Geriatric Psychiatry:Geriatric Psychiatry:An Introductory An Introductory

OverviewOverviewCarl I. Cohen M.D.Carl I. Cohen M.D.

Distinguished Service Distinguished Service Professor & DirectorProfessor & Director

Division of Geriatric Division of Geriatric PsychiatryPsychiatry

email: email: carl.cohen@downstate.educarl.cohen@downstate.edu

Case of Ms JonesCase of Ms Jones

Ms Jones is a 76-year-old African Ms Jones is a 76-year-old African American woman who presents with a American woman who presents with a history of not seeing her friends, loss history of not seeing her friends, loss of interest in sewing and gardening, of interest in sewing and gardening, and some forgetfulness. She has some and some forgetfulness. She has some difficulty hearing and also complains difficulty hearing and also complains of arthritic pain. She has of arthritic pain. She has hypertension, hyperlipidemia, and hypertension, hyperlipidemia, and type 2 diabetes. She takes type 2 diabetes. She takes medications for these conditions. medications for these conditions.

Several of her friends died in recent Several of her friends died in recent years, and her daughter has moved to years, and her daughter has moved to New Jersey. She has always been a New Jersey. She has always been a very independent woman, but now very independent woman, but now feels more helpless. feels more helpless.

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

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

Principles of Geriatric Principles of Geriatric PsychiatryPsychiatry

1. Older adults are the most 1. Older adults are the most heterogeneous group in the population.heterogeneous group in the population.

2. The demographics of aging are shifting.2. The demographics of aging are shifting.

3. Assessment is different in older age.3. Assessment is different in older age.

4. Disorders may present differently.4. Disorders may present differently.

5. Treatment may be different.5. Treatment may be different.

6. The course of disorders may be 6. The course of disorders may be different.different.

7. Aging is characterized by both 7. Aging is characterized by both longstanding conditions and late-onset longstanding conditions and late-onset conditions that may become chronic.conditions that may become chronic.

8. Nearly all older adults with psychiatric 8. Nearly all older adults with psychiatric disorders will have comorbid conditions, disorders will have comorbid conditions, although not all comorbity is alike.although not all comorbity is alike.

9. There is continuity in personality.9. There is continuity in personality.10. Psychiatric illness must be understood 10. Psychiatric illness must be understood

within a social and biological context.within a social and biological context.11. The prevalence of psychiatric disorders 11. The prevalence of psychiatric disorders

in older adults and mental disorders are in older adults and mental disorders are best viewed on a continuum.best viewed on a continuum.

12. It is essential to view the treatment 12. It is essential to view the treatment goals for older adults with mental illness goals for older adults with mental illness in the context of a life course trajectory.in the context of a life course trajectory.

13. Disorders overlap with respect to 13. Disorders overlap with respect to neuropathology and symptoms.neuropathology and symptoms.

14. Mental illness in older age is complex.14. Mental illness in older age is complex.

Question 1Question 1

Older adults are extremely Older adults are extremely heterogeneous and have little in heterogeneous and have little in common with each other?common with each other?

Answer: FalseAnswer: False

1. Older adults are the most 1. Older adults are the most heterogeneous group in heterogeneous group in the population.the population.

Older persons differ dramatically in their Older persons differ dramatically in their physical and mental health, functional physical and mental health, functional abilities, social networks, political and abilities, social networks, political and religious beliefs, and so forth. religious beliefs, and so forth.

Although we often categorize aged persons Although we often categorize aged persons based on chronological age –e.g., the census based on chronological age –e.g., the census bureau defines “older adults” as aged 55 to bureau defines “older adults” as aged 55 to 64, and elderly as 65 and over—there are 64, and elderly as 65 and over—there are marked differences in biological aging. marked differences in biological aging.

This is especially true among persons with This is especially true among persons with chronic schizophrenia who may have health chronic schizophrenia who may have health problems more characteristic of persons who problems more characteristic of persons who are 10 or 15 years older. are 10 or 15 years older.

Although older adults are heterogeneous Although older adults are heterogeneous they do share some common life they do share some common life experiences that may have psychosocial experiences that may have psychosocial ramifications (so called “cohort effects”). ramifications (so called “cohort effects”).

However, with the increasing number of However, with the increasing number of older persons reaching very old age, the older persons reaching very old age, the number of cohorts within the aging number of cohorts within the aging population has grown. population has grown.

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

the 1960s. the 1960s.

The oldest African Americans grew up during The oldest African Americans grew up during periods of marked racial segregation and periods of marked racial segregation and

discrimination, whereas “young-old” African discrimination, whereas “young-old” African Americans came of age during the period of the Americans came of age during the period of the

civil rights and black power movementscivil rights and black power movements

Clinical ImplicationsClinical Implications

Mental and physical health care to Mental and physical health care to older adults should not be determined older adults should not be determined solely by chronological age because of solely by chronological age because of the marked diversity within this age the marked diversity within this age group. group.

However, living through similar However, living through similar historical periods can provide a historical periods can provide a common background context for older common background context for older adults of the same age.adults of the same age.

Question 2: The 1 Question 2: The 1 percent percent

Which group is part of the 1%: The Which group is part of the 1%: The percentage of persons aged 90 and percentage of persons aged 90 and over or persons in gangs?over or persons in gangs?

Answer: Persons aged 90+; however, Answer: Persons aged 90+; however, persons in gangs (currently 1%) are persons in gangs (currently 1%) are one of the fastest growing segments of one of the fastest growing segments of society (40% in past 3 years)society (40% in past 3 years)

2. The demographics of aging 2. The demographics of aging are shifting.are shifting.

The baby boomers (people born between The baby boomers (people born between 1946 to 1964) will first turn 65 beginning 1946 to 1964) will first turn 65 beginning 2011. 2011.

