Geriatric Psychiatry: An Introductory Overview

1. Geriatric Psychiatry:An Introductory Overview Carl I. Cohen M.D. Distinguished Service Professor & Director Division of Geriatric Psychiatry email: carl.cohen@downstate.edu

2. Case of Ms Jones

3. Ms Jones is a 76-year-old African American woman who presents with a history of not seeing her friends, loss of interest in sewing and gardening, and some forgetfulness. She has some difficulty hearing and also complains of arthritic pain. She has hypertension, hyperlipidemia, and type 2 diabetes. She takes medications for these conditions. • Several of her friends died in recent years, and her daughter has moved to New Jersey. She has always been a very independent woman, but now feels more helpless.

4. On examination she is found to memory deficits and mild difficulties in executive functioning. She meets 3 of 9 DSM IVTR depression criteria. Laboratory tests and physical examination are within normal limits, except for a BP of 155/95 and elevated cholesterol.

5. She was initially treated for depression with medication and psychotherapy. She showed some improvements in mood and cognitive functioning initially. However, she never completely remitted, and three years later she showed evidence of early dementia, with impairments in cognition and daily functioning.

6. Principles of Geriatric Psychiatry 1. Older adults are the most heterogeneous group in the population. 2. The demographics of aging are shifting. 3. Assessment is different in older age. 4. Disorders may present differently. 5. Treatment may be different. 6. The course of disorders may be different. 7. Aging is characterized by both longstanding conditions and late-onset conditions that may become chronic.

7. 8. Nearly all older adults with psychiatric disorders will have comorbid conditions, although not all comorbity is alike. 9. There is continuity in personality. 10. Psychiatric illness must be understood within a social and biological context. 11. The prevalence of psychiatric disorders in older adults and mental disorders are best viewed on a continuum. 12. It is essential to view the treatment goals for older adults with mental illness in the context of a life course trajectory. 13. Disorders overlap with respect to neuropathology and symptoms. 14. Mental illness in older age is complex.

8. Question 1 • Older adults are extremely heterogeneous and have little in common with each other? • Answer: False

9. 1. Older adults are the most heterogeneous group in the population. Older persons differ dramatically in their physical and mental health, functional abilities, social networks, political and religious beliefs, and so forth. Although we often categorize aged persons based on chronological age –e.g., the census bureau defines “older adults” as aged 55 to 64, and elderly as 65 and over—there are marked differences in biological aging. This is especially true among persons with chronic schizophrenia who may have health problems more characteristic of persons who are 10 or 15 years older.

10. Although older adults are heterogeneous they do share some common life experiences that may have psychosocial ramifications (so called “cohort effects”). • However, with the increasing number of older persons reaching very old age, the number of cohorts within the aging population has grown.

11. Persons born before 1930 came of age during the Great Depression and World War II, whereas those born after the war came of age during more prosperous times and included the cultural and social turmoil of the 1960s.

12. The oldest African Americans grew up during periods of marked racial segregation and discrimination, whereas “young-old” African Americans came of age during the period of the civil rights and black power movements

13. Clinical Implications • Mental and physical health care to older adults should not be determined solely by chronological age because of the marked diversity within this age group. • However, living through similar historical periods can provide a common background context for older adults of the same age.

14. Question 2: The 1 percent • Which group is part of the 1%: The percentage of persons aged 90 and over or persons in gangs? • Answer: Persons aged 90+; however, persons in gangs (currently 1%) are one of the fastest growing segments of society (40% in past 3 years)

15. 2. The demographics of aging are shifting. • The baby boomers (people born between 1946 to 1964) will first turn 65 beginning 2011. • The older population is projected to nearly double from 38 million (12.6 %) in 2008 to 72 million (20%) in 2030. • Persons over aged 85 and over are the most rapidly growing segment of our population and their numbers will double over the first quarter of the century and more than quadruple over the first half the century (to over 19 million persons).

16. The older population is also growing more diverse. • In 2000, 16% of population were non-whites (Blacks, Hispanics, Asians, Native Americans) or 5.8 million persons. In 2050, 36% of population will be non- white or 29.5 million persons.

17. Thus, there will be a 5-fold increase in the number of minority elders over the first half of the 21st century.

18. Clinical Implications • Mental health providers can expect to be working with increasingly older and more diverse populations • They must possess appropriate clinical skills and cultural knowledge if they are to deliver competent care.

