THE ELDERLY: BIOLOGICAL STRESSES.

Of the elderly, only 5% are institutionalized in nursing homes, convalescent centers, or similar facilities. However, 45% of the elderly have some serious physical disability, such as heart disease, diabetes, lung disease, or arthritis. About 25% also have a significant functional psychological problem, with depression the most prevalent. Understandably, as life expectancy increases and we live longer, there is more vulnerability to the natural course of disease. For this part of the population, receiving medical care and paying medical bills can mean additional big problems. The elderly have twice as many visits to a physician, their average hospital stay is three and one-half times longer than for person under age 65, and the hospital stay costs five times more than for the under-65 group. Ironically, for this medically fragile group, insurance coverage (including Medicare) is often less adequate than is coverage for younger persons. Thus, those with the greatest need for medical care, the highest medical expenses, and the least ability to pay have the poorest insurance coverage of any group.

Alcoholism is also a big problem for the elderly. Dr. Robert Butler formerly of the National Institute of Aging estimates that 20% have a significant alcohol problem. These problems are also ignored for many of the same reasons that sex in the elderly is dismissed without a further thought. “That nice old lady drinks too much (or is interested in sex)!” “Never!” Some of these elderly have had a long history of alcohol use and abuse; they may have been alcoholics for a good long time, but with adequate medical care have somehow lived to old age. However, with the overall deterioration of physical functioning, the alcohol use may begin to take a heavier toll and become an increasingly difficult problem.

Also, among the elderly are persons who do not have a prior history of alcohol abuse; their alcoholism may be described as late onset. The stresses of aging may have been too great or come too fast and at the wrong time. They have turned to alcohol as a coping mechanism. The subgroup of the total population with the highest risk for alcoholism is widowers over age 65. Whatever the variety of alcoholism present, intervention is important. All too often we are likely to dismiss the elderly with “what do they have to live for anyway… they have been drinking all these years, they’ll never stop now… I don’t want to be the one who asks them to give up the bottle.” The quality of any amount of life left to any of us would better be the paramount concern. We would not hesitate to assume that a 35-year-old man ought to get treated for his problem even though he could easily be killed in an auto accident next year. The elderly deserve just as much, if not more, consideration.

Depressive illness is very prevalent among the elderly. There may well be a physiological basis for this. The levels of neurochemicals (serotonin and norepinephrine) thought to be associated with depression change in the brain as people get older. These depressions, then, are not necessarily tied solely to situational events. However, because so many things are likely to be going on in the surrounding environment for the elderly, it is too easy to forget the potential benefits of judiciously prescribed antidepressants. Malnourishment is all too common in the elderly. This can cause several syndromes that may look like depressions. Many physical ailments, due to disease processes themselves, manifest as depression.

Depression in the elderly may not present like depression in younger persons, with tearfulness, inability to sleep, or loss of appetite. Some of the tips for recognizing depression in the elderly are an increased sensitivity to pain, refusing to get out of bed when physical problems don’t require bed rest, poor concentration, a marked narrowing of coping style, and an upsurge of physical complaints. Often, the poor concentration leads to absent-mindedness and inattentiveness, which are misdiagnosed as defective memory and ultimately as “senility,” while the depression goes unrecognized and untreated. Senility is really a useless clinical term. The proper phrase should be dementia, which means irreversible cognitive impairment. However, all cognitive impairment should be considered reversible (delirium) until proven otherwise. It should also be remembered that alcohol abuse, as well as sometimes creating problems itself, can, in patients with dementia make the confusion worse. The elderly deserve an aggressive search for potentially treatable, reversible causes of organic brain syndromes by qualified medical personnel.

Suicide among the elderly is a very big problem. Twenty-five percent of those who commit suicide are over age 65. The rate of suicide for those over 65 is five times that of the general population. After age 75, the rate is eight times higher. In working with the elderly, a suicide evaluation is not to be neglected, because so many depressions are masked in their appearance.

