Mohamed Hatta Shaharom Forensic Psychiatrist & Founding Dean Faculty of Medicine

1. Mental Health of the Elderly Mohamed Hatta Shaharom Forensic Psychiatrist & Founding Dean Faculty of Medicine Cyberjaya University College of Medical Sciences Malaysia 28th FIMA Council Meeting Indonesian Islamic Medical Association Scientific Convention YARSI University Jakarta September 2011 / Shawwal 1432

2. بسم الله الرحمن الرحيم وَلَوْ جَعَلْنَاهُ قُرْآنًا أَعْجَمِيًّا لَّقَالُوا لَوْلَا فُصِّلَتْ آيَاتُهُ أَعْجَمِيٌّ وَعَرَبِيٌّ قُلْ هُوَ لِلَّذِينَ آمَنُوا هُدًى وَشِفَاء وَالَّذِينَ لَا يُؤْمِنُونَ فِي آذَانِهِمْ وَقْرٌ وَهُوَ عَلَيْهِمْ عَمًى (٤٤) أُوْلَئِكَ يُنَادَوْنَ مِن مَّكَانٍ بَعِيد Had We sent this as a Qur’an (in the language) other than Arabic, they would have said: "Why are not its verses explained in detail? What! (a Book) not in Arabic and (a Messenger) an Arab?" Say: "It is a Guide and a Healing to those who believe; and for those who believe not, there is a deafness in their ears, and it is blindness in their (eyes); They are (as it were) being called from a place far distant!" Fussilat (Explained in Detail) 41:44

3. Muqaddimah The Elderly (Mental Health & Illness) Mental health, medicine and sociology Psychiatric disorders and management Islamic care of the elderly.

4. PencegahanLebihBaikDaripadaRawatan Prevention is Better Than Cure

5. 1 Mental Health, Medicine and Sociology

6. الَّذِينَ آمَنُواْ وَتَطْمَئِنُّ قُلُوبُهُم بِذِكْرِ اللّهِ أَلاَ بِذِكْرِ اللّهِ تَطْمَئِنُّ الْقُلُوبُ "Those who believe, and whose hearts find tranquillity in the remembrance of Allah; for in the remembrance of Allah do hearts find tranquillity. Ar-Ra‘d (The Thunder) 13:28

7. Experiencing Old Age Retirement Dependence and independence in old age Alan Clarke, 2001. The Sociology of Healthcare. London: Prentice Hall. Pp 155-179.

8. Sociology and Older People Disengagement theory Structured dependency theory Theory of the third age Cultures of ageing Paul Higgs, 2008. Later life, health and society. In Graham Scambler (ed). Sociology as Applied to Medicine. Edinburgh: Saunders. Pp 176-189.

9. Fact 1 Many gerontologists are substituting age 85 for age 65 as the new chronological definition of old age. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

10. Fact 2 There are more differences among elders than any other segment of the U.S. population. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

11. Fact 3 Elders are the least likely to be lonely of any age group; and those who live alone are likely to be in close contact. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

12. Fact 4 It is only in the last half of the twentieth century that a large portion of the U.S. population lived to be 65 years old.

13. Fact 4 (cont) If people did live to be old, they were not treated any better than they are today. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

14. Fact 5 Senility is the result of disease and only affects about 5% of elders living in non- institutional setting. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

15. Fact 6 Though elders do gain certain advantage when they retire and when their children leave home, they still face a number of concerns. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

16. Fact 7 Most older people do have at least one chronic health problem, but the majority of elders live active lifestyles. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

17. Fact 8 Sexual interest does not diminish with age, but there is an alteration in sexual response. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

18. Fact 8 (cont) Nonetheless, many elder in reasonably good health have active and satisfying sex lives. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

19. Fact 9 Only approximately 4% of those above the age of 65 live in nursing homes, homes for the age, or other group quarters. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

20. Fact 10 Older adults are more likely to be retired, but they are very likely to be productively engaged at home and in the community. James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction to Community Health. Boston: Jones and Bartlett. Pp 236-237.

21. Mental State Examination Memory impairment Disorientation Needs physical help Risk in the home Risk outside Apathy

22. Mental State Examination (cont) vii. Poor communication viii. Repetitiveness ix. Uncontrolled behavior x. Incontinence xi. Emotional reactions

23. Mental State Examination (cont) Other reactions Mistaken beliefs Decision Making Burden on family Neil Anderson, Alan Jacques, 2004. Old-age psychiatry. In Eve Johnstone, D. Owens, S. Lawrie, M. Sharpe. C. Freeman. Companion to Psychiatric Studies. Edinburgh: Churchill Livingstone. Pp 613-660.

24. Investigations and Differential diagnoses Physical examination Full blood count ESR Urea and electrolytes Liver function tests

25. Investigations and Differential diagnoses (cont) Thyroid function test Calcium and phosphate Midstream urine Glucose Chest X-ray

26. Investigations and Differential diagnoses (cont) ECG Vitamin B12and folate Syphilis serology HIV testing Autoantibody screen

27. Investigations and Differential diagnoses (cont) xvi. Copper studies Heavy metal screen Lumbar puncture EEG CT scan

28. Investigations and Differential diagnoses (cont) xxi. MRI scan xxii. SPECT scan Neil Anderson, Alan Jacques, 2004. Old-age psychiatry. In Eve Johnstone, D. Owens, S. Lawrie, M. Sharpe. C. Freeman. Companion to Psychiatric Studies. Edinburgh: Churchill Livingstone. Pp 613-660.

