GERIATRIC MENTAL HEALTH AN OVERVIEW

It is not enough for a great nation merely to have added new years of life Our objective must also be to add new life to those years. John F Kennedy

INTRODUCTION
Improvement in health care system Declining death rates

Progressive rise in the aged population in recent years

India in a phase of demographic transition 1991 census- population of the elderly in India 57 million compared with 20 million in 1951 Projected that by 2050, the number of elderly people would rise to about 324 million India an ageing nation with 7.7% of its population being more than 60 years old Attributed to the decreasing fertility and mortality rates

GERIATRIC MENTAL HEALTH: 4 FACTS TO GUIDE PUBLIC POLICY

1) Dramatic recent and projected growth 2) Major direct and indirect impact on health outcomes, service use and costs 3) We know treatment works, but effective services are not reaching those in need 4) An alarming under-investment in knowledge dissemination, service development, and research to meet future need

IMPACT OF THE PROBLEM

Improved Health Care promises longevity but social & economic conditions such as poverty break up of joint families poor health services for elderly pose a psychiatric threat to them.

MAJOR LIFE ISSUES

Decline in Physical & Mental Abilities Social Roles Living Arrangements Family Relationship Work & Retirement Finances Death & Dying Grief & Bereavement

DECLINE IN PHYSICAL & MENTAL ABILITIES

Increase in vulnerability to acute & chronic illnesses ; health status & functional autonomy significant predictors of life satisfaction Worry, anxiety, frustration over memory loss due to slowing in retrieval processes influence general sense of wellbeing

SOCIAL ROLES

Role transitions inevitable due to physical & cognitive changes Fewer duties or expectations decline in role content loss of role definition isolation or alienation

LIVING ARRANGEMENTS

Most prefer to live in private homes but age related physical changes require change in living arrangements Living with children Independent living community Assisted living facility Nursing home facilities Continuing-care retirement communities

FAMILY RELATIONSHIP

Family, with children & grandchildren form the core of social life of older adults ; good relationship & regular contacts with children add to quality of life

Elder abuse physical or psychological mistreatment or neglect of elderly person

WORK & RETIREMENT

Work

In addition to obvious functions like income & social status, serves latent functions like structured use of time, context for social contact, self identity, activities to channelise intellectual physical, emotional energy & collective participation
-- Deprivation in these areas may pose threat to psychological wellbeing

Retirement

DEATH & DYING

A major task is confronting the reality of death Some alternate between accepting and denying their death while some may fear death Reasons-- actual process of dying (fear of being alone, in pain, loosing control of mind & body etc), & consequence of dying (fear of unknown, loss of identity, decomposition of body etc)

GRIEF & BEREAVEMENT

Psychosocial consequences of widowhood intense emotional grief, loss of social and emotional support, loss of material & instrumental support Emotions of depression, anger, shock, yearning for deceased partner observed

SUCCESSFUL AGING PARADIGM

SUCCESSFUL AGING PARADIGM

Maintaining physical health, mental abilities, social competence & overall satisfaction with ones life. Staying healthy & Able lifelong health habits and response to health crises of old age Retaining cognitive abilities education & cognitive adventurousness; new learning & use of new technology help to establish new connections between neurons, protect brain against cognitive deterioration.

SUCCESSFUL AGING PARADIGM

Social engagement social connectedness & participation in productive activities. Social support provides opportunity to give & receive support, reduces loneliness. Social structure facilitating purposeful roles, connectedness to peers, contribution to development of younger members. Productivity Volunteerism for altruistic reasons, venturing into new pursuits, and creativity give purpose in life, chance to interact with like minded peers, sense of competence. Life satisfaction sense of personal wellbeing determined by feeling of having , control and choice, perception of his situation (adequacy of social support, income), social comparison.

SUCCESSFUL AGING PARADIGM

Religious coping Tendencies to turn to religious beliefs and institutions in times of stress. Association between religious faith and physical and mental wellbeing found across diverse faiths, cultures and ethnic groups
(Zhou et al., 2002)

Attending religious services contributes to developing health habits, interaction with peers, chance to help others, encourages perseveration in dealing with chronic ailments. Also promotes intergenerational involvement i.e. passing on knowledge, wisdom and beliefs to younger individuals.

EPIDEMIOLOGY OF PSYCHIATRIC
DISORDERS
Varying mental health morbidity from as low as 2.3% (Dube, 1970) to as high as 49.3% (Sood et al, 2006) Mental health morbidity is seldom an isolated event in elderly and minimum two/ three other clinical diagnoses is a rule (Venkoba Rao, 1993). Average mental morbidity around 15 45%.

