Mental Health & Care of Older Adults

1. Mental Health & Care of Older Adults Lecture 7 October 31st, 2007

2. Tonight’s Topics • What are the mental health issues facing older adults? • Is depression inevitable in older adults? • How can depression be addressed? • Dementia and its misconceptions • How do older adults adapt and cope with the environment around them? • What factors help adaptation to a new environment such as a nursing home?

3. What Characterizes Mental Health? • Positive attitude toward self • Accurate perception of reality • Mastery of the environment • Autonomy • Personality balance • Growth and self-actualization • Pathology: • Behaviors become harmful to oneself or others. • Lower one’s well-being. • Perceived as distressing, disrupting, abnormal, or maladaptive.

4. Are There Differences Pertaining to Mental Health in Older Adults? • Some behaviors considered abnormal under the preceding criterion may be adaptive for many older people • Isolation • Passivity • Aggressiveness • Such behaviors may help older persons deal with their situation more effectively. • If adaptive: Not distressing, which is key in diagnosis of mental health issues

5. How Do Biological Forces Influence Mental Health? • Health problems increase with age • Evidence supports a genetic component to Alzheimer’s • Physical problems may present as psychological and vice versa • Irritability  thyroid problem • Memory loss  vitamin deficiencies • Depression  changes in appetite

6. Do Psychological Forces Have An Influence on Mental Health? • Normative age changes can mimic certain mental disorders. • Normative changes can mask true psychopathology. • Look to nature of relationships as key to understanding psychopathology. • Young  expanding relationships • Old  contracting relationships

7. What Are The Sociocultural Forces Influencing Mental Health? • Sociocultural forces • Paranoia or healthy suspicion? • Look at differences according to location • Differences in ethnicity? • Recent immigrants: Lack of access to mental health services • Differences: Canadians of Asian/South Asian/African vs. English vs. Jewish

8. How Do We Assess Mental Health? • Elements of Assessment • Measuring, understanding, and predicting behavior • Gathering medical, psychological, and sociocultural information • How? • Interviews, observation, tests, and clinical examinations

9. All About Assessment • Two central aspects • Reliability • Validity • Psychological areas of examination: • Intelligence tests, neuropsychological and mental status examination • Mini Mental State Exam

10. What Factors Influence Assessment? • Professionals’ preconceived ideas have negative effects • Biases: Negative and positive • Environmental conditions • Sensory or mobility problems • Health of client

11. What Are The Treatments Available? • How to treat the client • Medical Treatment • Psychotropic and other drugs • Psychotherapy • Single or group talk therapy • APA criterion • Well-established • Probably efficacious

12. What is Depression? • Beliefs pertaining to depression vary across cultures. • Lawrence et al. (2006): UK study looked at Black Carabbean, South Asian, and White British older adults. • All 3 groups believed it was a serious condition. • WB used the biomedical model of depression whereas SA participants were more liekly to see it as a normal byproduct of sadness or grief. • WB & BC defined in terms of low mood and hopelessness. BC and SA also put in terms of worry.

13. How Do Psychologists Define Depression? 1) Dysphoria – feeling down or blue • Loss of interest and pleasure • Feelings of worthlessness or guilt • Diminished ability to think • Thoughts of death or suicidal ideation 2) Physical symptoms • Insomnia/hypersomnia • Fatigue • Weight loss/gain • Agitation/psychomotor retardation

14. 3) Symptoms must last for at least 2 weeks. 4) Other causes for observed symptoms must be ruled out. 5) How are the symptoms affecting daily life? • Clinical depression involves significant impairment in normal living.

15. What Do You Think? • Can we equate being older with being more depressed? • Can older adults get better if they are depressed or are they unable to change?

16. Myths Concerning Depression In Older Adults • Depression is a normal state of affairs as one gets older. • It doesn’t need to be treated. • Older adults don’t want therapy. • Older adults can’t change with therapy. • The ratio of benefit to cost is too low.