The older population is projected to nearly The older population is projected to nearly double from 38 million (12.6 %) in 2008 to double from 38 million (12.6 %) in 2008 to 72 million (20%) in 2030. 72 million (20%) in 2030.

Persons over aged 85 and over are the Persons over aged 85 and over are the most rapidly growing segment of our most rapidly growing segment of our population and their numbers will double population and their numbers will double over the first quarter of the century and over the first quarter of the century and more than quadruple over the first half the more than quadruple over the first half the century (to over 19 million persons). century (to over 19 million persons).

The older population is also The older population is also growing more diverse. growing more diverse.

In 2000, 16% of population In 2000, 16% of population were non-whites (Blacks, were non-whites (Blacks, Hispanics, Asians, Native Hispanics, Asians, Native Americans) or 5.8 million Americans) or 5.8 million persons. In 2050, 36% of persons. In 2050, 36% of population will be non- white or population will be non- white or 29.5 million persons. 29.5 million persons.

Thus, there will be a 5-fold increase in the Thus, there will be a 5-fold increase in the number of minority elders over the first half number of minority elders over the first half

of the 21st century.of the 21st century.

Clinical ImplicationsClinical Implications

Mental health providers can Mental health providers can expect to be working with expect to be working with increasingly older and more increasingly older and more diverse populationsdiverse populations

They must possess appropriate They must possess appropriate clinical skills and cultural clinical skills and cultural knowledge if they are to deliver knowledge if they are to deliver competent care.competent care.

Question 3Question 3

Emergency rooms are an ideal place Emergency rooms are an ideal place to examine older adults?to examine older adults?

Answer: False Answer: False

3. Assessment is different in 3. Assessment is different in older ageolder age

The assessment of older adults must The assessment of older adults must take into account communication take into account communication difficulties in vision and hearing, difficulties in vision and hearing, physical handicaps, and cognitive physical handicaps, and cognitive difficulties.difficulties.

Clinical ImplicationsClinical Implications Clinicians should generally assess Clinicians should generally assess

cognitive and physical dysfunction on cognitive and physical dysfunction on the initial examination the initial examination

Continue to closely monitor for the Continue to closely monitor for the effects of treatment on the patient’s effects of treatment on the patient’s mental & physical functioning. mental & physical functioning.

Another key difference from younger Another key difference from younger persons is the likelihood that persons is the likelihood that caregivers, both formal and informal, caregivers, both formal and informal, will be more involved in providing will be more involved in providing information and treatment.information and treatment.

Question 4Question 4

Depressive symptoms in later life Depressive symptoms in later life are similar to those in younger are similar to those in younger personspersons

False False

4.4. Disorders may present differentlyDisorders may present differently

Like physical disorders, the clinical Like physical disorders, the clinical presentations of psychiatric disorders presentations of psychiatric disorders may differ in older persons. may differ in older persons.

Examples: Examples: Depression may present with fewer signs Depression may present with fewer signs

of sadness and with more symptoms of of sadness and with more symptoms of social withdrawal, somatic concerns, social withdrawal, somatic concerns, motor disturbances, and apathy. motor disturbances, and apathy. Sometimes described asSometimes described as::““Depression Depression without sadnesswithout sadness”” or a “ or a “depletion depletion syndrome”syndrome” manifested by manifested by withdrawal, withdrawal, apathy, and lack of vigor.apathy, and lack of vigor.

Also may see more executive dysfunction, Also may see more executive dysfunction, which may be due to vascular depression which may be due to vascular depression (see figure re: vascular depression). (see figure re: vascular depression).

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•Irritability is more common •Somatization (emotional issues expressed through bodily complaints)is more common

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.

Symptoms include Symptoms include greater levelsgreater levels of apathy, psychomotor of apathy, psychomotor retardation and disability, retardation and disability,

andand lessless agitation,psychoses, family agitation,psychoses, family

history of psychiatric illness, history of psychiatric illness, guilt, and insight versus other guilt, and insight versus other older depressed persons.older depressed persons.

Vascular Depression Vascular Depression HypothesisHypothesis

((Krishnan & McDonald, 1995;Sneed & Cuslng-Krishnan & McDonald, 1995;Sneed & Cuslng-

Reimlieb, 2011Reimlieb, 2011))Risk Factors•Age

•Hypertension

•Hyperlipidemia

•Smoking

•Diabetes

Artherosclerosis

Deep white matter lesions ( vulnerability to late onset depression)

Vascular depression with executive dysfunction

Negative life events Poor social support

Disorders may present Disorders may present differentlydifferently (cont.) (cont.)

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

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

Clinical ImplicationsClinical Implications

Clinicians must be vigilant for Clinicians must be vigilant for more atypical symptoms in older more atypical symptoms in older adults.adults.

Question 5Question 5

All drug metabolism is appreciably All drug metabolism is appreciably affected by agingaffected by aging

FalseFalse

5. Treatment may be 5. Treatment may be differentdifferent

With increased age:With increased age: There are declines in the absorption There are declines in the absorption

raterate of medications, although amount of medications, although amount of medication absorbed does not of medication absorbed does not change change

Distribution of drugs as a result of an Distribution of drugs as a result of an increase in adipose tissue relative to increase in adipose tissue relative to lean body mass lean body mass

Diminished metabolism in the liverDiminished metabolism in the liver Declines in renal clearance Declines in renal clearance

Clinical ImplicationsClinical Implications Dosages of medications may need to be Dosages of medications may need to be

lowerlower than in younger persons, and than in younger persons, and considerations of side effects and drug considerations of side effects and drug interactions become more relevant. interactions become more relevant.

