Mental Health in the

Elderly Maria Di Tomasso M.D. F.R.C.P

Overview

• Demographics

• Epidemiology of Depressive, Anxiety, and

Psychotic Disorders

• Different clinical presentations between older and

younger adults with mental illness

• Risk Factors and Protective Factors

• Treatment

–Socrates

“I enjoy talking with very old people. They

have gone before us on a road by which we,

too, may have to travel, and I think we do well

to learn from them what it is like.”

Introduction

Demographics

• Canada met a milestone in July 2015, for the first time

ever there are more Canadians age 65 and over than

there are under age 15

• The growth rate of people over 65 is four times faster

than the population at large

• In 2011, centenarians were the second most rapidly

growing segment of the population, after those aged

60-64, which experienced the fastest increase

• By 2030 25% of Canadians will be over 65

Canada's Aging Population

Geriatric Psychiatry • An official subspecialty of the Royal College of Canada

since 1999

• Managing elderly patients requires special knowledge

• Mental illness should not be a normal part of aging

• Canadian Community Health Survey found that 68.9 %

of seniors reported their mental health as very good or

excellent

• The majority of older individuals remain mentally

healthy and aging can be a time of growth and tapping

into one's potential

Classification

• Mood Disorders

• Anxiety Disorders

• Suicidal Behaviour

• Neurocognitive Disorders due to a medical condition including

Dementia and Delirium

• Personality Disorders

• Substance Use Disorders including Prescription drugs and Alcohol

• Psychotic Disorders

Late Life Mental Health

Challenges

Age is NOT a risk factor for a mental disorder

• Chronic health conditions is the biggest risk factor

• Death of a loved one

• Caregiving

• Significant loss of independence and limitation of activities

• Loss of societal roles

Late Life Approach to

Mental Health Disorders • High index of suspicion

• Use cohort appropriate language

• Interview family members for collateral information

• Review the medical history including medications to rule out a

medical cause

• Medical investigations

• Elderly are often on multiple drug regimens therefore vigilance of

drug-drug interactions is necessary

• Always evaluate cognition

Late Life

Depression

Late life depression is not a

single disorder but rather a

heterogeneous disorder

made up of a number of

clinical syndromes

Late Life Depression

Late Life Depression

Prevalence

Location Major Depression Depressive

Symptoms

Community 2%-4% 8%-6%

Primary Care 6%-9% 20%

Medical Settings 11% 25%

Nursing Homes 12%-25% 18%-30%

Barriers to Diagnosis • Patient Factors

- May not complain of sadness or depression

- Symptoms are different than younger adults

- Patients present with more somatic and cognitive symptoms

- Often do not seek mental health services, view depression as a

sign of weakness, stigma

- May be isolated with limited transportation

• Physician Factors

- Depression is seen as a normal response to aging

- Misattribute depressive symptoms to a physical illness

- Therapeutic nihilism

Late Life Depression

Common Presentations • Melancholic: anhedonia, early morning awakening, severe guilt,

psychomotor slowing

• Agitated: insomnia, restlessness, pacing, irritability

• Masked: somatic complaints, anxiety, hypochondriasis, negativity

• Psychotic: ego-syntonic delusions, auditory hallucinations

• Late Onset Depression: > age 60, silent strokes on CT or MRI,

cognitive deficits, loss of energy, physical disability

• Long-Term Care: signs observable by caregivers, new

oppositional behaviour, decreased socialization or self care

When to Suspect Depression

Special Clinical Features and Clues

• Prominent loss of interest and pleasure in activities

• Prominent cognitive complaints

• Irritability

• Heightened pain complaints

• Unexplained health worries

• Multiple visits to G.P. without resolution of the problem

• Slow recovery post surgery

• Refusal of treatment

• Prolonged hospitalization

• Excess disability

• Social withdrawal and avoidance of social interaction

• Unexplained functional decline

Causes of LLD

Etiological and Risk Factors

• Medical: High measures of medical burden triples the risk of depression

Theres is a reciprocal relationship between depression and medical illness.

Physical health impacts mental health and mental health impacts physical health.

- Neurological disease: Parkinson's disease, Stroke, Alzheimer's disease,

Silent Strokes or WMH

- Cardiovascular Disease

- Malignancies: Pancreatic cancer

- Endocrine disorders: Hypothyroidism

- Medications, polypharmacy, drug-drug interactions

- Sleep disturbance

• Disability alone ( measured by activities of daily living ) in the absence of medical illness

increases the risk of developing depression by a factor of 4 for elderly living in the community

Causes of LLD

Etiological and Risk Factors

• Psychosocial:

-Personality Attributes: Neuroticism, Insecure Attachment

Obsessional traits

Personality Disorder

- Behaviour: Learned helplessness

- Poor perceived health

- Loss of a spouse or loved one

- Caregiving

- Lack of social supports

- Marital separation, divorce or widowhood

- Low socioeconomic status

- Living in a nursing home

Comorbidity LLD and

Medical Illness • Stroke 22-50%

• Myocardial Infarction 15-19%

• Cancer 18-39%

• Rheumatoid Arthritis 13%

• Parkinson's Disease 10-37%

• Diabetes Mellitus 5-11%

Consequences of LLD Depression impacts older adults differently than younger adults

• Decrease in functional status

• Decreased compliance with medical care

• Poor outcome following MI, CVA, Hip

• Increased risk of osteoporosis in women

• Increase in death:

Post MI mortality rates are 5X higher

Post CVA mortality rates are 3.5X higher

• Increased risk of death in nursing homes is 2 fold

• Suicide

Graph

Suicide in Older Adults • Adults 65 and over have the highest suicide rate of any other age group

