MENTAL HEALTH AND OLDER ADULTS

WORLD MENTAL HEALTH DAY 2013

Ward One Grand Rounds Friday November 1st, 2013

DR. SHIVAN A.C. MAHABIR Psychiatry Department, SWRHA

Case History

P. S. 78 yr old female Pensioner Widowed. Lives with her son in Point Fortin Roman Catholic Housewife Attended Primary School only.

Case History

P/C: Thinking her daughter wanted to poison her Eating mud Wandering away from home Throwing away household items

HxP/C: Memory problems starting within last 5 yrs Paranoia for 1 year Travelled to USA 6/12 ago. May have gotten ill and been admitted to a psychiatric hospital there. Returned to Trinidad 3/52 ago. Since the behaviour as above along with c/o talking to herself, talking about the past and occasional aggressive behaviour.

Case History

Past Psychiatric Hx:

Known psychiatric patient Attended Point Fortin POPC many years ago but defaulted Diagnosis unknown Past Psychiatric Medication Stelazine ? Past Psychiatric Hospital Admissions ? Pre-morbid level of functioning

Past Medical Hx: + HTN

Case History

MSE:

Clean Cooperative Oriented to person and place ONLY Mood even Affect Congruent Speech relevant Denied Hallucinations + Paranoid Delusions Insight and Judgement were intact

MMSE: 18/30 (Moderate Impairment)

Case History

Physical Examination:

Lump in Left Axillary Region

Referred to Surgical Unit

Blood Ix:

Eosinophilia - ? Intestinal Parasites ? Allergies Creatinine 1.2 CK 1338 . Rpt on following day 165 HbA1C: 5.3%

Case History

Differential Diagnoses:

? Dementia ? Type ? Schizophrenia Hypertension Renal Impairment Lump in Axilla for Evaluation

Psychiatric illnesses in older people include:

Pre-existing psychiatric disorders in the aging patient

New disorders related to the specific stresses and circumstances of old age (e.g. bereavement, infirmity, dependence, sensory deficits, isolation).
Disorders due to the changing physiology of the aging brain, as well as psychiatric complications of neurological and systemic illnesses. The elderly are more likely to manifest physical symptoms of psychiatric disorder than younger adults

Prevalence of Psychiatric Illness in the Elderly

5% of people older than 65 yrs suffer from moderate to severe dementia and the prevalence increases to over 30% of those over 85 yrs2. In people >65 yrs approximately:

1.1% for schizophrenia;

1.4% for bipolar disorder; 12.5% for neurosis and personality disorder3. ~30% in old age homes have cognitive impairment 30-50% patients >65 yrs in general hospital wards have psychiatric disorder)

Psychogeriatrics
Psychiatric problems often coexist with physical problems,

Cognitive assessment and physical examination are always essential parts of psychiatric management of the older person.

Dementia is generally the main focus of interest in psychogeriatrics, but the discipline also concerns itself with depressive illness, paranoid states, and other late-onset problems.

Psychogeriatrics
Since older people are often dependent on others, consideration of the role and the needs of carers are important aspects of holistic care.

Psychiatric care of the elderly interfaces with multiple services, both state and independent (e.g. social services, housing and welfare services, the legal system, charity organisations, and religious institutions).

Neuro-Physiological Aspects of Aging

The weight and volume of the brain decreases by 5% between ages 30 and 70 yrs, by 10% by the age of 80, and by 20% by the age of 90. MRI shows decreased cortical grey matter with little change to white matter.

CBF in frontal and temporal lobes and thalamus decreases with age.
There is some nerve cell loss in the cortex, hippocampus, substantia nigra, and purkinje cells of the cerebellum. There may also be reduction in dendritic processes. The cytoplasm of nerve cells accumulates a pigment, (lipofuscin), while there are also changes in the components of the cytoskeleton. Tau protein (NFT)/ Senile plaques/ Lewy bodies

Psychological Aspects of Aging

Cognitive assessment is often complicated by physical illness or sensory deficits. IQ peaks at 25 yrs, plateaus until 60-70, and then declines. Problem solving deteriorates due to declining abstract ability and increasing difficulty applying information to another situation. Short-term memory (STM) does not alter with age. However, working memory (WM) shows a gradual decrease in capacity and this is worse with increased complexity of task and increased memory load. Long-term memory (LTM) declines, except for remote events of personal significance which may be recalled with great clarity.

