MENTAL ILLNES IN THE ELDERLY

OBJECTIVEMental disorders are common in old age but frequently remain undetected and untreated. Mental disorders induce functional disability, disturb rehabilitation, burden the health system and impair life-quality of old patients and their relatives. Geriatric patients are characterized by suffering from multiple diseases, being acutely at risk in the case of somatic disorders, for instance to loose functional autonomy. Old patients have a great need for both rehabilitation and for psychosocial services. Moreover, treatment of mental disorders is decisive to prognosis of other somatic diseases.Mental health and emotional well-being are as important in older age as at any other time of life. Most older people have good mental health, but older people are more likely to experience events that affect emotional well-being, such as bereavement or disability. Assessing the mental health needs of older people requires an understanding of the complex interaction between specific medical conditions and social circumstances. To be able to offer effective support, practitioners need to keep up-to-date with the latest research methods and legislation. Studies show that seniors are at greater risk of some mental disorders and their complications than younger people, and many of these illnesses can be accurately diagnosed and treated. However, many seniors are reluctant to seek psychiatric treatment that could alleviate or cure their symptoms and return them to their previous lifestyle.One of the reasons why psychological disorders in the elderly are more difficult to diagnose is that few people expect these issues. Instead, they may credit the isolation to aging or diminished social circles. The elderly fail to report these issues to health care providers and receive treatment from specialists in mental health care at far lower rates than the general public. Some disorders may appear to be common to aging, such as dementia and Alzheimer's disease, yet are not related to the aging process.Many people dont understand mental illness or even acknowledge its existence. Some seniors are ashamed or frightened by their symptoms or believe that they are an inevitable part of aging. Often, seniors, their loved ones and friends, and even their doctors fail to recognize the symptoms of treatable mental illness.The design and delivery of mental health services to older persons is a vital societal challenge, in light of the enormous increase in the elderly population that is projected to occur during the first half of this century. The purpose of this report is to highlight major issues in the field of mental health and aging; to discuss efforts to address these issues, including community-based services; and to identify the crucial challenges that must be confronted in the years ahead and strategies to meet them. This report is written as a companion document to Mental Health: A Report of theSurgeon General (USDHHS, 1999a). Because the Surgeon Generals report provides an excellent discussion of the nature, diagnosis, and treatment of mental disorders, this report will focus instead on community-based services that can be utilized by a wide range of elders, including older persons in good mental health, for whom outreach and education might be helpful; older persons who are experiencing acute stress or crisis; and those with severe mental disorders. While substance misuse and abuse are closely intertwined with mental health and merit full discussion, the primary focus of this report is on mental health and aging and the services and systems designated to deal with these areas of concern. Mental health and supportive services must address more effectively the ethnic and racial diversity of our older population. A supplement to Mental Health: A Report of the Surgeon General that will address mental health and ethnic minorities is in preparation. The need for and use of mental health services by distinct ethno-cultural groups over the life span, including a discussion of service use by older adults, is the domain of this second, much-anticipated supplement.The purpose of this document is to serve as a guide for health authorities or healthcare team in designing, developing, implementing and evaluating services that maximize quality of life for elderly people who have complex and challenging mental health problems.

SUMMARYMental disorders in old age are frequent and they are frequently underdiagnosed. Most mental disorders are treatable once detected. Untreated mental disorders strongly impair life quality of patients and care-givers, cost money, promote further disability and burden for the public health system. There is a strong and complex interrelationship between somatic illnesses, mental disorders and social factors in old age, which make geriatric medicine more time-consuming and more expensive than normal internal medicine. Mental health is of tremendous importance for functional independence and life-quality. Since it is impossible not to have any somatic diseases in old age, it is essential to develop strategies to cope with these impairments, which in turn strongly depend on mental, that is on both emotional, and cognitive health.

Thus, mental health is the basis of remaining autonomy and life quality in old age. Beside curing a patient, assurement of life-quality of the multimorbid old patients should be the main goal of medical gerontology.Not only internal medicine, but also a great array of medical disciplines will have to cooperate to reach this objective. In conclusion, there is a need for more education of physicians concerning the common mental disorders in the elderly in order to improve their management.

Primary care services and programs are the backbone of the elderly mental health care system. Professionals with specialized knowledge and skills in geriatric care who work in the secondary and tertiary care sectors only provide care to those elderly people whose problems are more complex or challenging than can be accommodated in the primary care system. They also provide consultation to many primary care providers to divert referrals from the secondary or tertiary system. The formal service system for elderly mental health care consists of:

PrimaryPreventive, diagnostic and therapeutic health care provided by general practitioners and other health care providers, such as home nursing, home support or, upon direct request by patients/clients, placement in a facility.EXECUTIVE SUMMARYSecondarySpecialized preventive, diagnostic and therapeutic care usually requiring referral from a primary source. Includes outreach community-based teams, inpatient elderly mental health care, day hospital services and outpatient clinics

TertiaryHighly specialized services including professional/technical skills, equipment or facilities usually requiring referral from a secondary source. Includes inpatient services, university research clinics and rural and remote community outreach.

Community outpatient/outreach mental health teams, whether hospital or community-based, and inpatient elderly mental health care constitute the foundation of the elderly mental health care system at the secondary care level. To be effective, an elderly mental health care service should remain closely connected to psychiatric expertise. This expertise is traditionally found in the mental health service structure. Effective elderly mental health care also requires the development of a formalized collaborative relationship with home and community care.3 Home and community care provides and/or coordinates many direct, in-home and residential services for elderly people, many of whom have complex mental health or behavioral issues. Elderly mental health care services provide specialized expertise in support of clients with more complex mental health or behavioral issues and their caregivers in a variety of care settings. Defining the organizational relationship should be done locally, taking into account the needs of the population, existing resources and the size and location of the community. The need for a formalized collaborative relationship is also required with adult mental health and inpatient services.