Must be cautious in prescribing drugs Must be cautious in prescribing drugs that are apt to affect the Cytochrome that are apt to affect the Cytochrome P450 metabolic pathways in the liver P450 metabolic pathways in the liver (Phase I hepatic metabolism), and if (Phase I hepatic metabolism), and if used, their potential interactions with used, their potential interactions with other medications should be reviewed. other medications should be reviewed.

Some pathways such as CYP1A2 and Some pathways such as CYP1A2 and CYP3A4 are most affected by aging. CYP3A4 are most affected by aging.

It is best to use drugs that do not It is best to use drugs that do not undergo Phase I hepatic metabolism, but undergo Phase I hepatic metabolism, but only Phase II hepatic metabolism only Phase II hepatic metabolism (conjugation), since this process is not (conjugation), since this process is not affected by aging. affected by aging.

Because of changes in the distribution of Because of changes in the distribution of drugs in the body, the fat soluble drugs, drugs in the body, the fat soluble drugs, which includes many of the drugs used in which includes many of the drugs used in psychiatry, tend to remain in the body psychiatry, tend to remain in the body longer and may cause toxicity. longer and may cause toxicity.

Conversely, water soluble drugs such as Conversely, water soluble drugs such as lithium need to be used cautiously because lithium need to be used cautiously because of the diminution of total body water with of the diminution of total body water with age. age.

Finally, some psychotropic drugs remain Finally, some psychotropic drugs remain active (e.g. lithium, gabapentin, active (e.g. lithium, gabapentin, rivastigmine) until they are cleared by the rivastigmine) until they are cleared by the kidney, and doses may need to be adjusted kidney, and doses may need to be adjusted in older adults. in older adults.

Question 6Question 6

Prognosis for depression in later life Prognosis for depression in later life is no worse than younger personsis no worse than younger persons

FalseFalse

6. The course of disorders may 6. The course of disorders may be differentbe differentInIn schizophrenia schizophrenia

There is a diminution in positive symptoms There is a diminution in positive symptoms with age. with age.

Levels of co-occurring depression may Levels of co-occurring depression may remain the same or increase.remain the same or increase.

Mild cognitive problems that present Mild cognitive problems that present earlier in life may worsen due to normal earlier in life may worsen due to normal effects of the aging process.Thus, older effects of the aging process.Thus, older persons may be at the level of a mild persons may be at the level of a mild dementia.dementia.

In In depression:depression: More subtypes (e.g. vascular More subtypes (e.g. vascular

depression; and depression with depression; and depression with cognitive deficits/dementia also known cognitive deficits/dementia also known as “pseudomentia”) that may be more as “pseudomentia”) that may be more resistant to treatment. resistant to treatment.

There is some evidence that older There is some evidence that older persons with major depression may be persons with major depression may be more prone to relapse and relapse more prone to relapse and relapse sooner than their younger sooner than their younger counterparts.counterparts.

Clinical ImplicationsClinical Implications

In treating persons with schizophrenia In treating persons with schizophrenia need to be aware of changes in need to be aware of changes in symptoms that occur with aging, and symptoms that occur with aging, and to adjust treatment accordingly. to adjust treatment accordingly.

In treating older adults with In treating older adults with depression, it is important to depression, it is important to determine the subtype of depression, determine the subtype of depression, because prognosis varies considerably because prognosis varies considerably depending on the etiology of the depending on the etiology of the depression. depression.

7. Aging is characterized by both 7. Aging is characterized by both longstanding conditions and late-longstanding conditions and late-

onset conditions that may become onset conditions that may become chronic.chronic. Depression in older adults is often chronic, Depression in older adults is often chronic,

and more than and more than halfhalf of persons with clinical of persons with clinical depression in later life remain syndromally depression in later life remain syndromally depressed and an additional depressed and an additional 30% 30% have have some residual symptoms (subsyndromal or some residual symptoms (subsyndromal or subthreshold depression).subthreshold depression).

Even under the most ideal treatment Even under the most ideal treatment conditions (e.g., medication and conditions (e.g., medication and psychotherapy), about psychotherapy), about one-third one-third of older of older persons with new –onset depression persons with new –onset depression relapse on 2-year follow-up (Reynolds et al, relapse on 2-year follow-up (Reynolds et al, 2006). 2006). Two-thirdsTwo-thirds relapse without relapse without medications.medications.

The line between The line between reversible and reversible and irreversibleirreversible illness may become illness may become less distinct.less distinct.

Examples:Examples:

Late-onset depression may be a Late-onset depression may be a prodromal symptom of dementia. It is prodromal symptom of dementia. It is estimated that estimated that two-fifths of late-onset two-fifths of late-onset depression with some cognitive depression with some cognitive problems (so called “pseudodementia”)problems (so called “pseudodementia”) may eventually progress to a true may eventually progress to a true dementia, despite there having been an dementia, despite there having been an initial resolution of depression.initial resolution of depression.

Persons with vascular depression are Persons with vascular depression are more prone to dementia.more prone to dementia.

Clinical ImplicationsClinical Implications Although treatment can help reduce Although treatment can help reduce

recurrence and levels of symptoms, the recurrence and levels of symptoms, the complex interaction of psychiatric and complex interaction of psychiatric and physical conditions may make full recovery physical conditions may make full recovery less likely. less likely.

Treatment of late-onset depression may Treatment of late-onset depression may benefit (i.e., reduced likelihood of dementia) benefit (i.e., reduced likelihood of dementia) from a combination of an SSRI and from a combination of an SSRI and cholinesterase inhibitor such as donepezil cholinesterase inhibitor such as donepezil (Aricept), although depression recurrence (Aricept), although depression recurrence may be higher.may be higher.

