IX.

Geriatric Psychiatry

65. DEVELOPMENTAL ISSUES IN LATE LIFE

RoGerta M.Richardsm, M.D
1. What are some of the central themes of development in the later years of adulthood?
According to Nemiroff and Colarusso,y a central theme of adult development is the normative crisis precipitated by a growing awareness of the finiteness of time and the inevitability of personal death. This normative crisis leads to thoughts and questions about the meaning of ones life, accomplishments, and mark on the world and may underlie such psychiatric presentations as the depression that sometimes accompanies retirement and anxiety about a decline in personal health, or illness and death of friends and loved ones. Erikson defines the developmental task of late life as integrity vs. despair. He refers to the task of reviewing life and integrating experiences into a value system that leads to a feeling of fulfillment and satisfaction. If this task is not accomplished, the emotion associated with this stage of life is most likely to be despair, caused by the conclusion that one did not accomplish what is perceived as necessary-and no longer has the time to do so. Jung noted that in the second half of life, men become more aware of their feminine side and women of their masculine side. Another central theme of late life involves repeated injury to self-esteem as the older adult is displaced at work, loses physical and possibly sexual prowess, and must accept a degree of dependence on others. The realities of aging undermine defenses in some individuals, leading to intense feelings of envy, rivalry, rage, and, subsequently, loneliness. Psychotherapy may be especially useful in such patients by assisting them to accept the changes of aging and refocusing their attention on positive feelings about themselves.

2. How can changes in relationships stimulate developmental crises in older adults? The aging and death of ones parents are major events in life. If parents become feeble, roles often are reversed. This reversal involves at least some degree of difficulty for most adult children. Psychologically, adult children can no longer maintain the fantasy that their parents will take care of them. This may be particularly difficult if psychological separation has not fully occurred and feelings about the adequacy of parenting received in childhood remain ambivalent. Thoughts of mortality are strongly stimulated by the death of parents, which brings the realization that ones own generation is the next to pass. Changes in relationships with grown children also may precipitate developmental crises in parents. The classic empty nest syndrome occurs later in life as childbearing is delayed and adult children stay longer in the home. Some parents may be reluctant to lose the parenting role as they face other losses and changes in their bodies. They may feel envy of their own children as they watch them start out with their whole lives ahead of them.
3. Discuss the compensating aspects of relationshipswith grandchildren. In most cases, relationships with grandchildren are idealized and mutually gratifying. Through grandchildren the displaced parent may recapture unqualified love and admiration. The grandparent may identify with the grandchild and act out frustrated, self-indulgent impulses through spoiling
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of the child. This process also may compensate for possible envious feelings toward adult children, the parents of the grandchild. Grandchildren also represent immortality. It may be tremendously gratifying and reassuring to notice inherited genetic features in a grandchild when one is struggling with questions about ones legacy and asking, Will I be remembered when Im gone?

4. How does late life development affect psychotherapy? The older patients experience of the therapist may be influenced by any number of important relationships i n life, such as parent, spouse, sibling, or child. When the therapist is young, a transference related to the patients relationship with his or her own children is more easily stimulated. Themes of unresolved expectations and disappointments with children may arise early. The therapist may be idealized as the good child who offers what the patients own children do not, or may become the focus of angry feelings about abandonment. The therapists reactions to the psychotherapeutic relationship with an elderly patient may color which themes and reactions emerge. The therapist may be uncomfortable, for example, with sexuality in an older person or with the patients dependency needs. If the patient is experienced as a parent, the therapists unresolved wishes to control the parent or fears of domination may interfere with the therapy. Ongoing problems with parents in real life may make it particularly difficult for some therapists to work with older patients.