INTRODUCTIONOlder adults, those aged 60 or above, make important contributions to society as family members, volunteers and as active participants in the workforce. While most have good mental health, many older adults are at risk of developing mental disorders, neurological disorders or substance use problems as well as physical illness or disability.

Like each phase of human development, late life poses both opportunities and threats to adaptation and mental well-being. Common late life transitions include retirement, relocation, death of spouse and friends, serious illness, assumption of caregiver roles and transfer of care responsibilities for mentally disabled or ill adult children. While older adults manage these transitions with resilience, hardiness and resourcefulness, those with specific vulnerabilitiesgenetic, environmental, recurrent/multiple stressorsmay develop maladaptive responses and mental illness. Persons living with a serious mental illness also grow old, and the changes associated with aging may further compromise a lifetime of challenged coping, thus exacerbating symptomatology and well-being.

Including elders with dementia, about 20 percent of older adults are estimated to have a mental illness. With the rapid aging of the population, the actual numbers of older persons with mental illness will soon overwhelm the mental health system (US DHHS, 1999). Responding to the many opportunities for mental health promotion and also recognizing the special needs, unique presentations and interventions for mental illness in older adults are imperative as nurses learn to practice in the general area of psychiatric-mental health nursing.

Demographic CharacteristicsThe elderly population is projected to grow rapidly between 2010 and 2030 as the 76 million baby boomers reach 65 years of age. By 2030, older adults will account for 20% of the nations people, up from 13% today. Simply by virtue of the growth of the older population, the need for geriatric mental health services will increase. In addition to being larger in number, the older adult population will be much more diverse with regard to generational cohorts, gender, minority status, income, living arrangements, and physical and mental health.

Stressors and AdaptationsDuring the normal process of aging, older persons encounter stressors that may trigger both appropriate and distorted emotional responses. Two of the most stressful unplanned life events include declines in health and loss of loved ones. In addition, chronic strains may also impact the older adult; for example, strains within the community, in relationships, or in the older persons immediate environment are all stressors. Most older persons are able to adapt to these changes and maintain their well-being by marshaling their personal and environmental resources. These include coping skills, social support, and maintaining a sense of control.

Service delivery issuesWhile there are substantial needs for mental health services, older adults have made very limited use of these services. The reasons for this underutilization include: denial of problems, reluctance to self-refer, failure by professionals to identify the signs and symptoms of mental illness, and access barriers. At the systems level, lack of collaboration between agencies and systems, funding issues, gaps in services, and shortages of mental health personnel trained in aging and aging professionals trained in mental health can affect access to and provision of appropriate services.

Mental Health and Aging Most older adults enjoy good mental health, but nearly 20% of those who are 55 years and older experience mental disorders that are not part of normal aging. The most common disorders, in order of prevalence, are anxiety disorders, such as phobias and obsessive-compulsive disorder; severe cognitive impairment, including Alzheimers disease; and mood disorders, such as depression. Schizophrenia and personality disorders are less common. However, some studies suggest that mental disorders in older adults are underreported. The rate of suicide is highest among older adults compared to other age groups. Older adults with mental illness vary widely with respect to the onset of their disorders. Some have suffered from serious and persistent mental illness most of their adult life, while others have had periodic episodes of mental illness. A substantial number experience mental health disorders or problems for the first time late in life problems which are frequently exacerbated by bereavement or other losses which tend to occur in old age. Yet another variable is severity. Mental disorders can range from problematic to disabling to fatal. Mental health services must be designed to meet the needs of older people at all points of the mental health continuum. However, the assessment, diagnosis and treatment in mental disorders among older adults present unique difficulties that must be contended with. Further efforts aimed at the prevention of mental disorders in older adults are also needed.

AGING AND MENTAL HEALTHAging and Mental Health considers the biological, psychological and social aspects of aging as they relate to mental health. It emphasizes the various strategies, therapies and services which may be directed at improving the mental health of the elderly.

Definition of Aging and Mental HealthWith improved diet, physical fitness, public health, and health care, more people are reaching retirement age (but not necessarily retiring) and they are in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining. While some disability is the result of more general losses of physiological functions with normal aging, extreme disability in older persons is not an inevitable part of aging. In fact, as it relates to mental health, even though those 60+ years of age make up over 12% of the population, they account for only 6% of the caseload of community mental health centers and only 2% of the caseload of mental health private practice. As we age, we face many changes and many sources of stress. We are not as strong as we used to be, illness is more of a problem, children move away from home, people we love die, we may become lonely, and eventually we must give up our jobs and retire.

Normal aging is a gradual process that ushers in some physical decline, such as decreased vision, hearing, and decreased pulmonary and immune functions. With aging comes certain changes in mental functioning, but very few of these changes match commonly held negative stereotypes about aging. In normal aging, important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life.

