REBECCA ROBERTS, host:
This is TALK OF THE NATION. Im Rebecca Roberts in Washington. Neal Conan is away.
Dr. Marc Agronin is a psychiatrist in Miami, where his average patient is 90 years old. Mental issues for the elderly often get filed away as general signs of aging and decline, but Dr. Agronin sees them as areas that deserve attention and treatment with the same dignity awarded to every other stage of life.
In his new book "How We Age," he argues that doctors give up on old people too easily because of our own impatience and despair with aging. We'll talk with Dr. Agronin this hour about mental health in old age - how our brains and bodies develop, and how mental illness can change when people reach their 80s, 90s and beyond.
Later in the hour: This morning, President Obama released his federal budget for next year, all $3.7 trillion. Senior Washington editor Ron Elving will explain where we go from here.
But first, aging and mental illness. If someone in your life is dealing with mental health problems late in life, or if you're wrestling with these issues yourself, tell us your story. Our number here in Washington is 800-989-8255. Our email address is firstname.lastname@example.org. And you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
Dr. Marc Agronin joins us now from member station WLRN in Miami, Florida. He's the medical director for mental health and clinical research for the Miami Jewish Health Systems. Welcome to TALK OF THE NATION.
Dr. MARC AGRONIN (Miami Jewish Health Systems): Thank you so much.
ROBERTS: And you say we're more comfortable, sort of generally as a society, talking about death with dignity than life with dignity. What do you mean by that?
Dr. AGRONIN: It's true. I make the observation that we are very accepting of hospice nowadays. The essential message of hospice is that 'til the very second that someone's life ends, we will be there for them; we will control their pain; we will provide them with as vital and meaningful a life as possible. It's a wonderful mission.
My point is that we need to take a step back, that there are many older individuals who have years - if not a decade or more - ahead of them, and we need to bring that same spirit and that same energy to helping them as well.
ROBERTS: So since you are a geriatric psychiatrist, you are generally treating people who have an issue that they are going to die with, not that they are going to die from. Sorry, go ahead.
Dr. AGRONIN: That's true. The most common diagnosis that I treat, and this would be the same for any geriatric psychiatrist, would be Alzheimer's disease with many different associated changes in both mood or behavior. And probably second to that would be mood disorders such as depression and then anxiety disorders.
ROBERTS: So describe an average day for you.
Dr. AGRONIN: I have a clinic on the grounds of our long-term care institution. We actually have, on grounds, the largest nursing home in Florida. And in the clinic, I'll see individuals ranging from those with Alzheimer's disease who are demonstrating behavioral disturbance such as agitation; I work with individuals suffering from depression - an incredible diversity of individuals, every walk of life, every type of symptom.
What's wonderful is to see individuals, especially of this current generation -the 80- and 90-year-olds who might in the past have never considered seeking psychiatric care, to come to our clinic to not only participate in either individual or group psychotherapy, but to learn that there's change that's still possible regardless of their age.
I recently had a man come into my office in his mid-90s. He's been suffering from depression for a number of years. And he really felt that there was just nothing we could do for him. And indeed, I would say this is probably the way a lot of us look at old age, as if we hit a certain point where change is simply not possible.
We've worked with him. We've been persistent, and just the other day he came in and said: Dr. Agronin, I want to tell you my life has been turned around. And when I asked him what he meant, he talked about how through individual therapy he was able to come to certain realizations that really changed his outlook on his depression, on his marriage, on the interactions with his family. It really made a tremendous difference.
And I thought: Here it is at 96 - for someone to make such a change should really give all of us incredible hope, especially for the beloved elders in our lives.
ROBERTS: And is this talk therapy; is it medication - is it both?
Dr. AGRONIN: It's often a combination. We use medications when the severity of certain illnesses warrants them. But we also encourage some form of talk therapy. And it really doesn't matter how old someone is. Even when individuals are facing early-stage memory changes, we can still intervene effectively with different forms of talk therapy.