• Men 65 and older have the highest rate in Canada

• Older adults tend to use more lethal means, firearms, hanging and poisoning

• Older adults less likely to discuss their plans, give fewer warning signs

• Nonviolent deaths from suicide may be mistakenly attributed to an illness: not taking

medications, refusal to eat,

• 50% of older adults who have committed suicide saw their GP within one month of the

suicide

• Depression is the foremost risk factor for suicide in older adults

• Passive suicidal ideation, the desire to die and the belief that life is not worth living, is not

normative in late life

• Suicide is PREVENTABLE

Late Life Depression

Protective Factors

• Spiritual and Religious Affiliations

• Social, Family, Community Supports

• Wisdom

• Physical Activity

• Socio-Emotional Selectivity

Depression and Dementia

• Depression and dementia frequently coexist and the differential diagnosis

can be challenging

• Historically major depression with cognitive deficits, "Pseudodementia" ,

was considered a reversible and benign condition

• However a subset of patients will continue to have cognitive impairment

even after remission of symptoms, with as many as 40% developing

dementia within 3-5 years

• Late onset depression with cognitive impairment is a risk factor for

dementia, may also be a prodrome or psychological reaction to an

already present cognitive deficit

• Additionally early onset depression is also considered to be a risk factor

for dementia

Treatment • The elderly have similar response rates as younger adults

• Antidepressants may take longer to start working

• Start low, go slow, but go

• Choice of antidepressant depends on previous response to treatments,

side effect profile, other medical problems, existing medications, type of

depression

• SSRI's, SNRI's, Bupropion, Mirtazapine

• Psychotherapy: Cognitive Behaviour Therapy, Interpersonal Therapy,

Problem Solving Therapy

• Electroconvulsive Therapy ECT

Late Life Anxiety Disorders

Epidemiology • Anxiety disorders are more prevalent among younger adults than older adults

• In the ECA study: 7.3% of adults 18-64

vs. 5.5% of adults >65

• Late onset anxiety disorders are infrequent, 90% of anxiety disorders begin before age of 41,

75% before the age of 21

• Different forms of anxiety occur later in life

• Generalized Anxiety Disorder and Phobias account for most anxiety in late life

• Panic Disorder is rare

• Agoraphobia and possibly Obsessive Compulsive Disorder in females, may occur for the first

time in old age

• Simple Phobia, Obsessive Compulsive Disorder in males, and Panic Disorder either persist

from younger years or arise in the context of another psychiatric or medical disorder

• Fear of falling is a unique geriatric anxiety syndrome

Clinical Presentation

• GAD: Worry is different in the elderly, focus is on health and illness in self or

spouse, not work and interpersonal issues, new onset GAD is often related to a

depressive disorder

• Agoraphobia: most common phobia, usually no history of Panic Disorder, may

appear for the first time following a stroke or medical condition

• Panic Disorder: fewer and less severe symptoms, lower levels of arousal, late

onset is very rare, suspect medical condition

• Obsessive Compulsive Disorder: more religious than contamination obsessions

and more hand washing compulsions and less symmetry and counting, more

hoarding, late onset OCD may be secondary to a neurological disorder

• PTSD: less frequent after a traumatic event, delayed onset or re-emergence of

symptoms, 30% of MI patients, correlates with impaired memory

Comorbidities

• Up to 25% of medically ill have anxiety symptoms, most common

comorbidites are with cardiovascular disease, COPD, gastrointestinal

problems,vestibular conditions, hyperthyroidism, and diabetes

• Anxiety often leads to depression, approx. half of elderly with

depression have a comorbid anxiety disorder

• All late onset anxiety should raise suspicion of a cognitive disorder

• MCI with comorbid anxiety may indicate an underlying

neurodegenerative process, twice as likely to develop Alzheimer's

Dementia in 3 years

• Substance misuse with alcohol, hypnotics and anxiolytics may be an

attempt to self medicate

Late Life Anxiety Disorders

Treatment

• Avoid benzodiazepines, benefits must outweigh the risks,

risks include falls, ataxia, cognitive impairment, short term

use only

• Citalopram, Escitalopram, Sertraline, Venlafaxine XR are

effective

• CBT, relaxation therapy, sleep hygiene, supportive therapy

• Memory aides and between session reminder telephone

calls lead to better compliance and greater treatment effect

Late Life Psychosis

Psychosis is a

symptom not a

disorder Prevalence is up to 23% of elderly

Risk Factors

Female Gender

Social isolation

Low socio-economic status

Sensory Deficits

Cognitive decline

Polypharmacy

Late Life Psychosis • Most common cause of psychosis in later life is Dementia, occurs mainly

during middle stages, hallucinations are visual> auditory, delusions of theft,

spousal infidelity, abandonment, house is not one's home, and persecution

• Second most common cause of psychosis in the elderly is Major Depression,

especially late onset depression, mood congruent delusions of guilt, poverty,

nihilism and somatization

• Most common cause of acute onset psychosis is Delirium or Substance

Induced Psychosis ( drugs/alcohol/medications, especially with anticholinergic,

sedative and analgesic medications

• Late Onset Schizophrenia ( age 40-60 ) and Very Late Onset Schizophrenia (

after age 60 ), higher rates of visual, olfactory and tactile hallucinations

• Very Late Onset Schizophrenia tends to be a prodrome of a neurodegenerative

disorder

Etiology

• What is the most common etiology of psychosis?

• Dementia 40%

• Major Depression 33%

• Delirium 7%

• Medical conditions 7%

• Mania 5%

• Substance induced 4%

• Delusional disorder 2%

• Schizophrenia 1%

Peggy Freydberg

• Began writing poetry at age 90

• Published her first poetry

book, Poems from the Pond,

at 107 years of age

Inga Rapaport

• Neonatologist who received a

doctorate in medicine at age 102