Somatic change with age can lead to mental disorders and interfere with healthy aging. Especially in vulnerable geriatric patients, mental disorders therefore have a particularly negative impact on morbidity and mortality. However, appropriate care of the growing number of geriatric patients with psychological distress requires knowledge of the psychosomatically relevant characteristics of these older patients.
Somatic change with age can lead to mental disorders and interfere with healthy aging. Especially in vulnerable geriatric patients, mental disorders therefore have a particularly negative impact on morbidity and mortality. However, appropriate care of the growing number of geriatric patients with psychological distress requires knowledge of the psychosomatically relevant characteristics of these older patients. The aim of this CME article is therefore to convey the special psychosomatically relevant aspects of dealing with the elderly as well as the possible applications of basic psychosomatic care, taking into account the current literature.
Introduction
Age and illness are not identical, just as age does not necessarily go hand in hand with mental problems! Rather, mental disorders interfere with healthy aging, as they have been shown to negatively impact both the aging process and morbidity and mortality [1–3]. In particular, loneliness and social isolation are considered to be the most frequent risk factors for the development of psychological problems, whose harmful effects on health can certainly be compared with those of known noxious substances such as nicotine and alcohol consumption and obesity.
However, the mobility that often decreases with age, combined with restrictions in organ function, is also considered a risk factor for the development of psychological problems, as dealing with these – in part age-physiological – somatic changes becomes a challenge for many people. In this context, people today also like to talk about the “developmental task of aging”. The occurrence of somatic complaints often prompts many patients to seek medical clarification. However, the psychological stress caused by somatic complaints also leads many patients to seek medical advice. The main contact for most elderly patients in these cases is their primary care physician. As a result, GP practices with a primarily somatic focus are faced with the major challenge of providing adequate diagnostic and therapeutic concepts for both somatic and psychological comorbidities.
Curricular continuing education“psychosomatic primary care
The Working Group on Basic Psychosomatic Care of the German Medical Association developed the structured curriculum “Basic Psychosomatic Care” in Germany in 2001 [2]. To date, the goal of this curriculum is to promote the quality of care for mental and psychosomatic illnesses through targeted basic continuing education for interested primary care physicians and specialists. On the basis of this further training, it should be possible for physicians who are primarily trained in somatic medicine to recognize and assess the psychotherapeutic or psychosomatic, or psychiatric treatment needs of their patients and, if necessary, to arrange further specialist and/or psychotherapeutic treatment. At the same time, those patients who are in a situation of psychological distress but who are not seeking psychotherapy, or who do not need it, can be offered the option of psychotherapeutically informed intervention in the familiar primary care setting. The curriculum, which teaches these treatment options, is a component of the 4-level model of sustainable care for the mentally and psychosomatically ill [2].
- Module 1: Acquisition of basic psychosomatic knowledge during medical studies
- Module 2: Acquisition of basic therapeutic competencies within the framework of curricular continuing education in primary psychosomatic care.
–> Treatment of patients with no compelling need for psychotherapeutic action or those who are unable or refuse psychotherapy.
- Building block 3: Acquisition of competencies in specialized psychotherapy
–> Treatment of patients with psychotherapeutic need for action but without need for psychiatric or psychosomatic care.
- Module 4: Acquisition of specialist competencies in psychiatry and/or psychosomatics, or – in the case of a basic psychological profession – acquisition of the license to practice as a psychological psychotherapist.
–> Differential, specialist psychotherapeutic treatment of complex psychiatric or psychosomatic patients.
Epidemiology of mental disorders in older age.
In Western European society, aging often takes on a negative connotation, as it is associated with the onset of disease, coupled with a decline in physical and mental performance. This negative image can also be reinforced psychosocially by the normative limitations of working life, subtly conveying a diminishing social relevance to the individual. Yet, especially nowadays, a healthy aging process is quite possible, which can be confirmed by sufficient satisfaction with the quality of life of >65-year-old seniors.
