Mental Health Concerns in the Elderly ________________________________________ What are they?

Mental health concerns specific to the elderly include dementia, delirium, psych osis, and depression. Generally, elderly patients are more sensitive to medicati ons and their side effects. Women are especially susceptible to the side effects of various medications prescribed for mental health problems. Dementia Many different kinds of dementia are known to occur in elderly patients, with Al zheimer's being the most prevalent type. Degeneration due to Alzheimer's dementi a can last anywhere from 5 to 20 years. Although sometimes uncomplicated, dement ia usually occurs with some or all of these symptoms: Delirium Delusions Depressed mood Behavioral disturbances Memory loss, language difficulties, difficulty in carrying out motor functions, failure to identify objects, and disturbances in planning and organizing all cha racterize early stages of dementia. It is common for some of these symptoms to b e confused with normal aging or depression. Many cases are not caught early beca use the growing deficiencies that the patient exhibit may be masked by the compe nsation of loved ones. Sometimes medications are used to treat symptoms that are secondary to dementia, such as sleep disruption, depression, and aggressive behaviors. These medicatio ns are only treating the symptoms that arise out of the underlying dementia, and do not treat the dementia itself. Delirium Elderly patients, and especially women, are extremely sensitive to things such a s surgery and anesthesia, drug toxicity, and infections like urinary tract infec tions (especially in women). The symptoms of delirium are often misdiagnosed as relating to other conditions. Common symptoms include: Sudden reduced ability to focus, sustain, or shift attention Disturbed consciousness Sudden onset of misperceptions Impaired judgement Increased or decreased motor activity If the symptoms develop over a short period of time, fluctuate over the course o f the day, or can be caused by a general medical condition, it is quite possible that the patient is suffering from delirium. A diagnosis of delirium can be mad e if the patient's EEG (electroencephalogram) findings show a slowing of activit y in the brain. In order to effectively treat delirium, the doctor needs to first identify the u nderlying cause. Haloperidol is commonly given to patients experiencing delirium to try to reduce the symptoms. Psychosis Psychosis is usually used as another term for schizophrenia or bipolar disorders . Schizophrenia is a group of mental disorders that involve disturbances of thin king, mood, and behavior. Bipolar disorders involve periods of depression follow ed by periods of mania. Mania can be accompanied by grandiosity, lack of sleep, and excessive activity. One well-known bipolar disorder is manic depression. Of all patients with schizophrenia, only 3% experience their first symptoms in t heir sixties or after. However, women comprise a large portion of that 3%. The t reatment of schizophrenia for elderly patients is largely the same as in other s chizophrenic patients. Some of the minor differences are the necessity to treat depression that often results in elderly patients as a result of psychosis. Youn ger patients are less likely to become depressed as a direct result of schizophr enia.

Bipolar disorders occur in approximately 1% of the population. They can be easil y confused with other thought disorders, so the patient needs to be carefully ev aluated before treated. Elderly patients who are diagnosed with psychosis may al so experience delirium or dementia, so these conditions must be treated in addit ion to the psychosis. Depression Depression is a common condition amongst elderly women. Research has shown that more than one third of all depressed patients seen by doctors will go untreated because they are not properly diagnosed. Therefore, it is very important to know the symptoms of depression so that a scenario of misdiagnosis or lack of diagno sis will not occur. Usually women will not complain directly of sadness. Rather, they will complain of a host of other, seemingly unrelated symptoms, which serv e to attract their doctor's attention. Common symptoms can include, but are not limited to: Disturbances in sleep, self-esteem, libido, appetite, interest, energy, concentr ation, memory, and movement Feelings of guilt Suicidal thoughts, plans, or attempts Pain Depression can be caused by several personal losses experienced in rapid sequenc e, which is often the case in the elderly. While the lifetime risk for major dep ression is only 7-12% in men, it is a whopping 20-25% in women. Why this is so i s not clear. What is clear, however, is that certain medical conditions seem to be associated with depression. These conditions include, among others: Alzheimer's disease Cancer (including breast and ovarian) Congestive heart failure Diabetes Parkinson's disease Rheumatoid arthritis Sexual dysfunction The elderly are also commonly taking many more medications than younger people a re. Some of these medications are known to be associated with depression. Follow ing is a selected list of these medications: Anticancer drugs Anti-inflammatory drugs Progesterone Anti-depressants are used to treat depression, and they usually are fairly succe ssful at improving the quality of life of the elderly patient. Psychotherapy is often used in combination with anti-depressants, which can include drugs in thes e classes: Tricyclics such as imipramine, desipramine, amitryptyline, and nortriptyline Heterocyclics Selective serotonin reuptake inhibitors (SSRIs) such as Prozac Monoamine oxidase inhibitors (MAOIs) There are quite a few side effects to these medications, which the elderly popul ation is more susceptible to. These side effects include: Blurred vision Dry mouth Urinary retention Confusion Constipation Drowsiness Insomnia Cardiac arrhythmia Hypotension Gastrointestinal distress Weight fluctuations Sexual dysfunction