ROBERTS: And you know, this is - obviously, if you're talking about people who are in their 90s now, they're World War II generation. Do you find that that doesn't necessarily come easily to them?
Dr. AGRONIN: It's true. What I often see is individuals who, even if they experienced some adversity earlier in life, they've really been able to adapt throughout middle life. But then, something happens.
It might be a change in memory. It might be a physical illness or infirmity. We see a lot of individuals who come into our facility after suffering an injury, such as a hip fracture, and then everything seems more difficult for them - and for their families as well.
This is a critical point at which we really need to intervene because sometimes what happens is that a depression develops or some other form of mental illness, and it's not recognized as such. And so the individual doesn't get the treatment that they need at that critical juncture.
ROBERTS: And because so much of finding the right treatment for a mood disorder, for instance, is so individualized, do you find that that - first of all, you have less time to kind of try out different drugs and different dosages to see what works, because this person, you know, is very old. But also, do you find that drugs just act differently in an older body?
Dr. AGRONIN: The good news is that individuals will respond to treatment -whether it's medications or therapy - much in the same manner that younger people will as well.
I think we have this notion that as you age, you're less able to change, or the brain is less able to adapt. But that's often not true. Even in the setting of memory disorders, it can be more difficult, and sometimes our options might be more limited. But it doesn't mean that there still is not some way that we can bring some improvement to the person's situation, regardless of what the diagnosis is.
ROBERTS: Let's hear from Holden(ph) in Elk Grove, California. Holden, welcome to TALK OF THE NATION.
HOLDEN (Caller): Hello?
ROBERTS: Hi, Holden, you're on the air.
HOLDEN: I have a couple comments. I actually live with my 92-year-old grandfather. I'm 27 years old - and have for the last couple of years. And so I've just been able to experience so many amazing things with him and kind of act as the bridge between, you know, the generation of my siblings and him, and kind of be able to be a historian for our family as well, and kind of fill in family history.
One thing I've noticed is that as his physical state starts to deteriorate and kind of reach this point where it doesn't seem like there's a lot that could be done to help him physically - this is a man who stayed incredibly active, incredibly healthful his whole life - the congruence of his mental state starting to loosen, with his physical state starting to deteriorate, is very strong. Like within a few weeks of him not being able to exercise, it seemed like his association started to loosen up; he started to really kind of exhibit some of those early signs of Alzheimer's.
And just in general also, just - your conversation is really about change, has really kind of made me think about his change that he's gone through in his life, you know: growing up in the Depression, dealing with racism and being a very racist person - just like I'm sure so many of his contemporaries and this society was at that time - and seeing him change to the point where he is now, is pretty amazing in itself as well. So anyway, that's my comment.
ROBERTS: Holden, thank you so much for your call. And Marc Agronin, that relationship between his physical health and his mental health, is that something that's pretty common?
Dr. AGRONIN: Sure. We see that at times. If someone has suffered an injury and for whatever reason, they've had some degree of brain damage; or they had surgery, and they suffered some complications afterwards, it might be a primary effect of whatever the disease state is that they're suffering from. But it also might be medications.
And this is where it's so critical to get someone in to be evaluated, and to take a step back and ask: Why are these changes going on? Is there something that's driving them, that's actually reversible?
And this is where - I'm certain - we sometimes fail, because make assumptions that this is simply old age, or this is a disease state that we can't do anything about. And I've had so many instances where that's not the case.
In the book, I talk about one particular situation where a man came to me, having been completely written off as suffering from very rapidly progressive Alzheimer's disease. In fact, when he came to my office he could barely walk, his speech was going, and I realized quite quickly that this was not as simple as Alzheimer's disease.
But if you would have seen this individual and reviewed his history, it would've been quite easy to simply say, this is a man in his early 80s; there's not much we can do. Let's prepare for the end.
And yet as it turned out, once we did a workup, he had a completely treatable brain tumor. He had surgery, and he emerged - I would say not 100 percent, I would say 110 percent from this surgery.
Now, this was three years ago. He's still active. He's a vital individual, and it speaks to the fact that sometimes, we can miss very simple things.
