Mental health issues not intrinsic to aging

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My colleague, Rachel, and I have been fighting the same battle for years: Achieving good mental health later in life.

Rachel, a psychologist, works with people who live in nursing homes. As a nurse, I work to improve care for older people during and after hospitalization. We both are troubled by the invisibility of mental health in later life.

Is mental health care for older people, invisible? I hear you saying: “Right, it’s just bad not invisible.” Like many, you might want to remind me that problems like depression, anxiety, and confusion are common among those over 65. But, you see, that’s where the real problem lies.

We expect to be depressed and live with this and other mental health concerns as we age. Think of the stereotypes – the sad nursing home resident, the anxious little old lady, the irascible old man. Late life is beset with images of sadness, fear, and isolation.

This expectation of poor mental health in later life is fundamentally flawed. There is nothing intrinsic about being older that guarantees mental health problems. But, in many ways, we’ve been schooled to view poor mental health is an inevitable part of aging.

Diagnoses like depression become a new “normal” – a regular part of being old – when we expect or view them as usual. When defined as normal, poor mental health becomes invisible. Think about it. We don’t see normal as a problem – you don’t try to fix normal, right? So depression or any other mental health concern fades from our view. The condition itself becomes something to be endured, unrecognized for the treatable problem it is.

Rachel faces the problem of invisible mental health problems – mostly depression – almost every day in the nursing home. There to improve the well-being of the older residents, she encounters many who need her help. She sees their depression and signs of other problems like anxiety.

The Centers for Disease Control and Prevention (CDC) suggests one in eight or more residents in long-term care facilities are depressed. The challenges lay in the response to changes in mental health that are observed. Rachel rarely receives requests from staff to treat these people. And the residents themselves almost never asked for help. It was as though their depression along with other concerns were invisible, overlooked and ignored.

Myth: Older people are normally depressed.

The CDC says “depression is a true and treatable medical condition, not a normal part of aging,” recognizing that older people who are depressed often are misdiagnosed and inadequately treated.

The National Alliance on Mental Illness (NAMI) puts late-life depression in perspective. NAMI suggests as many as 6.5 percent out of 35 million older Americans are depressed. That’s close to 1 in 5 community dwelling older Americans living with this treatable condition.

So, whether you live on your own or in a nursing home, depression is common, but doesn’t make it normal.

Depression often occurs when other chronic conditions create distressing symptoms; the end result of living with this. Pain, fatigue, and memory loss are truly depressing, no matter how old you are. The difference lies in how we think about that depression.

One reason so many older Americans are depressed is due to limited recognition and poor treatment. Some may have lived with depression for most of their adult lives. For others, depression is a new problem, emerging only in later years. Either situation may result in difficulty asking for and receiving mental health care.

Your generation and background can play a role in depression too. Seeking mental health care for depression and other conditions has become much more accepted in recent years. Some, however, won’t feel comfortable getting mental health help. For others, family background makes mental health care taboo.

Myth: People over age 65 usually get confused when they are stressed or sick.

Being physically ill or injured poses other more immediate mental health concerns. In my nursing practice, relatives and friends of older people who are hospitalized ask about confusion. During hospitalization or even at home, they see their older loved one’s behavior change drastically. Confusion, distraction, and even paranoid thoughts occur; transforming the person you love into someone you don’t know or understand.

As they witness this distress, these relatives and friends are concerned and puzzled. Is confusion an expected part of hospital admission; a “normal” hospital event? Is there “ICU psychosis?” (This outdated phrase was used to describe the confusion and other symptoms observed in people so ill that they needed intensive care.)

Many family members of those hospitalized assume confusion is expected – or normal, just like depression. Watching someone you love be confused is scary. It’s less invisible to family and friends than depression, probably because delirium begins so suddenly.

I try to reorient those who ask me about confusion by asking other questions before assuming confusion during a serious illness or injury is expected. Acute confusion in an ill or seriously injured elder is called delirium. First ask how and why delirium happens, then ask what can be done to prevent delirium in the first place.

In 2011, Susan Seliger contributed “Another Hospital Hazard for the Elderly” to the New York Times New Old Age Blog. Her story of her mother’s hospitalization is one I have heard many times.

Seliger interviewed Dr. Wes Ely at Vanderbilt University, an expert in delirium. Ely said delirium is invisible to healthcare workers, more so than it is to relatives and friends of older patients.

In fact, what healthcare workers do to care for older patients can contribute to delirium. The steps healthcare workers take to treat confusion and other symptoms like agitation commonly promote delirium. Medications, bed rest, even the noisy hospital environment adds to those at risk.

Those over 80 and those with other conditions like dementia are at high risk. Healthcare workers often miss identifying common risk factors for delirium in all patients but especially in the older.

Delirium easily generates a cascade of negative events and it is distressing to watch someone you love struggle with it. As a clinical syndrome, delirium alters our perception, focus, and sense of daily events. Normal conversations become quickly disjointed and strange. Focusing on a task like eating becomes an insurmountable obstacle. A patient told me delirium was like being trapped in a bad dream forever with no way out.

Myth: Older people who have mental health problems can’t be helped.

Mental health problems – like depression and delirium – are both preventable for many and treatable for all. Sadly, prevention and treatment can be difficult. Their invisibility makes many believe they are powerless to change mental health problems for older people.

There is good news about reducing depression. We are making strides in disputing the myth that it is a part of normal aging. The numbers of older Americans who are depressed may be falling, according to a study from last year out of the University of Michigan.

We are doing better at recognizing and treating difficulties that lead to depression. Pain is a good example. Better relief from pain caused by chronic problems like arthritis means less risk of depression. In essence, better prevention becomes effective treatment.

A recent report published by the Cochrane Library – a group dedicated to defining best evidence based healthcare – showed we need more and better research. More visibility for delirium as a syndrome to be prevented when possible, correctly diagnosed, and treated is important.

Left untreated, depression and delirium threatens full recovery and quality of life. offers a useful slide show to help recognize and act when a loved one may be depressed.

Just seven simple ideas including not dismissing symptoms, looking for subtle signs, and care for this common illness are important to keep in mind for those you love.

We used to think delirium would resolve on its own but untreated delirium may create lasting damage to cognitive function. Seliger wrote about this dimension of delirium after her mother’s hospitalization ( ).

She summarized useful guidance to prevent delirium, a great resource for anyone who has an older friend or relative in the hospital. My favorite tips include being sure eyeglasses, hearing aids, and other devices are working and used along keeping the patient moving. Getting up and moving may mean asking nurses and doctors to be sure activity is started as early as possible.

Remember that poor mental health is not a normal part of aging.

What are your thoughts on mental health and aging? Have you had experiences with depression, delirium, or other mental health disorders? I’d love to hear from you. Email me at and follow me on Twitter @SarahHKagan.

Dr. Sarah Kagan is a professor at the University of Pennsylvania School of Nursing where she specializes in geriatric issues and the care of older people. She is a visiting scholar at universities around the world and was awarded the John D. and Catherine T. MacArthur Fellowship for her work. Kagan lives in Philadelphia. Her column on aging myths appears in newspapers and on digital sites throughout Calkins Media Incorporated.

Dr. Sarah Kagan is a professor at the University of Pennsylvania School of Nursing, where she specializes in geriatric issues and the care of older people. She is a visiting scholar at universities around the world and was awarded the John D. and Catherine T. MacArthur Fellowship for her work. Kagan lives in Philadelphia. Her column on aging myths appears in newspapers and on digital sites throughout Calkins Media Inc.

Dr. Sarah Kagan is a professor at the University of Pennsylvania School of Nursing where she specializes in geriatric issues and the care of older people.