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Psychiatric treatment of elders
Psychiatric treatment of elders
By Dr. Stuart Bartle
Q. What are delusions?
A. Delusions are defined as a belief that has no basis in reality. Some are systematized and possible, such as having an unfaithful spouse, having a fatal illness, being infected by a (non-detectable) virus. Others are bizarre, such as the belief that you have some extraordinary powers, often God-given, that you are the object of pursuit or persecution by other people or by outside forces. Some people live in complex imaginary worlds. This may be normal in children, but it is not in adults who have to adapt to the real world. The exception, of course, is the creative artist.
Q. How do you talk with someone who has them?
A. You have to begin by realizing that you can’t talk people out of them. These delusions are usually quite fixed and serve an important function in the person’s life. They generally occur in a person who is paranoid. Often they are overcompensation for feelings of inferiority. If they don’t interfere with that person’s functions in life, they can be harmless and do not need treatment - and wouldn’t respond in any case. It is best to avoid arguing or reasoning, but not necessarily to agree with the person.
Q. A lot of people take antidepressants. Is it ever appropriate for elders who are taking a range of other medications?
A. The flotilla of antidepressants that began with Prozac in 1988 are rarely inappropriate, which is n to the same as saying they are always effective. Virtually all medications are metabolized by liver enzymes; adding any medications can cause a bottleneck if another medication is being metabolized by the same enzyme. Drugs such as Coumadin, which helps prevent clotting, are particularly sensitive to this since the tendency to clot has to be within a very narrow therapeutic range. There are many others and there are many published lists of possible effects as well as information in every drug information packet included with the medication. In addition, pharmacies now print our possible interactions.
Q. Electroshock treatment seems to arouse a lot of fear and controversy. What is the story? Is it dangerous to elders?
A. Electroshock treatment is now called electroconvulsive treatment, ECT, since the effective component is not the shock, but the tiny seizure that is caused by the stimulus. ECT has come a long way since "One Flew Over the Cuckoo’s Nest" where it was portrayed as barbaric . It now is given with very careful, almost instantaneous on-and-off anesthesia and muscle relaxants so the only visible sign of a seizure is often a small twitch of the fingers. Usually somewhere from six to 10 treatments are given at the rate of three a week with improvement often seen in the first week. It is 50-90% effective in depressed elders, far better than medicine which is effective in only about 50% in people older than 65.
Unfortunately, unwarranted fear of ECT can unduly prolong depression by maintaining a source of often multiple antidepressants that have their own risk.
Q. Are there any cautions someone should be aware of if ECT is suggested as a treatment?
A. A person should be prepared for varying degrees of memory loss for some time after ETC. Occasionally there is no memory of the events occurring just before or during treatment. However, there has been no evidence of brain damage in many technically sophisticated studies.
There are no absolute contraindications to ECT, but there are conditions of increased risk such as a very recent heart attack, brain tumor, advanced pulmonary disease. The overall mortality per treatment is 0.002 percent, i.e., one in 50,000 persons.
Dr. Bartle is a board certified psychiatrist with a specialty in Geriatrics. He is Berkshire Medical Center’s staff psychiatrist for Jones 2 and Assistant Clinical Professor at University of Massachusetts Department of Psychiatry.