While the ultimate goal for all patients may While the ultimate goal for all patients may be the remission of symptoms, sometimes be the remission of symptoms, sometimes treatment goals will have to be adjusted, and treatment goals will have to be adjusted, and like some chronic physical disorders, like some chronic physical disorders, persons may have to live with a modest level persons may have to live with a modest level of symptoms. of symptoms.

Question 7Question 7

Comorbid illnesses are important Comorbid illnesses are important determinants of outcome in older determinants of outcome in older adultsadults

TrueTrue

8. Nearly all older adults with 8. Nearly all older adults with psychiatric disorders will have psychiatric disorders will have

comorbid conditions, although not comorbid conditions, although not all comorbity is alikeall comorbity is alike Some comorbid conditions can Some comorbid conditions can

contribute substantially to disability contribute substantially to disability and functional decline (e.g., severe and functional decline (e.g., severe osteoarthritis, severe heart disease, osteoarthritis, severe heart disease, neurocognitive disorders), whereas neurocognitive disorders), whereas other conditions have minimal effects other conditions have minimal effects on functioning (e.g., controlled on functioning (e.g., controlled hypertension or hypertension or hypercholesterolemia). hypercholesterolemia).

There is a reciprocal interaction There is a reciprocal interaction between depression and many between depression and many physical disorders. Depression physical disorders. Depression may result in higher occurrence may result in higher occurrence of certain physical illnesses, and of certain physical illnesses, and physical disorders may increase physical disorders may increase levels of depression levels of depression

e.g. mortality rates are higher e.g. mortality rates are higher among post-myocardial infarct among post-myocardial infarct patients with depressionpatients with depression

Depression and anxiety often co-occur, Depression and anxiety often co-occur, and having more anxiety symptoms (e.g. and having more anxiety symptoms (e.g. half of persons with depression have half of persons with depression have anxietyanxiety), is a poor prognostic indicator in ), is a poor prognostic indicator in depression. depression.

One of the more significant health One of the more significant health challenges involve persons with some challenges involve persons with some combination of chronic pain , dementia, combination of chronic pain , dementia, depression, anxiety, bereavement, depression, anxiety, bereavement, multiple losses, social isolation and poor multiple losses, social isolation and poor nutrition. nutrition.

Clinical ImplicationsClinical Implications

There is some evidence that There is some evidence that treating depression can improve treating depression can improve health outcomes and that health outcomes and that improving physical health can improving physical health can improve depression and anxiety. improve depression and anxiety.

Unfortunately, the ability to Unfortunately, the ability to successfully treat depression is successfully treat depression is less robust in older persons with less robust in older persons with concomitant physical disorders.concomitant physical disorders.

Question 8 Question 8

There are considerable changes in There are considerable changes in personality over timepersonality over time

FalseFalse

9. There is continuity in 9. There is continuity in personalitypersonality

Each older person is a product of the Each older person is a product of the lifelong effects of physiological, lifelong effects of physiological, environmental, and psychological environmental, and psychological factors. factors.

With respect to psychological factors, With respect to psychological factors, although some changes occur across a although some changes occur across a lifespan, various personality traits (e.g., lifespan, various personality traits (e.g., coping , sense of control, self-esteem, coping , sense of control, self-esteem, interpersonal skills) tend to be fairly interpersonal skills) tend to be fairly stable over time, and they will affect stable over time, and they will affect how one deals with late-life stressors.how one deals with late-life stressors.

Clinical ImplicationsClinical Implications On the positive side, continuity means On the positive side, continuity means

that most older persons have been that most older persons have been able to successfully use various able to successfully use various coping strategies to manage their coping strategies to manage their stressors over the life course. stressors over the life course.

Therapists must help to gird up these Therapists must help to gird up these formerly successful coping formerly successful coping mechanisms, and in turn, improve the mechanisms, and in turn, improve the sense of self-esteem.sense of self-esteem.

However, with increasing age However, with increasing age and disability, formerly and disability, formerly successful strategies may not be successful strategies may not be working and therapy must working and therapy must address some of the physical, address some of the physical, cognitive, and social losses that cognitive, and social losses that occur in later life. occur in later life.

10. Psychiatric illness must be 10. Psychiatric illness must be understood within a social and understood within a social and

biological contextbiological context The importance of material and emotional The importance of material and emotional

resources as well as physiological conditions (co-resources as well as physiological conditions (co-occurring illness, medications) must be occurring illness, medications) must be considered.considered.

It is said that aging is a bit like gambling: It is said that aging is a bit like gambling: ““The longer you go on, the more likely you are to The longer you go on, the more likely you are to lose.” lose.” Thus, older adults have to confront and deal with Thus, older adults have to confront and deal with various various losseslosses, perhaps best summarized by the , perhaps best summarized by the 4D’s of Aging: 4D’s of Aging: disability,disability, dependencydependency, , desertiondesertion (e.g., loss of close relationships as (e.g., loss of close relationships as people move away or dying), and people move away or dying), and deathdeath (e.g., (e.g., one’s own mortality and the death of others).one’s own mortality and the death of others).

Clinical ImplicationsClinical Implications For some adults who are physically For some adults who are physically

healthy and have strong social healthy and have strong social resources, a useful strategy might be resources, a useful strategy might be to encourage activities and to encourage activities and engagement following losses of kin or engagement following losses of kin or friends or in the context of life friends or in the context of life stressors. stressors.

