Download Aging Demographics and Psychiatric Diagnoses in the Elderly

Aging Demographics and
Psychiatric Diagnoses in the
Elderly
Marguerite R. Poreda, MD
Assistant Professor
USF COM Department of Psychiatry
and Behavioral Medicine
Training Director Geriatric Psychiatry
Associate Director Memory Disorders Clinic
Adult, Geriatric and Forensic Psychiatry
The views expressed in this presentation are my own and do
not necessarily represent those of USF, MacDill AFB, the VA
or any other agency of the Federal Government or the State
of Florida. The speaker does not receive honoraria, grants or
research support from any pharmaceutical company nor is on
any pharmaceutical’s Speaker’s Bureau
Aging Demographics and Psychiatric Diagnoses
in the Elderly:
what I will review

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Aging demographics (baby boomers, the aging
population, the ‘old,’ ‘very old,’ ‘oldest old’; what
age defines geriatrics?)
Understanding psychiatric nomenclature:
Axis I - V
Psychiatric Diagnoses:
Axis I - depression, anxiety, BMD, psychotic
disorders, delirium, dementias, alcohol/SA;
Axis II – Personality Disorders and Mental
Retardation
Suicide risk factors
Elder abuse, neglect and exploitation
What is Geriatric Psychiatry?
Fastest growing field of psychiatry; branch of
medicine concerned with prevention, diagnosis,
and treatment of physical and psychological
disorders in the elderly and with the promotion
of longevity
 An ‘official’ ABPN subspecialty in 1989
 Managing elderly patients requires ‘special’
knowledge: possible differences in mental health
presentations, frequent co-exiting and
complicating chronic medical diseases, multiple
medications (drug-drug interactions,
pharmacodynamics and pharmacokinetics) and
aging specific issues

What’s in an age?
What age makes you a geriatric patient?
What makes you ‘elderly’?
Age 65 and older: elderly, ‘old’
 Age 85 and older: ‘very old’ or ‘old, old’
 Age 100 and older: ‘oldest old’


“Baby Boomers” – those born between 1946 1964, 78 million US Americans alive today and
will be turning 60 years of age in 2006 
2024.……“Graying of America”
Geriatric Statistics:
U.S. Bureau of the Census:
Life expectancy: 1950 = 68 years; 1991 = 79
years for women/72 years for men*
 In the year 2000 = 12.4% of the U.S. population
- 35 million Americans - were 65 years or
older*
 By 2030 = percentage increased to 20% -1 in 5
people will be older than 65; 2025 in Florida – 1
in 4 people
 People age 85 and older: are the fastest growing
segment of our population – from 4 M today to
20 M by 2050;* constitute 10% of those 65
years and older; there are 39 men for every
100 women 85 years old or older

*Administration on Aging. Statistics on the Aging Population, Rockville, MD; US Department of Health and Human Services; 2003; U.S. Bureau of the Census.
Geriatric Statistics
The old, old (age 85 and older) consume
the largest amount of Medicare resources;
5% of the Medicare population consumes
50% of the Medicare dollars – many are
the ‘frail elderly’
 On average, by age 75, older adults have
between two and three chronic medical
conditions; some as many as ten to twelve
medical conditions and as many
medications

