‘I’m still constipated, I’m in constant pain and I can’t sleep.’
Depression maybe isn’t your first thought – but that could be the source of the problem. As a busy GP, you work hard to rule out physical causes for the symptoms in front of you, but sometimes this doesn’t shed any light.
My elderly patient with constipation had not responded to any laxatives and tests did not reveal any organic causes. It was only when I began to speak to her about how she was feeling that I realised that I hadn’t asked about her mental health. Once I had diagnosed and treated her for depression, her constipation cleared up and she was able to get on with her life again.
When I was working as a GP, older patients were a big part of my workload. I remember these older patients having many long-term conditions that brought a lot of complexity. With a rapidly growing ageing population, the needs of elderly patients on GP practices are only going to increase.
I retrained as an old age psychiatrist and now spend my clinical time dealing with severe mental illnesses in older people. But as a former GP, I understand how difficult it can be to spot mental health issues in older patients in primary care – because their presentation is much more likely to be with physical rather than emotional symptoms. Mental health symptoms can often appear to be part of the ageing process.
Considering mental health issues
Whether or not older patients come to you complaining of a mental health issue, mental health issues need to be considered. NHS England has put together new free guidance ‘Mental Health In Older People: A Practice Primer’, which is endorsed by the Royal College of Psychiatrists and RCGP.
The guidance puts emphasis on practical advice to equip GPs with quick and effective ways to rule out mental illness as part of their investigations.
For example, just two simple questions could detect signs of potential depression within minutes. We should all be trying to ask our older patients whether in the last month they have:
- Been troubled by feeling down depressed or hopeless?
- Experienced little interest or pleasure in doing things?
This is simple but effective. If the answer to both questions is no then depression is highly unlikely. If either answer is yes, further assessment is indicated.
Mental health in older people
Quite rightfully there is now more public awareness about dementia, but far less attention has been given to other mental health issues in older people.
The DH has estimated that 40% of over 65s seeing their GP and 60% in care homes have a mental health problem. Depression is usually highly treatable with psychological interventions and medication, but studies have found that fewer than one in six older people with depression discussed their symptoms with their GP and less than half of them received adequate treatment.
Older people have a different social context – stigma can still be very strong and they are often less forthcoming about their mood. Some have out of date concerns about being put onto long-term ‘addictive’ antidepressants. As clinicians, we can’t always rely on older people to mention their mental health. We need to ask the right questions, so we can elicit the right information and administer the right treatments.
Anxiety disorders, bipolar disorder and psychotic symptoms are also all present in the elderly population to a significant degree.
Mental health conditions are a serious problem for older people. They reduce quality of life, increase risk of suicide, lead to higher use of health and social care services and result in poorer outcomes for physical illnesses. Nobody should suffer just because they are ‘old’.
I am confident the new practice primer will be of positive benefit to GPs and other health professionals in primary care. This is the first step on an important journey, so any comments and suggestions are greatly appreciated as we continue the work.
The primer also covers:
- Common mental health conditions found in older people in primary care including depression, bipolar disorder, psychosis, delirium, personality disorders, alcohol misuse and insomnia.
- Drug and psychological treatment options for each condition including the monitoring needed for common psychotropic drugs.
- How to identify people who merit referral to specialist services.
- Dr Amanda Thompsell, FRCPsych is chair of the Faculty of Old Age Psychiatry of the Royal College of Psychiatrists