AGING & MENTAL HEALTH

• inevitable senility MYTH!

• growing old ed mental health problems

• special issues for mental health & elderly?

• interpersonal factors (e.g., social support)

• intra-personal factors (e.g. stress, poverty) • biological/physical factors

• life-cycle factors (history, aging)

2 categories of mental disorders

(1) Organic

(a) acute: ~20% reversible if treated effectively

(b) chronic: severe, progressive

(2) Functional

• Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association

• normal changes with age make diagnosis difficult

Dementias• family of diseases characterized by cognitive and behavioural deficits involving some form of permanent brain damage

• must involve change in multiple domains of psychological functioning and impact on daily functioning

• estimated that there are over 50 causes of dementia!!

Alzheimer’s Disease (AD)

Diagnositic Criteria acc: DSM-IVA. Cognitive deficits manifested by both:

1. Memory impairment

2. One or more of the following: aphasia, apraxia, agnosia, exec. function disturbance

B. Impaired social/occupational functioning

C. Gradual onset, continuing cognitive decline

D. Deficits in A not due other medical conditions

E. Not delerium

F. Not better accounted for by another Axis I disorder

Alzheimer’s Disease (AD)

• neuritic plaques

• neurofibrillary tangles

• post-mortem - frequency of plaques & tangles

• hippocampus temporal lobe cortex

• Canada(1994): 5.1%; 1% 65-74, 26% for 85+ • 50-70% of dementia diagnoses • insidious onset, progressive

Histopathology

• cell loss (up to 40% brain mass lost)

• no definitive diagnosis

Alzheimer’s Disease (AD) cont’d ...

Possible AD• memory impairment (recent)• personality changes, depression, withdrawal• concentration difficulties, word finding

Mild AD• memory impairment worsens (remote, new)

• language deteriorates

• agitation, inappropriate emotions

• wandering, sleep disturbances, poor self-care

Alzheimer’s Disease (AD) cont’d ...

Moderate / Moderately Severe AD• increasingly dependent for daily activities

• extreme mood swings, psychotic tendencies

Severe AD• verbal abilities lost• extreme agitation

• bed-ridden, coma-like stage

do not die of AD, die with AD

life expectancy depends on when diagnosed

Suspected Causes of AD

Cholinergic Hypothesis• acetylcholine (ACh) in brains of AD patients

• basal forebrain - source of ACh• hippocampus & temporal lobe

- ACh is primary neurotransmitter

Genetic Hypothesis• ApoE e-4 allele, chromosome 21

Trace Metals• high Al content in brain of AD patients• olfactory regions - large accumulations

Risk Factors for AD

• family history: ~50% of 1st degree relative w/ AD

• age: risk doubles ~ every 5 years past age 60

• lower intelligence• smaller head circumference, brain size

• history of head trauma• decreased level of estrogen after menopause

Neuroimmune system / Inflammatory Response• inverse relationship btwn anti-inflammatory treatment and incidence of AD

Suspected Causes of AD cont’d

Treatment/Intervention for AD• irreversible, incurable• treatment primarily supportive in nature

• drugs / supplements:(a) to improve cognition tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon)

(b) to treat behavioural symptoms depression, agitation, sleep, paranoia, apathy

(c) natural supplements / prophylactic measuresVitamin E, Ginkgo biloba, hormones

• environment changes, psychotherapy

Multi-infarct Dementia/Vascular Dementia

• series of small strokes, at different brain sites

• sudden onset, stepwise progressive deterioration• sign & symptoms highly variable, especially early in the disease• multiples lacunes,grey and white matter

• somatic, neurological and cardiac complaints

• known risk factors, e.g., hypertension, diabetes

• may co-occur with AD

• survival of only 2-3 years

Fronto-temporal Dementia

• changes in frontal and ant. temporal lobes• ‘simple’ neuronal degeneration• Pick’s bodies

• 1st signs - behav. & personality changes (inappropriate behaviour, apathetic, hyper-orality, hypersexuality)

• ‘frontal symptoms’

• memory normal early on, recall may be affected later

• scant speech - mutism

Huntington’s Disease

• hereditary (chrom. 4), usual onset in midlife

• lesions in the striatum, atrophy, gliosis

• motor impairments - “Huntington’s chorea”

• psychiatric and personality problems

• cognitive problems late in disease, gradual

• death in 10-20 years

• genetic testing??