Geriatric Statistics: Mental Health
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20% of the US population over the age of 65 has a
mental illness**
As the population ages, the number of people with
mental illness will double to 15 million by 2030
Number of people over age 65 years with mental illness
will equal the number of people with mental illness in
ALL other age groups*
Older adults are less likely to seek mental health: only
4% of non-institutionalized US population seek mental
health treatment***
Older adults are more likely to be identified, diagnosed
and receive treatment from their primary care
physician****
*Bartels SJ (in press).
**Jeste, DV, Consensus statement on the upcoming crisis in geriatric mental health, Arch. Gen. Psychiatry 1999: 56(9): 848-53.
** * Olfson M, Outpatient mental health care in non-hospital settings. Am. J Psychiatry 1996; 153(10): 1353-6.
* ** * Kaplan MS, et al, Managing depressed and suicidal geriatric patients. Gerontologist 1999; 39(4): 417-25.
A Guide Through DSM-IV TR
for the non-psychiatrist
(for diagnosis, treatment and
medication management)
DSM-IV TR: Multiaxial System
Axis I: Clinical D/O
Axis II: Personality D/O
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Stressors (primary and/or secondary GMC,
support group, education, housing, access to
health care, occupational, financial, legal, social,
recent loss and other psychosocial and
environmental problems)
Axis V: GAF (Global Assessment of Functioning scale 0-100)
Multiaxial System - Example
Axis I: Major Depressive Disorder, recurrent,
moderate without psychotic features;
R/O alcohol abuse
Axis II: Cluster B traits
Axis III: hypothyroidism, DMII, HBP
Axis IV: poor social support – few friends and
husband has left/whereabouts unknown,
education – quit high school to get married and
have a baby, homeless after hurricane Katrina,
access to health care – lack of health coverage,
occupational and financial - unemployed, legal recent DUI
Axis V: GAF: 58
Axis I Disorders
Axis I Disorders:
Mood D/O (Depressive D/O and Bipolar D/O)*
Adjustment D/O*
Anxiety D/O*
Somatoform/Factitious/Dissociative D/O
Impulse Control D/O
Paraphilias/Sexual and Gender Identity D/O
Eating D/O
Sleep D/O*
Delirium, Dementia, Amnestic and other Cognitive D/O*
Alcohol and Substance Related D/O*
Schizophrenia and other Psychotic D/O
(such as Delusional D/O)
Axis II Disorders
Axis II:
Personality D/O
Mental Retardation (onset before age 18,
IQ at/below 70)
General Diagnostic Criteria for a
Personality Disorder
Simply put: an extreme variant of normal
personality traits
 ENDURING pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture, is
INFLEXIBLE and PERVASIVE across a broad
range of personal and social situations, leads to
clinically significant distress or impairment in
social, occupational, or other important areas of
functioning, is stable and of long duration
(traced back to early adolescence or early
adulthood) and not better accounted for by
another mental, substance abuse d/o or medical
condition (e.g. head trauma)

General Diagnostic Criteria for a
Personality Disorder
Manifested in 2 or more areas:
-cognition (ways of perceiving and
interpreting self, others, and events)
-affectivity (in range, intensity, lability and
appropriateness of emotional response)
-interpersonal functioning
-impulse control

Personality Disorders
 Cluster
A: Paranoid PD, Schizoid PD,
Schizotypal PD
 Cluster B: Antisocial PD, Borderline
PD, Histrionic PD, Narcissistic PD
 Cluster C: Avoidant PD, Dependent
PD, Obsessive-Compulsive PD
 PD NOS (mixed personality)
General Population Statistics
AS-PD = 2%
 B-PD = 2% (but 10% of all psych outpatients/75%-90%
are women)
 H-PD = 2-3%
 N-PD=<1%
BUT among chronic pain patients – a disproportionate
percentage:
 AS-PD = 5%
 B-PD = 7-25%
 H-PD = 8-26%
 N-PD = 5-22%
 NIH Survey (2001-2002 National Epidemiologic Survey)
estimated that 14.8% of American adults = 30.8 million
Americans met criteria for at least one PD

Late Life Stressors
that place older adults at risk of
mental health disorders
Chronic physical health condition(s)
 Death of a loved one
 Caregiving
 Social isolation/lack or loss of social
support
 Significant loss of independence
 History of mental health problems

Late Life Stressors
that place older adults at risk of
mental health disorders
Old age – even though older adults are more
likely to experience life stressors – old age is
NOT a risk factor for an increasing risk for a
mental health disorder; in fact, ‘most’ older
adults are able to cope with late life stressors
without developing significant mental health
disorders
 Successful aging: Vaillant; Success throughout
the life cycle: Neugarten

Most common mental disorders
of old age are…………

…..depressive disorders, cognitive disorders,
anxiety disorders and alcohol use disorders

Psychiatric disorders other than depression are
found in lower prevalence among the elderly
than at any other stages of the life cycle