Aging successfully should include good mental health, and the mental health of older adults is very much interconnected to their physical health. For instance, people who have physical problems like heart problems and diabetes are more likely to develop mental health problems. People with depression or anxiety are more likely to develop physical problems. In addition, older adults with mental health problems may experience them as physical problems such as lack of energy or trouble with memory and trouble concentrating.Many people mistake the symptoms of depression, anxiety, fears, and other mental health problems for the aging process itself. Unfortunately, many people think that confused thinking, irritability, depressed mood, and loss of energy are just signs that someone is getting older rather than signs that someone needs help. The aging process itself does not normally cause sudden intellectual or emotional changes.Coping with all the changes of aging can be difficult, but it can be done in a healthy way. The keys to coping include your long-term lifestyle, your ability to expect and plan for change, the strength of your relationships with surviving family and friends, and your willingness to stay interested in and involved with life. Therefore, It is important for you to think carefully about what will happen to you as you age and how you are going to deal with the changes that will happen.Dealing With Physical ChangesAs you grow older, your body will naturally change. For example, physically, emotionally and energy wise, you do not operate at the levels you once did. You may tire more easily than you used to. Your sex drive may change, You may become ill more often and take longer to recover from injury and illness. You may not see or hear as well as you did when you were younger. Your reaction times are slower. Here are a few things you can do to cope with these changes: *Accept reality. Denying these changes will only make life less enjoyable. Get the things that will help you - eyeglasses or hearing aids for example. *Keep a positive attitude. Remember that slowing down does not mean you have to come to a complete stop. *Continue to set goals for yourself and work toward them.*See your family doctor regularly. *Be careful about your medications. As you get older, they may begin to interact differently with other drugs and to affect you differently than before. Make sure your doctor knows about all your medications, even those prescribed by another doctor. *Get regular exercise. *Change your eating habits. Adopt a balanced diet with fewer fatty foods.*Keep active socially to prevent isolation.Dealing With BereavementMany older adults experience loss with aging (loss of social status, self-esteem, and loss of physical capacities) including the death of friends and loved ones. Sadness and depression are normal accompaniments to these kinds of losses, but the grief, sadness, and depression all need to be within normal limits. Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year. Bereavement is a natural response to death of a loved one. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, sleep problems, and eating problems. This constellation of symptoms does not by itself constitute a mental disorder. Only when symptoms persist for 2 months and longer after the loss does the DSM-IV a permit a diagnosis of either adjustment disorder or major depressive disorder. You may want to consider some of the following ways of coping with your grief and sadness.

*Do not deny your feelings. If you do not allow yourself to go through the grieving process, you are only storing up problems for a delayed reaction later on. *Accept the range of emotions you will feel. Tears, anger and guilt are all normal reactions. *Remember and talk about the deceased person. He/she was an important part of your life. Although your grief will pass, your memories will always stay with you. *Look to your family and friends for support. *Be supportive of those you know who have suffered a loss. They need the warmth and caring that friendship can bring, just as you will when it happens to you.*Continue to set goals for yourself and work toward them.Dealing with LonelinessEveryone needs some time alone, but being alone against your will is very painful. You risk losing your sense of purpose and self-worth, and becoming anxious and depressed. As family members and friends die and children become more involved in their own lives, it is important for you to find ways to cope with loneliness. You may want to consider some of the following suggestions:*Stay active, and look for new social contacts. . *Very young children can brighten up your life. Try to make friends with people of different ages. *Spend time with grandchildren and great-nieces and nephews.*Continue to set goals for yourself and work toward them.*Learn to recognize and deal with the signs of depression. Loss of appetite and weight, inability to sleep, loss of energy and motivation, and thoughts of suicide are all signs of depression.

Retirement may increase your sense of loneliness and can be a major source of stress. This stress may be even greater if you have been forced to retire because of retirement policies. You may lose your sense of identity and feel less worthwhile. You will probably miss the daily contact with friends from work. Retirement frequently is associated with negative myths and most people actually fare well in retirement. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of livingThe Facts About Mental Illness in the ElderlyYou might not be surprised to read that the most common mental health issue among the elderly is severe cognitive impairment or dementia, particularly caused by Alzheimers disease (National Alliance on Mental Illness). An estimated 5 million adults 65 and older currently have Alzheimers diseaseabout 11 percent of seniors, according to the Alzheimers Association. Other types of dementia bring the numbers even higher.Depression and mood disorders are also fairly widespread among older adults, and disturbingly, they often go undiagnosed and untreated. In a 2006 survey, 5% of seniors 65 and older reported having current depression, and about 10.5% reported a diagnosis of depression at some point in their lives (CDC).Often going along with depression in many individuals, anxiety is also one of the more prevalent mental health problems among the elderly. Anxiety disorders encompass a range of issues, from obsessive-compulsive disorder (including hoarding syndrome) to phobias to post-traumatic stress disorder (PTSD). About 7.6% of those over 65 have been diagnosed with an anxiety disorder at some point in their lives, reports the CDC.

Causes and Risk Factors for Senior Mental IllnessOne of the ongoing problem with diagnosis and treatment of mental illness in seniors is the fact that older adults are more likely to report physical symptoms than psychiatric complaints (CDC). However, even the normal physical and emotional stresses that go along with aging can be risk factors for mental illnesses like anxiety and depression. The Geriatric Mental Health Foundation lists a number of potential triggers for mental illness in the elderly: Physical disability Long-term illness (e.g., heart disease or cancer) Dementia-causing illness (e.g. Alzheimers disease) Physical illnesses that can affect thought, memory, and emotion (e.g. thyroid or adrenal disease) Change of environment, like moving into assisted living Illness or loss of a loved one Medication interactions Alcohol or substance abuse Poor diet or malnutritionIs it Mental Illness or Aging? 10 Symptoms of Mental IllnessAs our loved ones age, its natural for some changes to occur. Regular forgetfulness is one thing, however; persistent memory loss or cognitive impairment is another thing and potentially serious. The same goes for extreme anxiety or long-term depression. Caregivers should keep an eye out for the following warning signs, which could indicate a mental health concern:1. Sad or depressed mood lasting longer than two weeks1. Social withdrawal; loss of interest in things that used to be enjoyable1. Unexplained fatigue, energy loss, or sleep changes1. Confusion, disorientation, problems with concentration or decision-making1. Increase or decrease in appetite; changes in weight1. Memory loss, especially recent or short-term memory problems1. Feelings of worthlessness, inappropriate guilt, helplessness; thoughts of suicide1. Physical problems that cant otherwise be explained: aches, constipation, etc.1. Changes in appearance or dress, or problems maintaining the home or yard1. Trouble handling finances or working with numbersDont hesitate to seek help if your loved one is experiencing any of the symptoms above, urges the Geriatric Mental Health Foundation. There are professionals out there willing and able to help, including your family doctor, who is always a good place to start. You could also consult a counselor, a psychologist, or a geriatric psychiatrist. The important part is not to stand by and suffer alone. With the combined efforts of families, caregivers, and mental health professionals, we can help ward off mental illness in our older loved ones and make sure they are on the right track to healthy aging.If youve had to cope with mental illness in an older loved one, we invite you to share your experiences and advice for our readers. Please feel free to join the discussion below.

