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Introduction
Mental health and emotional well-being are as important in older age as at
any other time of life. Most older people have good mental health, but
older people are more likely to experience events that affect emotional
well-being, such as bereavement or disability. The Department of Health
estimates that perhaps 50 per cent of older people in general hospitals, and
60 per cent of care home residents, have a mental health problem.
Assessing the mental health needs of older people requires an
understanding of the complex interaction between specific medical
conditions and social circumstances. To be able to offer effective support,
practitioners need to keep up-to-date with the latest research methods and
legislation.
Improved living standard and success in combating many diseases have
led to increase life expectancy. industrialized societies people are
living healthier and longer than ever before
In the UK between 1971and2003 the number of people over 65 changed
28% and 2002 life expectancy for female 81 years and 76 for male
People aged 85 are fastest rising population
England currently over6000 people over 100 yrs asESRC
Added life to years not just more to life
A growing body of evidence counter the stereotype that ageing is
inevitable associated with sickness
The optimistic some of studies factor such as diet, ,marital stability,
exercise,education,mental stimulation
And social involvement are associated with longevity a
And quality of the life
Some study in Sweden for people aged 85.more than three quarters were
identified as having high levels of subjective well being measured by high
and moderate levels on morale scale
The combination of this higher frequency of the physical ill health
And disability with other factor associated with ageing cognitive
Impairment ,socio economic deprivation and social support deficit
This factor increase incidence of commonest metal health problem
Depression,anxiety disorders among oldest old
Trends for increasing proportion of older people in population and
having less disability and independent . Depend on continuing social
,economic ,and health care improvement
Older people live alone without family support structure present a
special challenge and need for innovation by health care providers
Older people mental health prevalence and impact of mental health
problems
Mental disorder are common in general population affecting more than
a quarter of all people at some time in their life WHO 2001.
Mental disorder accounted for four of 10 leading cause of the of
disability,.
Point prevalence rate for adult experiencing any mental disorder are 10 %
To 15% .
The frequency of mental illness in elderly may be under-reported" make
diagnosis in the presence of physical co-morbidity “
Depressive and anxiety disorder affect between 1-7 people1-10
Dementia and delirium of 11-17 and 1-25 {beekman1999,chew
graham 2004}.
SOME study in UK lower levels of common mental disorder in aged 60
And older these community studies are individual living in private
house
Exclude people in situation ,temporary hospitalized or homeless
UK 1996 33200 people living in hospital and 350000 older people having
care in homes as mental disorder
One in ten people aged 60 to 74 living in private households in
Great Britain (10 per cent) had a common mental disorder (such
as anxiety, depression and phobias) according to a survey report∗
published today by the Office for National Statistics.
Common mental disorders were strongly associated with
disability. Over a third of people interviewed (37 per cent) had
difficulty with one or more of seven common activities of daily
living (ADLs), (for example, personal care, household work,
getting out and about), and the likelihood of reporting difficulties
rose steadily with increasing severity of symptoms of common
mental disorder.
Difficulties with ADLs increased were also associated with longterm
physical health problems. However, at every level of
physical ill-health those with mental disorder were more likely
than those without to have difficulty with at least one ADL.
This report is also the first in the UK to examine systematically
cognitive impairment in older people. One sixth of those aged 60
to 64 rising to one quarter of those aged 70 to 74 were relatively
impaired in standard tests of memory and concentration. While
very few would be suffering from dementia, those with impairment
were much more likely than others to experience difficulties with
most ADLs.
This report is also the first in the UK to examine systematically
cognitive impairment in older people. One sixth of those aged 60
to 64 rising to one quarter of those aged 70 to 74 were relatively
impaired in standard tests of memory and concentration. While
very few would be suffering from dementia, those with impairment
were much more likely than others to experience difficulties with
most ADLs.
The report is part of a series based on a survey of psychiatric
Inter-relation between physical and mental disorder
Inter-relations between physical and psychological health are evident with in all age
however the frequency of negative association –co-morbidity rise with age .