What are the differences between older and younger persons with mental illness?
Assessment is different: e.g., cognitive assessment needed, recognize sensory impairments, allow more time Symptoms of disorders may be different: e.g., different symptoms in depression Treatment is different: e.g., different doses of meds, different psychotherapeutic approaches Outcome may be different: e.g., psychopathology in schizophrenia may improve with age

OVERVIEW

Psychotic depression
Schizophrenia with depression
depression

Depression with dementia (pseudodementia) Vascular depression with mild cognitive impairment MCI with depression dementia Dementia with depression PD with depression

psychosis

Schizophrenia with cognitive deficits PDD, LBD, AD, VaD with psychotic sx

med conditions & drugs movement disorders

PDD, LBD, PD+ with cognitive deficits

PDD, LBD, AD with movement sx

Schizophrenia with movement disorders

DEPRESSION IN ELDERLY

Depression is not a normal consequence of aging Older persons with depression need special efforts in recognition, diagnosis, and treatment.

CLINICAL PRESENTATION
Different from depression in younger adults. Less likely to endorse affective and cognitive symptoms of depression, including dysphoria and worthlessness Gallo et al.,1994 Psychomotor retardation, sleep problems, fatigue, loss of interest and hopelessness about the future are more prevalent Christensen et al.,1999 May endorse poor memory and concentration, while slowed cognitive processing and executive dysfunction are evident upon clinical exam. Butters et

al.,2004

ETIOLOGICAL FACTORS

Biological factors including genetics, medical illness and neurological changes that occur with normal aging or with age-associated diseases 20-30% of cardiac disease patients 20-25% among stroke patients In Type II diabetes as high as 25% Li et al.,2006 15-20% among those with Parkinson Disease
Reijnders et al.,2008

10%15% among those with AD

Park et al., 2007

Effects of environment and physical illness are still important to address!!

Depression is a frequent cause of emotional suffering in later life and frequently diminishes quality of life.

A key feature of depression in later life is COMORBIDITY--e.g., with physical illness such as stroke, myocardial infarcts, diabetes, and cognitive disorders (possibly bi-directional causality)

Bereavement(loss of a love one through death)

Grief (psychosocial reaction to any loss such as depression, anxiety, guilt, anger, etc)

Acute grief: traumatic distress, separation distress, guilt/remorse, social withdrawal, preoccupation with images of dead person---approximately 6 months--leads to Integrated Grief as a background state (reestablish interests, accessibility of memories of deceased but not preoccupied, more positive emotions)

FALLACY OF MISPLACED EMPATHY

Inappropriate to dismiss signs of major depression as normal in patients despondent because of loss

NORMAL GRIEF REACTION VERSUS MAJOR DEPRESSION

Guilt about things other actions taken at time of death Thoughts of death other survivor feelings Morbid preoccupation with worthlessness Marked psychomotor retardation Hallucinations other than transient voices or images of dead person Prolonged & marked functional impairment

Pseudodementiadepression with reversible dementia syndrome: dementia develops during depressive episode but subsides after remission of depression.

Vascular depression more common in late-onset disease Cerebrovascular disease may predispose or perpetuate depression Symptoms include greater levels of apathy, psychomotor retardation and disability, and less agitation, psychoses, family history of psychiatric illness, guilt, and insight versus other older depressed persons.

PSYCHOSIS

Psychosis in elderly is a growing clinical concern because

Psychotic symptoms most frequently occur as non cognitive manifestation of Alzheimers Side effects of drug therapy for Parkinsons disease Primary Schizophrenia

Psychotic symptoms can be associated aggressive or disruptive behavior

Factors contribute to an increased risk of psychosis in elderly are

Age related deterioration of frontal and temporal region, neurochemical changes Associated with ageing, social isolation sensory deficits, cognitive decline, Age related pharmacokinetic and pharmacodynamic changes and polypharmacy

(Targum and Abbott, 1999; Steven D. Targum 2001).

Delirium

Disturbance of consciousness with inattention that develops over a short time & fluctuates

Common condition especially children and elderly, especially in dementia Pre-existing brain damage, drug or alcohol addiction, recovery from anaesthesia, coma Delirium is a medical emergency, irrespective of age

CLINICAL FEATURES

OF

DELIRIUM

Poor attention Fluctuating course Disorganized thinking Altered Level of Consciousness

Disorientation Memory impairment Sleep/wake disturbance Psychomotor agitation/retardation Hallucinations/ misperceptions

DELIRIUM WORKUP

On History: time course of mental status changes? association with other events (i.e.. meds, illness)? Pre-existing impairments of cognition or sensory modalities?

