Connie Gardella, RNC and Gary S. Moak, M.D.

 

One of the most difficult challenges caregivers of older people with mental health problems face is convincing them to have a psychiatric evaluation.  At the Moak Center for Healthy Aging, we frequently receive calls from desperate caregivers seeking advice about how to get a reluctant senior to the office.   Common sense, cajoling, and begging have failed to lessen the older person’s vehement refusal to do what seems so necessary to the caregiver.

Unfortunately, older people often tenaciously resist mental health services. They grew up viewing mental health problems as causes for shame and embarrassment.  The “proper” approach to emotional problems, in their time, was to ignore them.  Psychiatric treatment carried an enormous stigma and often meant confinement in an “asylum”.  Despite the transformation of psychiatry into a modern medical specialty, older people retain a fearful defensiveness about mental health problems.  Any expression of concern about such problems is interpreted as an accusation of personal or moral weakness and failure.   Old people experience mental health problems as threats to their independence and autonomy that may result in their being “put away”.

Herein lies an irony that is a source of exasperation and anguish for caregivers.  Mental health problems are a leading precipitant of institutionalization for the elderly, and the psychiatric treatment they so fervently refuse may be all that stands in the way of this fate.  Helping a reluctant older person to agree to care that is clearly in their best interest is one of the things geriatric mental health specialists do all the time. 

Our patients sometimes are quite angry with family members for bringing them to our office “under duress.”   Most of the time getting over this first hurdle is the challenge; after that, things usually go smoothly.  Once the older patient discovers that the geriatric psychiatrist is a supportive professional who understands their problems, they usually are glad they came.  But how do you get them to go to a psychiatrist, even reluctantly, in the first place?  This article gives you some ideas about how to approach the problem.

To start with, there is no easy, one-size-fits-all approach.  Begin by trying to see past what might appear to be stubbornness to the person’s point of view. No matter how outwardly irrational, it usually is possible to see the inner reasons behind their perspective. Sometimes, you may be more successful by not trying as hard.  Older people who feel threatened by losing control of their mental health may resist help more if they feel they are being pushed into it. If they refuse to go to see the geriatric psychiatrist, then back off and try another approach, when the time is right.  Do not give up trying to persuade them.

Various common fears often are at the heart of an older person’s refusal to go to psychiatrist.  Patients experiencing memory impairment fear they are “losing their mind”.   Reassurance that they “only” have a memory problem and are not “going crazy” may help.  People with a wide range of mental health problems fear being sent to a nursing home, being “doped-up” with “mind-altering drugs”, or being addicted to such drugs.  They also fear being  “analyzed” or forced to talk about very sensitive, private past experiences.

When such fear is present, it may help to try to bring it out in the open.  In attempting this, it is important not be over zealous.  Steer clear of too forcefully trying to “get it out of” them or directly challenging their fears as irrational or ridiculous.  This can be needlessly provocative, and often aggravates the loss of autonomy.  Instead, take the fear seriously.  Listen sympathetically and avoid contradicting or negating their feelings. 

Find a way to present the appointment so that it makes sense to them.  People upset over taking “too many pills” might refuse to see a psychiatrist but might be open to an appointment with a specialist on medication use in older people, if it provides the chance for them to find out whether they still need all their pills. Use their own words, if possible, or find other terms acceptable to them.  Older patients who vehemently deny they are depressed might acknowledge that they feel sad or down-in-the-dumps.  They may be more open to getting help for “shot nerves” or a “shot memory”.  It may help to normalize the problem as the result of stress that has “taken its toll” on them.  Try not to use stigmatized words such as “Alzheimer’s” or “dementia”.   Instead, when they complain about forgetfulness, seize the opening to ask whether they would like to see a specialist for a consultation about keeping them sharp. 

Usually it is best to be truthful with elders who are fairly cognizant of what is happening.  People with mental disorders that cause them to be irrational, unreasonable, or unaware of their condition and needs may no longer be competent to decide what is best for them.   They may require help to ensure that their needs are met.  You may have to adjust how much or what you tell them about the purpose of the psychiatric visit.  They should be given an explanation that is palatable to them, fits their level of comprehension, responds to their fears and concerns, and helps them cooperate with the visit.  

If you have an appointment with a geriatric psychiatrist, explain it as a consultation with a doctor who specializes in the care of older people, particularly in their use of medications.  Traditionally older people have great respect for their primary care doctors.  If this is the situation, it may be appropriate to suggest that the family doctor has requested that they see the specialist, which often is the case, for a second opinion, to review their medications.

Geriatric psychiatrists who see only older people often try to design their practices to lessen some of the stigma associated with mental health services.   Waiting room artwork, furnishings, and background music may be selected to create age-appropriate familiarity that is welcoming for older people.  Office signage may be more medical and avoid explicit cues that it is a psychiatric setting.  Words such as “psychiatry” or “mental health” may be absent.   Office procedures may convey a more medical feel.  An office visit to a geriatric psychiatrist might include checks of blood pressure, pulse, or other vital signs, and relevant parts of a physical examination including listening to breathing, checking reflexes, or looking for swelling in the feet and ankles. Such activities have an important medical purpose.  But, in addition, these are normal experiences for a doctor visit, so they help older patients feel more comfortable.   Thus, the appointment is likely to be very different than how older people imagine a visit to a psychiatrist.

Occasionally it may be necessary to bend the truth a bit.  This is best reserved for fairly dire situations with patients who are no longer able to recognize the facts.  For example, we have had very confused patients brought to the office under the ruse that the visit was for a family member, typically the spouse.  They had been told that the geriatric psychiatrist needed to speak to them to get their perspective on their spouse’s health.  Since geriatric psychiatrists ordinarily seek input from various family members, this is a routine practice.  While not an ideal way to conduct an examination, skillful geriatric psychiatrists can learn a lot about the mental state of an older person through a discussion with them about close relatives. 

Flexibility may be needed regarding where the evaluation occurs.  We have done more than a few evaluations in the parking lot, inside the patient’s car, because they refused to get out of the car on arrival at the office.   Obviously, psychiatric treatment cannot be provided in a parking lot, but, in each case, we were able to convince the patient to come back for a second visit, this time inside the building. 

Geriatric psychiatrists sometimes make house calls, so this may be an option.  House calls generally are provided to patients who are housebound and unable to come to the office.  Sometimes a house call can be an appropriate way to evaluate an elder who will not go to the office.  House calls sometimes disarm defensive elders who enjoy remembering when the practice was commonplace.

And finally, if you are having no success getting an elder to go to a geriatric psychiatrist, call the office.  Make the staff aware of the problem.  You may be able to speak to a member of the team who can tell you about approaches that have worked with other patients.  Also, by making the staff aware of a prospective patient’s reluctance, they may be able to be extra sensitive to this or modify office procedures to ensure a successful visit.

Moak Center for Healthy Aging

March 2009