Dementia or Mental Illness?

With the mental health of aging Americans, it’s important to understand the distinctions between dementia and mental illness, the role medication plays in diagnoses and what personality changes might be signaling. Dementia or Mental Illness?

Read our tips for distinguishing mental illness in seniors and how to receive the proper diagnosis during Mental Health Awareness month.

Diagnosing Mental Illness

I could hear the low drone of the TV in the background. It had been a hectic afternoon, not unusual in the psychiatric group home where I cared for a dozen people — each with different challenges, diagnoses and personalities. Evenings were my favorite time of day when most residents would go relax on the back porch and soak in the night air. As I finished washing the last of the day’s dishes, an angry voice broke the silence, “Stop it, just stop it!” I dried my hands and hurried outside before the situation could escalate.

The scene I found was all too familiar; Renee was glaring angrily at Jason who looked near to tears. I gave Jason an encouraging smile and a reassuring touch on the shoulder as I steered Renee inside. Even though Jason and Renee were polite to each other during the day, this scenario had played out almost every night of late. As the evening wore on, Renee became more agitated, muttering to herself and pacing the halls.

Prior to her recent hospitalization, move to the group home and personality changes, Renee had been a seamstress and a stay-at-home mom. She was a doting 60-year-old grandmother who was active in her community and seemed to be aging well. Then, she began showing signs of aggressiveness, confusion and other inappropriate behavior, which prompted her daughter to make an appointment with her mother’s doctor.

The doctor referred her to a neurologist who diagnosed her with possible Alzheimer’s disease and started her on medication for dementia since the symptoms displayed seemed to match. The medication didn’t help and Renee continued to spiral downward, eventually trying to take her own life.

Dr. Bruce Shapiro, Clinical Professor of Psychiatry at Columbia University of Physicians and Surgeons, states that it can be difficult to differentiate dementia and mental illness in seniors, because the confusion, erratic behavior and memory loss symptoms they experience are present in both diseases. “These are very serious issues in seniors and it is often overlooked that the rate of suicide is higher in senior years than in any other age group,” Shapiro says.

He continues, “[First] a psychologist will attempt to clarify whether there are symptoms of anxiety, bipolar disorder, dementia, depression or psychosis. In reviewing these areas, it is often helpful for the psychologist to speak with involved family members who may have observations of difficulties that the patient does not see. Then, a careful review of history, thorough mental status examination and possible psychological testing will lead the psychologist to a diagnosis which will form the basis for treatment.”

Late-Onset Bipolar Disorder in Seniors

While at the hospital, Renee was given a complete mental, neurological and physical examination by a geriatric psychiatrist who changed her medication to a mood stabilizer. Her symptoms gradually improved and she was diagnosed with late-onset bipolar disorder.

Renee was an unusual case among bipolar patients, since most people with this disorder get diagnosed in early adulthood. “Late-onset bipolar disorder occurs infrequently,” says Dr. Shapiro. “The majority of bipolar disorders have their onset in the late teens and early adult years. It is estimated that only about 10% of individuals who have a bipolar disorder will have an onset after age 50, and that 5% will have an onset of the disorder after age 60.”

Because so few people, even clinicians, are aware of late-onset bipolar disorder, patients are often misdiagnosed and not medicated appropriately. In Renee’s case, her symptoms were aggravated by changing light in the evening, a characteristic common in both bipolar disorder and dementia.

A complete neuropsychiatric consultation to diagnose the disorder should include the following:

  • Cognitive tests
  • Complete medication and supplement review
  • Laboratory assessments
  • Mental status examinations
  • Neuroimaging such as CAT scan or MRI
  • Thorough developmental, physical and social history

Mental Health and Medication in Senior Living

Bipolar disorder in seniors is treated much like it is in adults, however, some mood stabilizers like lithium must be used cautiously as senior kidneys cannot clear the drug efficiently. Constant monitoring will also be needed to prevent lithium toxicity, which can be fatal.

“The metabolism in seniors differs from that of a younger individual,” explains Dr. Shapiro. “There are often changes in kidney and liver function in this age group. These changes will make the senior more sensitive to medications and many medications must be given with 1/3 to 1/2 reduction of the usual adult dosage in the elderly. As well, the elderly may be more susceptible to sedating medications or to the interaction of medications causing sedation and other side effects.”

With behavioral similarities between dementia and mental illness, it looks to be a potential challenge for assisted living communities. However, Dr. Shapiro explains that assisted living communities have a low chance of dealing with changes in personality or erratic behavior. “The likelihood of such changes correlates with age and particularly correlates with the onset of dementia. Erratic behavior, particularly involving agitation, is commonly seen in individuals whose dementia has progressed, and these individuals may have to move from the assisted living setting to the more acute dementia care setting.”

He adds that, “Most assisted living communities have a physician, psychiatrist or psychologist whom they can call to address these difficulties. There are medications which can be very effective in helping to deal with behavioral changes and striking the balance between helping to normalize behavior while not sedating the patient is key here. Seniors who take mood-stabilizing medications may have behavioral or personality changes, particularly if they experience changes in the blood levels of their mood-stabilizing medication. This is generally addressed with blood level testing and medication dosage adjustments.”

Proper Diagnosis Can Help

Because therapy needs in the geriatric age group differ from those who are younger adults, Dr. Shapiro expresses how important it is to take life changes into consideration. Cognitive decline, loss of loved ones, memory changes, physical changes and retirement can all bring on significant emotional issues — and a Geropsychologist knows how to deal with and explore these issues with seniors.

“Psychological or neuropsychological testing in this age group may prove very helpful in clarifying the diagnosis,” says Dr. Shapiro. “Treatment of seniors often involves working with the family as well. The role of psychotherapy, with both individuals and families, has unfortunately all too often been minimized during the geriatric years. Geriatric clients can benefit significantly from psychotherapeutic treatment. Short term, problem-focused therapies can be very beneficial in the treatment of seniors.”

Shortly after the latest incident with Jason, I scheduled Renee for a follow-up with her geriatric psychiatrist who adjusted her medication and referred her to a bipolar support group. It took a few months, but gradually her outbursts calmed and our evenings became peaceful again.

I bumped into Renee at the mall a few years ago. She had improved enough to be able to move out of the psychiatric group home and she now has an apartment that she shares with her sister. She is once again the active, doting grandmother she was before.

Have you had experience with a misdiagnosis or did the correct medication greatly improve a senior loved one’s mental illness? We’d like to hear your stories in the comments below.

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