Get a geriatric psychiatric evaluation when a parent shows persistent withdrawal, low mood, new anxiety, sleep or appetite changes, memory decline that affects daily life, personality change, or any talk of not wanting to live. These are not normal aging. A geriatric psychiatrist distinguishes depression, anxiety, dementia and delirium, reviews medications and treats what is found.
The phone calls usually come from a daughter or son. Dad has stopped going to his Tuesday golf game. Mom calls six times a day about the same worry. One parent has become short-tempered with the other after fifty years of marriage. A parent who was always sharp is repeating stories, or has let bills pile up. The question behind the call is always the same: is this just aging, or is something wrong?
Often something is wrong, and often it is treatable. Geriatric psychiatry exists because mental illness in older adults looks different, is caused by different things, is treated with different doses and different cautions, and is missed far more often than it should be.
What is not normal aging
Aging brings slower recall, longer time to learn new things and more effort to multitask. It does not bring depression, and it does not bring persistent anxiety. Late-life depression affects somewhere between 5 and 15 percent of community-dwelling older adults by most estimates, and far more among those in hospitals and nursing facilities, yet it is diagnosed in a fraction of them. The reasons are that older adults are less likely to say they feel sad, more likely to describe physical complaints, and more likely to have the symptoms attributed to a medical condition or to age itself.
The signs that should prompt an evaluation include:
- Withdrawal from activities, friends or family that used to matter.
- Irritability, anger or suspiciousness that is new.
- Persistent worry, repeated calls or questions, new fears about health, money or safety.
- Sleep changes, especially early waking or sleeping most of the day.
- Loss of appetite and unintended weight loss.
- Multiple physical complaints without a clear medical explanation.
- Memory or thinking problems that affect daily tasks: medications, bills, cooking, driving.
- Neglect of hygiene, the home or the dog.
- Increased alcohol use.
- Any statement about being a burden, not wanting to be here, or life not being worth living. Older white men have the highest suicide rate of any demographic group in the United States, and these statements must be taken seriously.
Four things that look alike
The central job of a geriatric evaluation is separating four conditions that overlap heavily in older adults.
Depression
Late-life depression often presents without sadness. Instead there is apathy, slowed thinking, poor concentration, fatigue, pain and a loss of interest that family may read as laziness or stubbornness. It commonly produces memory complaints severe enough to be mistaken for dementia, a picture once called pseudodementia. The tell is that a depressed person tends to say "I don't know" and is distressed by the memory problem, while a person with dementia tends to guess and minimize.
Anxiety
Generalized anxiety in older adults often centers on health, falls, finances and the safety of family members. It can appear for the first time after a medical event, a fall or a bereavement. It is frequently treated with benzodiazepines, which in older adults raise the risk of falls, fractures, confusion and accelerated cognitive decline, and which a geriatric psychiatrist will usually work to reduce.
Dementia
Alzheimer's disease and the other dementias cause progressive decline in memory, language, judgment and function. Early on, depression and dementia frequently coexist, and depression can be the first sign of a dementia that declares itself later. A geriatric psychiatrist screens cognition with standardized tools, orders imaging and labs when indicated and refers for neuropsychological testing or neurology when the picture calls for it. Treating a coexisting depression often improves function even when the dementia itself is progressive.
Delirium
Delirium is an acute confusional state, developing over hours to days, with fluctuating attention and alertness. It is caused by something medical: an infection, a new medication, dehydration, a metabolic disturbance, pain or recent surgery. It is a medical emergency, not a psychiatric diagnosis, and it is reversible when the cause is found. A parent who was fine last week and is confused this week needs a medical workup today, not a psychiatry appointment next month.
What a geriatric evaluation covers
A first visit for an older adult at Stedfast Psychiatry runs 60 to 90 minutes and ideally includes a family member. We take a full psychiatric history, with attention to whether this is a first episode late in life or the return of a problem from decades ago. We screen mood with the Geriatric Depression Scale, which was designed for this population, and cognition with the Montreal Cognitive Assessment or a similar tool.
The medication review is often the most consequential part. Older adults commonly take eight to twelve medications, and several classes can cause or worsen depression, anxiety and confusion: benzodiazepines, anticholinergic drugs for bladder or allergies, some blood pressure medications, steroids, opioids and sleep aids. The Beers Criteria from the American Geriatrics Society list drugs that are potentially inappropriate in older adults, and we use them. Sometimes the best psychiatric intervention is stopping something.
We also look for medical contributors: thyroid disease, B12 deficiency, anemia, untreated sleep apnea, hearing and vision loss that isolate a person, chronic pain and alcohol use. Labs are ordered when needed, and we coordinate with the primary care physician.