19. Question 3 • Emergency rooms are an ideal place to examine older adults? • Answer: False

20. 3. Assessment is different in older age The assessment of older adults must take into account communication difficulties in vision and hearing, physical handicaps, and cognitive difficulties.

21. Clinical Implications • Clinicians should generally assess cognitive and physical dysfunction on the initial examination • Continue to closely monitor for the effects of treatment on the patient’s mental & physical functioning. • Another key difference from younger persons is the likelihood that caregivers, both formal and informal, will be more involved in providing information and treatment.

22. Question 4 • Depressive symptoms in later life are similar to those in younger persons • False

23. 4.Disorders may present differently Like physical disorders, the clinical presentations of psychiatric disorders may differ in older persons.

24. Examples: • Depression may present with fewer signs of sadness and with more symptoms of social withdrawal, somatic concerns, motor disturbances, and apathy. Sometimes described as:“Depression without sadness” or a “depletion syndrome” manifested by withdrawal, apathy, and lack of vigor. • Also may see more executive dysfunction, which may be due to vascular depression (see figure re: vascular depression).

25. Major Depression •  Similar across lifespan but there may be some differences. Among older adults: • Psychomotor disturbances more prominent (either agitation or retardation), • Higher levels of melancholia(symptoms of non-interactiveness, psychological motor retardation or agitation, weight loss) • Tendency to talk more about bodily symptoms • Loss of interest is more common • Social withdrawal is more common • Irritabilityis more common • Somatization (emotional issues expressed through bodily complaints)is more common

26. Vascular depression (depression due to vascular lesions): more common in late-onset disease. Evidence that cerebrovascular disease seemingly plays a role in depression beginning in late life. Vascular lesions include periventricular hyperintensity, deep matter hyperintensity, and subcortical gray matter hyperintensity. Disruption of prefrontal systems may be responsible.

27. Symptoms include greater levels of apathy, psychomotor retardation and disability, • and • less agitation,psychoses, family history of psychiatric illness, guilt, and insight versus other older depressed persons.

28. Risk Factors • Age • Hypertension • Hyperlipidemia • Smoking • Diabetes Vascular Depression Hypothesis(Krishnan & McDonald, 1995;Sneed & Cuslng-Reimlieb, 2011) Artherosclerosis Deep white matter lesions ( vulnerability to late onset depression) Negative life events Poor social support Vascular depression with executive dysfunction

29. Disorders may present differently (cont.) • Late-onset schizophrenia—onset after age 40 or 45(about 15-20% of all schizophrenia)--tends to occur disproportionately more in women, to have more persecutory delusions, fewer negative symptoms, and formal thought disorders (see chart comparing early and late disorders)

30. Characteristics Early-Onset Schizophrenia Late-Onset Schizophrenia Persecutory delusions + +++ Visual hallucinations + ++ Olfactory hallucinations + ++ Tactile hallucinations + ++ Thought disorder +++ + Affective blunting +++ + Sensory impairment + ++ Male –female ratio Male slightly higher Women much higher Medication dosage high low Summary of differences between early and late onset schizophrenia

31. Clinical Implications • Clinicians must be vigilant for more atypical symptoms in older adults.

32. Question 5 • All drug metabolism is appreciably affected by aging • False

33. 5. Treatment may be different With increased age: • There are declines in the absorption rate of medications, although amount of medication absorbed does not change • Distribution of drugs as a result of an increase in adipose tissue relative to lean body mass • Diminished metabolism in the liver • Declines in renal clearance

34. Clinical Implications • Dosages of medications may need to be lower than in younger persons, and considerations of side effects and drug interactions become more relevant. • Must be cautious in prescribing drugs that are apt to affect the Cytochrome P450 metabolic pathways in the liver (Phase I hepatic metabolism), and if used, their potential interactions with other medications should be reviewed. • Some pathways such as CYP1A2 and CYP3A4 are most affected by aging. • It is best to use drugs that do not undergo Phase I hepatic metabolism, but only Phase II hepatic metabolism (conjugation), since this process is not affected by aging.