How to Approach Senior Care and Mental IllnessBringing up the topic of senior care support with a loved one can difficult, but the situation is even more fraught when that person suffers from a mental health issue. Many family caregivers are left wondering how to approach the subject, worried about upsetting their elderly parent, or even fearful of an irrational or violent reaction. Unfortunately, this is by no means an unusual situation. According to a 2012 report by the Institute of Medicine of the National Academies, between 14-20% of the nations senior population have one or more mental health issues, including depressive disorders, dementia-related symptoms, and substance abuse problems. In combination with the natural physical and cognitive impairments that occur with aging, psychological issues can endanger a seniors health and place stress on family members. So how should caregivers bring up the need for senior care?

CURRENT CONCERNSOver the last decade there has been a striking number of articles in professional journals and the public press attesting to the high prevalence of psychiatric disorders in the nation's elderly population. Although adults 60 years of age and older constitute 13 percent of the United States population, their use of inpatient and outpatient mental health services falls far below expectations.Elders account for only 7 percent of all inpatient psychiatric services, 6 percent of community mental health services, and 9 percent of private psychiatric care. Less than 3 percent of all Medicare reimbursement is for the psychiatric treatment of older patients. It is estimated that 18 to 25 percent of elders are in need of mental health care for depression, anxiety, psychosomatic disorders, adjustment to aging, and schizophrenia. Yet, few seem to receive proper care and treatment for these mental illnesses. It is also a distressing reality that the suicide rate of the elderly stands at an alarming 21 percent, the highest of all age groups in the United States. Every day 17 older individuals kill themselves. Given such statistics, why are millions of our nation's elderly deprived of adequate mental health care? There are numerous factors accounting for this apparent state of apathy and indifference towards the unmet mental health needs of the elderly. StigmaMany elders resist treatment for depression and other disorders, as their association with mental illness is based on images frequently propagated by the mass media and popular culture. Very often, television and movie portrayals of characters labeled mentally ill are frightening and powerful sources of mental illness misinformation. For the older generation, movies like "The Snakepit" and "Psycho" have left lasting negative perceptions of people experiencing psychological distress. The media rarely produces dramas depicting people coping with feelings of depression or anxiety who are not violent, nor do they have any regular programming that provides basic mental health information. It's therefore extremely important to have alternative TV programming that helps to re-educate people about what mental illness is and how it can be effectively treated.AgismMyths and misperceptions (ageism) about older people by the media, the public, and professional health and mental health providers have also affected mental health service delivery to elders. For administrators confronted with budgetary restraints, it has too often been the older population that has been cast aside, on the basis that they are too old to benefit from services. It would stand to reason that a society that places such great emphasis on youth and the importance of looking young does not lend enthusiastic support to better mental health care for the geriatric population.Primary Care PhysiciansGenerally, the first person elders turn to for help with problems that require mental health treatment is their primary care physician. Many of these physicians have limited training in the care and management of geriatric patients. This makes the current lack of adequate mental health care particularly insidious because neither the elderly person nor the health care provider may recognize the symptoms. In no other age group is the combination and interrelationship of physical, social, and economic problems as significant as with the elderly. Elders tend to assume that complaints such as sleep disturbances, changes in appetite, and mood differences are related to physical problems. This tendency is reinforced by physicians, who often attribute symptoms to the aging process. Medical practice today does not usually allocate time for the detailed medical and social history that would encourage a more accurate diagnosis.A 1990 study of elderly suicides in the Chicago area found that 20 percent of the suicide victims had seen their primary care physicians within 24 hours of their suicide, 41 percent within seven days, 84 percent within 30 days. This data greatly underscores the importance of early detection by health professionals and caregivers.Service DeliveryPractices and policies pertaining to the organization of elderly service delivery have not been based on actual experiential data, but on the attitudes and assumed efficiency of planners and funders in the private and public sectors. An illustration of this approach is the assumption that older consumers will self-refer to community mental health centers (CMHCs) for help with psychiatric disorders. In most instances, older adults do not appear at a CMHC unless they are brought by a relative or there is an acute crisis that requires an emergency visit. Even on those visits, few CMHCs have staff members that are responsive or knowledgeable about the special needs of this population.At the state and local level, there is a question as to which service organization - the county aging agency or the county mental health system - is responsible for the mental health care of the elderly. Conflicting priorities led each system to focus on what they regard as their primary functions rather than addressing collaborative programs and strategies. In recent years, the aging agencies have been more concerned with long-term care while the mental health systems in many states have focused on developing programs for the seriously and persistently mentally ill. A conundrum for advocates requesting additional mental health funding is the response from state funders that there is no point in additional allocations since they believe the elderly don't take advantage of the services already available. It is difficult to convince the people in control of the purse strings that the reason existing services aren't more frequently used is that the programs are not responsive to the needs of older consumers in the first place.Service Integration: Is it An Impossible Dream?The lack of coordinated, comprehensive health care has a negative impact on all age groups in the United States. For older adults who tend to have multiple needs, these health systems are highly fragmented and a bewildering source of patient confusion. Many elders withdraw from service feeling overwhelmed by the long waits and complex procedures.Connections between primary care and social services are limited as are links with primary care and mental health services for older adults. Although there is unanimous agreement about the value of communication and of streamlined intake procedures, most agencies continue to function in isolation from one other. A big reason for this is the limited and parallel funding the agencies receive, which does not encourage the sharing of resources. As a result, many service organizations are deeply concerned about maintaining their autonomy and their funding - attitudes which do not foster inter-agency collaboration.CMHCs in most areas of the country have devoted their resources to serving children and seriously mentally ill young populations. These centers have not been well integrated with social service agencies or with the network of primary care providers that are so important to older consumers. ReimbursementThere is a large disparity in Medicare and Medicaid reimbursement between psychiatric care and medical care. This has deterred many prospective psychiatrists, social workers, and psychologists from considering careers in geriatric mental health. Since its enactment in 1985, Medicare has specifically limited reimbursement to all the disciplines engaged in treating older adults. Not only are professionals reimbursed at lower rates, but co-payments for consumers are higher than for standard medical care. This is another drawback for older persons considering mental health treatment. Despite pressure from national professional organizations, there has been no significant improvement in this area from the Health Care Finance Corporation (HCFA),the agency that administers the Medicare program.Lack of Organized SupportIn contrast to the activities of groups such as the Alliance for the Mentally Ill (AMI), the National Mental Health Association, Disabled Americans, and Developmentally Disabled Children, there has been very little national attention directed to the quality and quantity of mental health services available to the nation's elders. Attempts to organize older people struggling with psychiatric disorders combined with physical impairments have met with minimal success. Local attempts to engage adult sons and daughters have not generated positive results.Does the absence of organized concern suggest indifference to the mental health needs of elders? There is no one reason why older people with mental health problems have been overlooked and underserved. If funds were available, a public health education campaign to sensitize legislators and the general public might be a positive initial step.

