Mental health and older people

1. Mental health and older people prepared by hassan abu rahma Supervised by : Dr. Abd Al Kareem Radwan

2. Background and epidemiology • AGEING AND HEALH • Older people mental health prevalence and impact of mental health problems • Prevalence 0f mental disorder 1n relation to demographic factors Inter-relation between physical and mental disorder • Inter-relation between disability and mental disorder • Older hospital setting patient in general • Older people in nursing and residential homes

3. Background and epidemiology • Improved living standard and success in combating many diseases have led to increase life expectancy • industrialized societies people are living healthier and longer than ever before • In the UK between 1971and2003 the number of people over 65 changed 28% and 2002 life expectancy for female 81 years and 76 for male • People aged 85 are fastest rising population • England currently over6000 people over 100 yrs

4. STAGE POPULATION POPULATION STRUCTURE • 1-THE FIRST AGE OF SOCIOLIZATION • 2- SECOND AGE OF WORK AND CHILD-REARING • 2_THIRD AGE POST EMPLOYMENT

5. يشير تقرير إحصائي صادر عن الجهاز المركزي للإحصاء الفلسطيني بمناسبة اليوم العالمي للمسنين تحسن طرأ على أوضاع المسنين الفلسطينيين أدى الى ارتفاع معدلات البقاء على قيد الحياة إلى نحو 5-6 سنوات خلال العقد ونصف العقد الماضيين. • وارتفع عمر المسنين من نحو 67.0 سنة لكل من الذكور والإناث عام 1992 إلى 71.8 سنة للذكور و 73.3 سنة للإناث لعام 2006، وقد أدى ارتفاع  معدل توقع البقاء على قيد الحياة عند الولادة  إلى ارتفاع أعداد كبار السن في الأراضي الفلسطينية.

6. ففي منتصف العام 2009 حسب الإحصاء الفلسطيني، بلغت نسبة كبار السن (الأفراد 60 سنة فأكثر) 4.4% من مجمل السكان في الأراضي الفلسطينية (بواقع 4.9% في الضفة الغربية و3.7% في قطاع غزة)، مع العلم أن نسبة كبار السن في الدول المتقدمة مجتمعة قد بلغت حوالي 16.0% من إجمالي سكان تلك الدول، في حين تبلغ نسبة كبار السن في الدول النامية مجتمعة حوالي 6.0% فقط من إجمالي سكان تلك الدول.

7. AGEING AND Health • Added life to years not just more to life • A growing body of evidence counter the stereotype that ageing is inevitable associated with sickness • The optimistic some of studies factor such as diet, ,marital stability, exercise,education,mental stimulation • And social involvement are associated with longevity a And quality of the life Some study in Sweden for people aged 85.more than three quarters were identified as having high levels of subjective well being measured by high and moderate levels on morale scale

8. The combination of this higher frequency of the physical ill health • And disability with other factor associated with ageing cognitive • Impairment ,socio economic deprivation and social support deficit • This factor increase incidence of commonest metal health problem • Depression, anxiety disorder among oldest old • Trends for increasing proportion of older people in population and having less disability and independent . Depend on continuing social • ,economic ,and health care improvement • Older people live alone without family support structure present a special challenge and need for innovation by health care providers

9. Older people mental health prevalence and impact of mental health problems • Mental disorder are common in general population affecting more than a quarter of all people at some time in their life WHO 2001 • Mental disorder accounted for four of 10 leading cause of the of disability • Point prevalence rate for adult experiencing any mental disorder are 10 % • To 15% • The frequency of mental illness in elderly may be under-reported" make diagnosis in the presence of physical co-morbidity “ • Depressive and anxiety disorder affect between 1-7 people1-10 • Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham 2004} • SOME study in UK lower levels of common mental disorder in aged 60 • And older these community studies are individual living in private house • Exclude people in situation ,temporary hospitalized or homeless • UK 1996 33200 people living in hospital and 350000 older people having care in homes as mental disorder

10. Prevalence 0f mental disorder 1n relation to demographic factors • 1-gender • 1male to2 female • 2-MARITAL STATUS • Marital disruption is consistently associated with higher rate of common mental disorder UK 7%MEN 12%FEMAL divorced status and separation associated mental disorder proportion divorce in Palestine 11.65 % • 3-socio-economic status • problem increase after 29 yrs that effects income ,social class unemployment • ,,financial strain and education status impact by disorder prevalence