The frequency of interaction and severity of its effects are magnified in older
Much research has explored the relationship between depression and cardiac
patient’ compare with non depressed cardiac patient .the mortality rate
threefold increased in cardiac patient have major depression
Epidemiological study has explored the dynamic of the interaction between
Physical illness and mental disorder .
Physical illness appear to be an important risk factor for development of
several mental agoraphobia in older people may be commonly precipitated
By stork and falls rather than associated with panic disorder. patient with
Chronic medical illness have increased risk of depressive illness
Older people have vascular disease prescribed medication may make mood disorder
Inter-relation between disability and mental disorder
study appear disability resulting from physical illness are
associated with common mental disorder especially depression
The disability arising from physical ill health has been estimated to be
Cause of up 70%of new cases of depression in older people
Depression cause disability features
1-reduce motivation
2-psychomotorretardation
3- poor sleep
4-lack of energy
5- avoidance and anhedonia
Are likely to limit activity and physical disability . They are mutual
reinforcement process
Older hospital setting patient in general
older people occupy tow –third of general hospital beds
And exhibit a high prevalence of co-morbid mental disorder
Predominantly delirium dementia and depression
Level of patient with depression 50%
{ames 1994}
Co-exist with medical condition especially chronic illness sush as
ischemic heart disease
,stroke ,cancer ,chronic lung disease ,Alzheimer's ,and Parkinson
disease likely to be prevalent At levels three time in the community
Problem affect mental disorder in hospital
1-length of stay
2- use of resource
3- cost of care
4- prognosis
the complex range of physical and emotional and social problems
are demand high level of skill from care staff and resource,
the recognition of mental problems in physical ill older
people is made more difficult by the inter action of illness
feature ,example such as
depression symptom of anorexia .poor sleeping , and weight
loss result from variety of physical condition
physical feature such as aches pains fatigue may be aspect
of mental disorder
should be have screening measure in the hospital to identify
mental health problem such as geriatric depression scale
Older people in nursing and residential homes
You may be living at home and finding it difficult to cope because you are
disabled or because you are getting more frail, or you might be in hospital
and know that returning to live at home will be difficult. Moving into a
residential care home is one possibility that might make your life easier.
Another setting is high prevalence of mental disorder among older people
with absence optimal management Is residential care . Care home are
differentiated on the basis of whether they provide personal and social car
Research indicate that new admissions to all types of care homes in the UK
increasingly old . Residents are more disabled than previously with
higher level of cognitive impairment , Prevalence level of dementia 50% .
Depression in USA PREVALENCE 20% TO 40% of residents.
Advantage of home care
• homes scored adequately in respect of non-restrictive care practice
,standard
• Of décor and cleanliness and facilities
• For activity and recreation
mental health and older people specific disorder
1- depression
2- anxiety disorder
3- dementia
4- delirium
Depression
Definition: Unipolar depression is another name for major depressive
disorder. It is a mood disorder characterized by a depressed mood, a lack of
interest in activities normally enjoyed, changes in weight and sleep,
fatigue, feelings of worthlessness and guilt, difficulty concentrating and
thoughts of death and suicide. If a person experiences the majority of these
symptoms for longer than a two-week period they may be diagnosed with
major depressive disorder.
The term unipolar depression is used to distinguish it from depression
which occurs within the context of bipolar disorder, a disorder in which a
person experiences alternating periods of depression and mania.
Type of depression
1. Major Depressive Disorder
When people use the terms depression or clinical depression, they are
generally referring to major depressive disorder. Major depressive disorder
is a mood disorder characterized by a depressed mood, a lack of interest in
activities normally enjoyed, changes in weight and sleep, fatigue, feelings
of worthlessness and guilt, difficulty concentrating and thoughts of death
and suicide. If a person experiences the majority of these symptoms for
longer than a two-week period, they may be diagnosed with major
depressive disorder.
Dysthymic Disorder
The terms dysthymia and dysthymic disorder refer to a mild, chronic state
of depression.