On the other hand, for persons with On the other hand, for persons with more disabilities and fewer resources, more disabilities and fewer resources, encouraging too much engagement encouraging too much engagement may be unrealistic and further may be unrealistic and further exacerbate their feelings of exacerbate their feelings of worthlessness and depression. worthlessness and depression.

11. The prevalence of psychiatric 11. The prevalence of psychiatric disorders in older adults and mental disorders in older adults and mental

disorders are best viewed on a disorders are best viewed on a continuumcontinuumOfficial psychiatric disorders may not accurately Official psychiatric disorders may not accurately

reflect psychiatric distress in the aging reflect psychiatric distress in the aging community because: community because:

Older adults may present atypically, Older adults may present atypically, Co-morbid physical and cognitive disorders may Co-morbid physical and cognitive disorders may

make fulfillment of the diagnostic criteria more make fulfillment of the diagnostic criteria more difficult, difficult,

Older adults with psychiatric disturbances may Older adults with psychiatric disturbances may cluster in certain settings so that they may not cluster in certain settings so that they may not be adequately sampled (e.g., natural occurring be adequately sampled (e.g., natural occurring retirement communities, assisted living retirement communities, assisted living facilities, and nursing homes). facilities, and nursing homes).

Thus, we may need to view illness on a Thus, we may need to view illness on a continuumcontinuum and looking at subsyndromal or and looking at subsyndromal or subthreshold disorders with respect to subthreshold disorders with respect to depression, anxiety disorders, psychoses, and depression, anxiety disorders, psychoses, and neurocognitive disorders. neurocognitive disorders.

The National Comorbidity Survey-The National Comorbidity Survey-Replication (NCS-R) allowed for the Replication (NCS-R) allowed for the most comprehensive examination of most comprehensive examination of psychiatric disorders among older psychiatric disorders among older adults in the United States. The 12-adults in the United States. The 12-month prevalence of depressive mood month prevalence of depressive mood disorders for persons aged 55+ was disorders for persons aged 55+ was 4.9%. There was a steady decline in 4.9%. There was a steady decline in prevalence across each decade, with prevalence across each decade, with the highest rates in the 55 to 64 year the highest rates in the 55 to 64 year old group (7.6%) and the lowest rates old group (7.6%) and the lowest rates in the 85 and over group(2.4%). in the 85 and over group(2.4%).

Prevalence of Depression

5575

85

Age pattern

The 12 -month prevalence for The 12 -month prevalence for anxiety disorders in older adults anxiety disorders in older adults was 11.6%. However, in this case, was 11.6%. However, in this case, while the youngest group (age while the youngest group (age 55-64) had the highest 55-64) had the highest levels(16.6%), the 75-84 year old levels(16.6%), the 75-84 year old age group had lower rates(6.0%) age group had lower rates(6.0%) than the oldest age (85+) group than the oldest age (85+) group (8.1%)(8.1%)

Prevalence of Anxiety

Age pattern55

75

85

By comparison, in the national sample, By comparison, in the national sample, across all age categories (age 18+) across all age categories (age 18+) thethe

12 –month prevalence for any mood 12 –month prevalence for any mood disorder or anxiety disorder was 9.5 % disorder or anxiety disorder was 9.5 % and 18.1%, respectively (Note the much and 18.1%, respectively (Note the much higher rates in younger than the older higher rates in younger than the older groups). In all age groups, major groups). In all age groups, major depression was the most common mood depression was the most common mood disorder and specific phobia were the disorder and specific phobia were the most common anxiety disorder. most common anxiety disorder.

Age differences

If non-DSM criteria are used, rates of If non-DSM criteria are used, rates of clinical or “syndromal” depression (based clinical or “syndromal” depression (based on meeting symptom prevalence and on meeting symptom prevalence and severity criteria) is about severity criteria) is about 12%(range 8-12%(range 8-16%)16%) and may be as high as and may be as high as 24%24% for for subsyndromal (“subthreshold” ) subsyndromal (“subthreshold” ) depression. Thus, about depression. Thus, about one-thirdone-third of of older adults may meet criteria for older adults may meet criteria for syndromal or subsyndromal depression. syndromal or subsyndromal depression.

Clinical depression is about Clinical depression is about 2525%% in in medically ill. medically ill.

Likewise, syndromal and subsyndromal Likewise, syndromal and subsyndromal anxiety may be found in slightly over anxiety may be found in slightly over 15%15% of the older population of the older population

Subsyndromal Depression and Anxiety

These findings are important These findings are important because subyndromal depressive because subyndromal depressive and anxiety disorders have been and anxiety disorders have been found to be associated with found to be associated with higher rates of functional higher rates of functional impairment, disability, medical impairment, disability, medical illness, and mortality. illness, and mortality.

Prevalence rates of psychoses are Prevalence rates of psychoses are especially difficult to determine because especially difficult to determine because of the clustering of persons with of the clustering of persons with psychoses in more supported psychoses in more supported environments or perhaps their environments or perhaps their unwillingness to consent to interviews. unwillingness to consent to interviews.

The Epidemiologic Catchment Area study The Epidemiologic Catchment Area study found only found only 0.3%0.3% of persons aged 65 and of persons aged 65 and over had a lifetime history of over had a lifetime history of schizophrenia . schizophrenia .

The National Comorbidity Study (NCS)-R The National Comorbidity Study (NCS)-R has not provided age data on non-has not provided age data on non-affective psychoses, although the general affective psychoses, although the general population was found to have a population was found to have a 1.5%1.5% lifetime prevalence. lifetime prevalence.