Suicide risk in the elderly
*National Institute of Mental Health’s Epidemiologic Catchment Area (ECA) Study
Suicide Risk Factors for Adults:
Demographic
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Men at greater risk than women; Caucasians account for
more than 90% of all suicides
Age clusters: age 15-19, 20-24 and over age 60
Marital status: widowed, divorced and single individuals
at greater risk than married individuals (more
pronounced in men)
Living alone; no children under age 18 living in
household
Alcohol/Substance Abuse history
History of mental illness; previous suicide attempt
Firearm(s) in the home
30% have seen a physician within 30 days; 60% have
seen a physician within 6 months
Suicide Assessment:
SAD PERSONS…….a mnemonic
Sex (male) - (age 65 – 15.5:100,000; white male older
than 85 - suicide rate of more than 50:100,000
compared to the US population in 2002)
 Age (older) – (beginning at age 60)
 Depression
 Previous suicide attempts
 ETOH/SA
 Rational thinking loss (psychosis)
 Social supports lacking
 Organized plan to commit suicide
 No spouse (divorced > widowed > single)
 Sickness (physical illness)

Risk of Suicide in People with Selected
Psychiatric Disorders
Condition………. Estimated Lifetime Suicide Risk
Major Depression………………….14.6
 Bipolar Mood Disorder…………….15.5
 Dysthymia…………………………... 8.6
 Schizophrenia………………………. 6.0
 Panic Disorder……………………….7.2
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Source: Pies(2004). Data from APA (2003); and Harris and Barraclough (1997)
Suicide Risk
Suicide risk can not be predicted from any
one factor
 Predicting suicide is VERY difficult BUT
failure to assess for suicidality is the key to
liability; asking about suicide does NOT
increase the risk

Depressive Disorders
MDE: single, recurrent; with atypical
features; with catatonia; with postpartum
onset; with psychotic features; with
seasonal pattern (SAD)
 Dysthymic Disorder
 Depressive Disorder NOS
................................................................
 Adjustment Disorder
 Bereavement/Abnormal Bereavement

Depression
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Prevalence rate: 4.4% - by DSM IV criteria
Up to 20% of community-dwelling older adults endorse
significant depressive symptoms that do not meet full
criteria for a mood disorder – subsyndromal depression
is the modal form in older adults*
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Late-onset depressive disorder is associated with being
widowed, having a chronic medical illness and with a
high rate of recurrence
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Up to 80% of patients in LTC (NH/ALF) may experience
a mood disorder
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Adjustment Disorders; (Abnormal) Bereavement
*APA Working Group on the Older Adult (Brochure) 1998; WDC.
Depression in the Elderly:
Signs and Symptoms
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Reduced energy and concentration
Decreased appetite, weight loss
Sleep complaints – early morning awakenings and
frequent awakenings
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SOMATIC COMPLAINTS
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‘pseudodementia’
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Episode with ‘melancholic features’, hypochondriasis,
hopelessness, feelings of worthlessness, paranoia and
suicidal ideation
Anxiety Disorders
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Usually begins in early or early or middle
adulthood but may appear after age 60

Prevalence rate: 5.5% -11.4* but with the
elderly - up to 20% with 37% comorbidity with depression, dementia and
medical illnesses such as CHF, CAD,
diabetes
*U.S. Department of Health and Human Services. Mental Health: Report of Surgeon General; 1999
Anxiety Disorders: Prevalence
(among older community-dwelling individuals)
GAD = 7.3%
 Phobias = 3.1%
 Panic D/O = 1.0%
 Obsessive-compulsive disorders = 0.6%

Interrelationships Among Depression
and Anxiety Disorders
Generalized
anxiety
disorder
Obsessive
compulsive
disorder
Social anxiety
disorder
Depression
Specific
(simple) phobia
Panic disorder
Posttraumatic
stress
disorder
There is considerable overlap among
symptoms of depression and anxiety disorders
DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
Major Symptoms of
Depression and GAD Overlap
Generalized anxiety disorder
Major depressive disorder
Worry
Anxiety
Muscle
tension
Palpitations
Sweating
Dry mouth
Sleep disturbance
Depressed mood
Psychomotor agitation
Concentration
difficulty
Irritability
Fatigue
Anhedonia
Appetite
disturbance
Worthlessness
Suicidal ideation
Nausea
DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
Continuum of Anxiety and Depression
Anxiety
disorders
Comorbid
depression
and
anxiety
Stahl SM. J Clin Psychiatry. 1993;54(1 suppl):33-38.
Major
depressive
disorder
Co-morbidity:
Depression and Anxiety
-- 1/3 –> 1/2 of people with depression
will meet criteria for an anxiety disorder
--More then 1/2 of people with an anxiety
disorder will eventually experience a
depressive disorder
--Even among patients diagnosed with a
depressive disorder who do NOT meet
criteria for a formal anxiety disorder, the
majority experience anxiety symptoms
The Affective Spectrum
Dysthymia…..
 Single MDE….
 Chronic MDE….
 Atypical MDD….
 Recurrent MDD….