TYPES OF MENTAL DISORDERSMental Health DisordersSome mental health disorders can develop early in life (occurring as young as childhood and adolescence), such as schizophrenia and bipolar disorder. Other mental health disorders, such as depression and anxiety, can develop at any time in life and tend to be fairly common in older adults. According to the Surgeon General's report on mental health, up to 20% of adults over 65 experience some type of mental disorder, yet researchers believe that more than 60% of those people needing mental health services go without. However, individuals who get proper treatment generally respond well.

Differences between Grief and DepressionCharacteristic Grief DepressionOnset of depressed feelings Caused by one or more recognizable losses (loved one,independence, financialsecurity,pet, etc.) May not relate to a particular life event or loss,or a loss may be seen as punishment Expressions of anger May be openly angry; anger often misdirected Irritable and may complain; does not express anger openly; anger primarily directed inwardly toward self Expressions of sadness Feelings of sadness, and emptiness, weeping Pervasive feelings of sadness, hopelessness;chronic feelings of emptiness; may have difficulty weeping or difficulty controlling weeping Physical complaints May have temporary physical complaints Chronic physical complaints Sleep May sometimes have difficulty getting to sleep; may have disturbing dreams Early morning wakening, insomnia or excessive sleeping (escape into sleep) Insight May be preoccupied with loss of person, object, or ability; may have guilt over some aspect of the loss; temporary loss of self-esteemPreoccupation with self; generalized feelings of guilt; may have thoughts of suicide; longer-term loss of self-esteemResponsiveness and acceptance of support Responds to comfort, support; may want not to impose grief on others Does not accept support; tends to isolate self; may be unresponsive Pleasure Ability to feel pleasure varies, but can still experience moments of enjoyment Often a persistent inability to feel pleasure Others' reactions toward the person Tendency for others to feel sympathy for person; may want to touch or hold person who is grieving Tendency for others to feel irritation with person; may not want to touch or hold the person who is depressed

So why wouldn't so many individuals get the treatment that they need? There may be severalreasons:_ First, many mental health problems may go unrecognized or unreported. The individualexperiencing the problem may not realize that they need mental health treatment, or feel tooembarrassed to ask for help. _ Others, including doctors and caregivers, may dismiss symptoms as a natural part of the aging process. For instance, the person who seems hopeless ormelancholy may be thought to be grieving or experiencing prolonged bereavement.As a result, what is actually depression may go untreated. _ Sometimes mental health symptoms can show up as physical complaints and an assessment may not fully explore causes and options._ The stigma of mental illness can prevent people from recognizing or admitting a mental health problem. Mental health disorders that are not severe can often be treated through one's primary care physician (PCP) if a thorough physical has been done. Biological or physical factors that can influence the mental health of individuals at any age include:_ a vitamin deficiency_ nutrition_ prescription medications_ vitamins or other nutritional supplements_ over-sensitivity to alcoholic beverages_ over-the-counter drugs (some may interact with prescriptions)_ herbal use_ type and amount of exercise_ stress of change and loss (common for older adults)_ bump on the head or other injury_ physical illness

More serious mental health disorders should be referred to a mental health professional. In New Hampshire there are private providers who accept various types of insurance. Community mental health centers exist in every region of the state and accept private insurance as well as Medicaidand Medicare. (See Appendix for listing of mental health centers). There are also some facilitiesthat specialize in the care of older adults with mental illness. This section will describe some of the disorders that occur and their treatments.DEPRESSIONDepression is considered the most common mental disorder of people aged 65 and older. Many researchers think this estimate is low because the symptoms of depression often appear in people who have other conditions, or can mimic the symptoms of dementiaits victims withdraw, cannot concentrate, and appear confused. Some experts estimate that as many as 10 percent of those diagnosed with dementia actually suffer from depression that, if treated, is reversible. DepressionDepression is not a normal part of aging. Yet depression is a widely underrecognized and undertreated medical illness.Depression often co-occurs with other serious illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson's disease. Because many older adults face these illnesses as well as various social and economic difficulties, health care professionals may mistakenly conclude that depression is a normal consequence of these problems an attitude often shared by patients themselves.These factors together contribute to the underdiagnosis and undertreatment of depressive disorders in older people. Depression can and should be treated when it co-occurs with other illnesses, for untreated depression can delay recovery from or worsen the outcome of these other illnesses.DepressionDepression is a common condition amongst elderly women. Research has shown that more than one third of all depressed patients seen by doctors will go untreated because they are not properly diagnosed. Therefore, it is very important to know the symptoms of depression so that a scenario of misdiagnosis or lack of diagnosis will not occur. Usually women will not complain directly of sadness. Rather, they will complain of a host of other, seemingly unrelated symptoms, which serve to attract their doctor's attention. Common symptoms can include, but are not limited to: Disturbances in sleep, self-esteem, libido, appetite, interest, energy, concentration, memory, and movement Feelings of guilt Suicidal thoughts, plans, or attempts PainDepression can be caused by several personal losses experienced in rapid sequence, which is often the case in the elderly. While the lifetime risk for major depression is only 7-12% in men, it is a whopping 20-25% in women. Why this is so is not clear. What is clear, however, is that certain medical conditions seem to be associated with depression. These conditions include, among others: Alzheimer's disease Cancer (including breast and ovarian) Congestive heart failure Diabetes Parkinson's disease Rheumatoid arthritis Sexual dysfunctionThe elderly are also commonly taking many more medications than younger people are. Some of these medications are known to be associated with depression. Following is a selected list of these medications: Anticancer drugs Anti-inflammatory drugs ProgesteroneAnti-depressants are used to treat depression, and they usually are 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: Tricyclics such as imipramine, desipramine, amitryptyline, and nortriptyline Heterocyclics Selective serotonin reuptake inhibitors (SSRIs) such as Prozac Monoamine oxidase inhibitors (MAOIs)There are quite a few side effects to these medications, which the elderly population is more susceptible to. These side effects include: Blurred vision Dry mouth Urinary retention Confusion Constipation Drowsiness Insomnia Cardiac arrhythmia Hypotension Gastrointestinal distress Weight fluctuations Sexual dysfunctionDepression