5. Do sex and sexuality continue to he a concern for people over the age of 60 years? In 1974 the Duke Longitudinal Study on Aging found that 70% of men at age 63 and 25% of
men at age 78 were still sexually active. Pearlmanlo found that 25% of men in their 60s and 10% of men over 70 reported sexual intercourse at least once a week. Data for older women are fewer. Christenson and Gagnon4 found that 50% of married women over age 65 reported regular coitus. For women the availability of a socially sanctioned partner is a significant factor in the frequency of sexual activity, whereas for men this factor is not as important. For example, it is culturally more acceptable for an elderly man than an elderly woman to date a younger partner. Single women in their later years, however, remain interested in sex, and many compensate for the lack of a partner by masturbation. Many doctors do not recognize the importance of sex and the prevalence of sexual dysfunction in olderpatients, because they do not ask. Doctors who routinely ask about sex estimate that 50% of geriatric patients have sexual complaints, whereas doctors who do not routinely ask place the estimate at less than 10%.

6. What normal changes in sexual functioning occur with aging? For men aging brings fewer spontaneous erections. Direct stimulation is usually required to
obtain full erection, and the process takes longer. The force of ejaculation is decreased, along with the volume of seminal fluid. Ejaculatory control is improved, but the refractory period is longer (i.e., a longer period is necessary before another erection is possible). For women late middle age often brings an increase in sexual desire, which gradually declines with old age. Lubrication decreases postmenopausally, and a longer period is required to achieve adequate lubrication. The vaginal vault decreases in size, with thinning walls. The orgasmic phase is shorter, and orgasmic uterine contractions may cause pain in the lower abdomen.

7. Discuss the causes of male impotence. According to Hackett: Achieving a normal erection is a complex event requiring an adequate blood and nerve supply to the penile area and appropriate psychological conditions. Although it used to be thought that psychological factors were primarily responsible for the great majority of cases of male impotence, it is now believed that at least 50% have an organic basis. As would be expected, the incidence of organic factors increases with age. Vasculogenic impotence is probably the most common organic type. It usually appears around age 50 and is characterized by partial erections and retained ability to achieve orgasm, which is

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37 I

neurologically controlled. Neurologic impotence occurs when diseases such as Parkinsons disease, multiple sclerosis, spinal cord injury, diabetes, alcoholism, or tumor interfere with the functioning of the nerves involved in developing and maintaining an erection. Endocrinologic impotence occurs when testosterone levels are low. Finally, many prescription drugs may decrease libido, reduce potency, or interfere with the ability to ejaculate, particularly antihypertensives and antidepressants. Psychological factors are the primary cause in about one-half of the cases of male impotence. Depression, both as a primary major affective disorder and as a mood associated with bereavement or other losses, is by far the most common psychological cause of impotence and other sexual dysfunction. Another major category of psychological impotence involves medical illnesses unrelated biologically to sexual function, including common fears of sexual activity after myocardial infarction and fears of hurting oneself or ones partner when diseases such as arthritis or chronic lung disease are present. Psychological factors often play a significant role in cases of impotence in which an organic cause is primary. Low self-esteem and performance anxiety may result from recognition of diminished sexual prowess.

8. What are the common complaints and causes of sexual dysfunction in elderly women? Dyspareunia (painful intercourse) is a common complaint after menopause because of decreased lubrication and/or narrowing of the vagina. The vaginal mucosa also atrophy. Such problems can be overcome with systemic estrogen or estrogen creams applied to the vagina. Nonhormonal vaginal lubricants also may be helpful. Psychological factors are equally important in the sexual functioning of older women and older men. Women may suffer from feelings of unattractiveness that makes them recoil from sexual activity. Such feelings may be caused or compounded by an apparent decrease in interest on the part of a spouse or partner who is having his own difficulties with sexual functioning. Often partners do not discuss the problem with each other, and the woman may assume that the cause is her loss of attractiveness. Mastectomy often leaves many women feeling disfigured and reluctant to pursue sexual activity. Fortunately, more and more hospitals anticipate this problem and address it immediately after or even before surgery. The partner often needs to be involved in the counseling. Involving the partner in surgical aftercare and rehabilitation is a good way to desensitize and address such issues. Wearing of a prosthesis during intercourse is not a good solution, because it tends to perpetuate denial and self-doubt. 9. How can the physician assist older patients with problems related to sex and sexuality? The most important intervention is to incorporate questions about sexual functioning into the routine history. Many people are uncomfortable bringing up such issues, even to the doctor. Often allowing the patient to air concerns and educating the patient about normal changes in sexual functioning with aging make all the difference. Once sexual difficulties are described, the physician first should consider the patients medical history, including medications, to see whether a physical factor is involved, especially one that can be corrected. Inquiries about alcohol and over-the-counter medications are also important. Referral to a urologist or gynecologist may be appropriate for further evaluation of specific problems. The patient also should be screened for depression, and inquiries should be made about relationship difficulties and sexual functioning of the partner. Pharmacologic treatment for depression may be appropriate, but the high incidence of sexual dysfunction caused by antidepressants should be kept in mind. A mental health referral may be appropriate.