Many, but not all, of the side effects can be overcome by changes in medication dosage or by substituting other drugs for the one causing the side effects.

Older People Home > Help & Information > Mental Health A-Z > Older People Theres an assumption that mental health problems are a 'normal' aspect of ageing. This is not true. Most older people do not develop mental health problems, and they can be helped if they do. However a significant number of people do develop dementia or depression in old age. Between 1016% of people over 65 have depression. An estimated 24% have severe depr ession. Older people living alone or in residential/nursing care and those with physical illnesses and/or disabilities are more at risk, with some 40% affected by depre ssion. An estimated 423% of older adults seen by medical staff have an alcohol problem Fewer than 1.6% of men and 0.5% of women aged 6065 have dementia, but this increa ses with age to over 32% of men and women aged 90+. Many older people experience psychological or emotional distress associated with factors linked to old age, including isolation, loss of independence, lonelines s and losses of many kinds, including bereavements. Depression in old age Depression describes a range of moods, from feeling a bit low in mood to feeling unable to cope with everyday life. People with severe depression experience a r ange of symptoms including low mood, loss of interest and pleasure and feelings of worthlessness or guilt. Depression can affect anyone, of any culture, age or background. It affects more older people than any other age group. Some 1016% of elderly people in the commu nity have depression, rising to some 40% of older people in residential and nurs ing care homes. This is because older people are much more vulnerable to factors that lead to depression. That said, depression is not an automatic feature of getting older; it can be pr evented, and older people respond just as well to the drug and psychological tre atments available to working age adults although they are not always offered the

m. What causes depression? Older people are more vulnerable to many of the factors that are known to cause depression, including: being widowed or divorced being retired/unemployed physical disability or illness loneliness and isolation. In addition, older people may develop depression because of: neurobiological changes associated with ageing prescribed medication for other conditions genetic susceptibility, which increases with age. Can depression be prevented? Depression in later life is a widely under-recognised and under-treated medical condition. Up until recently many health professionals including GPs failed to i dentify depression, seeing it as an inevitable feature of aging and so have not offered the treatments and support available to other age groups. Most forms of depression can be treated, regardless of the persons age, using medication, talki ng treatments or other interventions. It is can be difficult to diagnose depression in older people because it often o ccurs alongside other mental and physical illnesses, such as dementia and chroni c illnesses such as stroke, diabetes and cancer. In addition many older people d o not seek help from their GP. It is important to seek help as early as possible . Self-help strategies that can help reduce the risk of depression include: taking regular exercise planning for major life transitions such as retirement or moving home seeking support from family and friends following the death of a long-term partn er maintaining interests, activities and social involvement, including learning. Dementia Please visit our dementia page. Alcohol abuse in old age An estimated 4%23% of older adults seen by medical staff have an alcohol problem. Alcohol problems are more common in older men: around one in six older men and one in 15 older women are drinking alcohol at levels that could harm their healt h. Although alcohol abuse is a problem for people of all ages, it is more likely to go unrecognised among older people. About one in three older people with alcoho l problems only start drinking excessively in later life. Reasons for alcohol abuse in older age include bereavement and other losses, lon eliness, physical ill health, disability and pain, loss of independence, boredom and depression, which is also linked to the other factors. Retirement may also provide more opportunities for drinking too much. Approximately 1030% of older pe ople who abuse alcohol become depressed. They are also at greater risk of suicid e. Mental health problems associated with alcohol abuse include: anxiety depression hearing voices confusion dementia. Medication Prescribed medications can cause symptoms associated with mental illness in olde r people. Most older people are taking some kind of medication, and many are tak ing several at the same time. There are risks associated with taking multiple me dications, including confusion. Other mental health problems There are a number of rarer mental health problems that affect older people, inc luding delirium, anxiety and late-onset schizophrenia. The prevalence, nature, a