Psychological Aspects of Aging

There is a characteristic pattern of psychomotor slowing and impairment in the manipulation of new information.

Tests of well-rehearsed skills such as verbal comprehension show little or no decline.

Performance IQ drops faster than verbal IQ, which may be due to reduced processing speed or to the fact that verbal IQ depends largely on familiar crystallised information while performance IQ involves novel, fluid information.

Social Issues of Aging

Increasing numbers of elderly live alone or in homes for the aged. Losses include: loss of status, loss of independence, and loss of spouse/partner. Most elderly have limited income and are unemployed. Increase in medical problems compounds the dependency and care needs. The elderly face variable degrees of isolation, marginalisation, and stigmatisation.

Multi-disciplinary Assessment
Elderly people suffering from mental health problems often have a range of psychological, physical, and social needs. This implies that individual assessment, management, and follow-up requires collaboration between health, social, and voluntary organisations and family carers.

Assessment of the older patient with mental illness includes the following:
Full history from the patient, family, and carers Full physical and neurological examination MSE, including full cognitive assessment Functional assessment (evaluation of ability to perform functions of everyday living).

Social assessment (accommodation; need for care; financial and legal issues; social activities)
Assessment of carers' needs

Multi-disciplinary Assessment

The best place for performing an assessment is in the patient's home.

A domiciliary visit has the advantage of being more convenient and relaxing for the patient and it provides the health carer with an opportunity to assess living conditions, social activities, and medications kept in the house. In addition, family members, neighbours, and carers may be available for interviewing.

MSE needs to include an assessment of sight and hearing.

MMSE

Key questions for carers include:

Relationship to the patient Amount of care provided Degree of stress they are under What help they would accept Understanding and knowledge of the patient's illness What expectations they have from services Their awareness of support or voluntary organisations

Dementia

Dementia is a syndrome usually of a chronic or progressive nature in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. Dementia is caused by a variety of diseases and injuries that primarily or secondarily affect the brain, such as Alzheimer's disease or stroke.

Dementia
Early stage: the early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include:

forgetfulness
losing track of the time becoming lost in familiar places.

Middle stage: as dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include:

becoming forgetful of recent events and people's names becoming lost at home having increasing difficulty with communication needing help with personal care experiencing behaviour changes, including wandering and repeated questioning.

Dementia
Late stage: the late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include:

becoming unaware of the time and place having difficulty recognizing relatives and friends having an increasing need for assisted self-care having difficulty walking experiencing behaviour changes that may escalate and include aggression.

Positive features include wandering, aggression, flight of ideas, and logorrhoea:

Dementing Disorders
Epidemiology - Rare below 55yrs of age. 5-10% prevalence above 65yrs. 20% prevalence above 80yrs, and 70% of those over 100yrs.

Commonest causes - Alzheimer's disease. Vascular dementia, Lewy body dementia, Fronto-temporal dementia

Rarer causes: Alcohol/drug abuse, pellagra, Huntington's, CJD, Parkinson's, Pick's disease, HIV, cryptococcosis, progressive leukencephalopathy.

Ix: FBC, ESR; U&E; Ca2+; LFT; TSH; autoantibodies; folate/B12 (treat lownormals); syphilis serology; CT/MRI (any structural pathology?).

Dementing Disorders
Senile Dementia -Alzheimer's Type Cause: Accumulation beta-amyloid peptide, a degradation product of amyloid precursor protein, resulting in progressive neuronal damage, neurofibrillary tangles, increased numbers of senile plaques, and loss of the neurotransmitter acetylcholine. Neuronal loss is selective, and the hippocampus, amygdala, temporal neocortex and some subcortical nuclei, eg the nucleus basalis of Meynert are especially vulnerable

Risk factors: Defective genes on chromosomes 1, 14, 19, 21; the apoE4 variant brings forward age of onset. Insulin resistance may be important

Dementing Disorders

Ix: Diagnosis only confirmed at post-mortem. Brain imaging (CT;

MRI; PET) and neuropsychological tests help rule out frontotemporal, Lewy body and vascular dementias.

