Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
Â
Women, Aging, and Mental Health
1. Women, Aging and
Mental Health
Dr Cathy Shea
Associate Professor
Chair, Division of Geriatric Psychiatry
University of Ottawa
2. Topics we will cover
īŽ Demographics of aging
īŽ Growing older with early onset mental illness
īŽ Stigma
īŽ Changes with ânormalâ aging
īŽ Late onset mental illness â the three Dâs
īŽ Recovery
3.
4. Demography of Aging
īŽThe Baby Boomers are coming!
īŽBabies born in 1946 turned 65 in
2011.
īŽ 13% of Canadian population now over
65 and will double in by 2041to 23%
5. Demography of Aging
ī§ There are 147 women for every 100
men over age 65
īŽ Most older men are married (75-78%)
(and therefore have/will have familiar
caregivers when they are ill)
īŽ Most older women are widowed (52%)
6. If you have a mental illness of early
onset and live to grow old
īŽ ânormalâ biological changes might affect your
treatment with medication and the expression of side
effects of that treatment
īŽ Aging itself makes you vulnerable to develop mental
illnessâ particular to old age (maybe in addition to your
early onset mental illness)
īŽ Aging itself makes you vulnerable to develop physical
illnesses which affect your mental illness and the
treatment of both
īŽ Aging itself brings psycho-social issues which affect
your access to care and services
7. 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 and
express your emotions easily)
All three will affect your ability to obtain
diagnosis, treatment and to access services
for physical and mental illness
Note: Quadruple whammy if you are also a
member of a visible minority!
8. Mental disorders commonly
diagnosed earlier in life
īŽ Depression
īŽ Anxiety Disorders
īŽ Bipolar Disorder
īŽ Schizophrenia
īŽ Substance Use Disorders
9. Mental disorders commonly
diagnosed earlier in life
īŽ All can be diagnosed for the first time in individuals over 65
years of age and are then typically called âlate onsetâ or âlate
lifeâ disorders
īŽ Depression: 10-15 % of community dwelling elderly have
significant depressive symptoms. Rates are higher in hospitals
and long term care facilities. Female gender is a major risk
factor
īŽ Bipolar Disorder: M=F in late onset
īŽ Schizophrenia: 3% diagnosed after age 70, mostly women
īŽ Substance use disorders: 1.5% alcohol abuse in older
women. Problem drinking however can be as high as 27%.
10. What happens to us
with ânormalâ aging?
And why does it matter?
11.
12. Physiologic changes with normal
aging
īŽ Cardio-vascular changes (meds & dementia)
īŽ Increased blood pressure (noradrenergic (antidepressant) drugs can
worsen)
īŽ Increased susceptibility to develop heart failure if heart rate is increased
(e.g. by certain drugs with anti-cholinergic properties)
īŽ Increased (cumulative) vascular risk factors for dementia
īŽ Endocrine changes (metabolic complications)
īŽ Increased insulin resistance
īŽ Menopausal changes
13. Physiologic changes with normal
aging
īŽ Respiratory (lung) changes
īŽ Decreased vital capacity and decreased forced expiratory volume (can be
improved by aerobic exercise training)
īŽ Decreased pulmonary defense mechanisms & increased risk for
pneumonia (e.g. depressed patients who stay in bed)
īŽ Gastro Intestinal changes
īŽ Gum retraction + increased risk to lose teeth (ECT consideration)
īŽ Decreased acid secretion in stomach + decreased intrinsic factor
(increased risk of B12 deficiency)
īŽ Decreased absorption of calcium, osteoporosis (fractured bones with falls
from poor balance)
14. Pharmacokinetic changes with normal aging
(What the body does to the medications)
īŽ Absorption
īŽ Distribution *
īŽ Protein binding
īŽ Metabolism *
īŽ Renal (kidney) clearance *
15. Drug distribution changes with
normal aging
ī§ Aging results in an increased fat over muscle ratio:
So for fat soluble drugs in an aging body:
īŽ increased distribution volume of drug
