When Mental Health and Aging Collide

Pat Walker was feeling particularly low. A sister had just died, and after a huge fight with her daughter, she couldn’t get out of bed. For this active, engaged 74-year-old, that was unheard of.

So she sought therapy, which she had done in the past, but this time it was with a geropsychologist, someone who specializes in treating older people. For Walker, who is identified by a combination of her middle and maiden names to protect her privacy, that was life-changing. “It was extremely helpful to have someone with a knowledge of older people, who understands the whole notion that seniors go through periods of isolation and frustration mainly because of their age and their placement in life,” she says.

Geropsychology only became a specialty in professional psychology in 2010, according to the American Psychological Association, and the number of practitioners is still small. Although about 15% of Americans are age 65 and over, only 3% of licensed psychologists in the U.S. identify their primary or secondary specialty as geropsychology.

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Older people have distinct phases and challenges that call for geropsychologists. “Changes come in predictable ways as we age and require particular competencies and skills,” says Christina Pierpaoli Parker, a postdoctoral fellow of clinical psychology and behavioral medicine with a specialty in geropsychology at the University of Alabama.

Safety Equals Autonomy

Too often, health care providers dismiss the mental and physical complaints of older people as normal aging, geropsychologists say. For example, while joints may become more painful with age, “having pain all over the body is not normal aging — that’s a common indicator of depression. The same is true with lack of concentration,” says Erin Emery-Tiburcio, an associate professor of geriatric and rehabilitation psychology and co-director of the Rush Center for Excellence in Aging in Chicago.

Knowing the side effects of medication and especially combinations of medications is also essential.

“I had a patient several years ago who was sharp as a tack, and then when he came to see me three weeks later he was very confused and stumbling,” she recalls. “That acute change is not normal.”

Emery-Tiburcio asked the 80-year-old man if he was on any new medication. It turned out his doctor had prescribed a new drug for incontinence, which can create confusion and fall risks. “He had been to his primary physician that week who didn’t notice,” she says.

Ideally, psychologists — and geropsychologists in particular — should work as a team with doctors, clinical pharmacists and occupational therapists, says Melinda Ginne, who has practiced geropsychology in Northern California for 40 years. Some geropsychologists include the family in treatment and are often practical in their advice. Ginne, who is also one of the founding instructors in the Professional Program in Aging and Mental Health at UC Berkeley Extension, says she might advise family members, for example, that their mother needs home help twice a week for at least four hours, and suggest some agencies that can help.

Pierpaoli Parker developed the University of Alabama’s Integrated Behavioral Medicine Service, which provides both psychiatric services and primary care, with an emphasis on helping change behavior. That includes creating exercise plans, even if it’s going outside with a walker for 15 minutes or working out in a chair. She found that patients may be more willing to discuss physical problems first, such as insomnia or chronic pain, before eventually opening up about mental health challenges like depression.

Some of the concerns many older people have revolve around isolation or residential care. Ginne says she works to empower her patients. If the person resists getting help at home, she explains that “safety equals autonomy. If you have help at home, you can go out, you can have someone take you to the market and movies and senior center. I’ll say that about residential care as well.”

An Emphasis on Routine

Dementia is an inevitable part of working with older patients, and geropsychologists say treatment varies depending on the type and stage of dementia. Part of that treatment is providing perspective, Emery-Tiburcio says.

Depression tends to elevate the bad (my mind is deteriorating and I can’t do some of the things I used to) while ignoring the good (my daughter loves and supports me and I enjoy spending time with her). “If you focus on the losses, you are likely to get depressed,” she says, but if you concentrate on the present, “it’s a lot easier to not only function well but improve mood.”

Even if the person with dementia can’t remember the previous session, therapy can help, Emery-Tiburcio says. “Many people with dementia fear being a burden on their families. Having conversations with the family members present, talking about the future, and processing the emotions of the whole family can help to dispel myths and create plans that are acceptable to everyone involved. This experience can be very relieving.” The older person may forget the session, but the feeling of emotional resolution can continue, particularly if the family is able to remind the patient about the discussions and plan, she adds.

When someone with dementia is agitated or aggressive, that behavior “almost always is in reaction to the environment,” Emery-Tiburcio says. It might be a change in routine, a different caregiver or a new pain or infection that the patient can’t describe. The geropsychologist can work with the family and professional caregivers to identify the causes and possible solutions.

Another way to help those with dementia, Pierpaoli Parker says, is to emphasize routine, such as waking up and having meals at the same time each day. She tries to encourage an older adult to go outside in the morning to sit or walk. “That not only makes you feel better but tells your body when to be up and when to be asleep,” she says.

During her therapy, Walker, the 74-year-old who once struggled to get out of bed, focused on her goals and plans. Working with a geropsychologist, she says, has been eye-opening. “It took 70-plus years to come to this understanding about me.”