Symptoms
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sleep difficulties
fatigue
low self-esteem
difficulty concentrating or making decisions
feelings of hopelessness
3. Bipolar Disorder
Bipolar disorder is an illness that consists of alternating periods of elevated
moods, called manic episodes, and depression. Mood swings run on a
spectrum from mild mania (called hypomania) to more severe, debilitating
highs. Periods of mania can last for hours, days, weeks or even months
before depression returns.
4. Postpartum Depression
Pregnancy brings about many hormonal shifts. These dramatic shifts can
sometimes affect mood. This is commonly known as the "baby blues."
Postpartum depression can be more than just a case of the blues, however.
It can range from mild symptoms that go away without treatment all the
way up to postpartum psychosis, which left untreated, may be responsible
for tragic murders of children.
5. Seasonal Affective Disorder
If you experience depression, sleepiness, weight gain and
carbohydrate cravings during the winter months, but feel great as soon as
spring returns, you may have a condition called Seasonal Affective
Disorder (SAD).
Prevelance major depression among older people 1% to 4% and in minor
depression 4% to 12% . Increased over aged 80%
Older people with depression have longer duration of episodes and shorter
time of relapse than younger persons
30% remain chronicly depressed
• The longer duration of episodes appear
• To be co-existing physical illness
• To be poor self health status
• To be depressed severity
• Inadequacy social support
• Adverse life event
Depression ,loneliness and social support
The social environment plays crucial part in determining the quality of
older people lives . Inters personal relationship have been found to act
buffer between adverse event and depression . Loneliness is associated
with living alone and social isolation . Vulnerability factor for loneliness
Female, Chronic health problem and Marital status. Marital status
Suicide and depression Elderly people have the highest rate of completed
suicide rate of any age group. Depression in older people commonly
complicates because co-morbid medical illness or dementia
The clinical presentation may be typical and meet full criteria for
depressive disorder , Stigma prevent seek help for emotional problem
Useful questions for uncovered depression
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Are you sad?
Are you sleeping poorly?
Do you worry to much ?
What have you enjoyed doing later ?
Rating scale
during the past month ,have you often been bother by feeling
down ,depressed or hopeless? Yes or no
• During the past month have you often been bothered by little
interest or pleasure in doing things ?yes or no
Management
Antidepressant drug
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1- SSRI fluxetine, fluvoxamine
2- tricyclic imipramine , clomipramine
3-monoamone oxidase inhibition ,phenelzine,selegiline
4- atypical bupropion ,mitrazapine , nefazodone
5- SNRI duloxetine ,venlafaxine
Psychological therapies
Is important and enhancing the effect of medication and reducing relapse
follow cessation of treatment and it is consistently found to be more
acceptable than other treatment
Cognitive behavior therapy
Most establish treatment for depression and the aims to alter dysfunctional
beliefs and negative thoughts that characterize depression by sessions
CBT need some adaptation for work with older people because of different
life experience and value related ego
Anxiety disorder
(psychiatry) a relatively permanent state of worry and nervousness
occurring in a variety of mental disorders, usually accompanied by
compulsive behavior or attacks of panic and Is co morbid with depression
Anxiety symptom and disorder among older people are associated with
disability ,reduce equality of life, increase use health services Prevalence
10% making these mental disturbance in the late life ,The rate of anxiety
disorder are around twice a high among women as men
Vulnerability factor Lower level of education , External locus of
control , Resent loss of family and Physical illness
Other factors induce anxiety
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Aspect of environment
Medication side effects Alcohol intoxication or withdrawal
*factors contribute to poor recognition
1-other common mental disorder
2- medical co-morbidity
3- early age of onest and no treatment
Treatment for anxiety disorder in later life
• Tricyclic antidepressant
1-clomiparmine hydrochloride
2- imipramin hydrochloride
General anxiety improved with anti depressants drug
benzodiazepines
• Beneficial effect on symptoms of panic and general anxiety
disorders {diazepam , lorazepam }
• Side effect drowsiness {driving accident risk}
Psychological treatment
CBT IS EFFECTIVE for older people , Situational exposure ,
relaxation technique ,self control desensitization and cognitive
restructuring
provides psychotherapy and/or counseling to help you deal with a
variety of life adjustment problems and psychological disorders.