10. Discuss grief and its role in the evaluation and treatment of older adults. Grief is the emotional suffering experienced in reaction to loss. Late life is characterized by increasing numbers and severity of losses. The death of a spouse is perhaps the best known cause for grief in older people-and one of the most devastating. However, many other major losses also are common, Parents, siblings, and, as more people live to a more advanced age, children also die. Friends may die in fairly quick succession.

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Death of loved ones is not the only cause of grief. Older people lose relationships through retirement, changes in residence (by themselves or others), and inability to congregate for social activities because of loss of transportation or failing health. Grief also may be triggered by material loss, such as loss of home and possessions (when one must move to a smaller place). A move also may necessitate loss of a beloved pet. Finally, one may grieve for loss of body parts or functions, such as eyesight, hearing. or mobility. Avid readers, for example, may feel desperate when they no longer can see. Loss of hearing isolates one from others as communication becomes more and more difficult. The symptoms of grief are varied. Loss is often instrumental in precipitating major depressive episodes. Although antidepressant medications are often helpful and may be necessary, psychotherapy may be at least as important. Sometimes a depressive episode represents the culmination of a series of losses so close together that one is not dealt with before the next comes along, overwhelming individual coping capacity. Anger and resentment are also common reactions to loss, especially losses that undermine the sense of self-esteem, such as loss of physical function and opportunities. Anxiety and fear may underlie the anger or be frank expressions of loss. Suicide may be considered or threatened as a way of gaining a feeling of control over ones body and life. The deficit model of loss and grief is helpful in guiding intervention. A loss leads to deficits in the sufferers life. Grief will not be eased until other resources are found to compensate for such deficits. For example, loss of a spouse leads to loss of help with basic activities of living (e.g., he always balanced the checkbook), validating responses that enhance self-esteem, and emotional supports. It also leaves a deficit in social identity. Older people with a greater number of social contacts and a diversity of roles fare better than those who functioned mainly as a spouse, with few outside contacts.

