Women, Aging, and Mental Health
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  • 1. Women, Aging andMental HealthDr Cathy SheaAssociate ProfessorChair, Division of Geriatric PsychiatryUniversity of Ottawa
  • 2. Topics we will cover Demographics of aging Growing older with early onset mental illness Stigma Changes with “normal” aging Late onset mental illness – the three D’s Recovery
  • 3. Demography of AgingThe Baby Boomers are coming!Babies born in 1946 turned 65 in2011. 13% of Canadian population now over65 and will double in by 2041to 23%
  • 4. Demography of Aging There are 147 women for every 100men over age 65 Most older men are married (75-78%)(and therefore have/will have familiarcaregivers when they are ill) Most older women are widowed (52%)
  • 5. If you have a mental illness of earlyonset and live to grow old “normal” biological changes might affect yourtreatment with medication and the expression of sideeffects of that treatment Aging itself makes you vulnerable to develop mentalillness’ particular to old age (maybe in addition to yourearly onset mental illness) Aging itself makes you vulnerable to develop physicalillnesses which affect your mental illness and thetreatment of both Aging itself brings psycho-social issues which affectyour access to care and services
  • 6. The triple whammy for stigma!1. You have a mental illness (any age)2. You are old (so you must be frail/confused!)3. You are a woman (so complain a lot andexpress your emotions easily)All three will affect your ability to obtaindiagnosis, treatment and to access servicesfor physical and mental illnessNote: Quadruple whammy if you are also amember of a visible minority!
  • 7. Mental disorders commonlydiagnosed earlier in life Depression Anxiety Disorders Bipolar Disorder Schizophrenia Substance Use Disorders
  • 8. Mental disorders commonlydiagnosed earlier in life All can be diagnosed for the first time in individuals over 65years of age and are then typically called “late onset” or “latelife” disorders Depression: 10-15 % of community dwelling elderly havesignificant depressive symptoms. Rates are higher in hospitalsand long term care facilities. Female gender is a major riskfactor Bipolar Disorder: M=F in late onset Schizophrenia: 3% diagnosed after age 70, mostly women Substance use disorders: 1.5% alcohol abuse in olderwomen. Problem drinking however can be as high as 27%.
  • 9. What happens to uswith “normal” aging?And why does it matter?
  • 10. Physiologic changes with normalaging Cardio-vascular changes (meds & dementia) Increased blood pressure (noradrenergic (antidepressant) drugs canworsen) Increased susceptibility to develop heart failure if heart rate is increased(e.g. by certain drugs with anti-cholinergic properties) Increased (cumulative) vascular risk factors for dementia Endocrine changes (metabolic complications) Increased insulin resistance Menopausal changes
  • 11. Physiologic changes with normalaging Respiratory (lung) changes Decreased vital capacity and decreased forced expiratory volume (can beimproved by aerobic exercise training) Decreased pulmonary defense mechanisms & increased risk forpneumonia (e.g. depressed patients who stay in bed) Gastro Intestinal changes Gum retraction + increased risk to lose teeth (ECT consideration) Decreased acid secretion in stomach + decreased intrinsic factor(increased risk of B12 deficiency) Decreased absorption of calcium, osteoporosis (fractured bones with fallsfrom poor balance)
  • 12. Pharmacokinetic changes with normal aging(What the body does to the medications) Absorption Distribution * Protein binding Metabolism * Renal (kidney) clearance *
  • 13. Drug distribution changes withnormal aging Aging results in an increased fat over muscle ratio:So for fat soluble drugs in an aging body: increased distribution volume of drug decreased initial blood levels of drug increased risk of accumulation of drug Aging result in a decrease in total body water:So for water soluble drugs in an aging body: decreased distribution volume of drug increased blood levels of drug
  • 14. Drug Metabolism with normal aging Decreased liver mass and blood flow Decreased de-methylation and decreasedhydroxylation Decreased rate of elimination = increased levelsof the drug
  • 15. Renal (kidney) clearance of drugs withnormal aging Decreased glomerular filtration rate, tubularsecretion and decreased renal blood flow Decreases clearance of drugs eliminated by thekidney = increased levels of these drugs (eglithium)
  • 16. Brain changes with normal aging: Neuronal loss (<1% per year after age 60) Greater neuronal loss or loss of connections in: frontal/prefrontal cortex (executive function) hippocampus (memory) locus ceruleus (sleep) substantia nigra (gait) olfactory bulbs (smell / taste)
  • 17. Neuro-imaging in normal aging C.T. brain scan: shrinkage/atrophy (increased CSF space/decreased brain volume) M.R.I scan: Shrinkage/atrophy decreased gray-white density up to 30% white matter abnormalities ?
