Mental Health in the Elderly. Maria Di Tomasso M.D. F.R.C.P

Transcription

1 Mental Health in the Elderly Maria Di Tomasso M.D. F.R.C.P

2 Overview Demographics Epidemiology of Depressive, Anxiety, and Psychotic Disorders Different clinical presentations between older and younger adults with mental illness Risk Factors and Protective Factors Treatment

3 I enjoy talking with very old people. They have gone before us on a road by which we, too, may have to travel, and I think we do well to learn from them what it is like. Socrates

4 Introduction Demographics Canada met a milestone in July 2015, for the first time ever there are more Canadians age 65 and over than there are under age 15 The growth rate of people over 65 is four times faster than the population at large In 2011, centenarians were the second most rapidly growing segment of the population, after those aged 60-64, which experienced the fastest increase By % of Canadians will be over 65

5 Canada's Aging Population

6 Geriatric Psychiatry An official subspecialty of the Royal College of Canada since 1999 Managing elderly patients requires special knowledge Mental illness should not be a normal part of aging Canadian Community Health Survey found that 68.9 % of seniors reported their mental health as very good or excellent The majority of older individuals remain mentally healthy and aging can be a time of growth and tapping into one's potential

7 Classification Mood Disorders Anxiety Disorders Suicidal Behaviour Neurocognitive Disorders due to a medical condition including Dementia and Delirium Personality Disorders Substance Use Disorders including Prescription drugs and Alcohol Psychotic Disorders

8 Late Life Mental Health Challenges Age is NOT a risk factor for a mental disorder Chronic health conditions is the biggest risk factor Death of a loved one Caregiving Significant loss of independence and limitation of activities Loss of societal roles

9 Late Life Approach to Mental Health Disorders High index of suspicion Use cohort appropriate language Interview family members for collateral information Review the medical history including medications to rule out a medical cause Medical investigations Elderly are often on multiple drug regimens therefore vigilance of drug-drug interactions is necessary Always evaluate cognition

10 Late Life Depression Late life depression is not a single disorder but rather a heterogeneous disorder made up of a number of clinical syndromes

11 Late Life Depression

12 Late Life Depression Prevalence Location Major Depression Depressive Symptoms Community 2%-4% 8%-6% Primary Care 6%-9% 20% Medical Settings 11% 25% Nursing Homes 12%-25% 18%-30%

13 Barriers to Diagnosis Patient Factors - May not complain of sadness or depression - Symptoms are different than younger adults - Patients present with more somatic and cognitive symptoms - Often do not seek mental health services, view depression as a sign of weakness, stigma - May be isolated with limited transportation Physician Factors - Depression is seen as a normal response to aging - Misattribute depressive symptoms to a physical illness - Therapeutic nihilism

14 Late Life Depression Common Presentations Melancholic: anhedonia, early morning awakening, severe guilt, psychomotor slowing Agitated: insomnia, restlessness, pacing, irritability Masked: somatic complaints, anxiety, hypochondriasis, negativity Psychotic: ego-syntonic delusions, auditory hallucinations Late Onset Depression: > age 60, silent strokes on CT or MRI, cognitive deficits, loss of energy, physical disability Long-Term Care: signs observable by caregivers, new oppositional behaviour, decreased socialization or self care

15 When to Suspect Depression Special Clinical Features and Clues Prominent loss of interest and pleasure in activities Prominent cognitive complaints Irritability Heightened pain complaints Unexplained health worries Multiple visits to G.P. without resolution of the problem Slow recovery post surgery Refusal of treatment Prolonged hospitalization Excess disability Social withdrawal and avoidance of social interaction Unexplained functional decline

16 Causes of LLD Etiological and Risk Factors Medical: High measures of medical burden triples the risk of depression Theres is a reciprocal relationship between depression and medical illness. Physical health impacts mental health and mental health impacts physical health. - Neurological disease: Parkinson's disease, Stroke, Alzheimer's disease, Silent Strokes or WMH - Cardiovascular Disease - Malignancies: Pancreatic cancer - Endocrine disorders: Hypothyroidism - Medications, polypharmacy, drug-drug interactions - Sleep disturbance Disability alone ( measured by activities of daily living ) in the absence of medical illness increases the risk of developing depression by a factor of 4 for elderly living in the community

17 Causes of LLD Etiological and Risk Factors Psychosocial: -Personality Attributes: Neuroticism, Insecure Attachment Obsessional traits Personality Disorder - Behaviour: Learned helplessness - Poor perceived health - Loss of a spouse or loved one - Caregiving - Lack of social supports - Marital separation, divorce or widowhood - Low socioeconomic status - Living in a nursing home

18 Comorbidity LLD and Medical Illness Stroke 22-50% Myocardial Infarction 15-19% Cancer 18-39% Rheumatoid Arthritis 13% Parkinson's Disease 10-37% Diabetes Mellitus 5-11%

19 Consequences of LLD Depression impacts older adults differently than younger adults Decrease in functional status Decreased compliance with medical care Poor outcome following MI, CVA, Hip Increased risk of osteoporosis in women Increase in death: Post MI mortality rates are 5X higher Post CVA mortality rates are 3.5X higher Increased risk of death in nursing homes is 2 fold Suicide