Depression is a common disorder found in older adults, affecting as many as 20% of people over 65. However, it is not a normal part of the aging process and should not be ignored. Depression:_ may be overlooked by caregivers and treatment providers;_ is often associated with other medical problems, such as cancer and heart conditions, vitamin deficiency, diabetes, medical operations, and trauma such as from a car accident;_ can diminish a person's ability to recover from diseases;_ can increase the risk of suicide, which is higher in older adults than any other age group.Clinical depression should not be confused with bereavement, which is generally a grief reaction to some type of loss.

Signs of clinical depression include:_ change in sleep habits, either sleeping much more or much less_ poor appetite or overeating, resulting in significant weight loss or gain_ poor concentration or difficulty making decisions _ fatigue or loss of energy_ expressions of hopelessness or worthlessness_ persistent low mood or apathy_ low self-esteem_ loss of pleasure in usual activities_ expressing desire to die or thoughts about dying, and/or making suicide attemptThese symptoms generally persist for two weeks or more and can occur continuously or in cycles for periods of years. Sleep disturbance in and of itself is common in older adults and can be linked to depression, poor health, and other problems such as angina and overuse of tranquilizers. The good news is that depression is a very treatable disorder.

Questions to ask yourself:*In the past month:_ Have you been bothered by having little interest or pleasure in doing things?_ Have you been bothered by feeling down, depressed, or hopeless?_ Have you had difficulty sleeping or had a poor appetite with weight loss?_ Have you felt irritated or annoyed by little things?If you answered yes to any of these questions, talk to a professional who can assess your feelings and help you determine what might be beneficial.

TreatmentThere are different kinds of treatments:_ Medications: many older and newer antidepressants exist on the market. About 6580%of individuals will respond to the first medication used._ Counseling can be another useful part of treatment._ Hospitalization is sometimes used short term._ Electroconvulsive treatment may be used successfully, as determined with a doctor._ Other alternatives exist and should be discussed with a doctor.

Suicide: The Risk of Untreated Depression

Americans over the age of 65 have the highest rate of suicide of any age group. Statistically this rate increases even more for white males and persons over the age of 85. Older adults who are either single, widowed, or divorced are also at higher risk than those who are married. Some individuals may stop taking medications or may not eat because of a desire to fade away. Depression that goes untreated is a major factor in suicide attempts. An estimated 27 out of 30 people who commit suicide are clinically depressed. However, depression is very treatable!It is important to seek help immediately if a person seems to have lost interest in taking care of him/herself.

Suicide Risk Factors*Family members, health care providers, and other supporters should be aware of the followingsuicide risk factors:_ divorce, widowhood or single status-marriage has a minimizing effect_ males are at high risk within six months after the loss of a partner_ lower socioeconomic status_ retirement of those who have few other interests_ living in an urban area_ persistent insomnia_ marked feelings of guilt and inadequacy_ estrangement from family and friends_ extreme isolation_ delirium_ agitation_ alcoholism_ depression induced by a physical disorder_ painful, debilitating and/or terminal illness_ the threat of extreme dependency or institutionalization

People who are feeling suicidal may say something specific about their desire to die; but others may make only subtle comments or say nothing at all.

The following may be signs that a person is thinking about suicide, particularly if the person is experiencing other symptoms of depression:_ withdrawal from those close to them_ putting closure on relationships, saying goodbye, and/or expressing guilt and regrets_ writing or revising a will, and/or giving away possessions_ making statements like: I have nothing to live for or my family would be better off without me_ expressing plans to die, and describing a method that is thought through and feasible

Risk of suicide is increased with those who show signs of depression or thoughts of suicideand have the ability to carry out the plan, i.e. have access to a gun or other lethal means.

If you are feeling hopeless or are providing care for someone who may be suicidal, speak tosomeone you trust about it immediately and seek help from a professional. There are many simple solutions that can refocus a person's outlook:_ a mild antidepressant_ a visit by person's family_ a change of environment (i.e. a short trip away from home)_ leading the person to talk about joyful memories from their past_ work with health care professionals to address sleep and anxiety issues_ work to develop a close system of supportive people

What to do if you think someone is suicidal:_ Talking with the person and expressing your concern can open the opportunity for them to discuss their feelings and seek help._ Allow the person to talk as often and as long as they need to._ Get the person in touch with professionals who can evaluate them, such as a mental health center, if they are not already in treatment.

