surgeon general’s report ch 5 david satcher, m.d., ph.d
Post on 22-Dec-2015
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TRANSCRIPT
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
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