Psychotherapy is a process by which you examine your thoughts,
feelings, actions and relationships, evaluate where problems exist, and
learn how to make whatever changes are necessary to achieve better life
adjustment and satisfaction. The terms counseling and psychotherapy
are interchangeable because they describe the same process, and have
similar goals. Counseling has its roots in personal development and life
adjustment, while psychotherapy has its roots in a more medically
oriented model of treating a mental disease process. Health insurance
companies use a medical disease model, so insurance reimbursement is
for "psychotherapy" not "counseling." The distinction is unimportant in
applying the process to life management problems
dementia
Definition
• Dementia describes a loss of memory or problems with
memory cognition, and reasoning characterized by:
• impairment of short and long-term memory.
• change of personality
• impaired insight and judgment (old age).
• Due to general medical conditions or is substance-induced.
• Dementia is diagnosed only if the cognitive deficits are
present for at least several months.
Cortical and subcortical dementias:
The relationship is neuroanatomic lesions to symptoms.
a. Cortical dementia: characterized by the early appearance
of aphasia memory loss, and difficulties with calculation.
Disturbances of speech and psychomotor behavior are less
predominant.
b. b. Subcortical dementia characterized by the early
appearance of problems with executive functioning and
recall, dysarthria, motor skill impairment, and personality
changes.
Epidemiology (Dementias)
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5% between age 65-85 years of the population
20% over 85 years.
50 percent in monozygotic twin pairs
75% is heritable.
More than 75% of dementia is caused by Alzheimer disease and
cerebrovascular disease.
Diagnostic features (Dementias)
a-impairment. insidious, absent- Memory minded, misplacing
objects, learning deficits, and recent memories are lost with
progressive forget even their own names, social and occupational
even exposed to physical dangers, (fires, falling etc…)
b. Aphasia is an impairment or loss of language. difficult
constructing sentences, finding words, naming objects, may aphasia,
mutism, communication difficult.
c. Apraxia. (inability to execute complex motor behaviors, bathing,
dressing, driving, or drawing, due to impaired sensory (identify objects or
position) or motor function.
d. Agnosia. failure to recognize or identify known objects, or familiar
persons.
e. Disturbance in executive function. impaired ability to start, stop, think
abstractly, plan, sequence, monitor, conceptualizing or problem solving
(creating a report, making a grocery list, or adjusting the thermostat in a
house).
Associated features (Dementias)
a. Emotional changes. Individuals with dementia often become
emotionally uninhibited and labile. They may have outbursts of anger,
anxiety, or despair. Depressive symptoms are common and may exacerbate
cognitive deficits.
b. Personality disturbances. Even with relatively mild dementia,
individuals may undergo marked changes in personality, becoming
uninhibited, socially inappropriate, or moody. Irritability and
argumentative. Expansiveness and euphoria are sometimes present.
c. Psychotic symptoms. Delusions, especially of a persecutory nature,
may be present in individuals with dementia. Hallucinations can also occur.
d. Functional Neuroimaging. Abnormal findings on computed
tomography (CT) and magnetic resonance imaging (MRI),
Neurodegenerative diseases (generalized or focal cerebral atrophy),
Vascular disease, Neoplasm & traumatic injuries (focal lesions), Positron
emission tomography (PET) or single photon emission computed
tomography (SPECT) or Functional magnetic resonance imaging (MRIf)
focal hypometabolic activity.
e. Evidence of general medical conditions or substance use.
Substance-induced persisting dementia as prolonged substance abuse,
alcohol related, liver disease.
Diagnosis of Dementia
• A complete medical history (medical -thyroid -drug -tumors -etc).
• Examination of patients with mental disturbances.
• Basic medical tests & metabolic homeostasis, levels of electrolytes,
pH, hydration, metabolic and endocrine disorders and neoplasms
• Neuropsychological tests (memory -, problem solving -attention counting -language).
• Brain scans & EEG: (CT -MRI -EEG)
• Mental Status Examination: (Diagnostic Criteria