29. Neuroimaging in dementia Alzheimer’s disease Vascular dementia Dementia with Lewy bodies Frontotemporal dementia Neil Anderson, Alan Jacques, 2004. Old-age psychiatry. In Eve Johnstone, D. Owens, S. Lawrie, M. Sharpe. C. Freeman. Companion to Psychiatric Studies. Edinburgh: Churchill Livingstone. Pp 613-660.

30. 2 Psychiatric Disorders and Management

31. بسم الله الرحمن الرحيم فِي قُلُوبِهِم مَّرَضٌ فَزَادَهُمُ اللّهُ مَرَضاً وَلَهُم عَذَابٌ أَلِيمٌ بِمَا كَانُوا يَكْذِبُونَ In their hearts is a disease; and Allah has increased their disease; and grievous is the penalty they (incur), because they are false. Al-Baqarah (The Cow) 2:10

32. The Elderly and Mental Illness • From 15 to 25 percent of elderly people suffer from significant symptoms of mental disorders • Ratio of Moderate organic disorders : • Severe organic mental disorders • (Ratio of 2 : 1).

33. The Elderly and Suicide • The highest suicide rate in America is among those aged 65 and older. In 1985, this age group represented 12 percent of the total U.S. population, but accounted for 20 percent of suicides nationwide.

34. The Elderly and Mental Illness • Worldwide, elderly people lead the World Health Organization's list of new cases of mental illness: 236 elderly people per 100,000 suffer from mental illness, compared to 93 per 100,000 for those aged 45 to 64, the next younger group.

35. Nearly 25% of elderly persons suffer from symptoms of mental illness, • Only 4% of the patients in community mental health centers, 2% of the patients seen in private practitioners' offices or hospitals are elderly • Less than 1.5% of the direct costs for treating mental illness is spent on older people living in the community.

36. Depression (Epidemiology) Most common mental disorder, afflicts up to 5% of people aged 65 and older Can mimic dementia About 10% of those diagnosed with dementia actually suffer from depression that, if treated, is reversible More than one third of all depressed patients seen by doctors will go untreated due to misdiagnosis Lifetime risk for major depression is only 7-12% in men, but a whopping 20-25% in women!

37. Depression • (and Women’s Indirect Complaints) • The elderly are also commonly taking many • more medications than younger people are; • some of these medications: • Anti-inflammatory drugs • Progesterone • Anticancer drugs

38. Depression • (and Medications of the Elderly) • Usually women will not complain directly of • sadness; symptoms can include, but are not • limited to: • Alzheimer's disease • Cancer (including breast and ovarian) • Congestive heart failure • Parkinson's disease • Rheumatoid arthritis • Sexual dysfunction • Diabetes

39. Depression (Signs & Symptoms) • Feelings of worthlessness, hopelessness, helplessness, inappropriate guilt; • Prolonged sadness, crying spells; • Jumpiness, irritability; • Loss of interest in and withdrawal from formerly enjoyable activities, family, friends, work or sex (anhedonia); • Intellectual problems: loss of memory, cannot concentrate, disorientation.

40. Depression (presentation in brief) • Disturbances in sleep, self-esteem, libido, appetite, interest, energy, concentration, memory, and movement • Feelings of guilt • Suicidal thoughts, plans, or attempts • Physical pain

41. Therapies for Depression Pharmacotherapy (anti-depressants) is fairly successful at improving the quality of life of the elderly patient. Psychotherapy is often used in combination with anti-depressants, which can include drugs in these classes:

42. Anti-Depressants (Types) • Heterocyclics • Selective serotonin reuptake inhibitors (SSRIs) such as Prozac • Monoamine oxidase inhibitors (MAOIs) • Tricyclics such as imipramine, desipramine, amitryptyline, and nortriptyline.

43. Anti-Depressants (Side-effects) • (the elderly is more susceptible to) • Blurred vision • Dry mouth • Urinary retention • Confusion • Constipation • Drowsiness • Insomnia • Cardiac arrhythmia • Hypotension • Weight fluctuations • Gastrointestinal distress • Sexual dysfunction

44. Dementias Characterized by confusion, memory loss, and disorientation Only 15% of older Americans suffer from this condition (of that number, an estimated 60% suffer from Alzheimer's disease, a progressive mental deterioration for which no cause or cure has been found) Alzheimer's being the most prevalent type (degeneration can last from 5 to 20 years).

45. Dementias (Causes) About 40% of all dementias can be caused by complications of chronic high blood pressure, blood vessel disease or a previous stroke. Deterioration is in steps rather than in a steady progression.

46. Dementia (Symptoms) • Delirium • Depressed mood • Behavioral disturbances • Delusions

47. Sometimes medications are used to treat symptoms that are secondary to dementia, such as sleep disruption, depression, and aggressive behaviors. These medications are only treating the symptoms that arise out of the underlying dementia, and do not treat the dementia itself.

48. Dementia (and Parkinson’s) • Parkinson's disease, which generally begins with involuntary and small tremors or problems with voluntary movements. Dementia may occur when the disease is severe or very advanced.

49. Dementia (and Huntington’s) • Huntington's disease, a genetic disorder that begins in middle age and has symptoms of changed personality, mental decline, psychosis and movement disturbance.

50. Dementia and Creutzfeldt-Jakob • Creutzfeldt-Jakob disease, thought to be caused by a viral infection leading to rapid and progressive dementia.