Transcript xxxxxxxxxxx - University of Toronto

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 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
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!!
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
Alzheimer’s Disease (AD)
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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
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
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
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
Suspected Causes of AD cont’d
Neuroimmune system / Inflammatory Response
• inverse relationship btwn anti-inflammatory
treatment and incidence of AD
Risk Factors for 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
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
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
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
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??
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
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
Potentially Reversible Causes of Dementia
• depressive pseudodementia
• hypoxia
• malnutrition, anemia
• infection
• drugs, other toxic substances - “iatrogenic”
• head trauma
• medical conditions
Affective Disorders
Depression
Diagnosis of Major Depressive Episode (DSM-IV)
A. 5 or more of the following:
Depressed mood
Loss of interest
Changes in weight/appetite
Insomnia/hypersomnia
Psychomotor changes
B.
C.
D.
E.
Fatigue
Guilt/worthlessness
Poor concentration
Thoughts of death
Do not meet criteria for Mixed Episode
Distress/impairment in daily functioning
Not effect of substance or medical condition
Not better accounted for by bereavement
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
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
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
History and Behavioural Features
Measure
AD
DPD
Symptom duration
long
short
Prev. psychiatric history
unusual
usual
Progression of symptoms
slow
rapid
Patient complaint of deficit
variable
abundant
Patient valuation of
accomplishments
variable
minimized
Behaviour congruent with
cognitive deficits
usual
unusual
mood
independent
slow
mood
congruent
rapid
Delusions
Mood disorder
Cognitive Features
Measure
AD
DPD
Memory
impaired encoding
and storage
decreased
cognitive effort
Language
deteriorates w/
progression
intact
normal
Perception/
Construction
declines
Praxis
impaired
Attention
Problem Solving
Psychomotor Speed
intact
similar deficits in both
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
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
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
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
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
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
Alcoholism cont’d...
• Diagnostic clues of alcoholism in old age
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insomnia
impotence
problems with control of gout
rapid onset of confusional state
uncontrollable hypertension
unexplained falls/bruises
excessive sleepiness
flushed face
bloated appearance