 BIPOLAR
SPECTRUM………
The Affective Spectrum:
Bipolar Mood Disorders
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Bipolar l
Bipolar ll

Mania and Major Depression

Hypomania and Major Depression

Cyclothymia (non-major
depression as well as hypomania)

Hyperthymic temperament
(‘ascending order’ up the bipolar
spectrum)

Secondary Mania (due to other
illnesses or medications)
Bipolar lll
The Affective Spectrum:
Bipolar Mood Disorders...range of rates

Bipolar l

0.0 - 1.7%

Bipolar ll

0.2 – 3.0%
Bipolar Spectrum
Disorders
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
2.6 – 6.5%
overall = 3.4%
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Equal males/ females
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
Sex
(sex difference only significant
in BMD II and Cyclothymic
D/O)
Bipolar Mood Disorders
1.7% population = 3.3 million (US)
 6th leading cause of disability worldwide –
esp. from undertreated or resistant
depression
 Suicide: 25% attempt, 11-19% complete
 Complex non-Mendelian inheritance –
several genes involved
 >90% will have future episodes
 10-15% will have >10 episodes

Bipolar Mood Disorders
Onset (average in years):
--1st impairment = 15-19
--1st treatment = 22
--1st hospitalization = 25

Younger Age of Onset: AD medications,
stimulants, SA, ‘genetic’ anticipation
Late Life Onset: 30-60 years
Secondary Mania of Late Life
Bipolar Mood Disorders
69% of patients are misdiagnosed at least
once
 35% were symptomatic for more than 10
years before correct diagnosis
 Increased mortality (unnatural and natural
causes of death)
 Co-morbid anxiety rates in patients with
Bipolar Mood Disorder are between 30%
 40%*
*McElroy et al., Am J Psychiatry 158: 420-426, 2001

Symptom Domains
of Bipolar Disorder
Dysphoric or Negative Mood
Manic Mood and Behavior
and Behavior
• Euphoria
• Grandiosity
• Depression
• Pressured speech
• Anxiety
• Irritability
• Impulsivity
• Hostility
• Excessive libido
• Violence
BIPOLAR
• Recklessness
• Suicide
• Social intrusiveness
DISORDER
• Diminished need
for sleep
Psychotic Symptoms
•
•
Delusions
Hallucinations
Slide courtesy of Keck PE Jr.; adapted from Goodwin FK, Jamison KR.
Manic-Depressive Illness. Oxford University Press: New York, NY; 1990.
Cognitive Symptoms
•
•
•
•
Racing thoughts
Distractibility
Disorganization
Inattentiveness
Screening Tools:
The Mood Disorder Questionnaire
Important symptoms:

Hyper or more energetic than
usual

Predominately or thematically
irritable

Distinctly self-confident, positive
or self-assured
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Less sleep than usual

More talkative or speaking faster
than usual

Racing thoughts
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Easily distracted

Problems at work and socially
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More interest in sex

Taking unusual risks

Excessive spending
Screening Tools: The Mood Disorder Questionnaire
(cont.)

The Mood Disorder Questionnaire (MDQ)
 Derived from DSM-IV criteria and clinical experience
 Initial validation study of MDQ in psychiatric outpatients
(N = 198)
 Sensitivity = 73% and Specificity = 90% for Bipolar I and II
 Validation study of MDQ in general population (N = 711)
 Sensitivity = 28% and Specificity = 97% for Bipolar I and II

MDQ as screening tool (13 questions)
 Positive MDQ  7 “yes” responses; Negative MDQ  7 “yes”
responses
 Rapid screening tool – 10 minutes or less
 Patients can self-administer MDQ while in the waiting area
 Does not require trained evaluators
 Easily used in primary care settings
Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:53-59.
Bipolar Disorders: in Older Adults
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*
True prevalence is unknown (elderly underutilize
mental health services, underreport mental
health problems, receive care in other settings)
Co-morbidity is the rule rather than the
exception (neurological illness, diabetes….7 or
more co-morbid diagnoses in 20% of elderly
BMD)*
Lifetime rate of substance abuse: 20-30%
Difference between ‘early onset’ bipolar d/o vs.
‘late onset’ bipolar d/o
Mania associated with medical conditions
Depp & Jeste 2004; Regenold, et al.
Bipolar Disorders: in Older Adults
Primary vs. Secondary Mania