Tx: Evidence that cholinesterase inhibitors and memantine are modestly effective in treating AD is good. Cholinesterase inhibitors appear to be effective in mild-moderate AD. Memantine, alone or in combination with cholinesterase inhibitors, is effective in late stage disease. Memantine is an NMDA antagonist. (NMDA=N-methyl-D-aspartate). Normalize blood pressure. Avoid atypical antipsychotics in dementia. Use low dose haloperidol multiple dose per day. Observe for EPSE. Avoid CPZ risk of hypotension.

Dementing Disorders

Prevention:

Learn a new language Take up a hobby Do puzzles and crosswords. Go through photo albums. Routines at home.

Drug Abuse
Generally, illicit substance abuse is not a significant problem in the elderly. However, misuse of over the counter drugs such as nicotine and caffiene, laxatives and OTC analgesics and prescription drugs such as benzodiazepines, opiates, and analgesics frequently becomes a problem in this age group. Dependence on these medications may result from careless prescription of long-term treatments for common problems of ageing such as insomnia and arthritis. Older patients may abuse anxiolytics to allay chronic anxiety or to ensure sleep. The clinical presentation of older patients with alcohol and other substance use disorders varies and includes confusion, poor personal hygiene, depression, malnutrition, and the effects of exposure and falls.

Drug Abuse
The sudden onset of delirium in older persons hospitalized for medical illness is most often caused by alcohol withdrawal. Alcohol abuse also should be considered in older adults with chronic gastrointestinal problems. With the best of intentions, doctors sometimes believe that it is cruel to withdraw patients from these medications, especially if the patient has been using the drug for years and is advanced in age. However, it is important to consider whether withdrawal may actually enhance quality of life by diminishing chronic side-effects such as depression The maintenance of chronically ill cancer patients with narcotics prescribed by a physician produces dependence, but the need to provide pain relief takes precedence over the possibility of narcotic dependence and is entirely justified.

Alcohol Abuse
Older adults with alcohol dependence usually give a history of excessive drinking that began in young or middle adulthood. They usually are medically ill, primarily with liver disease, and are either divorced, widowed, or are men who never married. Many have arrest records and are numbered among homeless persons. With decreasing tolerance for alcohol in advancing age, there is a corresponding increase in risk of intoxication and adverse effects. Males predominate, although there is an increase in prevalence of alcohol problems in women in their 8th and 9th decades. Risk factors for late onset of alcohol problems include: female gender; higher socioeconomic class; physical ill-health; precipitating life events; neurotic personality; psychiatric illness. Wernicke's encephalopathy and Korsakoff psychosis are important sequelae in old cases.

Alcohol Abuse
Principles of management Prognosis is good if alcohol problems commence secondary to practical problems. Encourage and facilitate involvement in non-drinking social activities. In extreme cases consider need for supervision of finances. Orientate towards reducing physical problems. Moving to residential care may reduce social isolation.

Anxiety Disorders in the Elderly

By far the most common disorders are phobias (4 to 8 percent). The rate for panic disorder is 1 percent. Because of concurrent physical disability, older persons react more severely to PTSD than younger persons. Obsessions and compulsions may appear for the first time in older adults, although older adults with OCD usually had demonstrated evidence of the disorder (e.g., being orderly, perfectionistic, punctual, and parsimonious) when they were younger. Theories which seek to explain the aetiology of anxiety disorders in the elderly include: 1. Existential theories eg the person may deal with the thought of death with a sense of despair and anxiety, rather than with equanimity and Erikson's sense of integrity. 2. Physiological theories: The fragility of the autonomic nervous system in older persons may account for the development of anxiety after a major stressor.

Depression

Depressive symptoms are present in about 15 percent of all older adult community residents and nursing home patients. Age itself is not a risk factor for the development of depression, but being widowed and having a chronic medical illness are associated with vulnerability to depressive disorders.

Late-onset depression is characterized by high rates of recurrence.