BURDEN OF DELIRIUM

Increased mortality Increased nursing care Increased length of stay Increased risk of cognitive decline Increased risk of functional decline

BURDEN OF DELIRIUM

Delay in postoperative mobilization Prevention of early rehabilitation Increased need for home care services Increased distress to caregivers Barrier to psychosocial closure in terminally ill patient

DEMENTIA
Multiple

Cognitive Deficits:

Memory dysfunction
especially new learning, a prominent early symptom aphasia, apraxia, agnosia, or executive dysfunction

At least one additional cognitive deficit

Cognitive

Disturbances:

Sufficiently severe to cause impairment of occupational or social functioning and Must represent a decline from a previous level of functioning

DIFFERENTIAL DIAGNOSIS
Alzheimer Disease (pure ~40%, + mixed~70%) Vascular Disease, MID (5-20%) Drugs, Depression, Delirium Ethanol (5-15%) Medical / Metabolic Systems Endocrine (thyroid, diabetes), Ears, Eyes, Environ. Neurologic (other primary degenerations, etc.) Tumor, Toxin, Trauma Infection, Idiopathic, Immunologic Amnesia, Autoimmune

CLINICAL FEATURES

Memory Loss Symptoms: Confusion About Place Loss of Spontaneity Loss of Initiative Mood/Personality Changes Poor Judgment Takes Longer to Perform Routine chores Trouble Handling Money, Paying Bills

Problems recognizing family members, close friends. Repetitive statements and/or movements. Restless, especially in late afternoon and at night. Perceptual motor problems. Problems organizing thoughts, thinking logically. Cant find right words, makes up stories. Problems reading and writing. May be suspicious, irritable, fidgety, teary or silly.

Loss of weight Little capacity for self-care. Cant communicate with words. May put everything in mouth or touch everything. Cant control bladder or bowel. May have difficult with seizures, swallowing, skin breakdown, infections.

Loss of ability to ambulate. Loss of ability to sit. Loss of ability to smile. Loss of ability to hold up head. Loss of ability to swallow.

COMPLICATIONS
Delusions in up to 50%, most with paranoia Hallucinations in up to 25% Depression, social isolation may also occur Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) Dangerous behavior driving, creating fires, getting lost, unsafe use of firearms, neglect Sundowning nocturnal episodes of confusion with agitation, restlessness

ANXIETY DISORDERS
Common in elderly May occur first time after age 60, but not usually Phobias, especially agoraphobia are common May be due to medical causes or depression

SUBSTANCES AND ALCOHOL

Brain is more sensitive as ages Due to changes in metabolism, a given amount may produce a higher blood level May worsen normal changes in sleep and sexual functioning Sudden onset delirium in hospitalized patients usually from withdrawal

PERSONALITY DISORDERS
Borderline, narcissistic, and histrionic personality disorders may become less intense Before diagnosing a personality disorder, verify that it is not an improperly treated Axis I disorder Some personality traits may become more pronounced

SLEEP DISORDERS
Advanced age is associated with increased prevalence of sleep disorders REM sleep behavior disorder occurs among elderly men Advanced sleep phase Dementia associated with more arousals, increased stage I sleep; decreased stages 3/4

PSYCHOPHARMACOLGY
Alterations in absorption, metabolism and excretion the norm in the elderly Body fat content more, protein binding less, minimal renal/hepatic impairment causes higher drug levels Start low and go slow Side effects appear early and have disastrous consequences Drug interactions possible and polypharmacy not advised.

GERIATRIC MENTAL HEALTH: PSYCHIATRIC CONDITIONS AND BEHAVIORAL MANAGEMENT

Overview: Behavioral management principles Common causes of behavioral symptoms and potential interventions

BEHAVIORAL MANAGEMENT

Components of behavioral management Recognition and documentation of behavioral symptoms Common causes of behavioral symptoms Potential behavioral interventions Monitoring behaviors

BEHAVIORAL MANAGEMENT

Things to keep in mind Behavioral symptoms are very common among older persons with mental health conditions. Behavioral symptoms are a form of communication: All behavior has meaning. Behavior represents an expression of some need or desire. Behavioral symptoms are influenced by physiological function and medical illnesses. All behavioral symptoms have underlying causes.

PERHAPS AT THIS POINT YOU ARE WONDERING, WHAT ARE THESE BEHAVIORAL SYMPTOMS?
This terms captures behaviors such as hitting, kicking, pinching, throwing things, continuous disruptive yelling, making verbally abusive comments, throwing things, sexually acting out

CHARACTERISTICS OF BEHAVIOR
Characteristic Key Questions Nature & Relevant Factors Extent Scope Severity
When did the behavior start, and what were the circumstances surrounding its onset? What happens while the behavior is occurring? Did any specific circumstances contribute to the behavior? What makes it better? What aggravates it? Why is the behavior a problem, and to what extent? For example, does it affect the individual, others in the same living environment, or his/her caregivers? How often does the behavior occur?

What risk does this behavior pose to the individual or to others? What is the degree of social or household disruption?

COMMON CAUSES OF BEHAVIORAL SYMPTOMS

Several things can contribute to behavioral symptoms: Medications Physical health status Psychiatric illness Environment Personal or health care tasks

CONCLUSION
Due to demographic ageing, the population of elders and therefore, the numbers with mental disorders, are rising rapidly. 2. There is very poor awareness about these disorders. 3. Traditional family and social support systems for elders are rapidly changing. 4. This population requires specialized care, empathy and support.
1.