17. Prevalence of Depression

18. Gender and Depression • Women diagnosed as suffering from depression more often than men • Life satisfaction & depression

20. Early vs. Late Onset Depression • Late-onset depression: 1st episode after 60 years old • Van den Berg et al. (2001) found 3 subtypes: EO, LO with severe life stress & LO without severe life stress • EO: Associated with neuroticism & parental history of depression • LO without stress: Higher vascular risk factors than those with LO with stress.

21. Early vs. Late Onset Depression • Joost et al. (2006) screened a large group (n=3107) of older adults to find individuals with early onset (n=90) or late onset of depression (n=39). • Early onset and genetic vulnerability vs. late onset and vascular pathology? • Not found in this study • LOD: Being widowed (not recent loss), having poorer cognition, being older • EOD: More comorbidity with anxiety • Found no difference between the 2 groups in terms of levels of disability

22. Health Stresses and Depression Wrosch et al. (2004). Health stresses & depressive symptomatology in elderly adults: A control-process approach. Current Directions in Psychological Science. 13(1), 17-20.

23. Depression and Mortality • Schulz et al. (2000) • Is depression related to mortality? • High levels of depressive symptoms: 25% more likely to die within 6 years. • Model to explain the interaction between depression & death.

24. Depression and The Cascade to Death

25. What Tools Can We Use To Assess Depression? • Beck Depression Inventory • Feelings and physical symptoms • Geriatric Depression Scale • Physical symptoms omitted • Both more accurate with women than men.

26. Beck Depression Inventory (BDI-II, 1996) • 21 statements, each with 4 possible answers. Circle the statement that most represent how the respondant has felt in the last week. • Sample item: 0. I am not discouraged about my future1. I feel more discouraged about my future than I used to be. 2. I do not expect things to work out for me. 3. I feel my future is hopeless and will only get worse.

27. More About The BDI • Scoring: • <10: Normal mood • 10-15: Minimal depression • 16-19: Mild to moderate • 20-29: Moderate to severe • 30 and +: Severe depression • Face validity is very apparent, which makes it easier to dissimulate symptoms. • Not designed specifically to evaluate older adults however…

28. Geriatric Depression Scale (Yesavage et al., 1983) • Yes/no questions. • Short (15 items) and long (30 items) forms • Short form to minimize fatigue, but correlation is only 0.66 between the 2 forms. • e.g.: Are you basically satisfied with your life? • Have you dropped many of your activities and interests?

29. What Are The Causes of Depression? • Biological focus • Genetic predisposition • Neurotransmitters • Norepinephrine • Serotonin • Psychosocial focus • Loss and bereavement • Behavioral and cognitive-behavioral theories, a different approach.

30. Treatment of Depression • Severe forms of depression • Electroconvulsive therapy – ECT • Less severe forms • Prozac, Zoloft: SSRI • Tricyclics • MAO inhibitors • Lithium (bipolar disorder)

31. Satre et al. (2006) Article on CBT • What is CBT? Modifying thoughts and behaviours to influence emotions. • Article integrates findings about social and cognitive changes, cohort differences,…: Adapt the model to these changes. • Efficacy of CBT = medications, but less likely to relapse • Can address depression, anxiety, substance abuse, insomnia,…

32. What Is Delirium? • Disturbance of consciousness and change in cognition developing over a short period of time. • Fluctuation in impairment over time, unlike most dementia. • Individuals tend to recover within a few hours/days, although older adults are at risk for it to persist longer. • Caused by: • Stroke, cardiovascular disease, metabolic condition, medication side effects, substance intoxication or withdrawal, exposure to toxins, or combinations of the above

33. Alzheimer’s Disease: A Daughter’s Experience

34. Dementia • Affects 6 – 8% of people over 65 • Bad news: 50% of people over 85 have dementia. • Good news: 50% don’t! • Because more people are living to older age, the number with dementia is also increasing.