The presenting symptoms may be different in older depressed patients from those seen in younger adults because of an increased emphasis on somatic complaints in older persons. Older persons are particularly vulnerable to major depressive episodes with melancholic features, characterized by depression, hypochondriasis, low self-esteem, feelings of worthlessness, and self-accusatory trends (especially about sex and sinfulness) with paranoid and suicidal ideation. Dementia vs pseudo-dementia

Geriatric Depression Scale (Short Version)

Answers indicating depression are boldfaced. Each answer counts one point; scores greater than 5 indicate probable depression. 1. Are you basically satisfied with your life? Yes/No 2. Have you dropped many of your activities and interests? Yes/No 3. Do you feel that your life is empty? Yes/No 4. Do you often get bored? Yes/No 5. Are you in good spirits most of the time? Yes/ No 6. Are you afraid that something bad is going to happen to you? Yes/No 7. Do you feel happy most of the time? Yes/No 8. Do you often feel helpless? Yes/No 9. Do you prefer to stay at home, rather than going out and doing new things? Yes/No 10. Do you feel you have more problems with memory than most? Yes/No 11. Do you think it is wonderful to be alive now? Yes /No 12. Do you feel pretty worthless the way you are now? Yes/No 13. Do you feel full of energy? Yes/No 14. Do you feel that your situation is hopeless? Yes/No 15. Do you think that most people are better off than you are? Yes/No (From Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24:709, with permission.)

Other Psychiatric Illnesses affecting the Elderly

Somatoform Disorders:

Hypochondriasis is common in persons over 60 years of age, although the peak incidence is in those 40 to 50 years of age. The disorder usually is chronic, and the prognosis guarded. Repeated physical examinations help reassure patients that they do not have a fatal illness, but invasive and high-risk diagnostic procedures should be avoided unless medically indicated.
Telling patients that their symptoms are imaginary is counterproductive and usually engenders resentment. Clinicians should acknowledge that the complaint is real, that the pain is really there and perceived as such by the patient, and that a psychological or pharmacological approach to the problem is indicated.

Other Psychiatric Illnesses affecting the Elderly

Delusional Disorder

The age of onset of delusional disorder usually is between ages 40 and 55, but it can occur at any time during the geriatric period. In one study of persons older than 65 years of age, pervasive persecutory ideation was present in 4 percent of persons sampled. Delusions can take many forms; the most common are persecutory patients believe that they are being spied on, followed, poisoned, or harassed in some way. Persons with delusional disorder may become violent toward their supposed persecutors. Some persons lock themselves in their rooms and live reclusive lives. Somatic delusions, in which persons believe they have a fatal illness, also can occur in older persons.

Other Psychiatric Illnesses affecting the Elderly

Delusional Disorder

Among those who are vulnerable, delusional disorder can occur under physical or psychological stress and can be precipitated by the death of a spouse, loss of a job, retirement, social isolation, adverse financial circumstances, debilitating medical illness or surgery, visual impairment, and deafness. Delusions also can accompany other disorders such as dementia of the Alzheimer's type, alcohol use disorders, schizophrenia, depressive disorders, and bipolar I disorder which need to be ruled out. Delusional syndromes also can result from prescribed medications or be early signs of a brain tumor

Other Psychiatric Illnesses affecting the Elderly

Paraphrenia: a psychotic illness characterised by delusions and hallucinations, without changes in affect, form of thought, or personality It develops over several years and is not associated with dementia. Some believe that the disorder is a variant of schizophrenia that first becomes manifest after age 60. Patients with a family history of schizophrenia show an increased rate of paraphrenia

Other Psychiatric Illnesses affecting the Elderly

Schizophrenia:

Although first episodes diagnosed after age 65 are rare, a late-onset type beginning after age 45 has been described. Women are more likely to have a late onset of schizophrenia than men. Another difference between early-onset and late-onset schizophrenia is the greater prevalence of paranoid schizophrenia in the late-onset type Older persons with schizophrenic symptoms respond well to antipsychotic drugs. Medication must be administered judiciously, and lower-than-usual dosages often are effective for older adults

Sexual Issues
Factors influencing the sexual life of younger adults are relevant to older people too (e.g. social stresses, illness, and side-effects of medications). In addition, the elderly may experience added problems related to the specific physiological changes that accompany ageing. Dementia sufferers may become sexually demanding as part of the disinhibition that frequently characterises this disorder. Health carers may fail to detect sexual problems experienced by older people as a sexual history is commonly overlooked. This may result from incorrect assumptions that carers often make regarding sexuality in this age group. The client too may assume that his or her sexual dysfunction is a normal aspect of ageing. Some practical remedies are: hormone replacement therapy; vaginal lubricants and topical oestrogen; and, of course, Viagra.