However, it is also a fact that the prevalence of somatic diseases increases with age. The prevalence of mental illness among seniors, on the other hand, has long been controversial, due to an inhomogeneous and limited data base. The main reason for the difficulties in data collection was recognized to be that, on the one hand, mental illnesses can manifest themselves differently in old age than in younger people and, on the other hand, cognitive losses, as they occur in connection with the physiological aging process and especially with dementia or delirium, make it difficult to diagnose mental illnesses in old age. For Germany, the Berlin Aging Study of 1996 is still considered an important source of data to this day, as these data sets show that more than 50% of all over 70-year-olds suffered from psychopathological symptoms and up to 60% of elderly hospital patients [4] had psychosomatic/psychiatric comorbidity, but especially with subsyndromal symptoms, i.e., symptoms not fully meeting diagnostic criteria. However, the multicenter MentDis_ICF65+ study, launched across Europe in 2011, has since captured important new aspects related to the epidemiology of mental illness [3]. It could be shown that half of the interviewed >65-year-old seniors had biographically experienced a mental disorder once and one in four suffered from a mental disorder during the interview period [3]. The most common disorders were anxiety syndromes, affective disorders, and substance abuse [3]. Today, it can be assumed that mental disorders occur in all age groups, with certain disorder patterns predominating in older age. In addition to the disorders already mentioned, these include dementia [3]. The high clinical relevance of mental disorders in old age is based on the fact that they have a significant negative impact on morbidity and mortality of the affected persons, especially in the group of multimorbid geriatric patients [5]. For example, the aforementioned MentDis_ICF65+ study impressively demonstrated that older patients with a mental illness according to ICD10 have significantly more impaired somatic functionality compared to mentally healthy peers. In addition, it became clear that – conversely – physical limitations and disabilities were also closely related to the presence of anxiety syndromes, affective disorders, and somatoform disorders.
Close link between soma and psyche
These data underscore the close link between physical and mental health, especially in multimorbid very elderly patients. Limited psychological coping with physical changes can therefore lead to impairment of relevance to everyday life in affected patients, especially in the context of the presence of tumor disease. However, it is equally challenging for family members as well as professional caregivers in the health and social care system such as (family) physicians, nursing services and therapists [6]. The extent of this somato-psychic stress in the respective patients, as well as the coping strategies used, depends to a large extent on the premorbid personality structure of the persons concerned and their social environment [7].
However, although this close link between soma and psyche has immediate clinical relevance, especially in the very old patient, and the need for interdisciplinary, holistically oriented diagnostic and therapeutic approaches is becoming increasingly obvious, practical implementation in everyday clinical practice still remains rudimentary: At least two-thirds of patients with psychiatric or psychosomatic diagnoses are still treated exclusively by specialists in somatic medicine, both in outpatient and inpatient settings. Thus, somatically active specialists who treat elderly patients (such as general practitioners, geriatricians, cardiologists, orthopedists) are faced with the special challenge of always considering a psychosomatic cause or involvement in a differential diagnosis when an organic cause is excluded, but also in the context of individually pronounced experiences of suffering. The curricular continuing education in basic psychosomatic care is intended to give the primarily somatically oriented specialties the opportunity to make an additional, orienting assessment of the need for psychosomatic/psychiatric action. A prerequisite for effective application is therefore knowledge of the psychosomatically relevant aspects of dealing with the elderly, which will be discussed in more detail below.
Psychosomatically relevant aspects in dealing with the elderly
In order to create a stable relationship of trust between the practitioner and the elderly patient, there are a number of specifics that need to be considered:
1. development task “aging
Due to the increasingly close linkage of the physical, functional, mental, and social levels of health with increasing age, this topic takes on a central place among >60-year-olds, replacing other previously important central topics such as occupational problems, child rearing, and starting a business [1]. There is a reorientation of life goals, often combined with the desire to realize long-cherished dreams (“when I retire, then …”). Unfortunately, this reorientation not infrequently leads to a discrepancy between subjective experience and objective findings, whereby functional deficits can be both underestimated and overestimated. For many older people, therefore, the realization of physical, functional or even cognitive limits as well as the realization of the finiteness of one’s own life becomes a challenging maturation or developmental task. In this case, resources must be developed or reactivated in the therapeutic setting and life goals must be reformulated in alignment with the available functions. Therefore, especially in multimorbid geriatric patients, it is advisable, in the sense of a holistic approach, to conduct at least a basic geriatric assessment in addition to the psychosocial anamnesis, in order to objectively record functional resources in addition to the functional limitations, which can be used therapeutically in the psychosomatic approach. In a psychodynamic sense, this reorientation and adaptation to new health-relevant conditions is usually also an individuation process, during which some patients require therapeutic support within the framework of basic psychosomatic care.
