Surgeon General’s Report Ch 5

David Satcher, M.D., Ph.D.

Older Adults and Mental Health

(A.K.A. Sorry that we have class today.)

Increases in Percent over 65 & 85

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

More Disorders Anxiety Schizophrenia Alcohol abuse Substance abuse

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

THE END

Everyone Wake Up!!!!!