Personality Issues
Personality traits often become more prominent and rigid in old age; in particular traits such as cautiousness, introversion, and obsessionality Since personality disorder is by definition lifelong, any significant change in personality needs explanation. Both organic and functional brain disorders may manifest as a change in personality. Personality problems are often the cause of Diogenes syndromealso called senile squalor syndromein which eccentric and reclusive individuals become increasingly isolated and neglect themselves, living in filthy, poor conditions. They are often oblivious to their condition and resistant to help, necessitating intervention.

Suicide
Old age is a risk factor for suicide and it is estimated that approximately 20% of all suicides are of the elderly. There is a male predominance of 2:1 in this age group. Predictive factors for suicide in the elderly: Increasing age Male Physical illness (35-85% cases) Social isolation Widowed or separated

Alcohol abuse
Depressive illness, current or past (80% cases) Recent contact with psychiatric services Most elderly persons who commit suicide communicate their suicidal thoughts to family or friends before the act of suicide

Sleep Disorders
Sleep-related phenomena reported more frequently by older than by younger adults are sleeping problems, daytime sleepiness, daytime napping, and the use of hypnotic drugs. Clinically, older persons experience higher rates of breathing-related sleep disorder and medication-induced movement disorders than younger adults. Among the primary sleep disorders, dyssomnias are the most frequent, especially primary insomnia, nocturnal myoclonus, restless legs syndrome, and sleep apnea. Of the parasomnias, rapid eye movement (REM) sleep behavior disorder occurs almost exclusively among elderly men. The conditions that commonly interfere with sleep in older adults also include pain, nocturia, dyspnea, and heartburn. The lack of a daily structure and of social or vocational responsibilities contributes to poor sleep.

Sleep Disorders
Even modest amounts of alcohol can interfere with the quality of sleep and can cause sleep fragmentation and early morning awakening. Alcohol can also precipitate or aggravate obstructive sleep apnea

When prescribing sedative-hypnotic drugs for older persons, clinicians must monitor the patients for unwanted cognitive, behavioral, and psychomotor effects, including memory impairment (anterograde amnesia), residual sedation, rebound insomnia, daytime withdrawal, and unsteady gait.

Elder Abuse
Elder abuse is an all-inclusive term representing all types of mistreatment or abusive behaviour towards older adults. This mistreatment can be an act of commission (abuse) or omission (neglect), intentional or unintentional, and of one or more types: Physical, sexual verbal, or psychological abuse Physical or psychological neglect Financial exploitation The abuse or neglect results in unnecessary suffering, injury, pain, or loss and leads to a violation of human rights and a decrease in the quality of life.

Elder Abuse
Epidemiology of elder abuse Occurs in both domestic and institutional settings:

Domestic setting: Approximately 4-6% of elderly people report incidents of abuse or neglect in domestic settings. The most common forms of abuse are verbal abuse and financial exploitation by family members and physical abuse by spouses. Gender distribution (of victims) is equal and economic status and age are unrelated to risk of abuse. Importantly, elder abuse is under-reported.
Institutional settings: No data exists for the extent of abuse within institutional settings. However, one survey of nursing home staff in a US state disclosed that 36% of staff had witnessed at least one incident of physical abuse in the preceding year, while 10% admitted having committed at least one act of physical abuse themselves.

