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Aging Demographics and Psychiatric Diagnoses in the Elderly

Aging Demographics and Psychiatric Diagnoses in the Elderly. Marguerite R. Poreda, MD Assistant Professor USF COM Department of Psychiatry and Behavioral Medicine Training Director Geriatric Psychiatry Associate Director Memory Disorders Clinic Adult, Geriatric and Forensic Psychiatry

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Aging Demographics and Psychiatric Diagnoses in the Elderly

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  1. Aging Demographics and Psychiatric Diagnoses in the Elderly Marguerite R. Poreda, MD Assistant Professor USF COM Department of Psychiatry and Behavioral Medicine Training Director Geriatric Psychiatry Associate Director Memory Disorders Clinic Adult, Geriatric and Forensic Psychiatry The views expressed in this presentation are my own and do not necessarily represent those of USF, MacDill AFB, the VA or any other agency of the Federal Government or the State of Florida. The speaker does not receive honoraria, grants or research support from any pharmaceutical company nor is on any pharmaceutical’s Speaker’s Bureau

  2. Aging Demographics and Psychiatric Diagnoses in the Elderly: what I will review • Aging demographics (baby boomers, the aging population, the ‘old,’ ‘very old,’ ‘oldest old’; what age defines geriatrics?) • Understanding psychiatric nomenclature: Axis I - V • Psychiatric Diagnoses: Axis I - depression, anxiety, BMD, psychotic disorders, delirium, dementias, alcohol/SA; Axis II – Personality Disorders and Mental Retardation • Suicide risk factors • Elder abuse, neglect and exploitation

  3. What is Geriatric Psychiatry? • Fastest growing field of psychiatry; branch of medicine concerned with prevention, diagnosis, and treatment of physical and psychological disorders in the elderly and with the promotion of longevity • An ‘official’ ABPN subspecialty in 1989 • Managing elderly patients requires ‘special’ knowledge: possible differences in mental health presentations, frequent co-exiting and complicating chronic medical diseases, multiple medications (drug-drug interactions, pharmacodynamics and pharmacokinetics) and aging specific issues

  4. What’s in an age? What age makes you a geriatric patient? What makes you ‘elderly’? • Age 65 and older: elderly, ‘old’ • Age 85 and older: ‘very old’ or ‘old, old’ • Age 100 and older: ‘oldest old’ • “Baby Boomers” – those born between 1946 - 1964, 78 million US Americans alive today and will be turning 60 years of age in 2006  2024.……“Graying of America”

  5. Geriatric Statistics:U.S. Bureau of the Census: • Life expectancy: 1950 = 68 years; 1991 = 79 years for women/72 years for men* • In the year 2000 = 12.4% of the U.S. population - 35 million Americans - were 65 years or older* • By 2030 = percentage increased to 20% -1 in 5 people will be older than 65; 2025 in Florida – 1 in 4 people • People age 85 and older: are the fastest growing segment of our population – from 4 M today to 20 M by 2050;* constitute 10% of those 65 years and older; there are 39 men for every 100 women 85 years old or older *Administration on Aging. Statistics on the Aging Population, Rockville, MD; US Department of Health and Human Services; 2003; U.S. Bureau of the Census.

  6. Geriatric Statistics • The old, old (age 85 and older) consume the largest amount of Medicare resources; 5% of the Medicare population consumes 50% of the Medicare dollars – many are the ‘frail elderly’ • On average, by age 75, older adults have between two and three chronic medical conditions; some as many as ten to twelve medical conditions and as many medications

  7. Geriatric Statistics: Mental Health • 20% of the US population over the age of 65 has a mental illness** • As the population ages, the number of people with mental illness will double to 15 million by 2030 • Number of people over age 65 years with mental illness will equal the number of people with mental illness in ALL other age groups* • Older adults are less likely to seek mental health: only 4% of non-institutionalized US population seek mental health treatment*** • Older adults are more likely to be identified, diagnosed and receive treatment from their primary care physician**** *Bartels SJ (in press). **Jeste, DV, Consensus statement on the upcoming crisis in geriatric mental health, Arch. Gen. Psychiatry 1999: 56(9): 848-53. ** * Olfson M, Outpatient mental health care in non-hospital settings. Am. J Psychiatry 1996; 153(10): 1353-6. * ** * Kaplan MS, et al, Managing depressed and suicidal geriatric patients. Gerontologist 1999; 39(4): 417-25.

