Talking About Mental Illness in Long-Term Care: “If They Weren’t So Difficult”

In first encounters, age is one of the earliest characteristics we notice about other people.¹ This simple observation has, in part, served as the basis for this column series, which has sought to take a critical lens to the language employed when addressing elderly residents and patients with chronic illnesses as well as populations as a whole. 

To echo Cuddy and colleagues,¹ becoming aware of an individual’s age is not inherently offensive; rather, it is our preconceived notions of the elderly that can become “destructive.” Although to a lesser extent than decades past, stigmas and judgments risk fueling misconceptions about this population.

Mental illness remains complex at any age. In this final column, we will be focusing on this complexity in older adults—difficulties which are often complicated by the interplay of both mental and physical illnesses. This interplay creates “cycles,” and anyone who works with the elderly knows them well. Grandma’s hip fracture results in a lengthy hospital stay away from her home—where she has been living independently for years—and can perpetuate a depression that demotivates her ability to rehabilitate, resulting in a loss of mobility and a fear of never returning home. Alternatively, living with dementia may interfere in Grandpa’s ability to take his diabetic medications at the right time or dose, which puts him at ¬great risk for secondary complications of unregulated blood sugar levels. And, in both scenarios, the caregiver suffers a silent burnout.

These are difficult health care challenges to address and are largely unique to the older adult population. In fact, such challenges have served as the basis for prior iterations of this column when examining the language used to describe other mental and physical comorbidities with which older adults live. In this final piece, we will tie the knot by examining the notion of “being difficult” in the context of care of older adults, the implications of this mindset, and offer some closure moving forward.

Veritable Challenges

What I have come to appreciate as a physician-in-training is that, for various reasons, the field of geriatric medicine is difficult. Coordinating health care between practitioners and services is difficult. The social situations of patients and their families are difficult. Loss of independence, medication management, and end-of-life care are all difficult. 

However, what is surprisingly not difficult, typically, is the patient themselves. They largely comprise an under-serviced yet wholly appreciative demographic that never asked to live with their comorbidities, never wished to be tossed and turned in fragmented health care services, and, above all, never desired to be a burden to anyone. 

Yet throughout all this, it becomes deceptively easy to attribute medical challenges to who they are as a person.

Some will argue that an older adult’s personality traits, such as being “stubborn,” contribute significantly to the complications of their management (eg, their refusal to take their medications). True as this may be, working with patients of varying personalities lends itself to the art of medicine—medicine is still largely an art—and taking the time to listen empathically will enable the care provider to gain important insight into their lives and the reasons for such behaviors. If, instead, these apathetic or treatment-resistant behaviors stem from a progressive dementia or another personality-altering illness, we have already discussed^2-4 how using inappropriate language stigmatizes the elderly as if somehow having the illness was their fault. Although empathy may not be the default, it serves everyone better than lamenting that the patient is “being difficult.”

Recurring Themes

Moving forward, we must bear in mind the pervasive influence of ill-suited language on how those around us begin to perceive the elderly. As the coming years present critical opportunities to train students in geriatric health care, it becomes ever more important that we create positive, stigma-free learning environments. Those who work with the elderly know this message well: we treat the illness of the patient, not the patient as an illness.

Another theme that has permeated this series, and is worth reiterating, addresses the notion of being the “voice for the vulnerable,” ie, speaking in a manner as patients themselves would wish to be viewed. By this, I am not suggesting that an older adult should be assumed incapable of providing care for themselves. It has been shown that the majority of older adults are capable of moderating the impact of stressors that arise with age,⁵ and subjective well-being does not automatically diminish in later adulthood.⁶ Rather, for me, the term “vulnerable” serves as a constant reminder of the common hardships they face when finding themselves within a fragmented health care system.

Moving Forward

Labelling an individual as “difficult” erodes the practice of patient-centered care that we ought to be cultivating. Mental illnesses in the elderly, coupled with physical comorbidities, create particularly challenging medicine. It is my firm belief that any sort of stigmatization—intentional or ingrained—ultimately provides a disservice to patients and deters trainees from pursuing careers working with the elderly. 

We are well aware that aging patients and aging parents present new challenges to society, but I believe they present new opportunities as well. The skills of patience, problem-solving, and positivity are powerful tools in navigating these waters. Those among us who are immersed in the care of this population each day strive towards a common goal: to optimize quality of life through the largest and smallest acts, perhaps learning a bit more about ourselves along the way. 

1. Cuddy AJ, Norton MI, Fiske ST. This old stereotype: the pervasiveness and persistence of the elderly stereotype. J Soc Issues. 2005;61(2):267-285.

2. Perrella A. “All there.” Annals of Long-Term Care: Clinical Care and Aging. 2016;24(1):15-16.

3. Perrella A. “But she’s so depressing.” Annals of Long-Term Care: Clinical Care and Aging. 2016;24(4):21-22.

4. Perrella A. “The diabetic in room 204.” Annals of Long-Term Care: Clinical Care and Aging. 2016;24(8):17-18.

5. Janssen BM, Van Regenmortel T, Abma TA. Identifying sources of strength: resilience from the perspective of older people receiving long-term community care. Eur J Ageing. 2011;8(3):145-156.

6. Henchoz K, Cavalli S, Girardin M. Health perception and health status in advanced old age: a paradox of association. J Aging Stud. 2008;22(3):282-290.