Geriatric Mental Health Disaster and Emergency Preparedness

Chapter 14 Geriatric Assessment for Differential Diagnosis 285
eral sources as older persons often are not reliable in describing their underlying
mood states or distress.
As previously noted, many disorders may manifest with similar clinical
presentation. Social isolation may be a sign of depression or delirium. Agitation
is often seen in depression, anxiety states, delirium, and dementia as
well as substance-induced intoxication or withdrawal. Attention-seeking
behavior—the acting out of inner emotional conflicts—may also be the
only way the older client knows to ask for emotional help in response to a
crisis. Alexithymia is common in this cohort and will result in alternate ways
to express emotional distress. Physical symptoms such as fatigue, weariness,
chronic pain, and somatic preoccupations may indicate psychological
distress. Therefore, the assessment should include a thorough review of systems
from all major medical and organ systems to determine any physical
symptoms related to underlying psychological distress. The older client, for
example, may present with worsening pain complaints masking a progressive
depressive disorder. In our society, and particularly with this aging cohort,
it is more acceptable to present with physical rather than psychological
distress (Horowitz, 1976).
Such patients are often categorized as difficult or even hateful as they
are persistent in holding onto physical symptoms and are not good patients
in the sense that they do not want to get better. This confounds the treatment
team, frustrates their efforts, and may lead to unconscious punishment
of the client. For example, a repeat visitor to a clinic who has shifting
medical complaints may be labeled a crock and deemed not worthy of careful
attention. The examiner must understand that such patients are using
meta-requests as please for help and should offer them support, gentle encouragement,
and a clear plan for follow-up and treatment. The message
most successfully implied is that the treatment team hears the complaint
and will do what they can to relive distress. Treating clients in a rapid, cursory
manner only compounds their fears that they do not matter and are
worthless and insignificant. This may then lead to worsened depression,
withdrawal, social isolation, and even suicidal behavior.
The older cohort uses physical symptoms to manifest underlying psychological
conflict. The hypochondriac who focuses on specific symptom
complexes may have a depressive or anxious disorder at the core of his or her
pathology, and it is the work of the examiner to tease this out through careful
questioning, reviewing the client’s current clinical functioning, and reviewing
the meaning of the client’s symptoms. Older persons will commonly
express emotional distress through pain complaints, such as headache,