  • 18. Other changes with “normal” aging thataffect older patients Decline in mineralization of bones (8-10% per year forpost-menopausal women = fracture with falls) Impaired postural reflexes and increased sway, poorbalance (falls from side effects of prescription meds orOTC drugs) Hearing loss in up to 60% over age 70 ( may appear tobe cognitive problems) Decreased perception of acute pain
  • 19. So what about the woman withmental illness who is aging? Expect to lower doses of psychiatric meds toreduce side effects/obtain same treatment effectas when this woman was younger Expect medical conditions might be caused byor worsened by psychiatric meds (metabolicsyndromes, parkinsonism, postural hypotension(low BP), falls and fractures) New onset of confusion is not “normal” aging –increasing risk of developing dementia as weage, increasing risk of delirium from medicationsand medical problems
  • 20. Frequent Problems / Common Stressesof Aging for all Women: Dealing with death and loss of family/friends Retirement from work and other active roles Housing & relocation (planned or unplanned) Medical illness/physical disability/functionaldecline Changes in family relationships Caregiver role (whether wanted or not)
  • 21. Caregiver role Our health care system depends on unpaidcaregivers Most caregivers of elderly disabled individualsare women (wives, daughters, daughters-in-law,sisters, sisters-in-law, nieces) Many are themselves elderly Caregivers of elderly individuals with mentaland/or physical disorders are twice as likely todevelop depression
  • 22. Additional frequent problems/common stresses for older womenwith mental illness Poverty Social isolation Lack of transportation Exclusion from criteria for home care services Multiple medications with complex instructions Triaged with a “different lens” in ER andprimary care settings
  • 23. Late Onset MentalDisorders
  • 24. Dementia / Delirium /DepressionThe 3 D’s of Geriatric Psychiatry Dementia: A condition of acquired cognitive deficits,sufficient to interfere with functioning, in a personwithout depression (pseudo-dementia) or delirium Delirium: An acute, potentially reversible, conditioncharacterized by fluctuating attention & level ofconsciousness, disorientation, disorganized thinking,disrupted sleep/wake cycle Depression: Alteration in usual mood with sadness,despair, lack of enjoyment in previously enjoyedactivities and vegetative symptoms sufficient tointerfere with functioning
  • 25. Common psychiatric disordersin those over 65 years old Dementia: estimates are that 8% ofpopulation over 65 and 30% over 85 isaffected by dementia. Delirium: approx. 30% of general in-pts inmedicine and rehab. More frequent inneurology and common after surgery,especially orthopedic procedures.
  • 26. Psychiatric disorders often co-exist in the elderly Dementia is often complicated by delirium,depression, anxiety and psychoticsymptoms (hallucinations and delusions) Late onset depression is associated withhigh risk of developing dementia. Anxiety symptoms common in earlydementia, depression, substance usewithdrawal…
  • 27. Medical problems often co-occurin elderly with mental illness Medical problems can mimic psychiatric illness (e.g.Parkinson disease); cause or precipitate psychiatricillnesses (thyroid, strokes causing depression or mania)or cause anxiety or depressive symptoms. Medication for medical problems may interact withpsychiatric drugs or can cause depression, delirium. Psychiatric drugs can worsen some medical problems(BP problems, weight gain, blood sugars, falls andfractures, confusion, visual problems, urinary retention)
  • 28. Dementia Dementia: A condition of acquired cognitivedeficits, sufficient to interfere with functioning,in a person without depression (pseudo-dementia) or delirium Cognitive deficits: can be a decline comparedto previous levels in language, executivefunction, memory, orientation, visuo-spatialabilities etc.