Follow up to ensure that they are gettingtreatment._ In urgent situations, mental health centersaround NH have 24 hour emergency services;or contact the mental health provider with whom the person is in treatment. Call the police if you feel the person is in imminent risk and refusing to be evaluated. If a person who shows signs of being suicidal refuses to see someone for an evaluation, they may need to be brought in under an involuntary legal process called a Complaint and Prayer. This is a last resort option and community mental health centers can provide consultation as to when this would be appropriate. If someone is concerned about an individual who appears to be suicidal and refusing to be seen, consultation with a mental health professional should besought. The person should not be ignored if they refuse to seek help, but should be encouraged to talk with a person who may be able to help them. It may help if a support person offers to

Elder Mental Health Concern #2 Depression and SuicideStudies show that up to 20% of senior adults suffer from depression. As noted by the American Psychological Association (APA) , for older adults, depression has even more serious side effects than for younger individuals as even mild depression lowers a persons immunity, and because older adults typically deal with more chronic illnesses, this can have a devastating effect.In addition, depression is a major factor in suicide and suicide attempts. That is why it is so important to watch for any signs of depression in your older loved ones. Do not assume that depression is normal or part of being old or ill. It can be treated and should be.In fact, many suicides in older adults might be preventable. Studies show that 20% of individuals that commit suicide see their doctor the day that they pass on with 40% seeing their doctor in the same week, and 70% in the same month. You can help your loved one recognize the signs of depression. These include: Loss of appetite Sleeping more than normal Self-isolation Lack of interest in activities they normally enjoyElderly mental health is a concern for everyone from their family members to their doctors. Often doctors overlook the signs because older adults dont want to admit that they are depressed which is why it is so important for family members to be on the look out for the signs as well. By doing so you could save a life of someone close to you.

DEPRESSIONDepressive syndromes are frequent in old age (4 , 5) and especially frequent are minor forms of depression like dysthymia, or subsyndromal depression. Although late-life depression is a chronic and disabling illness, there is a common misconception that it is a normal feature of aging. Depression at old age is therefore under-recognized and severely under-treated, especially in very old age with high somatic comorbidity.The obsolete distinction between reactive depression on one hand and endogenous depression on the other hand is one major source of this undertreatment. Depressive syndromes in the elderly, even more than in younger patients, impair functioning, reduce life-quality and induce somatic complaints. Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. Beside comorbidorganic syndromes, personal history of depression, death of spouse, health related factors and anxiety disorders show significant associations with incidence of depression. Depression in old age is causally associated with somatic disorders and stress due to the patients. perception of diseases which are serious, life threatening, painful, chronic, untreatable or disabling. Some somatic diseases are associated with particularly high probabilities for the patients to suffer from depression. Cardial insufficiency, diabetes, stroke, or Parkinson.s disease are strongly associated with depressive disorder. Other diseases with high depressive comorbidity are Alzheimer dementia, coronary heart disease, cancer, and primary chronic polyarthritis. Since many aspects of physical health can be targeted for improvement in primary care, it is important to know that physical health problems are a predictor of both the onset and the persistence of depression. A recent study with a complex epidemiological design, part of the .Amsterdam Aging Study., has proven that depression in old age follows physical health problems in most cases. Persistent physical health problems are also strong predictors of chronicity of depression. Depression is enormously frequent in hospitals or chronic care units. More than 80 % of the patients at the Geriatric Care Hospital .Pflegeheim Lainz. . now called .Geriatric Center Wienerwald. suffered from pervasive depression in 1986. The treatment of depression in old age is at least as effective as it is in

Table 3: Mental disorders in old people (over 70 years) (except sleep disorders, except somatoform disorders) (2).Mental disorders in old peopleDementia 14 %Mild cognitive impairment ?? %Depression 9 %Subsyndromal depression 16 %Panic disorder 2 %Generalized anxiety disorder 12 %Social phobia 5 %Addiction 2 %At least one mental disorder 34 %

the younger patient. Antidepressants are as effective in acute treatment in older, as in younger, depressed adults. Maintenance antidepressant therapy also appears as effective in older patients. Modern antidepressive agents such as the selective serotonin re-uptake inhibitors (SSRIs) have a favorable safety and tolerability profiles, making them a suitable treatment option for older patients, who are more vulnerable to adverse effects. Organization of treatment of depression in old age would largely improve life quality of both patients and care-givers, but it would also save lives by preventing suicides.Depression Depression is an emotional state characterised by exaggerated feelings of sadness, dejection and helplessness. The elderly have a much higher risk of depression and suicide than the young because major losses tend to take place in the later stages of life eg. medical illnesses, changes in physical status, loss of income on retirement, death of parents and friends, loss of a life partner and changes in accommodation arrangements.Many depressions are missed or thought of as normal by the family and hence undetected. Early detection and proper treatment is crucial to prevent unnecessary suffering.The common symptoms of depression include a recent change in mood, especially pessimism, gloom and loss of cheerfulness. There may be poor concentration, lethargy, loss of interest in activities, a sense of guilt, changes in appetite and sleep. There are also abnormal symptoms of severe anxiety or bodily complaints. Eg. the affected person may develop unnecessary worry over apparently trivial issues, or may be constantly seeking attention for bodily aches and discomfort. Sometimes, depression can also cause memory changes.Signs and symptoms of depression in older adults and the elderlyRecognizing depression in the elderly starts with knowing the signs and symptoms. Depression red flags include: Sadness Fatigue Abandoning or losing interest in hobbies or other pleasurable pastimes Social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home) Weight loss or loss of appetite Sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness) Loss of self-worth (worries about being a burden, feelings of worthlessness, self-loathing) Increased use of alcohol or other drugs Fixation on death; suicidal thoughts or attempts

Depression without sadnessWhile depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly.Depression clues in older adultsOlder adults who deny feeling sad or depressed may still have major depression. Here are the clues to look for: Unexplained or aggravated aches and pains Feelings of hopelessness or helplessness Anxiety and worries Memory problems Lack of motivation and energy Slowed movement and speech Irritability Loss of interest in socializing and hobbies Neglecting personal care (skipping meals, forgetting meds, neglecting personal hygiene)