11. What are the tasks of the therapist in assisting grief-stricken older patients? The therapist helps patients by encouraging them to talk about the loss of the loved one. Although listening may seem like a clichC, the therapist may be the only person who is willing to sit quietly with patients while they cry, express their feelings, and repeat painful stories. Some therapists may be too quick to jump in with reassurances, platitudes, or distractions, giving the message that they do not want to hear the pain. The therapist must tolerate intense affect and let patients know that avoiding the pain often only prolongs grief or causes it to remain unresolved. Education about grief and loss is important, because many people had abnormal models or were taught myths about the grieving process. Grieving alone, keeping a stiff upper lip, and not feeling sorry for oneself are among the myths that many people have learned. Validating feelings of all kinds, including anger, relief, and guilt, is important. Assistance with problem solving also helps to replace the deficits left by loss. In the case of bereavement, the survivor must adjust to an environment from which the deceased is missing and reinvest emotional energy in other relationships. The bereaved may need concrete guidance and instructions for moving on to other people and activities. According to Taylor, effective work with grief must involve a search for meaning in the experience, an attempt to regain mastery over ones life, and an effort to enhance self-esteem. These guidelines are particularly helpful in assisting with losses of function and role that are almost inevitable in the elderly. For example, the man who is forced to retire at age 65 may not feel ready to leave his job, which may be his primary source of self-esteem and the area in which he feels most capable and in control. He may feel helpless and frustrated. The therapists task is to help the man look beyond his job for meaningful activity, self-esteem, and fulfillment. 12. Discuss the common fears older adults have about death and dying. Attitudes toward death are grounded in culture. North American culture tends to deny death and to stigmatize the notion of vulnerability. Independence, self-control, and autonomy are highly valued. Thus many adults come to old age with fears and conflicts about death with which they must struggle alone. Most people in North America do not die suddenly, but become progressively ill with one or more diseases that eventually kill them. Most of these diseases are chronic and ambiguous.

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Increasingly, even cancer is a diagnosis that may or may not be terminal. Thus, older people are fated to ponder the circumstances of their death. The most common fears center on the dying process, specifically on isolation or abandonment and loss of dignity and control. Fortunately, we seem to have passed the heyday of high-tech death, but many people still have fears of dying alone in a hospital room with tubes in every orifice and hisses and beeps for company. Many fear humiliating exposure in the presence of strangers as they struggle with terrible physical suffering and possible loss of mental capacities. Older people must have the opportunity to discuss such issues with their loved ones and doctors. They need assurances that they will be cared for with courtesy, concern for their dignity, and attention to alleviation of suffering. Most people also want reassurance that every effort will be made not to allow them to die alone. In addition, efforts should be made to clarify specific wishes for medical interventions near the end of life, before circumstances render the individual incompetent to choose. Such efforts should include choosing and executing some form of formal advance directive for health care, according to various state laws.

13. Discuss common characteristicsof people most likely to have a debilitating fear of death. People who have unresolved religious questions about death and dying may develop severe anxiety in late life. They may fear that they will die before resolving their doubts and suffer after death as a consequence; for example, by spending eternity in hell. Or they may have been raised in a tradition that promises a blissful afterlife but fear they instead will find an eternal unbearable nothingness. For some, the realization of personal death arouses intense separation anxiety. Such individuals have struggled with separation anxiety in their relationships throughout life. They may envision death as an agonizing aloneness. A resurgence of clinging, regressive behavior may be the manifestation of this unspoken fear. People with lingering guilt for hostile or impulsive acts and an immature ego structure may view death as a punishment and thus develop debilitating fears in late life. Such people continue to struggle with anger over their lot, feelings of mistreatment, and subsequent guilt over having and/or expressing such feelings. They present with mixed emotions of hostility, depression, and anxiety. On a more concrete level, people who live alone are more likely to develop debilitating fear of death, because they are afraid they will become ill or injured and die alone before they are able to get help. Additionally, an individual may fear leaving a disabled spouse alone.

14. What interventions are helpful to older people facing death? Assistance in clarifying beliefs and feelings about death and end-of-life issues may be helpful. Such issues may be discussed with the physician, a religious leader, family and friends, or a counselor or psychotherapist. The family may need assistance in knowing how to help a dying relative. The quality of close relationships strongly influences the reactions to dying. If problems are sufficiently debilitating to require professional therapy, the therapist can help the person to develop a fantasy of immortality. It is soothing for most people to feel that they will continue to live in a positive way through their children, creations, or even possessions. A life review also is therapeutic at this stage. The therapist guides the person through a review of the facts and accomplishments of his or her life to assist in developing a feeling that life has had meaning and purpose. Note that this technique is not advisable for patients suffering from major depression. The nature of depression leads patients to recall selectively and to dwell on negative life events and deeds, which is more harmful than helpful.
BIBLIOGRAPHY
1. Adams SG Jr, Dubbert PM, Chupurdia KM, et al: Assessment of sexual beliefs and information in aging