How treatment differs in older adults
The principle is start low, go slow, but do get there. Antidepressants work in late-life depression, with response rates comparable to younger adults, but older patients are more sensitive to side effects, metabolize drugs more slowly and are at higher risk of interactions, low sodium and falls. We start at half the usual dose, increase more gradually, and monitor sodium and blood pressure. Sertraline, escitalopram and mirtazapine are common first choices. We avoid tricyclics and paroxetine because of anticholinergic effects.
Psychotherapy works in older adults and is underused. Problem-solving therapy and cognitive behavioral therapy have good evidence for late-life depression and anxiety, including in patients with mild cognitive impairment. Medicare covers it.
For depression that has not responded to two adequate medication trials, Deep TMS, which is FDA-cleared for major depressive disorder, is a reasonable option and is covered by Medicare under local coverage criteria. It has no drug interactions and no cognitive side effects, which makes it attractive for older patients on many medications. We offer it at our Palm Beach Gardens office. Spravato is FDA-approved for treatment-resistant depression and is used in older adults with blood pressure monitoring; we offer it at three offices.
When your parent does not want help
Resistance is the norm, and it usually comes from one of three places: the generation's stigma about psychiatry, fear that admitting a problem means losing independence, or the depression itself, which strips away the belief that anything could help. Some approaches that work in practice:
- Frame it around the symptom, not the label. "Let's get your sleep and energy looked at" lands better than "I think you are depressed."
- Go through the primary care doctor, whom your parent already trusts, and ask for the referral to come from there.
- Offer to come to the appointment, and offer telehealth from the living room if the office feels like too much.
- Make it about you. "It would help me to know you have been checked" is honest and hard to refuse.
- If your parent lives in an assisted living or skilled nursing community, ask whether a psychiatric service visits on site. Our Stedfast Living program does exactly this across Florida and South Carolina, which removes the transportation barrier entirely.
If your parent is talking about not wanting to live, do not negotiate. Call us, call 988, or go to the emergency department.
Getting started
Stedfast Psychiatry evaluates and treats older adults at all 13 offices in Florida and South Carolina, by telehealth, and on site in facilities through Stedfast Living. We accept Medicare, including Medicare Advantage plans we are contracted with, and the self-pay new-patient rate is $185. If what you are seeing in your parent matches the list above, it is worth a visit. Late-life depression and anxiety are among the most treatable conditions we see, and the cost of leaving them untreated, in function, health and years, is high.
Frequently asked questions
What is the difference between a geriatric psychiatrist and a regular psychiatrist?
A geriatric psychiatrist has additional training or focused experience in mental health conditions of older adults, including how depression and anxiety present differently, how to separate them from dementia and delirium, and how to dose medications safely in people with multiple medical conditions. Many general psychiatrists, including those at Stedfast Psychiatry, treat older adults regularly with these principles.
Is depression a normal part of aging?
No. Aging brings slower recall and less energy, but persistent low mood, withdrawal, loss of interest and hopelessness are symptoms of depression, which affects an estimated 5 to 15 percent of older adults and is highly treatable. It is underdiagnosed because older adults often report physical complaints rather than sadness.
How can I tell if my parent has depression or dementia?
They often coexist and a clinical evaluation is needed. Depressed patients tend to be distressed by memory problems and answer "I don't know," while patients with dementia tend to guess and minimize. Depression usually has a clearer onset and fluctuates; dementia progresses steadily. Treating depression often improves cognition even when dementia is also present.
Does Medicare cover geriatric psychiatry?
Yes. Medicare Part B covers psychiatric evaluation, medication management and psychotherapy, and covers TMS for treatment-resistant depression under local criteria. Stedfast Psychiatry accepts Medicare at all 13 offices, by telehealth, and in assisted living and skilled nursing facilities through the Stedfast Living program.
What if my parent refuses to see a psychiatrist?
Frame the visit around specific symptoms like sleep or energy rather than a diagnosis, route the referral through their trusted primary care physician, offer to attend, or arrange a telehealth visit from home. For parents in a facility, on-site psychiatric visits remove the biggest barrier. Any talk of not wanting to live requires immediate action regardless of their preference.
Related reading
- Psychiatric Care in Assisted Living Facilities: What Families Should Know
- How to Find a Psychiatrist That Accepts Medicare
- What Happens at Your First Psychiatrist Appointment
- How Long Do Antidepressants Take to Work?
- Is TMS Covered by Medicare?
This article is educational and does not replace evaluation by a licensed clinician. If you are in crisis, call or text 988.