Primary Care Doctors Overlook Mental Health in Older Adults

Even symptoms of severe depression have been ignored

By Sharon O'Brien, About.com Guide

How the Eldercare Mental Health Study Was Done To determine how doctors deliver mental health care to older adults, researchers analyzed 385 videotaped visits of 35 doctors with 366 of their senior patients, identifying topics discussed and how much time was devoted to each topic. Here's what the researchers found: Mental health-related topics occurred in 22 percent of visits, typically lasting about two minutes An average visit lasted about 16 minutes overall, and the majority of that time was spent discussing biomedical and other topics. Among doctors who address mental health issues during patient visits, their efforts to treat or provide care for a mental health issue varied widely. Most doctors fell into one of these three patterns of care: listening to the patient for an extended period of time and referring him or her to a mental health care specialist; gathering information but providing inadequate treatment; or being dismissive toward the patient and his or her emotional distress, and failing to follow up. More female patients (27 percent) discussed a mental health topic during a typical visit than male patients (12 percent). In addition, researchers discovered that the gender pairing of doctor and patient affected the likelihood of discussing mental health issues. Women patients talking to female doctors were most likely to discuss mental health, while male patients with male doctors were least likely.

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Doctors spend little time discussing mental health issues with their older patients and rarely refer them to a mental health specialist even if they show symptoms of severe depression, according to a study funded by the National Institute of Mental Health and published December 2007 in the Journal of the American Geriatrics Society. Suicide Rate Higher in People age 65 and Older While people age 65-plus represent 12 percent of the U.S. population, they accounted for a disproportionate 16 percent of suicide deaths in 2004. The study suggests that improved mental health screening in primary care may improve detection and treatment of mental disorders before drastic consequences, such as suicide, can occur.

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Primary Care Doctors Need Support to Increase Focus on Mental Health The study researchers concluded that primary care doctors need more support in how to identify, treat and refer patients to mental health specialists. This can be especially important when treating older adults, who may be more isolated from family and friends who would notice behavior and mood changes.
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Talking about feelings, fears and negative thoughts, as well as how to manage them, can help alleviate depression, though it can be difficult to communicate at first when feeling low. Counselling can be useful as a sole treatment or in addition to antidepressants. There are many ways to reduce the risk of developing depression. Looking after one's physical, emotional, spiritual and social wellbeing is likely to lift the mood, enhance self-esteem and foster a sense of being meaningfully connected to the world. This is the best defence against depression, and small steps in these areas mark the way to lasting recovery.

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The Importance of Balance Exercises for Elderly People

SeniorJournal.com published an article in which a study published in the Journal of Gerontology was cited and explained. The study, conducted on patients aged 70 to 89, showed that scores on physical mobility testing for the elderly can be improved with the use of regular exercise. This affects the ability of the elderly to function and have a more independent lifestyle.

A Word of Caution: Before any new exercise is undertaken, a consultation with a doctor is recommended. Additionally, doing warm-up exercises (such as walking) for at least five minutes prior is advised. If your balance is poor, it is important for safety to have someone nearby to assist you.

Tai Chi, Pilates and Gentle Yoga

Multiple resources recommend one or a combination of these as part of a balance-oriented exercise program for the elderly. Tai Chi, Pilates and gentle yoga all can help build strength, endurance and balance. Additionally, all can be undertaken by a very sedentary person and increased in intensity, as the individual is able to do so. Whether it is through a personal trainer, class, television show, DVD or video tape, be sure it is specifically geared for senior citizens or the elderly.

Non-Exercise Balance Exercises

There are non-exercise means of improving balance. These balance exercises for elderly people can be incorporated into simple everyday activities. The National Institute on Aging and the National Institutes on Health suggest: Standing on one foot while resting one hand on a countertop, chair or wall, for support. Hold the position for 10 seconds; repeat for each leg 10-15 times. Do two cycles. Walk heel-to-toe for 20 steps, arms outstretched for balance. Stay focused on something straight ahead while walking. Hip extensions are another movement done while holding onto something like a chair or countertop for balance. With your weight on one foot, raise the other leg behind you. Tuck your tailbone in, and use the abdominal muscles to help. Flex your foot while raising your leg. Hold for about one second and then lower leg. Repeat 10 15 times for each leg. Do two cycles.

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Improved balance not only aids in mobility, but it helps reduce the risk of falling and sustaining serious injury. A study published in Geriatrics and Gerontology International concluded that because of the affect the weakening of lower limbs has on people as they age, something as simple as ankle exercises can be effective in helping to maintain balance and help prevent falls. Daily activity such as standing on tiptoe, walking on uneven surfaces and using stairs can be safer when balance is improved.

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Side leg raises are done while holding onto something like a chair for balance. Slowly lift one leg outward, with a straight back and forward-facing toes. Hold for about one second and then lower leg. Repeat 10 -15 times for each leg. Do two cycles. Back leg raises can be done while holding onto a chair or countertop. Simply lift one leg straight back slowly. Hold for about one second and then lower. Repeat this 10 to 15 times for each leg. Do two cycles.