Prevalence of Psychoses

If one views psychoses on a If one views psychoses on a continuum, NCS-R data indicated continuum, NCS-R data indicated that lifetime prevalence of that lifetime prevalence of psychotic symptoms in the older psychotic symptoms in the older adults in the general population is adults in the general population is 11%,11%, or over or over 77 times the lifetime times the lifetime prevalence of the formal diagnostic prevalence of the formal diagnostic category for psychotic illness. category for psychotic illness.

Prevalence of Dementia and Prevalence of Dementia and Mild Cognitive ImpairmentMild Cognitive Impairment The prevalence rates of dementia The prevalence rates of dementia

have been found to range from have been found to range from 5 5 to 10%.to 10%.

The prevalence rate is about 1% The prevalence rate is about 1% at age 65, but there is a at age 65, but there is a doubling doubling of prevalence rates every 5 years of prevalence rates every 5 years until age 90until age 90,, when the rates may when the rates may continue to increase but more continue to increase but more slowly. slowly.

Based on concern of pt/informant of significant cognitive decline and one or more of the following:

Memory & learning impairmentAttention impaired(sustained, selective, divided)Aphasia (expression, naming, understanding)

Agnosia/Apraxia/Art & visuospatial tasks Appropriate social cognition impaired

(emotional recognition, empathy)Abstraction and other executive functioning impaired

(planning, decisions, flexibility) --- PLUS---Absence of delirium Ability to function is impaired

.

“MA9” ----Mnemonic for Neurocognitive Disorders (formerly known as dementia & mild cognitive disorder)

  1. Alzheimer’s disease 60-70% (insidious onset; memory deficits early; consistency in loss of various cognitive functions) 2. Vascular 10-30% (sudden onset,stepwise; less consistency (“patchy”) in cognitive deficits) 3. Mixed (AD + Vascular) 10% 4. Lewy Body 10-25% (central feature: dementia & 2 of 3 core sx: parkinson sx; fluctuating cognition with variations in attention and alertness; visual hallucinations; also suggestive: neuroleptic sensitivity; REM sleep behavior; also milder cognitive deficits; falls; visuospatial deficits; 5. Depression 5-15% (‘pseudodementia’).

Causes of Dementia (and most defining features)

6. Frontotemporal 5-10% : executive or language (semantic/primary progressive aphasia) prominent early; memory less impaired early in disorder.

Three types of cellular inclusions:

a. Tar-DNA binding protein of 43kDa (TDP-43) --most common

b. Tau

c. Fused in sarcoma (FUS) protein

Both Tau and TDP are associated with diverse pathologic subtypes including CBD, Pick’s, PNP ALS,PD types and semantic dementia

7. Other 10-20% e.g. Parkinson’s disease (movement disorder early--1-yr before dementia)

Mild Neurocognitive Mild Neurocognitive Disorder (Mild Cognitive Disorder (Mild Cognitive

Disorder)Disorder) As with other disorders, a subsyndromal As with other disorders, a subsyndromal

category, “Mild Cognitive Impairment,” has category, “Mild Cognitive Impairment,” has been identified that consists of various been identified that consists of various objective cognitive deficits (same categories objective cognitive deficits (same categories as major cognitive disorder), usually in as major cognitive disorder), usually in memory, memory, but daily functioning remains but daily functioning remains largely intact and self/observer identified largely intact and self/observer identified decline is “mild”.decline is “mild”. It is estimated that about It is estimated that about 10%10% of persons aged 70 to 79 have MCI, of persons aged 70 to 79 have MCI, and this rate is about and this rate is about 20%20% in the 80 to 89 in the 80 to 89 year old category . year old category .

Clinical ImplicationsClinical Implications

Psychiatric symptoms among older Psychiatric symptoms among older adults are common and may cause adults are common and may cause dysfunction, even when they do not dysfunction, even when they do not meetmeet DSM IV criteria.DSM IV criteria.

Perhaps even more so than in any Perhaps even more so than in any other age category, it is important to other age category, it is important to not overly rely on strict diagnostic not overly rely on strict diagnostic criteria and to focus on the clinical criteria and to focus on the clinical symptoms that are causing distress. symptoms that are causing distress.

DSM Disorders in age 65+ (in order of frequency)

12 -month prevalence

Anxiety Disorders(phobic disorders,gen anx, panic)

6%-12% female>male

Dementia 5-10% female>male

Major depression 1-2% female>male

Dysthymic disorder 2% female>male

Alcohol abuse /dependence 1% male>female

Schizophrenia 0.3 -0.5% male=female

Bipolar 0.3% male=female

Any DSM disorder 12% female>male

12. It is essential to view the 12. It is essential to view the treatment goals for older adults treatment goals for older adults

with mental illness in the context with mental illness in the context of a life course trajectory.of a life course trajectory.

It is now recognized that the outcome for It is now recognized that the outcome for certain symptoms of certain symptoms of schizophreniaschizophrenia in later life are more favorable than in later life are more favorable than previously believed: previously believed:

One-half of persons attain clinical One-half of persons attain clinical remission (cross-sectional data) as remission (cross-sectional data) as defined as having mild or no symptoms defined as having mild or no symptoms in positive and negative symptoms, in positive and negative symptoms,

Nearly half may attain social recovery. Nearly half may attain social recovery.

Depression outcomeDepression outcome

Older persons with depression do less Older persons with depression do less well than previously believed, with well than previously believed, with roughly roughly halfhalf continuing to have clinical continuing to have clinical depression on follow-up, and perhaps depression on follow-up, and perhaps another another 30%30% may have appreciable may have appreciable residual symptoms. residual symptoms.