īŽ decreased initial blood levels of drug
īŽ increased risk of accumulation of drug
īŽ Aging result in a decrease in total body water:
So for water soluble drugs in an aging body:
īŽ decreased distribution volume of drug
īŽ increased blood levels of drug
16. Drug Metabolism with normal aging
īŽ Decreased liver mass and blood flow
īŽ Decreased de-methylation and decreased
hydroxylation
īŽ Decreased rate of elimination = increased levels
of the drug
17. Renal (kidney) clearance of drugs with
normal aging
īŽ Decreased glomerular filtration rate, tubular
secretion and decreased renal blood flow
īŽ Decreases clearance of drugs eliminated by the
kidney = increased levels of these drugs (eg
lithium)
18. Brain changes with normal aging:
īŽ Neuronal loss (<1% per year after age 60)
īŽ Greater neuronal loss or loss of connections in:
īŽ frontal/prefrontal cortex (executive function)
īŽ hippocampus (memory)
īŽ locus ceruleus (sleep)
īŽ substantia nigra (gait)
īŽ olfactory bulbs (smell / taste)
19. Neuro-imaging in normal aging
īŽ C.T. brain scan:
īŽ shrinkage/atrophy
īŽ (increased CSF space/decreased brain volume)
īŽ M.R.I scan:
īŽ Shrinkage/atrophy
īŽ decreased gray-white density
īŽ up to 30% white matter abnormalities ?
20. Other changes with ânormalâ aging that
affect older patients
īŽ Decline in mineralization of bones (8-10% per year for
post-menopausal women = fracture with falls)
īŽ Impaired postural reflexes and increased sway, poor
balance (falls from side effects of prescription meds or
OTC drugs)
īŽ Hearing loss in up to 60% over age 70 ( may appear to
be cognitive problems)
īŽ Decreased perception of acute pain
21. So what about the woman with
mental illness who is aging?
īŽ Expect to lower doses of psychiatric meds to
reduce side effects/obtain same treatment effect
as when this woman was younger
īŽ Expect medical conditions might be caused by
or worsened by psychiatric meds (metabolic
syndromes, parkinsonism, postural hypotension
(low BP), falls and fractures)
īŽ New onset of confusion is not ânormalâ aging â
increasing risk of developing dementia as we
age, increasing risk of delirium from medications
and medical problems
22. Frequent Problems / Common Stresses
of Aging for all Women:
īŽ Dealing with death and loss of family/friends
īŽ Retirement from work and other active roles
īŽ Housing & relocation (planned or unplanned)
īŽ Medical illness/physical disability/functional
decline
īŽ Changes in family relationships
īŽ Caregiver role (whether wanted or not)
23. Caregiver role
ī§ Our health care system depends on unpaid
caregivers
īŽ Most caregivers of elderly disabled individuals
are women (wives, daughters, daughters-in-law,
sisters, sisters-in-law, nieces)
īŽ Many are themselves elderly
īŽ Caregivers of elderly individuals with mental
and/or physical disorders are twice as likely to
develop depression
24.
25. Additional frequent problems
/common stresses for older women
with mental illness
īŽ Poverty
īŽ Social isolation
īŽ Lack of transportation
īŽ Exclusion from criteria for home care services
īŽ Multiple medications with complex instructions
īŽ Triaged with a âdifferent lensâ in ER and
primary care settings
27. Dementia / Delirium /Depression
The 3 Dâs of Geriatric Psychiatry
īŽ Dementia: A condition of acquired cognitive deficits,
sufficient to interfere with functioning, in a person
without depression (pseudo-dementia) or delirium
īŽ Delirium: An acute, potentially reversible, condition
characterized by fluctuating attention & level of
consciousness, disorientation, disorganized thinking,
disrupted sleep/wake cycle
īŽ Depression: Alteration in usual mood with sadness,
despair, lack of enjoyment in previously enjoyed
activities and vegetative symptoms sufficient to
interfere with functioning
28. Common psychiatric disorders
in those over 65 years old
īŽ Dementia: estimates are that 8% of
population over 65 and 30% over 85 is
affected by dementia.