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THE ELDERLY: BIOLOGICAL STRESSES.Of the elderly, only 5% are institutionalized in nursing homes, convalescent centers, or similar facilities. However, 45% of the elderly have some serious physical disability, such as heart disease, diabetes, lung disease, or arthritis. About 25% also have a significant functional psychological problem, with depression the most prevalent. Understandably, as life expectancy increases and we live longer, there is more vulnerability to the natural course of disease. For this part of the population, receiving medical care and paying medical bills can mean additional big problems. The elderly have twice as many visits to a physician, their average hospital stay is three and one-half times longer than for person under age 65, and the hospital stay costs five times more than for the under-65 group. Ironically, for this medically fragile group, insurance coverage (including Medicare) is often less adequate than is coverage for younger persons. Thus, those with the greatest need for medical care, the highest medical expenses, and the least ability to pay have the poorest insurance coverage of any group.Alcoholism is also a big problem for the elderly. Dr. Robert Butler formerly of the National Institute of Aging estimates that 20% have a significant alcohol problem. These problems are also ignored for many of the same reasons that sex in the elderly is dismissed without a further thought. “That nice old lady drinks too much (or is interested in sex)!” “Never!” Some of these elderly have had a long history of alcohol use and abuse; they may have been alcoholics for a good long time, but with adequate medical care have somehow lived to old age. However, with the overall deterioration of physical functioning, the alcohol use may begin to take a heavier toll and become an increasingly difficult problem.Also, among the elderly are persons who do not have a prior history of alcohol abuse; their alcoholism may be described as late onset. The stresses of aging may have been too great or come too fast and at the wrong time. They have turned to alcohol as a coping mechanism. The subgroup of the total population with the highest risk for alcoholism is widowers over age 65. Whatever the variety of alcoholism present, intervention is important. All too often we are likely to dismiss the elderly with “what do they have to live for anyway… they have been drinking all these years, they’ll never stop now… I don’t want to be the one who asks them to give up the bottle.” The quality of any amount of life left to any of us would better be the paramount concern. We would not hesitate to assume that a 35-year-old man ought to get treated for his problem even though he could easily be killed in an auto accident next year. The elderly deserve just as much, if not more, consideration.Depressive illness is very prevalent among the elderly. There may well be a physiological basis for this. The levels of neurochemicals (serotonin and norepinephrine) thought to be associated with depression change in the brain as people get older. These depressions, then, are not necessarily tied solely to situational events. However, because so many things are likely to be going on in the surrounding environment for the elderly, it is too easy to forget the potential benefits of judiciously prescribed antidepressants. Malnourishment is all too common in the elderly. This can cause several syndromes that may look like depressions. Many physical ailments, due to disease processes themselves, manifest as depression.Depression in the elderly may not present like depression in younger persons, with tearfulness, inability to sleep, or loss of appetite. Some of the tips for recognizing depression in the elderly are an increased sensitivity to pain, refusing to get out of bed when physical problems don’t require bed rest, poor concentration, a marked narrowing of coping style, and an upsurge of physical complaints. Often, the poor concentration leads to absent-mindedness and inattentiveness, which are misdiagnosed as defective memory and ultimately as “senility,” while the depression goes unrecognized and untreated. Senility is really a useless clinical term. The proper phrase should be dementia, which means irreversible cognitive impairment. However, all cognitive impairment should be considered reversible (delirium) until proven otherwise. It should also be remembered that alcohol abuse, as well as sometimes creating problems itself, can, in patients with dementia make the confusion worse. The elderly deserve an aggressive search for potentially treatable, reversible causes of organic brain syndromes by qualified medical personnel.Suicide among the elderly is a very big problem. Twenty-five percent of those who commit suicide are over age 65. The rate of suicide for those over 65 is five times that of the general population. After age 75, the rate is eight times higher. In working with the elderly, a suicide evaluation is not to be neglected, because so many depressions are masked in their appearance.*158\331\2*

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