Thus, only Thus, only one-fifthone-fifth may be in full may be in full remission on long-term follow-up. remission on long-term follow-up. However, with more aggressive and However, with more aggressive and creative treatment strategies, outcome creative treatment strategies, outcome can be improved. can be improved.

Outcome Across LifespanOutcome Across Lifespan For persons with severe mental illness, For persons with severe mental illness,

the ideal life trajectory can be viewed the ideal life trajectory can be viewed as a process moving from diminishing as a process moving from diminishing psychopathology and impaired psychopathology and impaired functioning to normalization to positive functioning to normalization to positive health and well-being. health and well-being.

Psychopathology Psychopathology Community Community IntegrationIntegrationSuccessful Successful AgingAging

The initial part of this trajectory may The initial part of this trajectory may be conceptualized as be conceptualized as “recovery,”“recovery,” whereas the latter part may be whereas the latter part may be conceptualized as conceptualized as “successful aging.”“successful aging.”

Successful agingSuccessful aging can be viewed as a can be viewed as a state involving the state involving the absence of absence of disability accompanied by high disability accompanied by high physical, cognitive, and social physical, cognitive, and social functioningfunctioning. It is a state that older . It is a state that older adults may aspire towards, but often adults may aspire towards, but often do not achieve. do not achieve.

Even among the general aging Even among the general aging population, only one-fifth attain population, only one-fifth attain “successful aging.” However, among “successful aging.” However, among persons with schizophrenia, only about persons with schizophrenia, only about 1 in 50 persons attain this status.1 in 50 persons attain this status.

Clinical ImplicationsClinical Implications

We now recognize that for many We now recognize that for many persons with schizophrenia, middle persons with schizophrenia, middle and older age is associated with and older age is associated with better outcomes than previously better outcomes than previously believed, and that as some of the believed, and that as some of the more severe symptoms relent, and more severe symptoms relent, and certain social pressures diminish certain social pressures diminish (e.g. need to have full-time work or (e.g. need to have full-time work or marry), it may be an optimal time to marry), it may be an optimal time to make strides toward greater make strides toward greater recovery. recovery.

For older persons with depression, For older persons with depression, complete and permanent recovery is complete and permanent recovery is difficult, and the clinician needs to difficult, and the clinician needs to recognize that depression in later life recognize that depression in later life is often a chronic disorder that is often a chronic disorder that requires more patience and clinical requires more patience and clinical efforts than previously believed. In efforts than previously believed. In some instances depression may be a some instances depression may be a prodrome of dementia or neurological prodrome of dementia or neurological disorders (e.g. Parkinson’s disease)disorders (e.g. Parkinson’s disease)

13. Disorders overlap with 13. Disorders overlap with respect to neuropathology respect to neuropathology

and symptomsand symptoms

We now recognize that many of We now recognize that many of the dementia disorders share the dementia disorders share neuropathology neuropathology

Overlap among Various Dementias

Pure ADPure PD

Pure LBD

AD (often with EPS)(40 -65%), PDD(75%), LBD(60-90%)

Vascular Dementia

•Pure AD and VaD may be rare.

•AD is multifactorial.

•Similar risk factors: cholesterol, APOE4, DM, HTN.

•Vascular pathology may contribute to cholinergic abnormalities in both disorders(cholinesterase inhibitors may help with both).

All have cholinergic deficits in cortex

Pure VaD

depression

movement

disorders

psychosisdementia

Depression with dementia (“pseudodementia”)

Dementia with depression

PD with depression

PDD, LBD, AD with movement sx

PDD, LBD, AD, VaD with psychotic sx

Psychotic depression

Schizophrenia with depression

Schizophrenia with cognitive deficits

Schizophrenia with movement disorders

PDD, LBD, PD+ with cognitive deficits

med conditions & drugs

Many disorders share symptoms

Vascular depression with mild cognitive impairment (MCI)

MCI with depression

Hallucinations:24%Delusions:50%Mood disturbances(depression,tearfulness):29% 

1. Prevalence of Neuropsychiatric Symptoms (i.e., Psychiatric and Behavioral Problems) in AD

Psychoses: about half

About one-quarter

Examples:

2. Hallucinations in PD, 2. Hallucinations in PD, DLB, PDDDLB, PDD

¼ Parkinson’s Disease¼ Parkinson’s Disease ½ Dementia Lewy Body½ Dementia Lewy Body ¾ Parkinson’s Disease Dementia¾ Parkinson’s Disease Dementia

Note: In PD and PDD medications may Note: In PD and PDD medications may contribute to psychotic sxcontribute to psychotic sx

3. Depression and 3. Depression and Parkinson’s DiseaseParkinson’s Disease

In Parkinson’s disease about 40-50% In Parkinson’s disease about 40-50% have depression; about 1/3 have have depression; about 1/3 have anxiety disorderanxiety disorder

Depression precedes motor Depression precedes motor dysfunction in 12 to 37% of PD dysfunction in 12 to 37% of PD patientspatients

Clinical ImplicationsClinical Implications

Because symptoms and Because symptoms and pathology overlap, obtaining pathology overlap, obtaining good histories and conducting good histories and conducting comprehensive evaluations are comprehensive evaluations are necessary to determine the necessary to determine the diagnosis.diagnosis.

