Women, Aging andMental HealthDr Cathy SheaAssociate ProfessorChair, Division of Geriatric PsychiatryUniversity of Ottawa
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
Demography of AgingThe Baby Boomers are coming!Babies born in 1946 turned 65 in2011. 13% of Canadian population now over65 and will double in by 2041to 23%
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%)
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
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!
Mental disorders commonlydiagnosed earlier in life Depression Anxiety Disorders Bipolar Disorder Schizophrenia Substance Use Disorders
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%.
What happens to uswith “normal” aging?And why does it matter?
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
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)
Pharmacokinetic changes with normal aging(What the body does to the medications) Absorption Distribution * Protein binding Metabolism * Renal (kidney) clearance *
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
Drug Metabolism with normal aging Decreased liver mass and blood flow Decreased de-methylation and decreasedhydroxylation Decreased rate of elimination = increased levelsof the drug
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)
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)
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 ?
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
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
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)
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
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
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
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.
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…
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)
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.
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
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”
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
Delirium Delirium: An acute, potentially reversible,condition characterized by fluctuating attention& level of consciousness, disorientation,disorganized thinking, disrupted sleep/wakecycle
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
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
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
Late Life Depression Common (but often undiagnosed) Costly Debilitating Potentially lethal Aging baby boomers are expected to havehigher rates than the current elderly cohort
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
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
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
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
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
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.
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
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
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
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
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!