nd course of these illnesses are different in older people, as are the treatment s that may be offered. Mental capacity and older people with mental illness People with dementia or severe mental illness may be unable to make and communic ate decisions. Very few people are completely incapable of making any choices or decisions, but some older people may have partial or fluctuating mental capacit y and may need help. People with dementia often need special support they may ta ke longer to make decisions, may need an advocate to speak on their behalf and t heir mental functioning may also vary by day, and time of day. Family members or carers are often useful sources of information but it is important to take acco unt of the views of the person with dementia alongside those of their carer. The Mental Capacity Act 2005 is the main law covering the rights and decision-ma king for people who lack mental capacity, including older people with dementia a nd other organic brain disorders. ________________________________________ Getting Help Get help for yourself or someone you know. Support Us We are the UK's leading mental health research, policy and service improvement c harity. Find out how you can support us and help us continue our life-saving wor k.

Mental Health of the Elderly Having good mental health throughout life does not ensure immunity from severe d epression, Alzheimer's disease, anxiety disorders and other disorders in the sen ior years of life. In fact, some studies show elderly people are at greater risk of mental disorders and their complications than are younger people. However, m any of these illnesses can be accurately diagnosed and treated.

 From 15 to 25 percent of elderly people in the United States suffer from signifi cant symptoms of mental illness. The highest suicide rate in America is among those aged 65 and older. In 1985, t his age group represented 12 percent of the total U.S. population, but accounted for 20 percent of suicides nationwide. That means close to 6,000 older American s kill themselves each year. Worldwide, elderly people lead the World Health Organization's list of new cases of mental illness: 236 elderly people per 100,000 suffer from mental illness, c ompared to 93 per 100,000 for those aged 45 to 64, the next younger group. Severe organic mental disorders afflict one million elderly people in this count ry and another two million suffer from moderate organic disorders. Sadly, many of the nation's elderly are reluctant to seek psychiatric treatment which could cure or alleviate their symptoms and return them to their previous l evel of functioning. Why? Many older people don't understand mental illnesses or acknowledge that they even exist. They feel ashamed of their symptoms or else f eel that they are an inevitable part of aging. Medicare, which sets the standard for health care insurance coverage, has traditionally discriminated against psy chiatric care by offering a low level of benefits. Elderly people, their loved o nes and friends and often their own doctors fail to recognize the symptoms of tr eatable mental illness in older people. They blame them on "old age" or think no thing can be done to alleviate the problem. As a result:

Though nearly 25 percent of elderly persons suffer from symptoms of mental illne ss, they do not seek care; only 4 percent of the patients in community mental he alth centers are elderly. Only two percent of the patients seen in private practitioners' offices or hospi tals are elderly. Less than 1.5 percent of the direct costs for treating mental illness is spent o n behalf of older people living in the community. Don't ignore noticeable changes in an older person's behavior or moods. These ch anges could be symptoms of depression, dementia, Alzheimer's disease, or other c onditions for which you can get help. Seek medical and psychiatric evaluations w hich can lead to treatments that can return an older person to a productive and happy life. Depression Depression, considered the most common mental disorder, afflicts up to five perc ent of people aged 65 and older. Many researchers think this is a low estimate, because depression can mimic dementia. Some experts thus estimate that as many a s ten percent of those diagnosed with dementia actually suffer from depression t hat, if treated, is reversible. If you or a loved one experience any of these symptoms of depression for more th an two weeks, you should seek help.

 Feelings of worthlessness, hopelessness, helplessness, inappropriate guilt; prol onged sadness or unexplained crying spells; jumpiness or irritability; loss of i nterest in and withdrawal from formerly enjoyable activities, family, friends, w ork or sex. Intellectual problems such as unexplainable loss of memory or the ability to con centrate; confusion and disorientation. Thoughts of death or suicide; suicide attempts (seek help immediately). Physical problems such as loss of appetite or a noticeable increase in appetite; persistent fatigue and lethargy; insomnia or a noticeable increase in the amoun t of sleep needed; aches and pains, constipation, or other physical ailments tha t cannot be otherwise explained. Dementias Dementia, which is characterized by confusion, memory loss, and disorientation, is not an inevitable part of growing old. In fact, only 15 percent of older Amer icans suffer from this condition. Of that number, an estimated 60 percent suffer from Alzheimer's disease, a progressive mental deterioration for which no cause or cure has been found. The other 40 percent of all dementias can be caused by:

