MENTAL HEALTH ISSUES IN AGING

The physiologic and cognitive changes of aging can also have major effects on an individual’s mental health and social well-being.

Depression

Depression is the most common mental health condition in adults ages 65 and older, but only 10% receive treatment. Depression is frequently confused with the effects of multiple illnesses and the medications used to treat them.

Older people may not have the obvious signs and symptoms of depression. Instead, they may:

Feel tired
Have trouble sleeping
Be grumpy or irritable
Feel confused
Struggle to concentrate
Fail to enjoy activities they used to
Move more slowly
Have a change in weight or appetite
Feel hopeless, worthless, or guilty
Endure aches and pains
Think of suicide or attempt suicide

Management of depression may include the following:

Antidepressants
Psychotherapy
Complementary therapies
Electroconvulsive therapy (ECT)
Stimulation techniques
(APA, 2023; NIA, 2021b)

Suicide

Older adults make up approximately 18% of suicide deaths. Men 65 and older face the highest overall rate of suicide. Older adults plan suicide more carefully and are also more likely to use more lethal methods. Among those who attempt suicide, 1 in 4 older adults will die by suicide, compared to 1 in 200 youths (NCOA, 2022).

It is important to recognize that older adults also may use less aggressive and less visible methods to hasten death, including voluntarily stopping eating and drinking (VSED), also referred to as silent suicide (Lowers et al., 2021).

Risk factors for suicide among older persons often differ from those among the young. Suicidal risk factors and warning signs in older persons include:

Male
Marital status (risk is nearly two times greater in nonmarried than married)
Living alone
Sexual orientation
Psychiatric disorders, such as depression, especially when accompanied by psychosis or anxiety
A sense of hopelessness; lack of interest in future plans
Painful or disabling medical conditions that significantly limit functioning or life expectancy
Chronic neurologic disorders
Financial concerns
Depression or persistent sadness even when other symptoms of depression have lessened
A history of drug or alcohol misuse or abuse
A history of prior suicide attempts
A history of suicide in family members
Traumatic experiences, including physical or sexual abuse
Well-defined plans for suicide
Verbal suicide threats such as, “You’d be better off without me” or “Maybe I won’t be around”
Giving away prized possessions
Daring or risk-taking behavior
Prior suicide attempts
Feelings of loss of independence or sense of purpose
History of military service
Impulsivity due to cognitive impairment
Sudden personality changes
Social isolation
Family discord or losses (e.g., recent death of a loved one)
Inflexible personality or marked difficulty in adapting to change
Access to lethal means (i.e., firearms, other weapons, etc.)
(MHA, 2023; Schreiber & Culpepper, 2023)

Suicide protective factors include:

Family and community support
Reasons for living, such as family, friends, pets, etc.
A strong sense of cultural identity
Feeling connected to others
Support from ongoing medical and mental healthcare relationships
Reduced access to lethal means
Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes and coping with stress
Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
(CDC, 2022)

Management of suicide risk for those categorized as low risk includes:

Outpatient referral
Creating a safety plan
Urging removal of means for suicide from the home
Providing emergency/crisis numbers (e.g., the National Suicide Prevention Lifeline, 1-800-273-TALK [8255])

For those with moderate risk:

Possible hospitalization
Developing a crisis plan
Taking suicide precautions
Providing emergency/crisis numbers

Those who have specific plans and the means to carry out their plans are at high risk, and inpatient admission should be offered (Norris & Clark, 2021).

Substance Use in Older Adults

Despite the known trends of increasing substance use disorder among older adults, geriatric addictions remain underidentified and undertreated (Reimers, 2021).

Regular marijuana used for medical or recreational reasons is associated with chronic respiratory conditions, depression, impaired memory, adverse cardiovascular function, and altered judgment and motor skills. Marijuana can interact with a number of prescription drugs and complicate existing health issues.

Regular nicotine use increases the risk for heart disease and cancer.

Alcohol is the most frequently used substance among older adults, with approximately 65% reporting high-risk drinking. More than one tenth of older adults currently binge drink, defined as five or more drinks on the same occasion for men and four or more for women.

Between 4% and 9% of adults ages 65 and older use prescription opioid pain medications for pain relief, and a portion of this population uses illicit opioid heroin (NIDA, 2020).

Signs of substance use in the older adult may include:

Losing interest in hobbies and activities
Depression
Anxiety
Memory loss
Spending more time alone
Hostility
Aggression
Forgetfulness
Confusion
Changes in sleep habits
Secretive behaviors
“Losing” prescriptions
Doctor shopping
Drastic changes to appearance
Drop in personal hygiene
Chronic health complaints
(Gilmore, 2023)

The U.S. Preventive Services Task Force recommends screening all adults for alcohol abuse. The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)is a screening instrument tailored to the needs of older adults. The Alcohol, Smoking, and Substance Involvement Screening Tests (ASSIST) tool can be used to screen across all substances, including tobacco, alcohol, and illegal drug use (JSI, 2023).

Management for substance abuse may consist of:

Brief intervention
Cognitive behavioral therapy
Contingency management
Motivational enhancement therapy
Community-based treatment
Twelve-step therapy
Residential treatment facilities
(Reimers, 2021)