Now, not every situation will be that simple, and often there are more complexities and the outcome won't be as stunning as it was with this individual. But there are still interventions that can improve the situation, that can either alleviate some degree of depression or bring some meaning to someone. And then we can draw upon their individual strengths.
The man was talking about his grandfather. And without question, this is someone who's been through so much in his life and certainly has an incredible history and strengths that we can draw upon. It's really a matter of getting to know and understand the person behind the disease. And the better that a physician can do that and the treatment team can do that, the outcome will always be superior.
ROBERTS: Well, also, having an injury and not feeling your best and having your mobility limiting is depressing at whatever age you're at.
Dr. AGRONIN: It's demoralizing. It's depressing. And - but one thing is clear, is that we can do something about that. We can't cure aging and right now for Alzheimer's disease and other disease states, we have treatments; we don't have cures.
But if we talk about loneliness, we talk about individuals feeling demoralized, being cut off from certain activities, we can do something about this. And this is where it takes the energy and the creativity of not only caregivers, but also of younger generations to get involved.
Right now, we still have the greatest generation with us. These are individuals who, literally, saved our country. And I feel so strongly, and I see in my daily practice, that we have not only the obligation but also the opportunity to remain vitally involved with these individuals and not give up, and realize that there are always avenues to intervene.
ROBERTS: Do you think we should try to cure aging?
Dr. AGRONIN: I don't see aging as a disease. I see this as an inherent part of living. And so the idea of curing it, to me, doesn't make sense. And if you look at mainstream aging researchers, everyone would essentially say the same thing, that aging is a physical property of nature. We need to accept it, but we also need to try to make life better.
ROBERTS: That's geriatric psychiatrist Dr. Marc Agronin. His book is called "How We Age." We will talk some more with Dr. Agronin after this break. You can join us by giving us a call, 800-989-8255. Or send us email, email@example.com. I'm Rebecca Roberts. It's TALK OF THE NATION from NPR News.
(Soundbite of music)
ROBERTS: This is TALK OF THE NATION from NPR News. I'm Rebecca Roberts.
Many people fear growing old. And too often, says Dr. Marc Agronin, we're so focused on what we'll lose that we forget that older people experience joy and love just like everyone else.
We're talking with Dr. Agronin this hour about his book "How We Age." And you can read about what he learned from a nursing home resident named Esther, in an excerpt at our website. That's at npr.org.
We've been talking about how mental illness can change when people get older, and we want to hear from you. If you or someone you know is wrestling with these issues, give us a call at 800-989-8255. You can also always reach us by email, firstname.lastname@example.org.
Let's take a call from Janet(ph) in Minneapolis, Minnesota. Janet, welcome to TALK OF THE NATION.
JANET (Caller): Thank you. I'm wondering about developmental disabilities. (clears throat) Excuse me. My husband was diagnosed with Asberger's syndrome, or high-functioning autism, less than a year ago - basically because I finally hit the wall and realized that he was dependent on me.
He tested socially at 18 years and three months, more than 35 years behind. And I, in retrospect, now believe that both my parents and my in-laws probably had this, undiagnosed. My dad was dead before it even existed as a diagnosis in this country, which was 1994.
And what I'm seeing is, as my husband and family members get older and are dealing with more and more changes, which is very difficult for them, their coping skills aren't there to handle it.
ROBERTS: And Janet, do you think that had he gotten a diagnosis younger, it would have been a different outcome?
JANET: Yes, I think my adult daughter has it also, and so unfortunately he's not accepting the fact, and she's avoiding the whole thing, and it's incredibly painful to watch.
ROBERTS: Marc Agronin, it seems like a couple of things are at play. Well, many things are at play in Janet's story, but certainly there is, you know, the changes that happen as life changes that might highlight an underlying disorder; a growing awareness on the part of the mental health community; you know, more diagnosis, more attention, all happening at once.
Dr. AGRONIN: Sure. There are a number of very important points here. The good news is that the stigma to mental illness is slowly decreasing. And so for this woman and her family, perhaps several decades ago, we would not even consider such a diagnosis - whether we didn't even understand it, but the idea of even considering this later in life would not have happened.