  8. A Guide Through DSM-IV TR for the non-psychiatrist(for diagnosis, treatment and medication management)

  9. DSM-IV TR: Multiaxial System Axis I: Clinical D/O Axis II: Personality D/O Mental Retardation Axis III: General Medical Conditions Axis IV: Stressors (primary and/or secondary GMC, support group, education, housing, access to health care, occupational, financial, legal, social, recent loss and other psychosocial and environmental problems) Axis V: GAF (Global Assessment of Functioning - scale 0-100)

  10. Multiaxial System - Example Axis I: Major Depressive Disorder, recurrent, moderate without psychotic features; R/O alcohol abuse Axis II: Cluster B traits Axis III: hypothyroidism, DMII, HBP Axis IV: poor social support – few friends and husband has left/whereabouts unknown, education – quit high school to get married and have a baby, homeless after hurricane Katrina, access to health care – lack of health coverage, occupational and financial - unemployed, legal - recent DUI Axis V: GAF: 58

  11. Axis I Disorders Axis I Disorders: Mood D/O (Depressive D/O and Bipolar D/O)* Adjustment D/O* Anxiety D/O* Somatoform/Factitious/Dissociative D/O Impulse Control D/O Paraphilias/Sexual and Gender Identity D/O Eating D/O Sleep D/O* Delirium, Dementia, Amnestic and other Cognitive D/O* Alcohol and Substance Related D/O* Schizophrenia and other Psychotic D/O (such as Delusional D/O)

  12. Axis II Disorders Axis II: Personality D/O Mental Retardation (onset before age 18, IQ at/below 70)

  13. General Diagnostic Criteria for a Personality Disorder • Simply put: an extreme variant of normal personality traits • ENDURING pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is INFLEXIBLE and PERVASIVE across a broad range of personal and social situations, leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning, is stable and of long duration (traced back to early adolescence or early adulthood) and not better accounted for by another mental, substance abuse d/o or medical condition (e.g. head trauma)

  14. General Diagnostic Criteria for a Personality Disorder • Manifested in 2 or more areas: -cognition (ways of perceiving and interpreting self, others, and events) -affectivity (in range, intensity, lability and appropriateness of emotional response) -interpersonal functioning -impulse control

  15. Personality Disorders • Cluster A: Paranoid PD, Schizoid PD, Schizotypal PD • Cluster B: Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD • Cluster C: Avoidant PD, Dependent PD, Obsessive-Compulsive PD • PD NOS (mixed personality)

  16. General Population Statistics • AS-PD = 2% • B-PD = 2% (but 10% of all psych outpatients/75%-90% are women) • H-PD = 2-3% • N-PD=<1% BUT among chronic pain patients – a disproportionate percentage: • AS-PD = 5% • B-PD = 7-25% • H-PD = 8-26% • N-PD = 5-22% • NIH Survey (2001-2002 National Epidemiologic Survey) estimated that 14.8% of American adults = 30.8 million Americans met criteria for at least one PD

  17. Late Life Stressors that place older adults at risk of mental health disorders • Chronic physical health condition(s) • Death of a loved one • Caregiving • Social isolation/lack or loss of social support • Significant loss of independence • History of mental health problems

  18. Late Life Stressors that place older adults at risk of mental health disorders • Old age – even though older adults are more likely to experience life stressors – old age is NOT a risk factor for an increasing risk for a mental health disorder; in fact, ‘most’ older adults are able to cope with late life stressors without developing significant mental health disorders • Successful aging: Vaillant; Success throughout the life cycle: Neugarten