11. Inter-relation between physical and mental disorder • Inter-relations between physical and psychological health are evident with in all age however the frequency of negative association –co-morbidity rise with age • The frequency of interaction and severity of its effects are magnified in older • Much research has explored the relationship between depression and cardiac • patient’ compare with non depressed cardiac patient .the mortality rate • threefold increased in cardiac patient have major depression • Epidemiological study has explored the dynamic of the interaction between • Physical illness and mental disorder • Physical illness appear to be an important risk factor for development of • several mental agoraphobia in older people may be commonly precipitated • By stork and falls rather than associated with panic disorder. patient with • Chronic medical illness have increased risk of depressive illness • Older people have vascular disease prescribed medication may make mood disorder

12. Inter-relation between disability and mental disorder study appear disability resulting from physical illness are associated with common mental disorder especially depression The disability arising from physical ill health has been estimated to be Cause of up 70%of new cases of depression in older people Depression cause disability features 1-reduce motivation 2-psychomotorretardation 3- poor sleep 4-lack of energy 5- avoidance and anhedonia Are likely to limit activity and physical disability . They are mutual reinforcement process

13. Older hospital setting patient in general older people occupy tow –third of general hospital beds And exhibit a high prevalence of co-morbid mental disorder Predominantly delirium dementia and depression Level of patient with depression 50% {ames 1994} Co-exist with medical condition especially chronic illness sush as ischemic heart disease ,stroke ,cancer ,chronic lung disease ,Alzheimer's ,and Parkinson disease likely to be prevalent At levels three time in the community

14. Problem affect mental disorder in hospital1-length of stay2- use of resource3- cost of care 4- prognosis the complex range of physical and emotional and social problems are demand high level of skill from care staff and resourcethe recognition of mental problems in physical ill older people is made more difficult by the inter action of illness feature

15. Example depression symptom of anorexia .poor sleeping , and weightloss result from variety of physical condition physical feature such as aches pains fatigue may be aspect of mental disorder should be have screening measure in the hospital to identify mental health problem such as geriatric depression scale

16. Older people in nursing and residential homes • Another setting ishigh prevalence of mental disorderamong older people with absence optimal management • Is residential care • Care home are differentiated on the basis of whether they provide personal and social car • Research indicate that new admissions to all types of care homes in the UK increasingly old • Residents are more disabled than previously with higher level of cognitive impairment • Prevalence level of dementia 50% • Depression in USA PREVALENCE 20% TO 40% of • residents

17. homes scored adequately in respect of non-restrictive care practice ,standard • Of décor and cleanliness and facilities • For activity and recreation

18. Mental disorder are common when residential facilities is poor ,limited social interaction and daily activity Challenges 1-staffing levels and skill mix match the type and complexity of client needs “support” 2- training of staff 3- absence of policy intervention 4-costs

19. mental health and older people specific disorder • 1- depression • 2- anxiety disorder • 3- dementia • 4- delirium

20. depression • Prevelance major depression among older people 1% to 4% and in minor depression 4% to 12% . Increased over aged 80% • Older people with depression have longer duration of episodes and shorter time of relapse than younger persons • 30% remain chronicly depressed

21. The longer duration of episodes appear • To be co-existing physical illness • To be poor self health status • To be depressed severity • Inadequacy social support • Adverse life event

22. Depression ,loneliness and social support • The social environment plays crucial part in determining the quality of older people lives • Inters personal relationship have been found to act buffer between adverse event and depression • Loneliness is associated with living alone and social isolation

23. Vulnerability factor for loneliness • Female • Chronic health problem • Marital status • Loneliness cause to increase depression and caused increased mortality rate

24. Suicide and depression • Elderly people have the highest rate of completed suicide rate of any age group

26. Assessment of depression and suicide risk in older people • Depression in older people commonly complicates • because co-morbid medical illness or dementia • The clinical presentation may be typical and meet full criteria for depressive disorder • Stigma prevent seek help for emotional problem

27. Useful questions for uncovered depression • Are you sad? • Are you sleeping poorly? • Do you worry to much ? • What have you enjoyed doing later ? • Rating scale • during the past month ,have you often been bother by feeling down ,depressed or hopeless? Yes or no • During the past month have you often been bothered by little interest or pleasuer in doing things ?yes or no

29. Depression management • Ani depression treatment • Psychological treatment • Cognitive treatment • Problem solving therapy

30. Antidepressant treatment • 50% to60% of older people improved • Studies have indicated that older patient treated with antidepressants should stay 12 month to two year's • Older patient are have more side effect because of higher levels of multiple drug prescribing