2. time factor
Functional limitations such as hearing loss, aphasia, or visual acuity reduction are not only a risk factor for the development of psychosocial distress [8]. They may also require planning for a longer time frame, just as mobility mitigations do. In addition, the older psychosomatic patient looks back on a long life history, which he should have sufficient time to rewrite. In this context, changed life circumstances and experiences of loss and mourning play a particularly important individual role, which is why their mention should be acknowledged by an appropriate time frame.
3. loneliness
After World War II, especially in Germany, family structures changed, including greater distance of living places between family members. While older people used to continue to live together within the extended family comprising several generations in the same house or in the same place and were cared for by the family, due to the more distant places of living, the organization of care must more often be carried out by the seniors themselves or by outsiders. In 2013, a survey of loneliness prevalence among 40- to 85-year-olds showed a rate of about 7%, with reported loneliness declining among the very old aged between 70 and 85 years [9]. Gender-specific research showed that women were more likely to recognize the importance of sustaining psychosocial contacts at an early age. Men, on the other hand, are still less likely to maintain close friendships, which is why they tend to enter into partnerships again in old age to compensate for this lack of interpersonal closeness. The causes for the development of loneliness in old age are manifold and range from immobilization due to illness with inability to leave the house to pathological grief reactions after the loss of a partner. According to a 2010 meta-analysis, good social networks are a protective factor for a 50% higher probability of survival [10].
4. (War) traumatization
The current generation of geriatric patients includes those born between 1925 and 1955. In Europe, they thus belong to the generations of “war children” and “post-war children” who may have experienced the horrors of the Second World War as well as National Socialism and the Holocaust either directly as direct victims or indirectly through family burdens. Many of these people suffered trauma that never received any consideration during the war and post-war period and remained untreated. In old age, with the increase of physical morbidity and dependence, the trauma sequelae often show themselves through trauma reactivations (= current situation reminds of repressed trauma situation and evokes comparable emotions; example: fireworks – bombing) or through re-traumatizations (re-experiencing of a comparable trauma evokes comparable emotions; example: loss of home by displacement – loss of home by moving into a retirement home). Only in this way can long repressed and never processed traumas become manifest. Traumatization thus also affects the social environment of the person concerned. A survey of professional nurses in outpatient and inpatient settings a few years ago found that 82% of respondents dealt with war traumatized patients and more than 75% of nurses also felt a direct impact of psychological distress on their daily care [7]. The authors concluded that sensitization of professional nurses has great relevance especially in dealing with very elderly war traumatized patients [7]. When working with very old (potentially traumatized) patients, it therefore makes sense in principle to obtain at least an orienting historical classification by asking for key biographical data. Basic historical knowledge as well as respectful treatment of the patient’s biographical experience contribute significantly to the formation of a therapeutic relationship of trust.
5. doctor-patient interaction
A key feature of working with elders is that the patient is at a stage in life that the younger physician is not even aware of. When interacting with younger patients or patients of the same age, it is usually easy for the physician to feel validated in his or her self-image as a giver of advice and a helper. The sometimes large age difference with older patients and the longer life experience inevitably associated with it can also cause insecurity and fears about one’s own aging in the younger practitioner [11]. Often there is also a reversal of the classic transference situation: while with younger patients the physician tends to assume the role of a parent, sibling or friend of the same age, with the older patient the younger physician tends to see himself in the role of the child or grandchild with all the associated fears, desires, anxieties and conflicts. In the countertransference, the older patient can also see himself, his son or grandson in a younger doctor and involuntarily feels in a sending function based on the longer life experience. Unresolved conflicts and dissatisfactions with one’s own or the son’s or grandson’s career may come to the fore, which, if recognized, should be used therapeutically.
Transference phenomena are not necessarily a problem, they should only be considered in principle and addressed at the latest when it becomes apparent that they threaten to develop into a conflictual and stressful situation for one or even both sides.