Primary:
-onset early in life
-no obvious medical
cause

Secondary:
-onset later in life
-related medical cause
(CNS lesions,
metabolic disease)
-higher familial rate of
bipolar illness
-better general
response to lithium
-lower familial rate of
bipolar illness
-generally poor
response to lithium
Bipolar Disorders: in Older Adults
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Depression usually precedes mania by 20
years
In general, manic symptoms are milder
compared to younger patients
May present with mixed, manic, dysphoric or
agitated states
More likely to have irritability, treatment
resistance, higher mortality rate
Develop dementia at a higher rate than elderly
without bipolar illness
BMD – late onset
Persons age 60 years and older may constitute
as much as 25% of the population with BMD*
 New-onset BMD frequency declines with
advanced age with as few as 6%-8% of all new
cases of BMD developing in persons age 60
years and older*
 Co-morbid Axis I disorders include: alcohol
abuse disorders = 38.1%, dysthymia = 15.5%,
GAD = 20.5%, panic disorder = 19.0% (men –
greater prevalence of alcoholism; women
greater prevalence of panic disorder)**

*
*
**
Sajatovic M, et al: New-onset bipolar disorder in later life. Am J Geriatr Psychiatry 2005; 13: 282-289.
Almeida, OP, Fenner, S: Bipolar disorder. Int Psychogeriatr 2002; 14:311-322.
Goldstein, BI, et al: Am J Psychiatry 2006; 163:319-321.
Sleep Disturbances in the
Elderly
Prevalence of Insomnia by age group*:
Age
Age
Age
Age
18-34
35-49
50-64
65-79
–
–
–
–
14%
15%
20%
25%
*Mellinger GD et al. Arch Gen Psychiatry 1985;42:225-232.
Medications
Primary Sleep Disorders
Medical Conditions
Complaint of Insomnia
Psychiatric Conditions
Psychosocial Factors
Poor Sleep Hygiene
Examples of ‘Legal’ Drugs That Cause
Insomnia
 Alcohol
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Decongestants
CNS stimulants
Stimulating
antidepressants
Beta-blockers
Diuretics
Thyroid hormones
Bronchodilators
 Nicotine

Calcium channel
blockers
 Caffeine





Corticosteriods
CNS Depressants
Quinidine
Anticonvulsants
Antiparkinsonian agents
Overlap in Sleep Disorders Associated with Poor
Sleep &/or Excessive Daytime Sleepiness
Narcolepsy
Circadian Rhythm
Sleep Disorder/
Shift Work Sleep Disorder
Central Sleep Apnea
Obstructive
Sleep Apnea
Excessive
Sleepiness
Inadequate Sleep and/or
Poor Sleep Hygiene
Medication
Side Effects
PLM D/O
RLS
Primary RLS
Overall prevalence: 3-15%
 Mean age of onset: 34 +/- 20 years
 Highly variable course
 Primary (idiopathic) RLS make up majority
of cases; majority are hereditary


Not all patients with PLMD have RLS BUT
most patients with RLS have PLMD
Secondary RLS

Iron deficiency (5% of patients with RLS have iron

Renal failure
Pregnancy
Parkinson’s Disease
Neuropathy
Medications may aggravate: antihistamines,
TCAs, SSRIs, DA receptor blockers




deficiency; 25-30% of patients with iron deficiency
anemia have RLS)
Medical Condition
CV disease
 Pulmonary Disease e.g. COPD
 GERD
 Renal failure
 Parkinsonism
 Chronic Pain
 Nocturia

Psychiatric Condition
Depression
 Anxiety
 Dementia – with DAT: circadian rhythm
disruption with pronounced fragmentation
of sleep-wake pattern
 Substance Abuse

Vulnerability to Sleep D/O
Older age (besides that which relates to medical
problems and medications): as relates to sleep
efficiency and brain’s sleep-generating processes
and age related advanced sleep phase
 Personality and ability to handle external
stressors
 Biological clock sensitivity to changes in time, to
go to bed and/or wake up
 Even modest amounts of alcohol can interfere
with sleep quality causing sleep fragmentation
and early morning awakenings; aggravates OSA

