Clinical Geriatrics

I’ve been practicing geriatric psychiatry since the early 1980s. Over this period, patients have come and gone; some left because they got better, some because they did not. But there is also a group of patients who neither get better nor leave. With time, they have become an increasing proportion of my clientele. A typical patient would be a 70ish, divorced/separated/widowed, African-American female, who along with her hypertension, obesity, arthritis, and diabetes has also been diagnosed with depression. The depression is relatively long-standing, and despite modest benefits from various antidepressants, most of which seem to produce only side effects, I continue to prescribe them. During the course of her treatment, this patient probably would have had several sessions with my psychiatric social worker focusing on her life situation, but again, with little benefit. It is unlikely that her symptoms would significantly improve in the future, and therefore she would continue to see me until I retire or she dies.

The details of each of such patients’ lives vary. Undoubtedly, if my practice setting was different—a private practice in the suburbs, for instance—the specifics might be dramatically different. But I suspect that the theme would be the same. The patient’s life and her illness are inextricably connected—but not because over the years her life has been insidiously warped by her psychiatric condition; she had no such problems until she was in her late 60s. Nor has the trajectory of her life been dramatically altered by the seriousness of her psychiatric illness. Her illness is not severe, and her life has continued on its course. Rather, her life and her distress seem one and the same.

This patient and her associated problems can be viewed from many perspectives. From the sociological, she is a member of the African-American Diaspora who migrated north during and after World War II. This is why she lives on the South Side of Chicago, in an area that became predominantly black in the 1950s due to white flight. Her uncles and aunts, if not already deceased, still live in the South, while her brothers, sisters, nieces, and nephews live in Detroit, Washington, Cleveland, and LA. Her children, some of whom have become successful, live in the suburbs or have been taken by their careers to distant cities. They are busy with their jobs, their spouses also work, and they have children and grandchildren of their own. Even those who live in the greater Chicago area see her primarily on holidays or her birthday.

She lives on a Social Security check and spends the majority of it on her rent. She can shop for food and necessities at the corner convenience store, but there is no other retail shopping nearby. Shopping malls are in the suburbs, inaccessible to those without a car, and downtown stores where she might at least window shop require taking several buses. Her major means of transportation is the Medi-Van, which brings her to her numerous physician visits. She can visit distant relatives only when someone else pays the airfare. This means that she usually only travels to attend funerals.

She grew up on a farm, attended school through the eighth grade, worked in a factory, kept house, and brought up her children. Free time was spent at church or at family events. She had no time for tennis, bridge, or hobbies. Now she watches TV, talks occasionally on the phone, and looks out the window. On Sundays and holidays she still goes to church, but because of problems with transportation she no longer attends Wednesday bible study. She can do some light housework and still is able to cook, but since it is only for herself, she keeps this to a minimum.

From a psychiatric perspective, she presents many of the features of depression. She complains of decreased mood with frequent crying spells, difficulty sleeping, low energy, poor concentration, and a decrease in self-esteem.