Women, Aging and Mental Health


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By Dr. Cathy Shea, Associate Professor, Chair, Division of Geriatric Psychiatry, University of Ottawa

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Women, Aging and Mental Health

  1. 1. Women, Aging and Mental Health Dr Cathy Shea Associate Professor Chair, Division of Geriatric Psychiatry University of Ottawa
  2. 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. 3. Demography of Aging  The Baby Boomers are coming!  Babies born in 1946 turned 65 in 2011.  13% of Canadian population now over 65 and will double in by 2041to 23%
  4. 4. Demography of Aging  There are 147 women for every 100 men over age 65  Most older men are married (75-78%) (and therefore have/will have familiar caregivers when they are ill)  Most older women are widowed (52%)
  5. 5. If you have a mental illness of early onset and live to grow old     “normal” biological changes might affect your treatment with medication and the expression of side effects of that treatment Aging itself makes you vulnerable to develop mental illness’ particular to old age (maybe in addition to your early onset mental illness) Aging itself makes you vulnerable to develop physical illnesses which affect your mental illness and the treatment of both Aging itself brings psycho-social issues which affect your access to care and services
  6. 6. The triple whammy for stigma! 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! 1.
  7. 7. Mental disorders commonly diagnosed earlier in life      Depression Anxiety Disorders Bipolar Disorder Schizophrenia Substance Use Disorders
  8. 8. Mental disorders commonly diagnosed earlier in life All can be diagnosed for the first time in individuals over 65 years of age and are then typically called “late onset” or “late life” disorders  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  Bipolar Disorder: M=F in late onset    Schizophrenia: 3% diagnosed after age 70, mostly women Substance use disorders: 1.5% alcohol abuse in older women. Problem drinking however can be as high as 27%.
  9. 9. What happens to us with “normal” aging? And why does it matter?
  10. 10. Physiologic changes with normal aging  Cardio-vascular changes (meds & dementia)     Increased blood pressure (noradrenergic (antidepressant) drugs can worsen) 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. 11. Physiologic changes with normal aging  Respiratory (lung) changes    Decreased vital capacity and decreased forced expiratory volume (can be improved by aerobic exercise training) Decreased pulmonary defense mechanisms & increased risk for pneumonia (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 falls from poor balance)
  12. 12. Pharmacokinetic changes with normal aging (What the body does to the medications)      Absorption Distribution * Protein binding Metabolism * Renal (kidney) clearance *
  13. 13. Drug distribution changes with normal 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. 14. Drug Metabolism with normal aging    Decreased liver mass and blood flow Decreased de-methylation and decreased hydroxylation Decreased rate of elimination = increased levels of the drug
  15. 15. Renal (kidney) clearance of drugs with normal aging   Decreased glomerular filtration rate, tubular secretion and decreased renal blood flow Decreases clearance of drugs eliminated by the kidney = increased levels of these drugs (eg lithium)
  16. 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. 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. 18. Other changes with “normal” aging that affect older patients     Decline in mineralization of bones (8-10% per year for post-menopausal women = fracture with falls) Impaired postural reflexes and increased sway, poor balance (falls from side effects of prescription meds or OTC drugs) Hearing loss in up to 60% over age 70 ( may appear to be cognitive problems) Decreased perception of acute pain
  19. 19. So what about the woman with mental illness who is aging?    Expect to lower doses of psychiatric meds to reduce side effects/obtain same treatment effect as when this woman was younger Expect medical conditions might be caused by or worsened by psychiatric meds (metabolic syndromes, parkinsonism, postural hypotension (low BP), falls and fractures) New onset of confusion is not “normal” aging – increasing risk of developing dementia as we age, increasing risk of delirium from medications and medical problems
  20. 20. Frequent Problems / Common Stresses of 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/functional decline Changes in family relationships Caregiver role (whether wanted or not)
  21. 21. Caregiver role  Our health care system depends on unpaid    caregivers Most caregivers of elderly disabled individuals are women (wives, daughters, daughters-in-law, sisters, sisters-in-law, nieces) Many are themselves elderly Caregivers of elderly individuals with mental and/or physical disorders are twice as likely to develop depression
  22. 22. Additional frequent problems /common stresses for older women with 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 and primary care settings
  23. 23. Late Onset Mental Disorders
  24. 24. Dementia / Delirium /Depression The 3 D’s of Geriatric Psychiatry    Dementia: A condition of acquired cognitive deficits, sufficient to interfere with functioning, in a person without depression (pseudo-dementia) or delirium Delirium: An acute, potentially reversible, condition characterized by fluctuating attention & level of consciousness, disorientation, disorganized thinking, disrupted sleep/wake cycle Depression: Alteration in usual mood with sadness, despair, lack of enjoyment in previously enjoyed activities and vegetative symptoms sufficient to interfere with functioning
  25. 25. Common psychiatric disorders in those over 65 years old Dementia: estimates are that 8% of population over 65 and 30% over 85 is affected by dementia.  Delirium: approx. 30% of general in-pts in medicine and rehab. More frequent in neurology and common after surgery, especially orthopedic procedures. 