31. Antidepressant drug • 1- SSRI fluxetine, fluvoxamine • 2- tricyclic imipramine , clomipramine • 3-monoamone oxidase inhibition ,phenelzine,selegiline • 4- atypical bupropion ,mitrazapine , nefazodone • 5- SNRI duloxetine ,venlafaxine

32. Other antidepressant substance • Folk remedies • Extract of st john wort • 5-hydroxytryptophan and tryptophan • Is amioacde available as dietary supplement and alternative treatment {conventional } difficult conclusion about efficacy

33. Psychological therapies • Is important and enhancing the effect of medication and reducing relapse follow cessation of treatment and it is consistently found to be more acceptable than other treatment

34. Cognitive behavior therapy • Most establish treatment for depression and the aims to alter dysfunctional beliefs and negative thoughts that characterize depression by sessions • CBT need some adaptation for work with older people because of different life experience and value related ego

35. Problem solving therapy • Defining the problem and goal selecting and Appling means of achieving the goal

36. Model of care :community mental health team for older people • The involvement of community mental health teams for older people in depression management is associated with improved outcomes • Co ordinate by a multi-disciplinary team compared with normal primary care delivered improvement for disable elderly receiving home care • Regular monitoring physical health review, antidepressant prescribing and promotion of social involvment

37. Collaborative and case managementapproaches • Primary care occupies a strategic potion in the management of late life depression and more feasible treatment setting for all except the sever and complex presentation • Approaches applies • Chronic disease model to care, uses evidence based guideline, adherence program telephone support, with rapid direct access to specialist advice and support

38. Anxiety disorder • Is co morbid with depression • Anxiety symptom and disorder among older people are associated with disability ,reduce equality of life, increase use health services • Prevalence 10% making these mental disturbance in the late life • The rate of anxiety disorder are around twice a high among women as men

39. Vulnerability factor • Lower level of education • External locus of control • Resent loss of family • Physical illness

40. Other factors induce anxiety • Aspect of environment • Medication side effects {table 17.3} • Alcohol intoxication or withdrawal • *factors contribute to poor recognition • 1-other common mental disorder • 2- medical co-morbidity • 3- early age of onest and no treatment

41. Treatment for anxiety disorder in later life • Tricyclic antidepressant • 1-clomiparmine hydrochloride • 2- imipramin hydrochloride • General anxiety improved with anti depressants drug

42. benzodiazepines • Commonly used • Beneficial effect on symptoms of panic and general anxiety disorders • Side effect drowsiness {driving accident risk}

43. Psychological treatment • CBT IS EFFECTIVE for older people • Situational exposure , relaxation technique ,self control desensitization and cognitive restructuring

44. dementia • Major health public problem • It is neurodegenerative syndrome characterized by global ,progressive impairment of cerebral function .it is primary disturbs higher brain function such as memory ,thinking, orientation , comprehension, calculation learning , language and judgment • Manifests in loss memory {resent event } and loss executive function such as ability to organise complex tasks or make decision • Demintia affect about 7%of people aged over 65 years and 30% aged over 90 years

45. Subtype of dementia • 1- Alzheimer disease • 2- vascular dementia • 3- lewy bodies and frontal lobe dementia • Alzheimer disease is the commonest 50% of cases slow onset slow deterioration • Vascular dementia abrupt onset step –wise deterioration ,early gait ,seizure, urinary disturbance and history of stroke • [greater prevalence of hypertension and stroke • Important risk factor for dementia age and family history

46. Cerbrovaccular disease • Risk factor • 1- raised blood pressure • 2- DM • 3- HIGH CHOLESTROL • 4- High fat in take 5- obesity 6- smoking

47. assessment • Patient need to link primary health care and secondary ,social services voluntary organization…… • Stigma can effect on treatment so patient and family need education • Clinical assessment memory impairment aphasia agnosia, apraxia function disturbance {instrumental activities of daily living} • Physical examination is very important

48. Mini-mental state examination • 25-30 normal • 18-24 mild to moderate impairment • 17 or less impairment in daily activity

49. treatment • Prevention strategies and interventions to slow disease progress • 1- blood pressure and vascular factor • 2- nutrition ,diet and dietary supplement • 1-omega 3 polyunsaturated fatty acid {oily fish • 3- limits vitamin C and E • 4-limit green tea 5- ginkgo biloba {leaf decorative tree} 3- life style social involvement , physical exercise and cognitive activities

50. Drug treatment • 1- Cholinesterase inhibitor • 1- donepezil • 2- rivastigmine • 3- galantamine • 2-atypical neuroleptic drug treat behavioral manifistation of demintia {lewy bodeis}