couples with sexual dysfunction. Arch Sex Behav 25:249-260, 1996. la. Atchley RC: The aging self. Psychother Theory Res Pract 19:388-396, 1982. 2. Baum N, Sakauye K: Whats causing your patients impotence? Senior Patient Oct:21-26, 1990. 3. Butler RN: The life-review: An unrecognized bonanza. Intl J Aging Hum Dev 12:35-38, 1980. 4. Christenson CV, Gagnon JG: Sexual behavior in a group of older women. J Gerontol20:351-356, 1965.

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5. Fry PS: Depression, Stress, and Adaptations in the Elderly. Rockville, MD, Aspen, 1986,pp 323-347. 6 . Hackett TP: Sexual activity in the elderly. In Jenicke MA (ed): Clinical Perspectives on Aging. Philadelphia,

Wyeth-Ayerst Laboratories, 1985. 7. James JW, Cherry F: The Grief Recovery Handbook. New York, Harper & Row, 1988. 8. Meston CM: Aging and sexuality.West J Med 167:285-290, 1997. 9. Nemiroff RA, Colarusso CA: The Race Against Time. New York, Plenum Press, 1985. 10. Pearlman CK: Frequency of intercourse in males at different ages. Med Aspects Hum Sex 6:92, 1972. 1 1. Pipher M: Another Country: Navigating the Emotional Terrain of Our Elders. Riverhead Books, 1999. 12. Weisman A: On Dying and Denying. Behavioral Publications, 1972, pp 137-157. 13. Zarit SH, Knight BG (eds): A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life State Context. Washington, DC, American Psychological Association, Oct 1997.

66. PSYCHOPHARMACOLOGY FOR ELDERLY PATIENTS

RoGerta M. Richardson, M.D

1. How do changes in body composition that occur with aging affect your choice of psychotropic medication? The aging body shows a significant decrease in lean body mass, corresponding increase in total body fat, and decrease in total body water. Thus, water-soluble drugs have a greater concentration per unit dose because of the apparent decrease in the size of the reservoir. The blood alcohol level per drink rises with age, and the usual two martinis a day cant be tolerated at age 70. Fat-soluble drugs have a greater volume of distribution. They are stored in fat and released gradually, and therefore show a longer half-life in the elderly. The highly fat-soluble benzodiazepines, such as diazepam, have a greatly increased half-life in older individuals, and typical antipsychotics are affected by this phenomenon as well. Remember, too, that the brain is a very fatty organ.

2. Why is it essential to know the route of metabolism of any drug prescribed?

Most drugs are metabolized primarily in the liver. In general, hepatic blood flow and size decrease significantly with aging. However, individual variation in activity of liver enzymes is vast. For this reason, there can be a 20-fold difference in appropriate dose of some antidepressants among patients of the same advanced age. Ignorance of this fact leads to two common prescribing mistakes: overdosing and underdosing. Remember to start low, go slow-but dont stop too soon. Also take into account metabolic interactions with other medications. This is especially crucial for older patients who may be taking a number of different medications, and who are more vulnerable to adverse effects of blood levels that climb too high, or drop too low. Medications with renal metabolism are more predictable. Creatinine clearance decreases steadily and predictably with age. Age and body weight are factors, such that the older and smaller a person is, the lower his or her creatinine clearance will be. Lithium is the psychotropic medication most influenced by this phenomenon. Dosages must be drastically reduced in the elderly to avoid toxicity. Some of the benzodiazepines also are metabolized renally and have a slower clearance in elderly patients.

3. How are changes in receptor sensitivity and neurotransmitters relevant?

Aging brings reduced sensitivity to some pharmacologic agents and increased sensitivity to others. The most important consideration in prescribing psychotropics, however, is the cholinergic neurotransmitter system. Several of the commonly used psychotropic agents have significant