  19. Most common mental disorders of old age are………… • …..depressive disorders, cognitive disorders, anxiety disorders and alcohol use disorders • Psychiatric disorders other than depression are found in lower prevalence among the elderly than at any other stages of the life cycle • Suicide risk in the elderly *National Institute of Mental Health’s Epidemiologic Catchment Area (ECA) Study

  20. Suicide Risk Factors for Adults:Demographic • Men at greater risk than women; Caucasians account for more than 90% of all suicides • Age clusters: age 15-19, 20-24 and over age 60 • Marital status: widowed, divorced and single individuals at greater risk than married individuals (more pronounced in men) • Living alone; no children under age 18 living in household • Alcohol/Substance Abuse history • History of mental illness; previous suicide attempt • Firearm(s) in the home • 30% have seen a physician within 30 days; 60% have seen a physician within 6 months

  21. Suicide Assessment: SAD PERSONS…….a mnemonic • Sex (male) - (age 65 – 15.5:100,000; white male older than 85 - suicide rate of more than 50:100,000 compared to the US population in 2002) • Age (older) – (beginning at age 60) • Depression • Previous suicide attempts • ETOH/SA • Rational thinking loss (psychosis) • Social supports lacking • Organized plan to commit suicide • No spouse (divorced > widowed > single) • Sickness (physical illness)

  22. Risk of Suicide in People with Selected Psychiatric DisordersCondition………. Estimated Lifetime Suicide Risk • Major Depression………………….14.6 • Bipolar Mood Disorder…………….15.5 • Dysthymia…………………………... 8.6 • Schizophrenia………………………. 6.0 • Panic Disorder……………………….7.2 • Source: Pies(2004). Data from APA (2003); and Harris and Barraclough (1997)

  23. Suicide Risk • Suicide risk can not be predicted from any one factor • Predicting suicide is VERY difficult BUT failure to assess for suicidality is the key to liability; asking about suicide does NOT increase the risk

  24. Depressive Disorders • MDE: single, recurrent; with atypical features; with catatonia; with postpartum onset; with psychotic features; with seasonal pattern (SAD) • Dysthymic Disorder • Depressive Disorder NOS ................................................................ • Adjustment Disorder • Bereavement/Abnormal Bereavement

  25. Depression • Prevalence rate: 4.4% - by DSM IV criteria • Up to 20% of community-dwelling older adults endorse significant depressive symptoms that do not meet full criteria for a mood disorder – subsyndromal depression is the modal form in older adults* • Late-onset depressive disorder is associated with being widowed, having a chronic medical illness and with a high rate of recurrence • Up to 80% of patients in LTC (NH/ALF) may experience a mood disorder • Adjustment Disorders; (Abnormal) Bereavement *APA Working Group on the Older Adult (Brochure) 1998; WDC.

  26. Depression in the Elderly:Signs and Symptoms • Reduced energy and concentration • Decreased appetite, weight loss • Sleep complaints – early morning awakenings and frequent awakenings • SOMATIC COMPLAINTS • ‘pseudodementia’ • Episode with ‘melancholic features’, hypochondriasis, hopelessness, feelings of worthlessness, paranoia and suicidal ideation

  27. Anxiety Disorders • Usually begins in early or early or middle adulthood but may appear after age 60 • Prevalence rate: 5.5% -11.4* but with the elderly - up to 20% with 37% co-morbidity with depression, dementia and medical illnesses such as CHF, CAD, diabetes *U.S. Department of Health and Human Services. Mental Health: Report of Surgeon General; 1999

  28. Anxiety Disorders: Prevalence(among older community-dwelling individuals) • GAD = 7.3% • Phobias = 3.1% • Panic D/O = 1.0% • Obsessive-compulsive disorders = 0.6%