The more we can understand the underlying changes that someone goes through as they age, with mental illness, the better we can intervene. And the good news is that there are many effective treatments for nearly every form of mental illness.
Probably one of the most difficult issues is not whether or not there's a treatment, it's whether someone will get into treatment. And it sounds like in her family, there might be some degree of denial, which can complicate it.
The more we get the message out that there's not a family in the country that's not touched by some form of mental illness, the more we can realize that these are common, that they're diseases like any physical disease, and that there are treatments.
And age is really not a barrier at all. This is a key lesson that I've seen time and time again with older individuals. They enter the clinic, and families are despairing over the situation. They don't understand it. Once we shine light on it, once we form a bond with them and engage a treatment, the outcome at times can be spectacular.
ROBERTS: Janet, how has your husband responded to the idea of getting treatment?
JANET: Let's just say I was served with divorce papers last week.
ROBERTS: Oh, I'm so sorry.
JANET: Because in his mind, if I quit saying it's a problem, it'll go away - when I know it won't.
Dr. AGRONIN: It's unfortunate that it's come to that, and I'm so sorry to hear about that. Sometimes, we have to weigh the risks and the benefits of different treatments and make a bargain that's not always ideal.
A lot of individuals, as they age they treasure their independence so much that the idea of going into treatment can seem very frightening. And we have to introduce at a very slow rate, and decide what makes sense at a given time.
I just had a fascinating conversation this weekend with a patient I was evaluating, and the family. He really is resisting the idea of having help come into the house because it's symbolic for him of a change, of loss of his independence.
And my suggestion to the family was to take a step back and focus on other aspects that can enhance his life, and see if over time we can introduce it more slowly or in a different way that will have a better outcome.
ROBERTS: And Janet, thank you so much for calling in and sharing that, in the hopes that other people don't feel like they're quite so alone. We really appreciate your courage there.
We have an email from Janine(ph) in Modesto, who says: My grandmother has been widowed now for four years. I believe that many of the behaviors she's exhibiting are as a result of depression.
She's become more dependent on my mother, her primary caretaker. My mom has become more reluctant in spending quality time with Grandma because of her neediness. The relationship between my mother and aunt is increasingly deteriorating. How can I, we, convince Grandma to get some mental health help?
Dr. AGRONIN: Well, this can be a very generational challenge because as I mentioned earlier, for a lot of individuals in their 80s and 90s, the idea of going to see a psychiatrist is frightening. They associate it with being severely mentally ill, or receiving treatment against one's will.
And yet I find often, when they finally meet with someone, they find it's a very different experience, and they really embrace it.
I often suggest, in a situation like that, to start with the internist because if someone has a good relationship with their doctor, and they're relatively compliant, sometimes you can ask the physician to be the starting point, whether it's starting a medication - in this case, perhaps an antidepressant - or simply talking to someone, to understanding - to try to understand what the barriers are; it might provide a better avenue to get the person into treatment.
But in the end, you have to be persistent because the longer someone avoids getting treatment, the possible downside only accumulates.
ROBERTS: Let's hear from Greg(ph) in Minneapolis. Greg, welcome to TALK OF THE NATION.
GREG (Caller): Hi, thanks for taking my call. Right now, I'm struggling, watching my grandfather age. He's 85. Seems as though he's suffering from some form of Alzheimer's. But more importantly, to my call, is he suffers from a lot of guilt.
And like a previous caller mentioned - or I believe it was the doctor - this is the greatest generation of Americans we've ever seen. And they struggle with guilt stemming from issues of war.
And I was wondering if the doctor has encountered that in his practice. And if so, how does he deal with those issues?
Dr. AGRONIN: I work with lots of veterans, in particular lots of World War II veterans. And sometimes we can see re-emergent symptoms from the past. Someone may have had post-traumatic stress after the war for a few years and got over it, and then certain stresses of aging can reawaken that. And certainly, guilty feelings can be some of that.