Evaluating Causes of Insomnia
Situational factors that are major stressors such
as a life trauma or an upcoming important event
 Environmental factors such as too much noise,
temperature that are too hot or too cold, or
working a night shift
 Factors related to medications, both prescription
and nonprescription (i.e. CNS
stimulants/activating antidepressants)
 Medical problems such as pain d/o, endocrine
d/o, menopause, BPH, incontinence, CHF,
PUD/GERD, COPD, allergic rhinitis, seizure d/o

Consequences of Poor Sleep
in older adults
Ancoli-Israel s, Cook JR. J Am Geriatr Soc 2005;53 (suppl):S264-S271
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Difficulty sustaining
attention and slowed
response time
Decreased ability to
accomplish daily tasks
Impairments in memory
and concentration
Increased consumption of
healthcare resources
higher incidence of
symptoms related to
depression and anxiety

Increased risk of falls (even
after controlling for
medication use, age,
difficulty walking,
difficulty seeing and
depression)
Shorter survival/increased
institutionalization rate
 Inability to enjoy social
relationships/decreased QOL
 Increased incidence of
cognitive decline
 Increased incidence of pain

Improving Sleep Complaints





Treat underlying depression (up to 80%
experience insomnia)
Treat underlying anxiety disorder
Treat underlying schizophrenia
Treat underlying Sleep D/O (i.e. obstructive
sleep apnea with CPAP/weight loss)
Treat underlying Medical D/O and Neurological
D/O
‘Manage’ medication(s)
 Limit alcohol
 Behavioral interventions tend to be more
effective over time = GOOD SLEEP HYGIENE

Prevalence:
Alcohol Abuse/Dependence

More than half of people over age 65 do not drink at all

‘At risk drinking’ (more than 2 drinks/day for a man and
more than 1 drink/day for a woman): 6-9% (minimum)

Up to 17% of older adults (over age 60) misuse alcohol
or prescription drugs (5% - 10% of patients seen in an
outpatient setting and 7% - 22% of medical inpatients)*

(approximately) 2/3 of alcohol problems are “long
standing” while 1/3 are a late-onset problem appearing
for the 1st time later in life POSSIBLY associated with
retirement, bereavement or depression
*J. Geriatr. Psychiatry Neuro. 2000:13;106-14.
Prevalence:
Alcohol Abuse/Dependence

“heavy alcohol use” = 3 – 25%

“alcohol abuse” = 15% men/12% women
……..drinking in excess of recommended
limits/guidelines – with women, rapid
progression to alcohol-related illnesses
such as cirrhosis, sleep problems and
cognitive problems
Prevalence:
Alcohol Abuse/Dependence
Alcohol dependence: prevalence is 8 –
14%; most common psychiatric disorder
 Often accompanied by other substance
abuse d/o (particularly nicotine),
anxiety/panic, mood disorders and
antisocial personality disorder

Guidelines

National Institute on Alcohol
Abuse: no more than 1 drink
per day and/or no more than 2
drinks on any occasion or 7
standard drinks/week; never
more than 4 standard drinks
on any drinking day

AAFP: no more than 2 drinks
per day for men/1 drink per
day for women

If you give a 30 year old vs. 80
year old, each 2 drinks, the 80
year old will have a BAL of 3
drinks = age related changes
in lean body mass/total body
water/increased body
fat/increased sensitivity and
decreased tolerance to alcohol
coupled with drug-drug
interaction/metabolic changes
(pharmacokineticspharmacodynamics)
Statistics:
National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Alcoholism is a lifelong disease with a
relapsing, remitting course, has a genetic
component along with environmental and
interpersonal factors………….
Other ‘Illegal’ Substances of Abuse
Marijuana
 Cocaine
 Amphetamines
 Hallucinogens/NMDA
 Phencyclidine

………………………….
 Few statistics available for the elderly;
many addicts die before they reach an
older age because of overdoses,
deterioration in health/health
consequences/premature death and death
due to violence