Elder Abuse
The main risk factors for elder abuse are: dependency and social isolation of the victim; carer has mental or substance misuse problems; absence of a suitable guardian. Factors vary according to the type of abuse; for example, dependency is a risk factor for financial or emotional abuse, but not necessarily for physical abuse. Also the causes of spouse abuse may differ from the causes of abuse by adult offspring. Prevention of elder abuse is the best approach and a number of measures have proved effective including: training and support of carers; reducing isolation of elders; respite care; CPN visits; etc. Responding to abuse effectively requires a multidisciplinary approach and a proactive system of assessment of suspicious cases (a number of assessment instruments have been developed3,4)

Pharmacokinetics
The physiological changes associated with ageing mean that the older patient's system handles drugs quite differently from that of a younger individual. Absorption generally remains the same, although there are reductions in gastric pH and mesenteric blood flow. Distribution of drugs is altered however: reduced body mass, body water, and plasma proteins, together with increased body fat causes increased levels of free drug and longer half-lives (especially of psychotropics). Drug metabolism is reduced due to decreased blood flow to the liver and loss of efficiency of liver microsomes. Excretion is reduced with the drop in renal clearance that accompanies old age. Thus drug effects are generally prolonged and cumulative and the risk of toxicity is high.

Pharmacodynamics

Dopaminergic system - there are less DA cells in the basal ganglia; thus there is increased sensitivity to the EPSEs of neuroleptics (not dystonias).

Cholinergic system - there is a normal reduction in cholinergic receptors with advancing age (and a gross reduction in DAT). Noradrenergic system - NA levels decrease with age, which may cause this age group to become increasingly vulnerable to mood disorders. Narcotics and sedative hypnotics - there is increased sensitivity to sedatives in the elderly due to a reduction in the number of available receptors. The implications of these changes are that elderly patients are more sensitive to almost all drugs used in psychiatry.

Pharmacokinetics and Pharmacodynamics

General principles of prescribing include: Start with a very low dose.

Increases should be made slowly.

Maximum efficacy is often achieved at significantly lower doses than in younger adults. Beware of dangerous side-effects such as postural hypotension and arrhythmias. The elderly are particularly sensitive to EPSEs and anticholinergic side-effects.

Beware of drug interactions due to common problem of polypharmacy in the elderly.

Pharmacokinetics and Pharmacodynamics

General principles of prescribing continued: Atypical neuroleptics are generally better tolerated than conventionals. SSRIs, SNRIs, and NARIs are generally safer than TCAs; while MAOIs and lithium may be useful in resistant depression. Monitor lithium therapy closely as levels can fluctuate easily and long-term effects on thyroid and renal function are not infrequent. Always consider suicide risk as old age is a risk factor for suicide. A pretreatment medical evaluation is essential, including an electrocardiogram (ECG).

Pharmacokinetics and Pharmacodynamics

General principles of prescribing continued: Most psychotropic drugs should be given in equally divided doses three or four times over a 24-hour period. Older patients may not be able to tolerate a sudden rise in drug blood level resulting from one large daily dose. Any changes in blood pressure and pulse rate and other side effects should be watched. For patients with insomnia, however, giving the major portion of an antipsychotic or antidepressant at bedtime takes advantage of its sedating and soporific effects.

Pharmacokinetics and Pharmacodynamics

General principles of prescribing continued: Liquid preparations are useful for older patients who cannot, or will not, swallow tablets. Clinicians should frequently reassess all patients to determine the need for maintenance medication, changes in dosage, and development of adverse effects.

If a patient is taking psychotropic drugs at the time of the evaluation, the clinician should discontinue these medications, if possible, and, after a washout period, reevaluate the patient during a drug-free baseline state

Services for the Elderly

In principle, the ideal service should plan to:

Maintain the elderly person at home for as long as possible Respond quickly to medical and social problems as they arise Ensure coordination of the work of those providing continuing care Support relatives and others who care for the elderly at home Promote liaison between medical and social and voluntary services

These include: primary care, CPN, domiciliary services, residential and nursing care, acute and long term hospital services, day and outpatient care, informal carers

Palliative Care and Living Wills

PALLIATIVE CARE is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

A LIVING WILL is an advance directive (usually written and witnessed) made by an individual regarding their preferences for future treatment during their final illness. Usually the person specifies the degree of irreversible deterioration after which they want no further life-sustaining treatment. They may also give clear instructions refusing certain medical interventions

Thank You For Your Attention!!

Questions?