īŽ Delirium: approx. 30% of general in-pts in
medicine and rehab. More frequent in
neurology and common after surgery,
especially orthopedic procedures.
29. Psychiatric disorders often co-
exist in the elderly
īŽ Dementia is often complicated by delirium,
depression, anxiety and psychotic
symptoms (hallucinations and delusions)
īŽ Late onset depression is associated with
high risk of developing dementia.
īŽ Anxiety symptoms common in early
dementia, depression, substance use
withdrawalâĻ
30. Medical problems often co-occur
in elderly with mental illness
īŽ Medical problems can mimic psychiatric illness (e.g.
Parkinson disease); cause or precipitate psychiatric
illnesses (thyroid, strokes causing depression or mania)
or cause anxiety or depressive symptoms.
īŽ Medication for medical problems may interact with
psychiatric drugs or can cause depression, delirium.
īŽ Psychiatric drugs can worsen some medical problems
(BP problems, weight gain, blood sugars, falls and
fractures, confusion, visual problems, urinary retention)
31. Dementia
īŽ Dementia: A condition of acquired cognitive
deficits, sufficient to interfere with functioning,
in a person without depression (pseudo-
dementia) or delirium
īŽ Cognitive deficits: can be a decline compared
to previous levels in language, executive
function, memory, orientation, visuo-spatial
abilities etc.
32. Dementia is Common
2.4
11.1
34.5
0
5
10
15
20
25
30
35
65-74 75-84 85+
% Prevalence
īŽ Age related risk:
īŽ > 65: Overall:
īŽ Incidence: 2 %
īŽ Prevalence: 8 %
īŽ Prevalence doubles every ~5
years
īŽ An intervention that would
delay onset by 5 years would
decrease prevalence by 50%
īŽ Females>Males
Lindsay et al. Can J Psychiatry 2004;49:83-91. CSHA CMAJ 1994;
150: 899-913; CSHA. Neurology 2000; 55: 66-73
33. Warning signs of Dementia
10 Warning Signs for
Caregivers*
īŽ Difficulty performing
familiar tasks
īŽ Problems with language
īŽ Disorientation to time and
place
īŽ Poor or decreased judgment
īŽ Problems with abstract
thinking
īŽ Misplacing things
īŽ Changes in mood and
behaviour
īŽ Changes in personality
īŽ Loss of initiative
īŽ Memory loss that affects
day-to-day function
Behavioural Flags for Health
Care Professionals
īŽ Frequent phone calls
īŽ Poor historian, vague
īŽ Poor compliance: meds
/instructions
īŽ Change in Appearance /
hygiene / makeup
īŽ Word finding / decreased
interaction
īŽ Appointments - missing /
wrong day
īŽ Confusion: surgery, meds
īŽ Weight loss / dwindles
īŽ Driving: accident / problems
īŽ âHead turning signâ
34. How many drivers have
dementia?
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1986 2000 2028
65+
80+
īŽ Combined Ontario
Ministry of
Transportation data
with census data and
dementia prevalence
data to give âbest
estimateâ of
proportion of drivers
with dementia
īŽ F > M
Hopkins et al. Can J Psychiatry 2004
35. Delirium
īŽ Delirium: An acute, potentially reversible,
condition characterized by fluctuating attention
& level of consciousness, disorientation,
disorganized thinking, disrupted sleep/wake
cycle
36. Delirium Recognition
īŽ Low rate of recognition by health care
professionals â why?