OTC and Prescription Use/Misuse
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Laxatives
Antihistamines
OTC stimulants and herbals
Antibiotics
BZDs/meprobomate - for sedation or anxiety
Analgesics/opioids
63-79% of ER MDs fail to recognize elderly alcoholic
it is estimated that as many as 20% of elderly inpatients
are ‘alcoholic’ and up to 30% are problem users of
sedative/hypnotics, antianxiety agents and/or analgesics;
interactions of alcohol and (legal/prescribed) drugs
Clinical Presentation in the Elderly
with an Alcohol/SA Problem
Do NOT present as: substance seeking
behavior such as characterized by crime,
manipulativeness, and antisocial behavior
 Presentations vary but may include:
marital discord, falls, confusion, poor
personal hygiene, depression, anxiety,
sleep complaints, malnutrition, delirium,
dementia

Pain*:
International Association for the Study of Pain (IASP)

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50 million Americans suffer from chronic pain
Chronic pain disables more people and adds more to
health care costs than does heart disease and cancer
combined
25-50% of community-dwelling older adults suffer pain
problems; 45-80% of NH patients suffer pain problems
50% of adults older than 60 suffer from some form of
LBP
Incidence of OA - increases with age: affects 21M of USA
population; 80% of patients older than 65
(knee/hip/hand)
*MMWR 53 [18]: 388-89, 2004.
Classifying Pain
Acute
Duration
vs
Chronic
Nociceptive
Pathophysiology
vs
Neuropathic
Acute vs Chronic Pain States
Acute
vs
Chronic
• Associated with tissue
• Extends beyond expected
damage
• Increased autonomic
nervous activity
• Resolves with healing of
injury
• Serves protective function
period of healing
• No protective function
• Degrades health and
functioning
• Contributes to depressed
mood
Turk, Okifuji.
Okifuji. In: Bonica’
Bonica’s Management of Pain. 2001; Chapman, Stillman. In: Pain and Touch. Handbook
of Perception and Cognition.
Cognition. 2nd ed. 1996; Fields. Neuropsychiatr Neuropsychol Behav Neurol. 1991;4:831991;4:83-92.
Examples of Nociceptive and
Neuropathic Pain
Nociceptive
Mixed
Neuropathic
Caused by
tissue damage
Caused by
combination
of primary
injury and
secondary
effects
Caused by
lesion or dysfunction
in the nervous system
• Arthritis
• Mechanical low
back pain
• Sports/exercise injuries
• Postoperative pain
•
•
•
•
Low back pain
Fibromyalgia
Neck pain
Cancer pain
•
•
•
•
•
•
•
Painful DPN
PHN
Neuropathic low back pain
Trigeminal neuralgia
Central poststroke pain
Complex regional pain syndrome
Distal HIV polyneuropathy
Effects of Chronic Pain on the Patient

Physical
Functioning/Quality of
Life:
-ability to perform ADLs
-sleep disturbances

Social Consequences:
-Relationship with family &
friends
-intimacy/sexual activity
-social isolation

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Psychosocial Morbidity:
-depression
-anxiety
-anger
-loss of self esteem
Societal Consequences
-healthcare costs
-disability
-lost workdays
In the elderly, with use of BZDs,
Sleep Medications, Muscle Relaxants,
and Opioids…
-- watch for cognitive, behavioral, and
psychomotor effects such as memory
impairment, residual daytime sedation,
rebound insomnia and unsteady gait 
falls
Dementia
 2nd
most common cause of disability
among people age 65 and older (second
only to arthritis)
DAT
Dementia: Statistics
(Dementia of Alzheimer’s Type)
Incidence:
5-8% ……….over age 65
15-20%……..over age 75
25-50+%……..over age 85
Women > Men (1.2-1.5 to 1.0)
If trends continue, population with DAT will
quadruple within the next 50 years……..
New Cases/Year=360,000=40 new cases/hour
Projected Prevalence of
Alzheimer’s Disease (AD)
16
4 Million AD Cases Today—
Over 14 Million Projected Within a Generation
14.3
14
11.3
12
10
8.7
8
6
4
5.8
6.8
4
2
0
2000
2010
2020
2030
Year
Evans DA. Milbank Q 1990;68:267-289.
Wacanta J. European Psychiatry 2003; 18: (2003) 306–313
2040
2050
Dementia: DAT

Alzheimer’s Dementia accounts for 50-75% of all
dementias

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5 million Americans have DAT (2000); by 2050 – 14 million
1/3 of risk for DAT is genetics; 2/3 involves non-genetic
factors – particularly lifestyle choices we make like physical
activity, good diet, optimizing mental health, continued
cognitive challenges/learning, high BMI, fat intake, HBP,
high cholesterol, vascular changes and neural changes