35. Because of changes in the distribution of drugs in the body, the fat soluble drugs, which includes many of the drugs used in psychiatry, tend to remain in the body longer and may cause toxicity. • Conversely, water soluble drugs such as lithium need to be used cautiously because of the diminution of total body water with age. • Finally, some psychotropic drugs remain active (e.g. lithium, gabapentin, rivastigmine) until they are cleared by the kidney, and doses may need to be adjusted in older adults.

36. Question 6 • Prognosis for depression in later life is no worse than younger persons • False

37. 6. The course of disorders may be different Inschizophrenia • There is a diminution in positive symptoms with age. • Levels of co-occurring depression may remain the same or increase. • Mild cognitive problems that present earlier in life may worsen due to normal effects of the aging process.Thus, older persons may be at the level of a mild dementia.

38. In depression: • More subtypes (e.g. vascular depression; and depression with cognitive deficits/dementia also known as “pseudomentia”) that may be more resistant to treatment. • There is some evidence that older persons with major depression may be more prone to relapse and relapse sooner than their younger counterparts.

39. Clinical Implications • In treating persons with schizophrenia need to be aware of changes in symptoms that occur with aging, and to adjust treatment accordingly. • In treating older adults with depression, it is important to determine the subtype of depression, because prognosis varies considerably depending on the etiology of the depression.

40. 7. Aging is characterized by both longstanding conditions and late-onset conditions that may become chronic. • Depression in older adults is often chronic, and more than half of persons with clinical depression in later life remain syndromally depressed and an additional 30% have some residual symptoms (subsyndromal or subthreshold depression). • Even under the most ideal treatment conditions (e.g., medication and psychotherapy), about one-third of older persons with new –onset depression relapse on 2-year follow-up (Reynolds et al, 2006). Two-thirds relapse without medications.

41. The line between reversible and irreversible illness may become less distinct. Examples: • Late-onset depression may be a prodromal symptom of dementia. It is estimated that two-fifths of late-onset depression with some cognitive problems (so called “pseudodementia”) may eventually progress to a true dementia, despite there having been an initial resolution of depression. • Persons with vascular depression are more prone to dementia.

42. Clinical Implications • Although treatment can help reduce recurrence and levels of symptoms, the complex interaction of psychiatric and physical conditions may make full recovery less likely. • Treatment of late-onset depression may benefit (i.e., reduced likelihood of dementia) from a combination of an SSRI and cholinesterase inhibitor such as donepezil (Aricept), although depression recurrence may be higher. • While the ultimate goal for all patients may be the remission of symptoms, sometimes treatment goals will have to be adjusted, and like some chronic physical disorders, persons may have to live with a modest level of symptoms.

43. Question 7 • Comorbid illnesses are important determinants of outcome in older adults • True

44. 8. Nearly all older adults with psychiatric disorders will have comorbid conditions, although not all comorbity is alike • Some comorbid conditions can contribute substantially to disability and functional decline (e.g., severe osteoarthritis, severe heart disease, neurocognitive disorders), whereas other conditions have minimal effects on functioning (e.g., controlled hypertension or hypercholesterolemia).

45. There is a reciprocal interaction between depression and many physical disorders. Depression may result in higher occurrence of certain physical illnesses, and physical disorders may increase levels of depression e.g. mortality rates are higher among post-myocardial infarct patients with depression

46. Depression and anxiety often co-occur, and having more anxiety symptoms (e.g. half of persons with depression have anxiety), is a poor prognostic indicator in depression. • One of the more significant health challenges involve persons with some combination of chronic pain , dementia, depression, anxiety, bereavement, multiple losses, social isolation and poor nutrition.

47. Clinical Implications • There is some evidence that treating depression can improve health outcomes and that improving physical health can improve depression and anxiety. • Unfortunately, the ability to successfully treat depression is less robust in older persons with concomitant physical disorders.

48. Question 8 • There are considerable changes in personality over time • False

49. 9. There is continuity in personality • Each older person is a product of the lifelong effects of physiological, environmental, and psychological factors. • With respect to psychological factors, although some changes occur across a lifespan, various personality traits (e.g., coping , sense of control, self-esteem, interpersonal skills) tend to be fairly stable over time, and they will affect how one deals with late-life stressors.

50. Clinical Implications • On the positive side, continuity means that most older persons have been able to successfully use various coping strategies to manage their stressors over the life course. • Therapists must help to gird up these formerly successful coping mechanisms, and in turn, improve the sense of self-esteem.