AGING & MENTAL HEALTH

1. 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. 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

3. 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!!

4. Alzheimer’s Disease (AD) Diagnositic Criteria acc: DSM-IV A. 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

5. Alzheimer’s Disease (AD) • Canada(1994): 5.1%; 1% 65-74, 26% for 85+ • 50-70% of dementia diagnoses • insidious onset, progressive • no definitive diagnosis Histopathology • neuritic plaques • neurofibrillary tangles • cell loss (up to 40% brain mass lost) • post-mortem - frequency of plaques & tangles • hippocampus  temporal lobe  cortex

6. 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

7. 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

8. 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

9. Suspected Causes of AD cont’d Risk Factors for AD Neuroimmune system / Inflammatory Response • inverse relationship btwn anti-inflammatory • treatment and incidence of 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

10. Treatment/Intervention for AD • irreversible, incurable • treatment primarily supportive in nature • environment changes, psychotherapy • 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 measures Vitamin E, Ginkgo biloba, hormones

11. 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

12. 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

13. 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??

14. 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

15. 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

16. Potentially Reversible Causes of Dementia • depressive pseudodementia • hypoxia • malnutrition, anemia • infection • drugs, other toxic substances - “iatrogenic” • head trauma • medical conditions

17. Affective Disorders Depression Diagnosis of Major Depressive Episode (DSM-IV) A. 5 or more of the following: Depressed mood Fatigue Loss of interest Guilt/worthlessness Changes in weight/appetite Poor concentration Insomnia/hypersomnia Thoughts of death Psychomotor changes B. Do not meet criteria for Mixed Episode C. Distress/impairment in daily functioning D. Not effect of substance or medical condition E. Not better accounted for by bereavement

18. Depression contin’d • 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

19. Depression cont’d ... • Early-onset / recurring - genetic? Early trauma? • Late-onset: psychological factors • biological factors • neurological factors • depression and dementia: patient • caregiver • treatment options: • drugs • ECT • psychotherapy, social intervention

20. 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

21. History and Behavioural Features Measure AD DPD Symptom duration long short Prev. psychiatric history unusual usual rapid Progression of symptoms slow Patient complaint of deficit variable abundant Patient valuation of accomplishments minimized variable Behaviour congruent with cognitive deficits usual unusual mood independent mood congruent Delusions Mood disorder slow rapid

22. Cognitive Features Measure AD DPD Memory impaired encoding and storage decreased cognitive effort Language deteriorates w/ progression intact normal Perception/ Construction declines Praxis impaired intact Attention Problem Solving Psychomotor Speed similar deficits in both

23. 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 old • e.g., ‘chronic suicide’ • attempts:completed drops dramatically w/ age • women more likely to attempt, men to succeed •  suicide ideation,  premeditation • but give fewer warnings

24. 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

25. 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

26. 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

27. 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 • may serve a function for the demented • most often unhospitalised, harmless but • unable to experience intimacy

28. 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, or • grow old, but with consequences vs. late-onset: 1/2-1/3 of all elderly alcoholics more common in older women

29. Alcoholism cont’d... • Diagnostic clues of alcoholism in old age • insomnia • impotence • problems with control of gout • rapid onset of confusional state • uncontrollable hypertension • unexplained falls/bruises • excessive sleepiness • flushed face • bloated appearance