  29. There is considerable overlap among symptoms of depression and anxiety disorders Interrelationships Among Depression and Anxiety Disorders Obsessive compulsive disorder Generalized anxiety disorder Social anxiety disorder Depression Specific (simple) phobia Panic disorder Post- traumatic stress disorder DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

  30. Major Symptoms of Depression and GAD Overlap Generalized anxiety disorder Major depressive disorder Worry Anxiety Muscle tension Palpitations Sweating Dry mouth Nausea Depressed mood Anhedonia Appetite disturbance Worthlessness Suicidal ideation Sleep disturbance Psychomotor agitation Concentration difficulty Irritability Fatigue DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

  31. Continuum of Anxiety and Depression Comorbid depression and anxiety Major depressive disorder Anxiety disorders Stahl SM. J Clin Psychiatry. 1993;54(1 suppl):33-38.

  32. Co-morbidity: Depression and Anxiety -- 1/3 –> 1/2 of people with depression will meet criteria for an anxiety disorder --More then 1/2 of people with an anxiety disorder will eventually experience a depressive disorder --Even among patients diagnosed with a depressive disorder who do NOT meet criteria for a formal anxiety disorder, the majority experience anxiety symptoms

  33. The Affective Spectrum • Dysthymia….. • Single MDE…. • Chronic MDE…. • Atypical MDD…. • Recurrent MDD…. • BIPOLAR SPECTRUM………

  34. Bipolar l Bipolar ll Bipolar lll Mania and Major Depression Hypomania and Major Depression Cyclothymia (non-major depression as well as hypomania) Hyperthymic temperament (‘ascending order’ up the bipolar spectrum) Secondary Mania (due to other illnesses or medications) The Affective Spectrum: Bipolar Mood Disorders

  35. Bipolar l Bipolar ll Bipolar Spectrum Disorders Sex 0.0 - 1.7% 0.2 – 3.0% 2.6 – 6.5% overall = 3.4% Equal males/ females (sex difference only significant in BMD II and Cyclothymic D/O) The Affective Spectrum: Bipolar Mood Disorders...range of rates

  36. Bipolar Mood Disorders • 1.7% population = 3.3 million (US) • 6th leading cause of disability worldwide – esp. from undertreated or resistant depression • Suicide: 25% attempt, 11-19% complete • Complex non-Mendelian inheritance – several genes involved • >90% will have future episodes • 10-15% will have >10 episodes

  37. Bipolar Mood Disorders • Onset (average in years): --1st impairment = 15-19 --1st treatment = 22 --1st hospitalization = 25 Younger Age of Onset: AD medications, stimulants, SA, ‘genetic’ anticipation Late Life Onset: 30-60 years Secondary Mania of Late Life

  38. Bipolar Mood Disorders • 69% of patients are misdiagnosed at least once • 35% were symptomatic for more than 10 years before correct diagnosis • Increased mortality (unnatural and natural causes of death) • Co-morbid anxiety rates in patients with Bipolar Mood Disorder are between 30%  40%* *McElroy et al., Am J Psychiatry 158: 420-426, 2001

  39. Racing thoughts Distractibility Disorganization Inattentiveness Delusions Hallucinations Symptom Domainsof Bipolar Disorder Dysphoric or Negative Mood and Behavior Manic Mood and Behavior • Euphoria • Grandiosity • Pressured speech • Impulsivity • Excessive libido • Recklessness • Social intrusiveness • Diminished need for sleep • Depression • Anxiety • Irritability • Hostility • Violence • Suicide BIPOLARDISORDER Psychotic Symptoms Cognitive Symptoms Slide courtesy of Keck PE Jr.; adapted from Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press: New York, NY; 1990.