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22 Suicide in Older Adults Adults 65 and over have the highest suicide rate of any other age group Men 65 and older have the highest rate in Canada Older adults tend to use more lethal means, firearms, hanging and poisoning Older adults less likely to discuss their plans, give fewer warning signs Nonviolent deaths from suicide may be mistakenly attributed to an illness: not taking medications, refusal to eat, 50% of older adults who have committed suicide saw their GP within one month of the suicide Depression is the foremost risk factor for suicide in older adults Passive suicidal ideation, the desire to die and the belief that life is not worth living, is not normative in late life Suicide is PREVENTABLE

23 Late Life Depression Protective Factors Spiritual and Religious Affiliations Social, Family, Community Supports Wisdom Physical Activity Socio-Emotional Selectivity

24 Depression and Dementia Depression and dementia frequently coexist and the differential diagnosis can be challenging Historically major depression with cognitive deficits, "Pseudodementia", was considered a reversible and benign condition However a subset of patients will continue to have cognitive impairment even after remission of symptoms, with as many as 40% developing dementia within 3-5 years Late onset depression with cognitive impairment is a risk factor for dementia, may also be a prodrome or psychological reaction to an already present cognitive deficit Additionally early onset depression is also considered to be a risk factor for dementia

25 Treatment The elderly have similar response rates as younger adults Antidepressants may take longer to start working Start low, go slow, but go Choice of antidepressant depends on previous response to treatments, side effect profile, other medical problems, existing medications, type of depression SSRI's, SNRI's, Bupropion, Mirtazapine Psychotherapy: Cognitive Behaviour Therapy, Interpersonal Therapy, Problem Solving Therapy Electroconvulsive Therapy ECT

26 Late Life Anxiety Disorders Epidemiology Anxiety disorders are more prevalent among younger adults than older adults In the ECA study: 7.3% of adults vs. 5.5% of adults >65 Late onset anxiety disorders are infrequent, 90% of anxiety disorders begin before age of 41, 75% before the age of 21 Different forms of anxiety occur later in life Generalized Anxiety Disorder and Phobias account for most anxiety in late life Panic Disorder is rare Agoraphobia and possibly Obsessive Compulsive Disorder in females, may occur for the first time in old age Simple Phobia, Obsessive Compulsive Disorder in males, and Panic Disorder either persist from younger years or arise in the context of another psychiatric or medical disorder Fear of falling is a unique geriatric anxiety syndrome

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29 Clinical Presentation GAD: Worry is different in the elderly, focus is on health and illness in self or spouse, not work and interpersonal issues, new onset GAD is often related to a depressive disorder Agoraphobia: most common phobia, usually no history of Panic Disorder, may appear for the first time following a stroke or medical condition Panic Disorder: fewer and less severe symptoms, lower levels of arousal, late onset is very rare, suspect medical condition Obsessive Compulsive Disorder: more religious than contamination obsessions and more hand washing compulsions and less symmetry and counting, more hoarding, late onset OCD may be secondary to a neurological disorder PTSD: less frequent after a traumatic event, delayed onset or re-emergence of symptoms, 30% of MI patients, correlates with impaired memory

30 Comorbidities Up to 25% of medically ill have anxiety symptoms, most common comorbidites are with cardiovascular disease, COPD, gastrointestinal problems,vestibular conditions, hyperthyroidism, and diabetes Anxiety often leads to depression, approx. half of elderly with depression have a comorbid anxiety disorder All late onset anxiety should raise suspicion of a cognitive disorder MCI with comorbid anxiety may indicate an underlying neurodegenerative process, twice as likely to develop Alzheimer's Dementia in 3 years Substance misuse with alcohol, hypnotics and anxiolytics may be an attempt to self medicate

31 Late Life Anxiety Disorders Treatment Avoid benzodiazepines, benefits must outweigh the risks, risks include falls, ataxia, cognitive impairment, short term use only Citalopram, Escitalopram, Sertraline, Venlafaxine XR are effective CBT, relaxation therapy, sleep hygiene, supportive therapy Memory aides and between session reminder telephone calls lead to better compliance and greater treatment effect

32 Late Life Psychosis Psychosis is a symptom not a disorder Prevalence is up to 23% of elderly Risk Factors Female Gender Social isolation Low socio-economic status Sensory Deficits Cognitive decline Polypharmacy

33 Late Life Psychosis Most common cause of psychosis in later life is Dementia, occurs mainly during middle stages, hallucinations are visual> auditory, delusions of theft, spousal infidelity, abandonment, house is not one's home, and persecution Second most common cause of psychosis in the elderly is Major Depression, especially late onset depression, mood congruent delusions of guilt, poverty, nihilism and somatization Most common cause of acute onset psychosis is Delirium or Substance Induced Psychosis ( drugs/alcohol/medications, especially with anticholinergic, sedative and analgesic medications Late Onset Schizophrenia ( age ) and Very Late Onset Schizophrenia ( after age 60 ), higher rates of visual, olfactory and tactile hallucinations Very Late Onset Schizophrenia tends to be a prodrome of a neurodegenerative disorder

34 Etiology What is the most common etiology of psychosis? Dementia 40% Major Depression 33% Delirium 7% Medical conditions 7% Mania 5% Substance induced 4% Delusional disorder 2% Schizophrenia 1%

35 Peggy Freydberg Began writing poetry at age 90 Published her first poetry book, Poems from the Pond, at 107 years of age

36 Inga Rapaport Neonatologist who received a doctorate in medicine at age 102