  • 29. Dementia is Common2.411.134.50510152025303565-74 75-84 85+% Prevalence Age related risk: > 65: Overall: Incidence: 2 % Prevalence: 8 % Prevalence doubles every ~5years An intervention that woulddelay onset by 5 years woulddecrease prevalence by 50% Females>MalesLindsay et al. Can J Psychiatry 2004;49:83-91. CSHA CMAJ 1994;150: 899-913; CSHA. Neurology 2000; 55: 66-73
  • 30. Warning signs of Dementia10 Warning Signs forCaregivers* Difficulty performingfamiliar tasks Problems with language Disorientation to time andplace Poor or decreased judgment Problems with abstractthinking Misplacing things Changes in mood andbehaviour Changes in personality Loss of initiative Memory loss that affectsday-to-day functionBehavioural Flags for HealthCare Professionals Frequent phone calls Poor historian, vague Poor compliance: meds/instructions Change in Appearance /hygiene / makeup Word finding / decreasedinteraction Appointments - missing /wrong day Confusion: surgery, meds Weight loss / dwindles Driving: accident / problems “Head turning sign”
  • 31. How many drivers havedementia?01000020000300004000050000600007000080000900001000001986 2000 202865+80+ Combined OntarioMinistry ofTransportation datawith census data anddementia prevalencedata to give “bestestimate” ofproportion of driverswith dementia F > MHopkins et al. Can J Psychiatry 2004
  • 32. Delirium Delirium: An acute, potentially reversible,condition characterized by fluctuating attention& level of consciousness, disorientation,disorganized thinking, disrupted sleep/wakecycle
  • 33. Delirium Recognition Low rate of recognition by health careprofessionals – why? Hospitals are organized around “one-thing-wrong-at-once” principle and delirious patients are complex Patient is often unable to give a history (a sensitivebut non-specific marker!) so viewed asuncooperative, demented or a “poor historian” Assumptions are made about “usual” functioning Frequent falls are not recognized as possibleimportant marker
  • 34. Delirium – So What? Patients with delirium have:- prolonged length of stay in hospital- worse functional outcomes- higher rates of nursing home placement- increased risk of permanent cognitive decline- higher death rates- worse rehabilitation outcomes Delayed recognition → worse outcomes
  • 35. Late life depression Depression: Alteration in usual mood withsadness or negative mood state (anger,irritability, despair), lack of enjoyment inpreviously enjoyed activities and vegetativesymptoms sufficient to interfere withfunctioning
  • 36. Late Life Depression Common (but often undiagnosed) Costly Debilitating Potentially lethal Aging baby boomers are expected to havehigher rates than the current elderly cohort
  • 37. Late Life Depression View late life depression as a sentinel eventthat substantially increases the risk fordecline in general health and function Frequently heralding the onset of cognitivedecline/dementia
  • 38. Risk factors for late lifedepression FEMALE Major life events such as widowed ordivorced Structural brain changes Peripheral body changes such as major physicalor chronic debilitating illness
  • 39. Risk Factors for late lifedepression Previous history of depression Caregiver for person with dementia orother debilitating medical condition Excessive alcohol consumption Taking medications, such as centrallyacting BP meds, analgesics, steroids,antiparkinsons, benzodiazepines
  • 40. Mood Disorder due to MedicalCondition: common in late life Stroke induced depression or mania Depression associated with Parkinsons disease Depression or mania due to endocrine disorders(thyroid, adrenal) Depression due to infectious illnesses Substance-induced depressive or manic syndromes(alcohol, benzo) Depression and cognitive problems due to sleep apnea
  • 41. Use of Health Care Services inDepressed Elderly Twice the number of medical appointments Increased number of medications taken Twice the length of stay in hospital In Nursing homes: Increased nursing time
  • 42. Suicide rates in Canada Highest rates for men: 20-24 age group and 80-84 age group (30/100,000) 85+ highest with 35/100,000 Highest rates for women: 45-49 age group (9/100,000) Ratio of attempts: completed suicide after 65 muchlower than younger adult 2:1 men; 4:1 women.
  • 43. Improving recognition of late lifedepression Clinician factors Incorrectly attribute depressive symptoms to theaging process (“I’d be depressed too!”) More focus on concurrent medical conditions Time pressures/fee-for-service payment Problems in integration of mental health andprimary care systems
  • 44. Improving recognition of late lifedepression Patient factors Stigma (patient and caregivers) Ageism (patient and caregivers) Misinformation More comfortable to report physical symptoms Dementia may color the picture
  • 45. Treatment and recovery/well being Possible for all (early and late onset) mentaldisorders for elderly women Many recent best practice guidelines to focus onmental disorders in the elderly Recent enhancement of training/education forgeneral psychiatrists, primary care physicians New Royal College official subspecialty inGeriatric Psychiatry
  • 46. Treatment and recovery/well being Medication can be an important part oftreatment/recovery Psychotherapies can be an important part oftreatment/recovery ECT can be an important part of treatment/recovery Physical exercise, healthy diet, stable housing, stablefinances, spiritual well being, social connections,laughter, brain exercise are all important parts ofrecovery and well being
  • 47. Take Home Messages Growing old with mental illness is not for sissies !! Early onset mental illness requires a fresh perspectiveby health care professionals as women grow older Late onset mental illness can be complex Prevention, early identification, treatment and follow-up are key to recovery/well being Mental health services for the elderly can befragmented, lack availability and are plagued by stigmabut improvements are happening!
  • 48. Thank youAny questions?