Creuzfeldt-Jakob Disease

• very rare, not an illness of old age

• caused by ‘slow virus’, or prions

• progression is rapid, death within 9-12 months

• behavioural symptoms precede onset

• pattern of decline variable

• myoclonus, seizures, motor problems, EEG abnormalities frequently develop

• diagnosis based on rapid clinical course, confirmed at autopsy

Illnesses That Can Cause Dementia

Parkinson’s Disease• chiefly a motor disease • higher than average risk of dementing as disease advances

Syphilis

• if untreated, atrophy in CNS over decades

AIDS Dementia Complex• insidious early on (concentration, memory)

• late stages - confusion, disinhibition, motor

Potentially Reversible Causes of Dementia

• depressive pseudodementia

• hypoxia

• malnutrition, anemia

• infection

• drugs, other toxic substances - “iatrogenic”

• head trauma

• medical conditions

Affective DisordersDepressionDiagnosis of Major Depressive Episode (DSM-IV)A. 5 or more of the following:

Depressed mood Loss of interestChanges in weight/appetiteInsomnia/hypersomniaPsychomotor changes

Fatigue Guilt/worthlessness Poor concentration Thoughts of death

B. Do not meet criteria for Mixed EpisodeC. Distress/impairment in daily functioningD. Not effect of substance or medical conditionE. Not better accounted for by bereavement

• mainly affective, may include cognitive changes

• incidence unclear - no more clinical depression in old but perhaps more depressive symptoms

• diagnosis w/ DSM-IV often problematic in old

• overlooked, myth that it is normal

• may manifest differently - depletion syndrome

• somatic complaints

• stigma

• rule out other health problems

Depression contin’d

Depression cont’d ...

• Early-onset / recurring - genetic? Early trauma?

• Late-onset: psychological factorsbiological factorsneurological factors

• depression and dementia: patientcaregiver

• treatment options: • drugs• ECT• psychotherapy, social intervention

Depressive Pseudodementia• cognitive dysfunction in depression can mimic dementia• depression is severe, dementia is mild• reversible tragic not to intervene• history, behaviour and neuropsychological measures best for differential diagnosis

Predementia?• pathological neuronal degeneration not yet clinically diagnosable as AD• superimpose depression AD-like symptoms• red flag follow-up

History and Behavioural Features

Measure AD DPD Symptom duration long short

Prev. psychiatric history unusual usual

Progression of symptoms slow rapid

Patient complaint of deficit variable abundant

Patient valuation of accomplishments

variable minimized

Behaviour congruent with cognitive deficits

usual unusual

Delusions mood independent

mood congruent

Mood disorder slow rapid

Cognitive Features

Measure AD DPD Memory impaired encoding

and storagedecreased cognitive effort

Language deteriorates w/ progression

intact

Perception/Construction

declines normal

Praxis impaired intact

AttentionProblem SolvingPsychomotor Speed

similar deficits in both

Suicide

• risk in older depressed patients• 2x higher than in adolescence• older white men highest, 7x er than elderly female

• rates may be underestimated in olde.g., ‘chronic suicide’

• attempts:completed drops dramatically w/ age• women more likely to attempt, men to succeed • suicide ideation, premeditation

but give fewer warnings

Anxiety Disorders• some studies show more common in old, others show reduced rates compared to young

• common psychiatric condition in old

• men: health triggers; women: personality triggers

• not age, per se, rather changes encountered more often by old

• must consider if appropriate response

• treatments:• benzodiazepines - may be problematic• psychotherapy

Personality Disorders• behaviour v. different from cultural expectations

• rates across lifespan unclear, some may improve

• late-life onset many factors - environment,interpersonal, stress, coping, health

• interpersonal e.g., stealing accusations • excessive health concerns e.g., hypochondriac

• may also be adaptive:

• schizotypal comfortable w/ loneliness• dependent welcome greater dependency • obsessive-compulsive ‘take care’ of things

Psychotic Disorders

Schizophrenia• marked disturbance of thought, mood, behav• once thought to onset prior to age 45

• chronic schizophrenia: • institutionalized for decades• not always continual decline

• late-onset schizophrenia/paraphrenia:• rare, mostly women, relegated to institutions • vis/aud impairment, less thought disorder, more paranoid symptoms • risk factors - personality, isolation

Psychotic Disorders

Delusional (Paranoid) Disorder• pseudo-logical delusions

• 1st symptom after 65 yrs. common

• crucial association w/ motor/sensory impairment

• subtypes: erotomatic, grandiose, somatic, persecutory, jealous, unspecified

• paranoias may be discrete/circumscribed

• most often unhospitalised, harmless but unable to experience intimacy

• may serve a function for the demented

Alcoholism

• estimates of prevalence in elderly vary• highest in 75+ widowers, nursing homes• 2-6x er in older men than women

• rates in elderly probably underestimated: hidden, unnoticed, misattributed, gradual es, reluctance to report or diagnose

• early-onset: die at younger age, orgrow old, but with consequences

vs. late-onset: 1/2-1/3 of all elderly alcoholicsmore common in older women

Alcoholism cont’d...

• Diagnostic clues of alcoholism in old age

• insomnia • impotence

• rapid onset of confusional state • uncontrollable hypertension• unexplained falls/bruises

• problems with control of gout

• excessive sleepiness• flushed face• bloated appearance