  26. 26. Psychiatric disorders often coexist in the elderly Dementia is often complicated by delirium, depression, anxiety and psychotic symptoms (hallucinations and delusions)  Late onset depression is associated with high risk of developing dementia.  Anxiety symptoms common in early dementia, depression, substance use withdrawal… 
  27. 27. Medical problems often co-occur in elderly with mental illness    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. Medication for medical problems may interact with psychiatric drugs or can cause depression, delirium. Psychiatric drugs can worsen some medical problems (BP problems, weight gain, blood sugars, falls and fractures, confusion, visual problems, urinary retention)
  28. 28. Dementia   Dementia: A condition of acquired cognitive deficits, sufficient to interfere with functioning, in a person without depression (pseudodementia) or delirium Cognitive deficits: can be a decline compared to previous levels in language, executive function, memory, orientation, visuo-spatial abilities etc.
  29. 29. Dementia is Common  % Prevalence  > 65: Overall:  35 30   34.5 25 20 15 10 5 0 Age related risk:  2.4 65-74 11.1 75-84 85+  Lindsay et al. Can J Psychiatry 2004;49:83-91. CSHA CMAJ 1994; 150: 899-913; CSHA. Neurology 2000; 55: 66-73 Incidence: 2 % Prevalence: 8 % Prevalence doubles every ~5 years An intervention that would delay onset by 5 years would decrease prevalence by 50% Females>Males
  30. 30. Warning signs of Dementia 10 Warning Signs for Caregivers*           Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood and behaviour Changes in personality Loss of initiative Memory loss that affects day-to-day function Behavioural Flags for Health Care Professionals           Frequent phone calls Poor historian, vague Poor compliance: meds /instructions Change in Appearance / hygiene / makeup Word finding / decreased interaction Appointments - missing / wrong day Confusion: surgery, meds Weight loss / dwindles Driving: accident / problems “Head turning sign”
  31. 31. How many drivers have dementia? 100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 0  65+ 80+ 1986 2000 2028 Hopkins et al. Can J Psychiatry 2004  Combined Ontario Ministry of Transportation data with census data and dementia prevalence data to give “best estimate” of proportion of drivers with dementia F>M
  32. 32. Delirium  Delirium: An acute, potentially reversible, condition characterized by fluctuating attention & level of consciousness, disorientation, disorganized thinking, disrupted sleep/wake cycle
  33. 33. Delirium Recognition  Low rate of recognition by health care professionals – why? Hospitals are organized around “one-thing-wrongat-once” principle and delirious patients are complex  Patient is often unable to give a history (a sensitive but non-specific marker!) so viewed as uncooperative, demented or a “poor historian”  Assumptions are made about “usual” functioning  Frequent falls are not recognized as possible important marker 
  34. 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. 35. Late life depression  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
  36. 36. Late Life Depression      Common (but often undiagnosed) Costly Debilitating Potentially lethal Aging baby boomers are expected to have higher rates than the current elderly cohort
  37. 37. Late Life Depression View late life depression as a sentinel event that substantially increases the risk for decline in general health and function  Frequently heralding the onset of cognitive decline/dementia 
  38. 38. Risk factors for late life depression  FEMALE  Major life events such as widowed or divorced  Structural brain changes  Peripheral body changes such as major physical or chronic debilitating illness
  39. 39. Risk Factors for late life depression Previous history of depression  Caregiver for person with dementia or other debilitating medical condition  Excessive alcohol consumption  Taking medications, such as centrally acting BP meds, analgesics, steroids, antiparkinsons, benzodiazepines 
  40. 40. Mood Disorder due to Medical Condition: common in late life       Stroke induced depression or mania Depression associated with Parkinson's 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. 41. Use of Health Care Services in Depressed 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. 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 much lower than younger adult  2:1 men; 4:1 women.
  43. 43. Improving recognition of late life depression  Clinician factors Incorrectly attribute depressive symptoms to the aging process (“I’d be depressed too!”)  More focus on concurrent medical conditions  Time pressures/fee-for-service payment  Problems in integration of mental health and primary care systems 
  44. 44. Improving recognition of late life depression  Patient factors Stigma (patient and caregivers)  Ageism (patient and caregivers)  Misinformation  More comfortable to report physical symptoms  Dementia may color the picture 
  45. 45. Treatment and recovery/well being     Possible for all (early and late onset) mental disorders for elderly women Many recent best practice guidelines to focus on mental disorders in the elderly Recent enhancement of training/education for general psychiatrists, primary care physicians New Royal College official subspecialty in Geriatric Psychiatry
  46. 46. Treatment and recovery/well being     Medication can be an important part of treatment/recovery Psychotherapies can be an important part of treatment/recovery ECT can be an important part of treatment/recovery 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
  47. 47. Take Home Messages  Growing old with mental illness is not for sissies !!     Early onset mental illness requires a fresh perspective by health care professionals as women grow older Late onset mental illness can be complex Prevention, early identification, treatment and followup are key to recovery/well being Mental health services for the elderly can be fragmented, lack availability and are plagued by stigma but improvements are happening!
  48. 48. Thank you Any questions?