References:
Senior Citizens Gain Health, Independence, Balance with Exercise. November 22, 2006. Senior Journal. http://seniorjournal.com/NEWS/Fitness/6-11-22SeniorCitizensGain.htm Ankle exercises build seniors strength, balance. Reuters. (Source: Geriatrics and Gerontology International, March 2009). http://www.reuters.com/article/idUSTRE52563D20090306 U.S National Institutes of Health. National Institute on Aging. Exercise & Physical Activity: Your Everyday Guide from the National Institute on Aging. Last updated November 11, 2009. http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/default.htm Exercise and Physical Activity for Older Adults. Exercises to Try Balance Exercise. Last Reviewed January 20, 2010. National Institutes of Health Senior Health. http://nihseniorhealth.gov/exerciseforolderadults/balanceexercises/01.html Reaction: Arguably, the best reason for being physically active is that it can be fun, and a way of getting away from the stresses and strains of everyday life. Whatever activities you choose - and whether you do it in a group or on your own, indoors or out - you're likely to benefit psychologically. The other health benefits of exercise are already well known. People who are regularly active are at half the risk of developing coronary heart disease. It reduces high blood pressure, obesity and high cholesterol. Keeping up an active lifestyle is good for the bones, joints and muscles and can help to delay osteoporosis and arthritis. In keeping muscles strong and flexible, you can participate in everyday life to the full, with less risk of injury or falling. Being physically active can also help control conditions such as diabetes, and make you less exposed to some cancers (in particular bowel cancer).Physical activity has many positive benefits for both physical and mental health, particularly for specific conditions such as depression. Our physical ability changes as we age.
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Geriatric Inmates Face Challenges Unique to Prison

Brie Williams, MD ----The prison inmate population is aging rapidly, but prisons have not yet adapted to the physical and mental needs of geriatric prisoners, according to a study conducted by researchers at the San Francisco VA Medical Center. The study, which analyzed questionnaire responses by 120 female prisoners aged 55 or older in the California prison system, appears in the April 2006 issue of the Journal of the American Geriatrics Society. It is currently available in the Online Early issue of the journal. Prison is a not a safe place for vulnerable older people to be, says lead author Brie Williams, MD, a geriatrician at SFVAMC. Prisons arent geared to the needs and vulnerabilities of older people. In the prison environment, there are a number of unique physical tasks that must be performed every day in order to retain independence. Theyre not the same tasks that are called for in the community. According to the study, while many aging prisoners share the same challenges faced by their counterparts in the community - such as bathing, dressing, and using the bathroom - they also must perform activities of daily living that are specific to prison. These include dropping to the floor rapidly when an alarm goes off, climbing onto a top bunk, hearing orders from correctional officers, standing in line to be counted, and walking to the dining hall, which may be a considerable distance from a prisoners cell. When an alarm goes off, every inmate has to get down on the floor immediately, in order for the staff to maintain control of the inmates. Even some people in wheelchairs are expected to get out of their chairs and onto the floor, explains Williams, who is also a fellow in aging research at the University of California, San Francisco. You can imagine that for someone who has trouble walking, or with brittle bones, a very quick drop to the floor can be quite hazardous. And alarms may sometimes go off several times a day. The study found that 69 percent of the women reported that at least one prison activity of daily living was very difficult to perform. Sixteen percent reported needing help with one or more daily activity - twice the rate of the general U.S. population aged 65 and older - and 51 percent reported falling in the previous year.
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The women were also less healthy than the general population, reporting significantly higher rates of hypertension, asthma or other lung disease, and arthritis. According to Williams, the issue of physical independence for older prisoners is becoming increasingly urgent. She observes that the prison system was never designed or built for geriatric prisoners, yet the population of older prisoners in the United States is increasing exponentially, with the number of geriatric female prisoners in California up 350 percent in the last decade. It is projected that by 2030 ... one third of the U.S. prison population will be geriatric, write the study authors. For the short term, Williams makes several recommendations that she says would help make prisons safer for older inmates: Every prisoner 55 and over should be assigned to a bottom bunk unless the person specifically requests otherwise, and should be in a cell with grab bars near the toilets. They should be housed closer to the dining hall, and given more time to drop to the floor during alarms. There should be grab bars in showers, and rubber mats on shower floors. She points out that these modifications would make prison safer for younger inmates with physical impairments as well. Williams also expresses broader, more long-term concerns. As threestrikes laws and mandatory minimum sentencing laws become stricter, more and more people will be spending their entire lives, including old age, in prison, she observes. In addition to the economic burden, the incarceration of the elderly poses fundamental questions of how we as a society treat our elders. What do we, as a society, want to do with a prisoner who is so demented he doesnt remember his name, or who has had a stroke and is completely paralyzed? As a physician and as a citizen, I think we need to ask how we can make society safe but also have a reasonable system of incarceration. Co-authors of the paper are Karla Lindquist, MS, of UCSF; Rebecca L. Sudore, MD, of SFVAMC and UCSF; Heidi M. Strupp and Donna J. Willmott, MPH, of Legal Services for Prisoners with Children; and Louise C. Walter, MD, of SFVAMC and UCSF. The research was supported by funding from the Department of Veterans Affairs and a grant from the National Institute on Aging that was administered by
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the Northern California Institute for Research and Education. Design of the health survey and recruitment of subjects were sponsored by Legal Services for Prisoners with Children. UCSF is a leading university that consistently defines health care worldwide by conducting advanced biomedical research, educating graduate students in the life sciences, and providing complex patient care. The mission of NCIRE is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.
Reaction: Prisons are small, self-contained societies that are sometimes described as total institutions. Studies of prison life have detailed the existence of prison subcultures, or inmate worlds, replete with inmate values, social roles, and lifestyles. New inmates who are socialized into prison subculture are said to undergo the process of prisonization. Prison subcultures are very influential, and both inmates and staff must reckon with them. Today's prisons are miniature societies, reflecting the problems and challenges that exist in the larger society of which they are a part.

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