How to Spot Older Patients With Hidden Mental Health Issues

Kelly Ragan

August 19, 2022

Dee McClure works with many older people who don’t think they’re depressed. They may be down in the dumps. They may be blue. But they aren’t depressed — because they aren’t crazy.

Dee McClure

McClure, coordinator of the Community Based and Peer Counseling Program at North Range Behavioral Health , in Greeley, Colorado, doesn’t judge them for their hesitancy. 

“Back in the day, people went to the hospital and never came home,” McClure said.

Mental illness was something to be feared. For decades until the 1960s, people with mental illness could be institutionalized against their will.

While great efforts have been made to tackle stigma around mental health issues since then, older patients may not understand or want to admit to feeling depressed, McClure said. But the answer may change if the patient is asked whether they feel “down in the dumps,” “blue,” or, “sad.”

“If you ask the question like that, many will say they don’t care whether they live or die,” she said.

According to the Centers for Disease Control and Prevention, depression is not a usual symptom of aging. While elderly patients may be reluctant to say they’re depressed, caregivers can offer valuable insights if doctors are willing to listen.

New findings published in the Journal of Patient-Reported Outcomes show asking family members for help assessing symptoms can lead to a more accurate picture of any mental health issues patients might be experiencing.  

The study included 188 patient and caregiver couples and 200 patients without an identified caregiver. All patients were 65 years or older, had at least one primary care visit in the past 12 months, and had at least one chronic condition. Nearly 70% were women, almost half were White, and 47.3% were Black.

Patients with a serious mental illness such as bipolar disorder or schizophrenia, or who lived in a long-term care facility, were excluded from the study. Most caregivers in the study were children or partners of the patient.

The researchers used four patient-reported scales, including the Patient Health Questionnaire-9, which measures depression, the General Anxiety Disorder-7, the Pain, Enjoyment, and General activity scale, and SymTrak, developed by the study authors, which measures depression, anxiety, and pain.

Dr Kurt Kroenke

Kurt Kroenke, MD, MACP, lead author of the study, said the amount of distress the caregiver was under, and the severity of their symptoms, appeared to influence how well the reports from caregivers and patients agreed.

Caregivers who reported feeling stress were more likely to overreport the symptoms or distress that the patient reported. And if a patient reported experiencing more acute symptoms, the caregiver was more likely to underreport what they thought the patient was experiencing.

Using Proxy Reports to Triangulate

Clinicians should keep these discrepancies in mind when they evaluate patients, and especially those with cognitive impairments, Kroenke said.

“If you take the clinician’s view, then you have three views,” one from the patient, one from the proxy, and one from the clinician, he said. “In those situations, you might have to triangulate the three perspectives.”

The patient might say they aren’t depressed, and the proxy may disagree.

“I think the truth could be somewhere in between,” Kroenke said. “If you have a couple different views, you can get a fuller picture of what’s going on. As the provider, you may want to integrate those two views and decide on management.”

Rick Black PT DPT MS

Rick Black, PT, DPT, MS, corporate rehabilitation director with ProMedica, a healthcare system in northwest Ohio and southeast Michigan, said gathering information from multiple sources can especially be important when making clinical decisions for elderly patients with cognitive impairments.

Patients with cognitive impairments may not be able to verbalize pain or emotional distress, prompting health providers to label them as “difficult” or “unmotivated.”

“I can’t tell you how many patients I’ve worked with who were labeled as unmotivated, but were really depressed,” he said.

After his patients receive care for their mental health issues, they often are able to participate in activities of daily living and improve physically, he said.

Healthcare providers should routinely use standardized screenings, to make sure people don’t get written off by care providers. “We need to incorporate these questions into regular practice so we can identify these patients early on,” he said.

Pair Screenings With Observations

Karen Nichols, MD, remembers working with a patient in his late 50s.

Dr Karen Nichols

Often, after the patient went home from appointments, his wife asked him a slew of questions that he couldn’t answer. Nichols, an internal medicine physician, eventually told her patient to write down his wife’s questions for upcoming visits.  

Nichols, who is now the chief medical officer for nine-state health system Trinity Health’s Programs of All-Inclusive Care for the Elderly, read concerns from the wife that her patient had never raised.

“It pushed him to do some things he needed to,” like getting cancer screenings and other preventive tests, Nichols said.

Nichols also gained a better sense of health concerns her patient wasn’t disclosing.

Standardized, regular screening questions can help improve care, Nichols said, but healthcare providers should observe their patients over time.

“Watch what this person’s routine is like and get to know what they do that gives them pleasure or joy and revisit that at a later date,” Nichols said. “If they always, no matter what, want ice cream, and suddenly they don’t, that may be a clue.”

If patients say they rely on a caregiver to pick up medications, but their blood pressure isn’t under control, clinicians should investigate what is going on at home, she said. 

Nichols said proxy reports are helpful, but providers should use caution in reading the results.

“Rather than just take everything at face value, you really have to have a little bit of a jaded eye on the information you’re being given if you’re going to treat the patient appropriately,” she said. “Ultimately, it’s about what you do for the patient.”

Kroenke and other authors report no relevant financial relationships. 

Journal of Patient-Reported Outcomes. Published May 14, 2022. Abstract.

Kelly Ragan is an editor and writer based in Colorado.

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