Part of the question is: How does it affect him on a day-to-day basis, and is he willing to talk to someone about it? Because it - feelings like that can be quite amenable to some form of talk therapy. We have a much clearer understanding of post-traumatic stress disorder, especially as it unfolds over time. Medications can sometimes be effective.
But the key is to actively bring him for an evaluation, and try to find some form of therapy for him. If he's a veteran, sometimes the local veterans hospital may have a positive association for him, and he'd be willing to go there and engage in some treatment.
But I would encourage you to be persistent and to be hopeful, because when he sees that someone cares for him so deeply and values him, he might be more apt to realize that there is something he can do about it, and he'll be willing to engage in that.
ROBERTS: And do you find that that generation also is more prone to, say, self-medication with drinking or other addictive behavior?
Dr. AGRONIN: Well, I would say most generations can be prone to that. If anything, we're seeing greater degrees of substance abuse with newer generations coming up.
So in particular, with the baby-boomer generation, my guess is we'll see more of a trend of late-life substance abuse. But it is not only a frequent issue but something that we often miss, because we have stereotypes that someone in their 80s and 90s is not drinking. Or they're suffering from the effects of it, but we don't ascribe it to the use of alcohol or some other drug; we ascribe it to age. And so we can miss it.
So this is, again, where that evaluation is so key because someone who works with older individuals will know the right questions to ask, and will be able to find what's behind the mask at times, and identify what may be the single most important problem for someone.
ROBERTS: Addiction also - obviously - a mental disorder in many ways. Does it manifest differently in older people?
Dr. AGRONIN: I would say the most common situation I see is an older individual experiencing changes in memory or frequent injury - they're falling a lot - and we don't consider soon enough the fact that they could be drinking.
Keep this in mind: If someone has memory loss, that one cocktail a day that they enjoy might become two or three because they simply forget that they had the drink earlier. And family members often are very reluctant to intervene in these situations, or they simply don't know about it. Or they don't take it seriously enough because they think, well, this person is in their 80s and 90s; it's not a problem. But this is a great mistake because then what happens is something catastrophic happens, and then we're dealing with a much more serious problem.
ROBERTS: We have an email from Rose(ph) in New York, who says: My 84-year-old mother recently was diagnosed with aphasia - which is a language disorder, right?
Dr. AGRONIN: Yes.
ROBERTS: Sort of losing some speech or the meaning of speech.
Dr. AGRONIN: Yes.
ROBERTS: Our problem is that she will not let her friends and other family know about it, and feels that it will present more of a problem. We want her to have speech therapy, but she refuses.
Dr. AGRONIN: Well, aphasia can have many different causes, but it can be extremely frustrating for someone and embarrassing, especially someone who prides himself with their social skills. In fact, a woman I saw this morning, since having a stroke, has had very minor word-finding difficulty. But what she told me this morning is that she used to be a great storyteller. And whenever she's in social situations, certain words just don't come to her. And she's embarrassed and so she's stopped going.
For many of these individuals with aphasia, if it's due to stroke or some other type of brain damage, speech therapy can be very effective. And at times, you do have to put a little bit of pressure on the person to get them in there because the outcome and the advantages far outweigh the downside here.
In Alzheimer's disease and other forms of progressive dementia, as the disease progresses, people eventually lose language function. And so then in those situations, we're certainly more limited because any gains you could get from therapy are lost very quickly.
ROBERTS: So, then, it's a question of trying to figure out what the aphasia is a symptom of?
Dr. AGRONIN: And getting to know the person, and finding ways to communicate with them. In one of the chapters in the book, I talk about a woman who had a particular form of dementia in which her memory and other cognitive faculties were relatively well-preserved, but her language function itself was going. And as I got to know her, I realized she had other ways of communicating with me -through gestures, through certain vocalizations.
I tell the story - how one day, I was sitting in my clinic and the door burst open. She came in; she grabbed me by the arm. And she literally pulled me out of my desk and pulled me down the hallway, and pushed me up to her sister-in-law, who was in pain and needed some medical attention. And I marveled at how well she was able to make herself known and to communicate.