6. cognitive deficits
Among the most common psychological disorders in cognitively impaired people are depression and anxiety. These disorders are often closely linked to the occurrence of behavioral disorders, which are summarized in clinical practice under the term BPSD (behavioral and psychological symptoms in dementia). Several different approaches to the treatment of BPSD symptoms are described in the literature, but due to the still limited number of studies, no general recommendation can be made for any of the approaches. For affective syndromes in cognitive disorders, a systematic review is available, according to which a positive treatment effect could only be demonstrated for music therapy. Life review therapy approaches have shown positive effects, especially in nursing home residents, in terms of quality of life as well as memory performance, mood, and communication. Nevertheless, results of randomized controlled trials are lacking so far, also regarding effectiveness of individual versus group interventions. A systematic review of summaries of non-drug interventions in the treatment of behavioral problems in dementia concluded that only music therapy and behavioral therapy approaches were found to be effective in reducing BPSD symptomatology [12]. The technique of appreciative communication through active listening according to Carl Rogers, which has also proven itself outside the therapeutic setting, is also used in the concept of Validation. Although the validation technique has hardly been scientifically proven so far and has therefore not yet found its way into medical guidelines and recommendations for action, it now has a firm place in the field of nursing.
7. migration biography
The data on psychosomatic problems of older migrants is still thin, despite a growing population. Difficulties in understanding and being understood in the linguistic and figurative sense can be listed as the main reasons for this, both on the therapist’s and the client’s side. In addition to language barriers, traditional ideas of age and illness play a role, as does a lack of knowledge about psychotherapeutic treatment options. In most cases, the first generation has internalized traditional ideas and views of life in such a way that experiencing completely different rhythms of life within the host culture can seem like an extreme challenge, leading to psychological tension and feelings of disruption [13]. Age-related functional limitations, as well as physical illness and especially cognitive limitations, can challenge the traditional, internalized role model, which can lead to enormous tension, especially in strictly hierarchical family structures. Somatization disorders are a common diagnosis among immigrant patients [13]. This expression of psychological stress in the form of physical complaints can lead to interactively difficult situations in our primarily somatically oriented orthodox medicine, when the physical findings seem to be out of proportion to the complaints described – often pain. However, this pain can be interpreted as a symbolic expression of the perceived psychological pressure of suffering, which the patients are, however, not aware of. To relieve themselves, patients then often develop very regressive and appellative behavior, which is intended to secure the attention and affection of trusted persons, but also causes rejection in the other person. This attention can then be seen as secondary disease gain, whereas the primary disease gain consists in the (unconscious) defense against the psychological burden of the outwardly presented pain. This can lead to undesirable tensions in everyday practice. Especially in connection with this growing group of patients, an awareness of their special stress situation is necessary for adequate therapeutic care.
8. crises, life fatigue and suicidality in old age.
Old age brings with it a variety of psychological life crises, be it losses of important people, important physical, psychological, and social functions, or coming to terms with finitude, death, and dying. Especially in view of the current debate about personal decisions regarding one’s own death, many elderly and especially very elderly people are confronted with their own conflicting memories, reflections and fears, which they experience in the conflicting field between autonomy desires and experiences of connectedness with people important to you. Here, family doctors are particularly in demand, who offer themselves as serious interlocutors on an equal footing, promoting psychological development and offering neither quick solutions nor dismissive dismissal, but rather a serious discussion aimed at repetition and continuation, with an understanding of the background and the search for possibilities for help and support [14].
Practical implementation
In Germany, basic curricular training in basic psychosomatic care is an obligatory requirement for general practitioners in internal medicine, general medicine and gynecology, whereas it is only optional for other specialties. In everyday practice, therapy sessions are at least 15 minutes, usually 20 minutes, and can also be coupled with appropriately justified documentation. Unlike outpatient psychotherapy, basic psychosomatic care does not require an application to be submitted to the payer and there is no limit on the number of sessions. In addition, many patients experience the conversations as less stigmatizing because they are familiar with the primary care setting. Due to the pandemic, video consultations are increasingly used in everyday practice and offer an interesting alternative in basic psychosomatic care, especially for patients with limited mobility.
Take-Home Messages
- Psychosocial stability promotes healthy aging.
- Impaired coping with somatic changes in old age can lead to psycho-social stress with disease value.
- As a basic service for seniors under biopsychosocial stress, psychosomatic primary care offers a meaningful opportunity for initial relief and reorientation in the familiar environment of a family doctor.
- Multimorbid and mobility-impaired patients in particular can receive effective care for psychological distress in a timely manner and without external referrals due to the flexible design options using the familiar primary care physician relationship.
- Primary psychosomatic care should be seen as a complement to existing psychosomatic and psychotherapeutic therapies, not as a substitute for them.
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InFo NEUROLOGY & PSYCHIATRY 2022; 20(2): 10-15.