35. DSM-IV Criteria to Diagnose A.D. • Memory impairment + one of the following: aphasia, apraxia, agnosia & disturbance in executive functioning. • Represent a significant change in functioning. • Gradual onset and continuing decline. • Not due to other physical illness or substance. • Do not occur during the course of delirium. • Do not represent another Axis-I disorder.

37. Characteristics of Alzheimer’s disease • Accounts for 70% of all dementia, although mixed dementia with vascular features becoming more commonly recognized. • Neurological changes in Alzheimer’s disease • Microscopic • Rapid cell death in hippocampus, cortex, basal forebrain • Neurofibrillary tangles (tau protein) • Neuritic plaques (Beta-amyloid protein) • Is Alzheimer’s merely an exaggeration of normal aging?

38. What Might Be The Causes of AD? • Neurotransmitters: Acetylcholine, serotonin • Cellular changes: Phospoholipids, Beta-amyloid, tau protein • Genes: Chromosome 19: ApoE4 • Metabolism: Glucose & oxygen changes, calcium • Environment: Aluminum, zinc, food toxins, viruses

39. Early Onset vs. Late Onset? • Late onset is probably due to combination of factors previously mentioned. • Early-onset Alzheimer's may be caused by genetic mutations • Autosomal dominant pattern – chromosomal causes • Pick’s disease • Huntington’s disease • Down’s syndrome (Chromosome 21-similar changes with beta-amyloid as AD; Chromosomes 1 & 14 as well)

40. Are There Interventions Possible? • Intervention strategies • Caring for patients with dementia at home • Caregivers have significant problems • Effective behavioral strategies • Differential reinforcement of incompatible behavior (DRI) • Arguing with patient is counterproductive • Respite care and adult daycare

41. Other Forms of Dementia • Other forms of dementia • Vascular Dementia – CVA (stroke) • Frontotemporal Dementia (FTD) • Parkinson’s Disease • Associated with dopamine deficiency • 14% to 40% will develop dementia • Huntington’s Disease • Associated with GABA deficiency • Alcohol Dementia Complex • Wernicke-Korzakoff’s Disease • AIDS Dementia Complex (ADC)

42. Are There Other Mental Disorders Fairly Prevalent in Older Adults? • Anxiety Disorders • Symptoms and diagnosis of anxiety disorders • Treating anxiety disorders • Drugs – Valium, Librium, Serax, Ativan • Psychotic Disorders • Schizophrenia • Treating schizophrenia

44. Substance Abuse in The Elderly • Prescription & over the counter (OTC) • Alcohol abuse – Four symptoms • Craving • Impaired control • Physical dependence • Tolerance • Left untreated, alcohol dependency does not improve over time

46. How Are Person-Environment Interactions Described? • Kurt Lewin (1936) came up with a formula to describe them. • B = f(P, E) Where: • B = Behavior • P = Person • E = Environment

47. Competence & Environmental Press • Competence is the theoretical upper limit of a person’s capacity to function. • Five domains of competence (Lawton & Nahemow, 1973) • Biological Health • Sensory-perceptual functioning • Motor skills • Cognitive skills • Ego strength • Environmental Press: Environments can be classified on the basis of the varying demands they place on the person. • Interactions between physical, interpersonal & social demands.

48. The Congruence Model • According to Kahana’s (1982) congruence model, people with particular needs search for the environments that meet them best • Can you think of examples? 1. A person without personal transportation seeks a house near a bus route. 2. A handicapped person needs a home adapted to a wheelchair (no steps). 3. An elderly person may need to relocate to an assisted-living facility.

49. Stress & Coping Framework • Interaction with the environment can produce stress (Lazarus, 1984) • Evaluating one’s situation and surroundings for potential threat value • Harmful • Beneficial • Irrelevant • If harmful, what is the coping mechanism and response? Outcome positive or negative?

50. The Loss Continuum Concept • Loss continuum • Children leaving • Loss of social role • Loss of income • Death of spouse/close friends and relatives • Loss of sensory acuity • Loss of mobility accompanied by • Loss of health