential for the loss of a role, status, or independence, all of which can be further affected by advanced age.

Psychotherapy is a noninvasive and evidence-based approach for treating various mental health conditions, often considered a safer alternative to medication for older patients. When providing psychotherapy to older adults, it is important to consider their unique needs. These patients may strive to find a balance between self-acceptance, contentment, engagement, and personal growth in later life [12]. Functional limitations, family stressors, and social support factors should be considered during psychotherapy sessions.

Cognitive-Behavioral Therapy

According to the National Collaborating Centre for Mental Health, the recom-mended high-intensity psychological intervention for persons with generalized anxiety disorder is cognitive-behavioral therapy (CBT) or applied relaxation.

(https://www.nice.org.uk/guidance/cg113 Last Accessed: January 24, 2025)

Level of Evidence: Expert Opinion/Consensus Statement

CBT is widely used in psychotherapy, including with older adults, for treating various conditions such as depression, anxiety, schizophrenia, insomnia, dementia, and bipolar disorder [12]. This approach aims to identify and challenge faulty or harmful perceptions, enhance understanding of the problem, promote healthier thinking patterns, and improve behavioral outcomes. When working with older adults, adjustments to the treatment plan may be necessary. The therapist can address multiple physical, emotional, social, and cognitive issues brought by the older adult by setting weekly agendas, prioritizing topics, building skills, and focusing on abilities rather than disabilities [12].

CBT for insomnia (CBT-I) is a particularly effective nonpharmacological treatment option for insomnia in older adults. Instead of prescribing potentially inappropriate medications, CBT-I targets the underlying causes of insomnia and has demonstrated efficacy and safety as a first-line treatment for healthy older adults [65]. In general, CBT should be considered as a primary treatment approach for various psychiatric symptoms in older adults.

Phototherapy, also known as bright-light therapy, is a nonpharmacologic intervention most notably used in the treatment of seasonal affective disorder. With this approach, the patient follows the daily habit of sitting in front of a 1,500–10,000 lux lightbox each morning before sunrise [21]. One study explored the use of phototherapy in the treatment of mild-to-severe dementia. The researchers found that the phototherapy was more effective in managing the behaviors associated with severe dementia than mild-to-moderate dementia, but overall, the phototherapy was no more effective than placebo [66]. Another study focused on the treatment of sleep-related problems and the potential role of phototherapy, finding the approach effective for improving the sleep of healthy older people [67]. Another study noted the documented efficacy of phototherapy for seasonal affective disorder and bipolar depression, but studies including and/or focusing on older adults are limited.