īŽ Hospitals are organized around âone-thing-wrong-
at-onceâ principle and delirious patients are complex
īŽ Patient is often unable to give a history (a sensitive
but non-specific marker!) so viewed as
uncooperative, demented or a âpoor historianâ
īŽ Assumptions are made about âusualâ functioning
īŽ Frequent falls are not recognized as possible
important marker
37. Delirium â So What?
īŽ 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
īŽ Delayed recognition â worse outcomes
38. Late life depression
īŽ Depression: Alteration in usual mood with
sadness or negative mood state (anger,
irritability, despair), lack of enjoyment in
previously enjoyed activities and vegetative
symptoms sufficient to interfere with
functioning
39. Late Life Depression
īŽ Common (but often undiagnosed)
īŽ Costly
īŽ Debilitating
īŽ Potentially lethal
īŽ Aging baby boomers are expected to have
higher rates than the current elderly cohort
40. Late Life Depression
īŽ View late life depression as a sentinel event
that substantially increases the risk for
decline in general health and function
īŽ Frequently heralding the onset of cognitive
decline/dementia
41. Risk factors for late life
depression
ī§ FEMALE
īŽ Major life events such as widowed or
divorced
īŽ Structural brain changes
īŽ Peripheral body changes such as major physical
or chronic debilitating illness
42. Risk Factors for late life
depression
īŽ Previous history of depression
īŽ Caregiver for person with dementia or
other debilitating medical condition
īŽ Excessive alcohol consumption
īŽ Taking medications, such as centrally
acting BP meds, analgesics, steroids,
antiparkinsons, benzodiazepines
43. Mood Disorder due to Medical
Condition: common in late life
ī§ Stroke induced depression or mania
ī§ Depression associated with Parkinson's disease
ī§ Depression or mania due to endocrine disorders
(thyroid, adrenal)
ī§ Depression due to infectious illnesses
ī§ Substance-induced depressive or manic syndromes
(alcohol, benzo)
ī§ Depression and cognitive problems due to sleep apnea
44. Use of Health Care Services in
Depressed Elderly
īŽ Twice the number of medical appointments
īŽ Increased number of medications taken
īŽ Twice the length of stay in hospital
īŽ In Nursing homes:
īŽ Increased nursing time
45. Suicide rates in Canada
īŽ Highest rates for men:
īŽ 20-24 age group and 80-84 age group (30/100,000)
īŽ 85+ highest with 35/100,000
īŽ Highest rates for women:
īŽ 45-49 age group (9/100,000)
īŽ Ratio of attempts: completed suicide after 65 much
lower than younger adult
īŽ 2:1 men; 4:1 women.
46. Improving recognition of late life
depression
īŽ Clinician factors
īŽ Incorrectly attribute depressive symptoms to the
aging process (âIâd be depressed too!â)
īŽ More focus on concurrent medical conditions
īŽ Time pressures/fee-for-service payment
īŽ Problems in integration of mental health and
primary care systems
47. Improving recognition of late life
depression
īŽ Patient factors
īŽ Stigma (patient and caregivers)
īŽ Ageism (patient and caregivers)
īŽ Misinformation
īŽ More comfortable to report physical symptoms
īŽ Dementia may color the picture
48. Treatment and recovery/well being
īŽ Possible for all (early and late onset) mental
disorders for elderly women
īŽ Many recent best practice guidelines to focus on
mental disorders in the elderly
īŽ Recent enhancement of training/education for
general psychiatrists, primary care physicians
īŽ New Royal College official subspecialty in
Geriatric Psychiatry
49. Treatment and recovery/well being
īŽ Medication can be an important part of
treatment/recovery
īŽ Psychotherapies can be an important part of
treatment/recovery
īŽ ECT can be an important part of treatment/recovery
īŽ Physical exercise, healthy diet, stable housing, stable
finances, spiritual well being, social connections,
laughter, brain exercise are all important parts of
recovery and well being
50. Take Home Messages
ī§ Growing old with mental illness is not for sissies !!
īŽ Early onset mental illness requires a fresh perspective
by health care professionals as women grow older
īŽ Late onset mental illness can be complex
īŽ Prevention, early identification, treatment and follow-
up are key to recovery/well being
īŽ Mental health services for the elderly can be
fragmented, lack availability and are plagued by stigma
but improvements are happening!