Obtaining a good history is criticalObtaining a good history is critical

Psychoses Cognitive Impairment Depression Movement Disorder

Recent Onset Longer duration

Secondary to physical illness or drugs: Delirium Psychoses Depression

Primary Mental Illness: Schizophrenia (bizarre delusions, auditory hallucinations more common, psychoses precedes depression & any movement sx); Delusional disorder (circumscribed delusion; mild hallucinations, depressed mood secondary to delusions)

Psychiatric sx are secondary: Alzheimer’s disease (dementia depression psychoses movement disorders); Lewy Body Dementia ( psychoses and dementia and movement disorder within 1 year) Parkinson’s Disease (movement disorder psychoses dementia

Primary Mental Illness: Depression (mood congruent delusions)

Five “Ds” of Psychiatric Five “Ds” of Psychiatric Disease in Older AdultsDisease in Older Adults

Think of these possibilities and Think of these possibilities and consider course:consider course:

Delirium: Delirium: days to weeksdays to weeks Drugs: Drugs: days to months days to months Disease: Disease: days to months days to months Depression: Depression: weeks to monthsweeks to months Dementia: Dementia: months to yearsmonths to years

14. Mental illness in older age 14. Mental illness in older age is complexis complex

Items 2 through 13 suggest a high Items 2 through 13 suggest a high degree of complexity with respect to degree of complexity with respect to the interaction of age and mental the interaction of age and mental illness. illness.

In later life there is a complex In later life there is a complex interaction between depression, interaction between depression, anxiety, physical illness, cognitive anxiety, physical illness, cognitive impairment, personality factors, and impairment, personality factors, and life stress. life stress.

Although aging is associated with Although aging is associated with a multitude of stressful events, a multitude of stressful events, older adults do not develop more older adults do not develop more psychiatric disturbances. psychiatric disturbances.

For example, the prevalence of For example, the prevalence of major depression is lower in major depression is lower in elderly persons than young and elderly persons than young and middle-aged adults .middle-aged adults .

Many elders have physiological, Many elders have physiological, psychological, and environmental psychological, and environmental resources that modify these resources that modify these processes and avert unfavorable processes and avert unfavorable outcomes.outcomes.

Clinical ImplicationsClinical Implications A good clinician must recognize the A good clinician must recognize the

biopsychosocial factors influencing biopsychosocial factors influencing the mental state. the mental state.

Care of the older adult, each Care of the older adult, each biological, psychological, and social biological, psychological, and social element is likely to be more element is likely to be more complex than in younger adults complex than in younger adults because their longer life has because their longer life has provided more experiences as well provided more experiences as well as more chances for interactions as more chances for interactions among these elements. among these elements.

•Importantly, older adults are Importantly, older adults are

survivorssurvivors,, having outlived many of having outlived many of their original age cohorts, and they have their original age cohorts, and they have strengths that must be recognized along strengths that must be recognized along with any shortcomings.with any shortcomings.

Test yourself on Alzheimer’s disease(AD) Test yourself on Alzheimer’s disease(AD) and dementia—True or False?and dementia—True or False?

1.Memory loss must always be present in dementia1.Memory loss must always be present in dementia

2. Depression is found in about ½ of AD patients2. Depression is found in about ½ of AD patients

3. Dementia is occurs about 5-10% of the elderly 3. Dementia is occurs about 5-10% of the elderly population population

4. Mild cognitive impairment includes memory problems 4. Mild cognitive impairment includes memory problems and functional impairment and functional impairment

5. Plaques and tangles may be found in AD, PD, and LBD5. Plaques and tangles may be found in AD, PD, and LBD

6. Psedodementia is usually not a prodrome of dementia6. Psedodementia is usually not a prodrome of dementia

7. LBD is characterized by visual hallucinations, EPS, and 7. LBD is characterized by visual hallucinations, EPS, and cognitive sxcognitive sx

true

false

true

false

true

false

true

Important : Use these questions to study for examination

Test yourself on depression and anxiety—true Test yourself on depression and anxiety—true or false?or false?

1. About one-fourth to one-third of community elders have syndromal 1. About one-fourth to one-third of community elders have syndromal or subsyndromal depressionor subsyndromal depression

2. Among older adults, the highest rates of DSM depressive 2. Among older adults, the highest rates of DSM depressive disorders are found in the 85+ groupdisorders are found in the 85+ group

3. About ¼ of medically ill persons suffer from depression3. About ¼ of medically ill persons suffer from depression

4. Mortality rates are not greater among post MI pts with depression4. Mortality rates are not greater among post MI pts with depression

5.Social withdrawal is rare among older depressed pts5.Social withdrawal is rare among older depressed pts

6. Vascular depression is associated with apathy6. Vascular depression is associated with apathy

7. Elders with major depression are more likely to show social 7. Elders with major depression are more likely to show social withdrawal withdrawal

8. Elders with major depression are more likely to talk about physical 8. Elders with major depression are more likely to talk about physical symptoms symptoms

9. Anxiety and depression rarely occur together9. Anxiety and depression rarely occur together

10. It is best to use drugs that undergo phase 1 and phase 2 10. It is best to use drugs that undergo phase 1 and phase 2 metabolism in older adultsmetabolism in older adults

11. Anxiety disorders are the most common disorders in elderly 11. Anxiety disorders are the most common disorders in elderly personspersons

true

false

true

false

false

true

true

true

false

false

true

Test yourself on schizophrenia-true or Test yourself on schizophrenia-true or false?false?

1. 1. About ¾ of schizophrenia begins before About ¾ of schizophrenia begins before age 40age 40

2. Compared to early onset cases, persons 2. Compared to early onset cases, persons with late-onset schizophrenia are more with late-onset schizophrenia are more likely to have visual hallucinations, to be likely to have visual hallucinations, to be more paranoid, and to be womenmore paranoid, and to be women

3. Psychotic symptoms generally do not 3. Psychotic symptoms generally do not improve over the life course of improve over the life course of schizophrenic personsschizophrenic persons

true

true

false

Congratulations—you are Congratulations—you are now an expert in now an expert in

geriatric psychiatrygeriatric psychiatry