Complications of chronic high blood pressure, blood vessel disease or a previous stroke. Deterioration is in steps rather than in a steady progression. Parkinson's disease, which generally begins with involuntary and small tremors o r problems with voluntary movements. Dementia may occur when the disease is seve re or very advanced. Huntington's disease, a genetic disorder that begins in middle age and has sympt oms of changed personality, mental decline, psychosis and movement disturbance. Creutzfeldt-Jakob disease, thought to be caused by a viral infection leading to rapid and progressive dementia. Pseudodementias Elderly people may become forgetful, disoriented, or confused because they have developed a quickly reversible condition that is totally unrelated to dementia. For example, drug interactions or overdoses, poor diet and other physical or men tal problems cause symptoms that mimic dementia. Depression often resembles deme ntia in that its victims withdraw, cannot concentrate and appear confused. These pseudodementias can be reversed when their causes are diagnosed and treate d. It is therefore important that a psychiatrist first complete a thorough medic al evaluation. The evaluation can differentiate true dementia from the following other factors that could mimic the condition: Medications. Elderly people take many more prescription and over-the-counter med ications than other age groups. Because metabolism is slower in the elderly, the se substances can stay in the body longer and reach toxic levels more quickly. M oreover, because many older people take more than one medication and may drink a lcoholic beverages, there is a high risk that the drugs will interact, causing c onfusion, mood changes and other symptoms of dementia.

Malnutrition caused by poor eating habits. Because the brain requires a steady s upply of proper nutrients, poor eating habits or problems with digestion can ups et the way the brain functions. For example, pernicious anemia, a blood disorder caused by inability to use B vitamins, causes irritability, depression or demen tia. Too little sugar in the bloodstream also causes confusion and personality c hange. Changed eating habits may result from dental problems. An elderly person may drop certain important foods from the diet because they are hard to chew. Diseases of the heart or lungs. The brain also requires a great deal of oxygen t o work properly. If diseased lungs cannot draw enough oxygen into the blood or a diseased heart fails to pump enough blood to the brain, lack of oxygen can affe ct the brain and behavior. Diseases of the adrenal, thyroid, pituitary or other glands. These glands help r egulate emotions, perceptions, memory and thought processes. When they don't fun ction, these mental processes are affected. Alzheimer's Disease One form of dementia--Alzheimer's disease--has received increasing attention in the years since German psychiatrist Alois Alzheimer first described it in 1907. Alzheimer's disease is the fourth leading cause of death in America. An adult's chances of developing the illness are one in 100. One million people over 65 are severely afflicted with Alzheimer's disease and another two million are moderat ely affected. The odds of developing Alzheimer's disease increase fourfold among family members of a person suffering from the disorder. Alzheimer's disease, which causes the brain's cells to die, often begins in a pa rt of the brain that controls memory. As it spreads to other parts of the brain, the illness affects a greater number of intellectual, emotional and behavioral abilities. Symptoms The onset of Alzheimer's disease is usually very slow and gradual. The first sym ptom is often a loss of recent, short-term memory. For example, a person forgets to turn off the stove or can't remember which medications he or she took that m orning. Mild personality changes, such as increased apathy or social withdrawal, also occur. As the disease progresses, patients have trouble with abstract thinking, handlin g money, working with numbers when paying bills, understanding what they are rea ding or organizing their days. They also may become more irritable, agitated, qu arrelsome and less neat in appearance. In late stages of the disease, the patient becomes confused or disoriented about time and date and unable to describe where he or she lives or name a recently v