Course lasts from 2 – 22 years

Average life span following diagnosis is 7 – 10 years; life
expectancy is significantly shortened
(Other) Dementias…………
-Vascular Dementias are estimated to
account for 15% of all dementias
-Dementia with Lewy Bodies* estimated to
account for 7-26%
-Parkinson’s Disease: dementia occurs in 2060% of PD patients (20% DAT)
-Parkinson Plus Syndromes
(Other) Dementias…………
-Pick’s Disease/FTD/PPA
-Huntington’s Disease
-Creutzfeldt-Jakob disease
-Associated with long term use of alcohol
Overlapping classifications
Alzheimer’s Disease
Dementia of the Alzheimer’s Type
Marlatt M.W. et al. Curr Med Chem. 2005;12:1137-47
Relative prevalence of different forms of dementia
50-60%
Neuropsychiatric Clusters in
Dementia
Apathy: withdrawn, lack of interest,
amotivation
 Depression: sad, tearful, hopeless, low
self-esteem, anxiety, guilt
 Aggression: aggressive resistance,
physical aggression, verbal aggression
 Agitation: walking aimlessly, pacing,
trailing, restlessness, repetitive actions,
dressing/undressing, sleep disturbance
 Psychosis: hallucinations, delusions,
misidentifications

LTC Setting – Patient
Demographics
--2/3 LTC patients carry a diagnosis of
Dementia (80% due to DAT)
--ONLY 25% of adults diagnosed with
dementia are in LTC!!!!!!!
--Caregiver: Burden/Stress/Depression/
Premature Death
Caregivers

30-50% of caregivers of patients with
dementia met the criteria for major
depression and a larger proportion of
caregivers suffer from psychiatric
symptoms but are below the thresholds
for psychiatric diagnoses*
*Cohen and Eisdorfer 1989; Tennstedt et al 1992
Mild Cognitive Impairment (MCI)
MCI (mild cognitive impairment): Cognitive
impairment in elderly persons not of sufficient
severity to qualify for a diagnosis of
dementia……patients have complaints of
impairment in memory or other areas of
cognitive functioning usually noticeable to them
or to those around them; performance on
‘memory or cognitive’ tests are usually below
that expected for their age and education
 A ‘precursor’ to DAT in 50% of patients over 34 years

MCI
Prevalence Rate in the Community
Normal aging  MCI  early DAT
 Prevalence rate for >60 years of age: 3%
 Prevalence rate for >75 years of age: 15%
 Annual conversion rate to DAT: 625%/year

Elder Abuse, Neglect and
Exploitation
Elder Abuse, Neglect and Exploitation
Types of elder abuse: physical abuse, sexual
abuse, emotional/psychologic abuse, financial
exploitation/victimization/undue influence,
neglect, abandonment and self-neglect
 Most common type of elder abuse: neglect depriving an elder of something needed for daily
living
 Second most common type of elder abuse:
physical abuse
 Third most common type of elder abuse:
financial exploitation

Elder Abuse Statistics
Prevalence: 1% - 12%
 Women more than men
 75% of victims are physically frail; 50%
are unable to care for themselves; many
are confused or disoriented – some or
most of the time
 Majority occurs in home setting
 Majority of perpetrators are family
members usually a spouse or adult child

STATISTICS: Elderly
Physical or psychological abuse or neglect, financial
exploitation/undue influence and violation of rights
 Can occur in family homes, nursing homes, board
and care facilities, and hospitals
 Mistreated by their spouses, partners, children and
other relatives and friends
 Elder partner abuse: long standing pattern of marital
violence or as abuse originating in old age – as
relates to issues in aging/disability, stress and
changing family relationships

Risk Factors for Abuse
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Older age (>75)
Female
Unmarried/widowed/divorced
Lack of access to resources
Low income
Social isolation
Minority status
Low level of education
Functional debility/taking multiple medications
Substance abuse by caregiver or elder person
Psychologic disorders (depression, anxiety) and character pathology
Previous history of family violence
Caregiver burnout and frustration
Cognitive impairment
Fear of change of living situation (home  ALF/NH)
The End
 QUESTIONS?