And we see this often. The more you know someone, and the more comfortable they are with them - with you, whether you're a caregiver or whether you're a clinician, it can be easier to find ways to still get a message across - or at least show them that they still have value, and you want to know what their perspective is.
ROBERTS: You're listening to TALK OF THE NATION from NPR News.
Let's take a call from Melissa(ph) in Point Pleasant, New Jersey. Melissa, welcome to TALK OF THE NATION.
MELISSA (Caller): Hi. Good afternoon. How are you?
ROBERTS: I'm well. How are you?
MELISSA: I'm good. I had a comment. I have an elderly grandfather. He is 74. And about four years ago, he suffered a heart attack. And since that time, he became unable to live. He had to go into an assisted-living type situation. And we found as a family that - we moved him to four different facilities because we found that they weren't addressing the mental health aspect at all. And you know, and it was affecting his care. I mean, he had a heart attack. There was no interventions being put in place for him because of his age and his medical condition. But I found that disturbing.
And, you know, in general, that's the common - that was like, the common factor in this area. I live in New Jersey, but he was up in New York. And a lot of the physicians and the care in the long-term care facility he's in at the nursing homes, they don't seem to address that - or link up the physical, I mean, and the mental pieces. And I was wondering if you thought that these facilities, since they are going toward, you know, when - ultimately, these people are ending up in large groups, in numbers in these facilities. Do you see them going toward that, you know, focusing in on that mental health piece and recovery towards, you know, independence?
Dr. AGRONIN: Well, that's - it's true that sometimes, the major deficit might be that someone has a depression or some other mental illness that is simply not being addressed. And so while they've recovered physically, they still are suffering from anxiety or depression or some other mental change that's really hampering not only how well they can adapt to the situation, but how involved they can be in the - wherever they're living, whether it's a nursing home or an assisted-living facility.
You have to be actively involved because for every nursing home, there are certain regulations which mandate mental health care, and so a facility that doesn't have that - there's something that's just not being done right.
But I also emphasize to families that when someone goes into a nursing home or some other form of long-term care setting, it's not that you drop them off at the door and that's the end of the story. Think about the analogy with schools. If you're child goes to a school, you're involved with the PTO; you know the teachers; you track how things are going. You have to maintain that involvement with any long-term care setting as well, to make it a living community.
There's nothing inherent to a nursing home that has to make it a terrible place. But it depends upon the active involvement of not only its residents, but family members and caregivers as well, to transform it.
And I can show you - at any given nursing home, you can find one room where an individual's family is involved, and they've really made it a home; in another room where those efforts have not been made and it is - it can be a very lonely and cold existence. So we certainly have to do better. And you have to maintain that involvement with the person and where - the setting in which they're residing.
ROBERTS: And I should also mention: Your book, "How We Age," is full of hopeful, optimistic stories about things you have learned from people at this age.
Mr. AGRONIN: In every chapter, I describe a situation that seems insurmountable. And I emphasize a point, that I'm not putting a gloss on aging. I describe some of the worst situations because that's what I see on a daily basis. These are individuals that I evaluate - suffering from memory loss, from physical disability, from social problems, many of whom have hit a wall. And frankly, as a physician, sometimes I am stumped, and I'm not certain what to do.
But those are the key cases in which you have to persist and realize that there always are options with respect to treatment, and these are options that have scientific validity to them. And so I describe in each story how I'm able to overcome those very difficult challenges.
ROBERTS: Dr. Marc Agronin is a geriatric psychiatrist and the medical director for mental health and clinical research for the Miami Jewish Health Systems. He joined us from member station WLRN. You can read an excerpt from his new book "How We Age: A Doctor's Journey into the Heart of Growing Old," at our website. Go to npr.org, and click on TALK OF THE NATION.
Thank you so much.
Mr. AGRONIN: Thank you so much. It's been a pleasure.
ROBERTS: It's TALK OF THE NATION from NPR News.