  40. Screening Tools:The Mood Disorder Questionnaire Important symptoms: • Hyper or more energetic than usual • Predominately or thematically irritable • Distinctly self-confident, positive or self-assured • Less sleep than usual • More talkative or speaking faster than usual • Racing thoughts • Easily distracted • Problems at work and socially • More interest in sex • Taking unusual risks • Excessive spending

  41. Screening Tools: The Mood Disorder Questionnaire (cont.) • The Mood Disorder Questionnaire (MDQ) • Derived from DSM-IV criteria and clinical experience • Initial validation study of MDQ in psychiatric outpatients (N = 198) • Sensitivity = 73% and Specificity = 90% for Bipolar I and II • Validation study of MDQ in general population (N = 711) • Sensitivity = 28% and Specificity = 97% for Bipolar I and II • MDQ as screening tool (13 questions) • Positive MDQ  7 “yes” responses; Negative MDQ  7 “yes” responses • Rapid screening tool – 10 minutes or less • Patients can self-administer MDQ while in the waiting area • Does not require trained evaluators • Easily used in primary care settings • Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:53-59.

  42. Bipolar Disorders: in Older Adults • True prevalence is unknown (elderly underutilize mental health services, underreport mental health problems, receive care in other settings) • Co-morbidity is the rule rather than the exception (neurological illness, diabetes….7 or more co-morbid diagnoses in 20% of elderly BMD)* • Lifetime rate of substance abuse: 20-30% • Difference between ‘early onset’ bipolar d/o vs. ‘late onset’ bipolar d/o • Mania associated with medical conditions * Depp & Jeste 2004; Regenold, et al.

  43. Primary: -onset early in life -no obvious medical cause -higher familial rate of bipolar illness -better general response to lithium Secondary: -onset later in life -related medical cause (CNS lesions, metabolic disease) -lower familial rate of bipolar illness -generally poor response to lithium Bipolar Disorders: in Older AdultsPrimary vs. Secondary Mania

  44. Bipolar Disorders: in Older Adults • Depression usually precedes mania by 20 years • In general, manic symptoms are milder compared to younger patients • May present with mixed, manic, dysphoric or agitated states • More likely to have irritability, treatment resistance, higher mortality rate • Develop dementia at a higher rate than elderly without bipolar illness

  45. BMD – late onset • Persons age 60 years and older may constitute as much as 25% of the population with BMD* • New-onset BMD frequency declines with advanced age with as few as 6%-8% of all new cases of BMD developing in persons age 60 years and older* • Co-morbid Axis I disorders include: alcohol abuse disorders = 38.1%, dysthymia = 15.5%, GAD = 20.5%, panic disorder = 19.0% (men – greater prevalence of alcoholism; women greater prevalence of panic disorder)** * Sajatovic M, et al: New-onset bipolar disorder in later life. Am J Geriatr Psychiatry 2005; 13: 282-289. * Almeida, OP, Fenner, S: Bipolar disorder. Int Psychogeriatr 2002; 14:311-322. ** Goldstein, BI, et al: Am J Psychiatry 2006; 163:319-321.

  46. Sleep Disturbances in the Elderly Prevalence of Insomnia by age group*: Age 18-34 – 14% Age 35-49 – 15% Age 50-64 – 20% Age 65-79 – 25% *Mellinger GD et al. Arch Gen Psychiatry 1985;42:225-232.

  47. Psychiatric Conditions Psychosocial Factors Poor Sleep Hygiene

  48. Alcohol Decongestants CNS stimulants Stimulating antidepressants Beta-blockers Diuretics Thyroid hormones Bronchodilators Nicotine Calcium channel blockers Caffeine Corticosteriods CNS Depressants Quinidine Anticonvulsants Antiparkinsonian agents Examples of ‘Legal’ Drugs That Cause Insomnia

  49. Overlap in Sleep Disorders Associated with Poor Sleep &/or Excessive Daytime Sleepiness

  50. Primary RLS • Overall prevalence: 3-15% • Mean age of onset: 34 +/- 20 years • Highly variable course • Primary (idiopathic) RLS make up majority of cases; majority are hereditary • Not all patients with PLMD have RLS BUT most patients with RLS have PLMD

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