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Surgeon General’s Report Ch 5 David Satcher, M.D., Ph.D. Older Adults and Mental Health (A.K.A. Sorry that we have class today.) Increases in Percent over 65 & 85 And you thought you were safe….. In population of 55 and up, almost 20% experience mental disorders not part of normal aging. These include: unrecognized or untreated depression, Alzheimer’s, alcohol drug abuse, anxiety, late-life schizophrenia, and other impairments. Stuff to Look Forward To Chronic disability in older people is declining. Decreased sensory abilities (e.g. vision and hearing) Decreased pulmonary and immune function More Stuff to Look Forward to Some loss of cognitive capacity Declining working and long-term memory Slowing of information processing, selective attention, and problem-solving ability Decline in fluid intelligence, the ability to solve novel problems Don’t Give up Hope Yet Important cognitive functions are spared People who complain of memory loss tend to do better on memory tasks then people who do not complain Fluid intelligence can be enhanced through skills training Keeping your Cognitive Ability Four Factors Education Strenuous activity in the home Peak pulmonary flow rate Self-efficacy Aging Successfully Avoid disease and disability Sustain high cognitive and physical function Be engaging with life Losing Loved Ones 800,000 older Americans are widowed each year Bereavement includes crying and sorrow, anxiety and agitation, insomnia, and loss of appetite Symptoms persisting over 2 months equals diagnosis of adjustment disorder or major depressive disorder Risk factor for depression Primary Prevention of Mental Disorders Prevention of disease before it occurs Understanding risk factors, etiology, and the course of mental disorders Depression in Older Adults Leads to impairments in physical, mental,and social functioning Often undiagnosed or untreated Hard to distinguish from other disorders that affect older people Depressive symptoms more common then full fledged major depression Late-onset-first onset after 60 More Depression Major • • • • • Depressed mood Loss of interest or pleasure in activities Significant weight loss or gain Sleep disturbance Feelings of worthlessness Minor • • • • More frequent Diagnosis not yet standardized 8-20% of community residents 51 more days lost from work then major Barriers to Diagnosis and Treatment Looks like other disorders Less likely to report feelings of dysphoria and worthlessness Stigma Pay attention only to physical effects Provider may be reluctant to inform older patient about his depression May think it is inevitable part of aging Interactions with Somatic Illness Often detected with somatic illnesses Relationship thought to be reciprocal Depression often occurs with heart disease, stroke, lung disease, cancer, arthritis, Alzheimer’s, and Parkinson’s Sleep disturbances related to depression Consequences For 85 and older, suicide rates 21 per 100,000, twice the national average Older white men 65 per 100,000 People 75 and up, 60-75% of suicides have diagnosable depression Can lead to higher mortality from other diseases, particularly heart disease and cancer Chronic depression can raise risk of cancer by 88% in older people Treatment Everyone can respond to drugs, 60-80% to antidepressants, 30-40% to placebos Problems with drug interactions, especially with SSRIs Best response with drugs plus therapy with a longer time to remission and twice the rate for relapse ECT may be better for no drug interactions and sensitivity but followed by confusion and memory loss Alzheimer’s Disease (Not Old Timer’s) Strikes 8-15% of people over 65 Lack of biological markers Characterized by memory loss The most prevalent form of dementia Symptoms Cognitive deficits in language, object recognition, and executive function Psychosis Agitation Depression Wandering Diagnosis can only be verified after death in an autopsy Alzheimer’s Other forms of dementia must be ruled out Early symptoms of cognitive decline may be considered by family as “senility” Very under recognized Early detection=more treatable symptoms such as hyperthyroidism Not curable More Symptoms Insomnia Incontinence Catastrophic verbal, emotional, or physical outbursts Sexual disorders Weight loss Behavioral symptoms may cause distress to the caregiver which can result in abuse Course Gradual decline in functioning throughout the course Loss of 4 points per year on the Mini Mental Status Exam typically Memory dementia is usually first symptom noticed Later, deficits in language appear Depression appears with dementia Behavioral symptoms (agitation) appear later Onset of symptoms to death is 8-10 years Prevalence and Incidence: Am I going to get it? Prevalence of dementia nearly doubles with every 5 yrs after 60 Prevalence seemingly higher in women then men (Women live longer) Increases in number related to increasing life expectancy Increase in education related to decrease in frequency Etiology Not completely understood combo of genetics and environment Familial form- mutations in chromosome 21, 14, 1. Creates a overproduction of protein in neuritic plaques, ß-amyloid. Only a small number of cases 50% of people with family history, in their 80s-90s develop it Other genes studied More Etiology Biological risk factors include aging and cognitive capacities These include neuron and synaptic loss, decreased dendritic span, decreased size and density of neurons in nucleus basalis of Meynert, and lower cortical acetylcholine levels If everyone lived long enough, would we all get Alzheimer’s? How do I Stop this Thing? Adding the ApoE-e2 allele decreases risk Go to school: higher educational level= later onset Nonsteroidal anti-inflammatory drugs and estrogen replacement may delay onset Vitamin E and selegiline (deprenyl) delay milestones of the illness like moving to a nursing home, disease progression, and even death The Actual Physical Stuff Neuritic plaques Neurofirillary changes Synaptic loss Hippocampal granulovaculor degeneration Amyloid angiopathy Everyone’s Favorite Neurotransmitter Acetycholine has something to do with it Loss of basal forebrain and cortical cholinergic neurons, and depletion of the enzyme in the synthesis of ACh in patients Degree of cholinergic neurons is correlated with level of dementia Treatments Drug experiments Experiments with ACh Use either cholinergic receptor agonists (nicotine) and AChE inhibitors to increase ACh in synaptic cleft Keeps cognitive function Improves attention Helping the Family Too Caregivers need much support Caregivers are at risk for depression, anxiety, and somatic problems Need training in use of memory aids and note taking Need preparation for future symptoms like aggression More Disorders Anxiety Schizophrenia Alcohol abuse Substance abuse Anxiety 11.4% in 55 and older meet criteria in one year Phobic anxiety disorders most common Lower panic and bipolar disorder rates PTSD as Vietnam vets get older Benzodiazepines same as on younger people Use has to be more limited because they stay longer in older people’s systems— use less then 6 months Schizophrenia Can extend to and appear later in life Same criteria as for younger people Very costly, more so then other disorders Patients with late-onset are mainly women with paranoia Require lower medication doses Less positive symptoms, less severe symptoms, more negative symptoms Alcohol and Substance Abuse and Misuse Misuse of prescription drugs rather then abuse of illicit drugs more common Prevalence of heavy drinking: 3-9% but prevalence of alcohol abuse and dependence: 0.9%-2.2% 4 times more common in men then women 65 and older Believed that alcohol use will increase with the baby boomers aging Drugs Older people use prescription drugs 3 times as frequently as general population and even more over-the-counter drugs Spend $15 billion annually on prescriptions Older women are more likely to be prescribed psychoactive drugs Men are more likely to report use of sedatives, tranquilizers, and stimulants Elderly Services Community based care More emphasis 95% of elderly 30% live alone, mostly women Institutions Nursing homes Place to put people with mental disorders Costly THE END Everyone Wake Up!!!!!