isited place. The person ultimately stops conversing, becomes erratic in mood an d uncooperative, incontinent and, in the end, becomes unable to care for himself or herself. Scientists have not yet defined the cause of Alzheimer's disease. Researchers ha ve learned that the brains of patients with Alzheimer's have inappropriate level s of the enzyme choline acetyltransferase, a brain chemical that is important in memory loss and disorientation. Still other research has focused on the possibi lity that a slow-acting virus causes the progressive brain damage seen in Alzhei mer's disease. Until the cause of Alzheimer's disease is known, the cure remains elusive. Because this disease is so widespread, many associations have organized support groups and developed educational materials and insurance information for Alzheim er's sufferers and their families. Many support groups offer day-care activities for patients and counseling for family members who are often faced with years o f care for their loved one. Bibliography Butler, Robert N. Aging and Mental Health: Positive Psychosocial, and Biomedical Approaches. New York, NY: Merrill, 1991 The Dementias: Hope Through Research. U.S. Department of Health and Human Servic es, National Institutes of Health Publication No. 81-2252, Washington, D.C.: Sup erintendent of Documents, U.S.Government Printing Office, 1981. Fact Sheet: Depression in the Elderly. U.S. Department of Health and Human Servi ces, Public Health Service, Alcohol, Drug Abuse and Mental Health Administration , 5600 Fishers Lane, Rockville, MD 20857. Humphrey, James H. Stress Among Older Adults: Understanding and Coping. Illinos: Thomas, 1992 Plain Talk About Aging. National Institute of Mental Health, Division of Communi cations and Education, 5600 Fishers Lane, Rockville, MD 20857. Powell, Lenore, M.D. and Katie Courtice. Alzheimer's Disease: A Guide For Famili es. Reading, MA: Addison-Wesley, 1983. Progress Report on Senile Dementia of the Alzheimer's Type. National Institute o n Aging, NIH Publication No. 81-2343, September 1981. U.S. Dept. of Health and H uman Services, National Institute on Aging Information Office, 5600 Fishers Lane , Rockville, MD 20857. Books published by The AMERICAN PSYCHIATRIC PRESS, INC. 1000 Wilson Blvd., #1825 Arlington, VA 22209

(800) 368-5777 Busse, Ewald W., and Blazer, Dan G. Textbook of Geriatric Psychiatry. 1995. 560 pgs. $89.95. Fogel, Barry S., M.D., Furino, Antonio, Ph.D., and Gottlieb, Gary L., M.D., M.B. A., editors. Mental Health Policy for Older Americans: Protecting Minds at Risk. 1990. 367 pgs. $33.50. Katona, Cornelius, and Levy, Raymond, editors. Delusions and Hallucinations in O ld Age. 1992. 248 pages. $32.00. Myers, Wayne A., M.D., editor. New Techniques in the Psychotherapy of Older Pati ents. 1991. 290 pages. $39.95. Sakauye, Kenneth M., M.D., Chairman. Ethnic Minority Elderly. 1993. 192 pages. $ 28.00 Schneider, Lon S., M.D., Reynolds, Charles F. III, M.D., Lebowitz, Barry D., Ph. D., and Friedhoff, Arnold J. M.D., editors. Diagnosis and Treatment of Depressio n in Late Life: Results of the NIH Consensus Development Conference. 1994. 535 p ages. $46.50. Shamoian, Charles A., M.D., Ph.D., editor. Treatment of Affective Disorders in t he Elderly. 1985. 84 pages. $21.00. The Elderly Mentally Ill. Hospital and Community Psychiatry Service. 1985. 56 pa ges. $7.50. MHC is grateful for this information provided by the APA. Mental health: minimental state examination and geriatric depression score of el derly Europeans in the SENECA study of 1993. Haller J, Weggemans RM, Ferry M, Guigoz Y. Source F Hoffmann-La Roche Ltd, Basel, Switzerland. Abstract OBJECTIVE: Assessment of the mental health of the European elderly and its correlations wit h micronutrient plasma levels, education and ability to carry out activities of daily living. DESIGN: Cross-sectional study. SETTING: Eleven small towns in nine European countries. SUBJECTS: Randomised sample of 880 subjects of both sexes born in the period 1913 to 1918, stratified according to age and sex. INTERVENTIONS: The mental status was assessed by means of the Mini-Mental State Examination (MM SE) and the 15-item Geriatric Depression Scale (GDS). RESULTS:

The overall mean MMSE score was 26.7 and this was also the mean for both sexes. MMSE scores below 23 were found in 8.5% of the men and 10.9% of the women. The o verall mean GDS score was 3.9, 3.2 for the men and 4.6 for the women. GDS scores above the cut-off of 5 were found in 11.6% of the men and 27.5% of the women. T here were many correlations between the MMSE and the GDS scores and education, A ctivities of Daily Living scores, subjective health and plasma micronutrient lev els, particularly the carotenoids. No geographical pattern of the distribution o f MMSE and GDS scores was discernible. CONCLUSIONS: The overall cognitive function of these elderly subjects aged 74 to 79 years was on the whole well preserved. The GDS scores suggest that the prevalence of depr ession was high in this sample. Education and higher plasma levels of certain vi tamins and carotenoids appear to be associated with lower risk of developing dem entia.