Depression: A problem for many older adults and the elderlyHave you lost interest in the activities you used to enjoy? Do you struggle with feelings of helplessness and hopelessness? Are you finding it harder and harder to get through the day? If so, youre not alone.Depression is a common problem in older adults. The symptoms of depression affect every aspect of your life, including your energy, appetite, sleep, and interest in work, hobbies, and relationships.Unfortunately, all too many depressed seniors fail to recognize the symptoms of depression, or dont take the steps to get the help they need. There are many reasons depression in older adults and the elderly is so often overlooked: You may assume you have good reason to be down or that depression is just part of aging. You may be isolatedwhich in itself can lead to depressionwith few around to notice your distress. You may not realize that your physical complaints are signs of depression. You may be reluctant to talk about your feelings or ask for help.Feeling good as you ageDepression isnt a sign of weakness or a character flaw. It can happen to anyone, at any age, no matter your background or your previous accomplishments in life. Similarly, physical illness, loss, and the challenges of aging dont have to keep you down. Whether youre 18 or 80, you dont have to live with depression. Senior depression can be treated, and with the right support, treatment, and self-help strategies you can feel better and live a happy and vibrant life.Causes of depression in older adults and the elderlyAs you grow older, you face significant life changes that can put you at risk for depression. Causes and risk factors that contribute to depression in older adults and the elderly include: Health problems Illness and disability; chronic or severe pain; cognitive decline; damage to body image due to surgery or disease. Loneliness and isolation Living alone; a dwindling social circle due to deaths or relocation; decreased mobility due to illness or loss of driving privileges. Reduced sense of purpose Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities. Fears Fear of death or dying; anxiety over financial problems or health issues. Recent bereavements The death of friends, family members, and pets; the loss of a spouse or partner.Bereavement, loss, and depression in older adults and the elderlyAs you age, you experience many losses. Loss is painfulwhether its a loss of independence, mobility, health, your long-time career, or someone you love. Grieving over these losses is normal and healthy, even if the feelings of sadness last for a long time. Losing all hope and joy, however, is not common.Is it grief or depression?Distinguishing between grief and clinical depression isnt always easy, since they share many symptoms. However, there are ways to tell the difference. Remember, grief is a roller coaster involving a wide variety of emotions and a mix of good and bad days. Even when youre in the middle of the grieving process, you will have moments of pleasure or happiness. With depression, on the other hand, the feelings of emptiness and despair are constant.While theres no set timetable for grieving, if it doesnt let up over time or extinguishes all signs of joylaughing at a good joke, brightening in response to a hug, appreciating a beautiful sunsetit may be depression.Other symptoms that suggest depression, not just grief: Intense, pervasive sense of guilt. Thoughts of suicide or a preoccupation with dying. Feelings of hopelessness or worthlessness. Slow speech and body movements. Inability to function at work, home, and/or school. Seeing or hearing things that arent there.

Depression and illness in older adults and the elderlyDepression in older adults and the elderly is often linked to physical illness, which can increase the risk for depression. Chronic pain and physical disability can understandably get you down. Symptoms of depression can also occur as part of medical problems such as dementia or as a side effect of prescription drugs.Medical conditions can cause depression in older adultsIts important to be aware that medical problems can cause depression in older adults and the elderly, either directly or as a psychological reaction to the illness. Any chronic medical condition, particularly if it is painful, disabling, or life-threatening, can lead to depression or make depression symptomsworse.

These include: Parkinsons disease stroke heart disease cancer diabetes thyroid disorders Vitamin B12 deficiency dementia and Alzheimers disease lupus multiple sclerosis

Prescription medications and depression in older adultsSymptoms of depression are a side effect of many commonly prescribed drugs. Youre particularly at risk if youre taking multiple medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because, as we age, our bodies become less efficient at metabolizing and processing drugs.Medications that can cause or worsen depression include: Blood pressure medication (clonidine) Beta-blockers (e.g. Lopressor, Inderal) Sleeping pills Tranquilizers (e.g. Valium, Xanax, Halcion) Calcium-channel blockers Medication for Parkinsons disease Ulcer medication (e.g. Zantac, Tagamet) Heart drugs containing reserpine Steroids (e.g. cortisone and prednisone) High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor) Painkillers and arthritis drugs Estrogens (e.g. Premarin, Prempro)

If you feel depressed after starting a new medication, talk to your doctor. You may be able to lower your dose or switch to another medication that doesnt impact your mood. Alcohol and depression in older adultsIt can be tempting to use alcohol to deal with physical and emotional pain as you get older. It may help you take your mind off an illness or make you feel less lonely. Or maybe you drink at night to help you get to sleep.While alcohol may make you feel better in the short term, it can cause problems over time. Alcohol makes symptoms of depression, irritability, and anxiety worse and impairs your brain function. Alcohol also interacts in negative ways with numerous medications, including antidepressants. And while drinking may help you nod off, it can impair the quality of your sleep.Dementia vs. depression in the elderlyNever assume that a loss of mental sharpness is just a normal sign of old age. It could be a sign of either depression or dementia, both of which are common in older adults and the elderly.Since depression and dementia share many similar symptoms, including memory problems, sluggish speech and movements, and low motivation, it can be difficult to tell the two apart. There are, however, some differences that can help you distinguish between the two.Is it Depression or Dementia?

Symptoms of DepressionSymptoms of Dementia

Mental decline is relatively rapidMental decline happens slowly

Knows the correct time, date, and where he or she isConfused and disoriented; becomes lost in familiar locations

Difficulty concentratingDifficulty with short-term memory

Language and motor skills are slow, but normalWriting, speaking, and motor skills are impaired

Notices or worries about memory problemsDoesnt notice memory problems or seem to care

Whether cognitive decline is caused by dementia or depression, its important to see a doctor right away. If its depression, memory, concentration, and energy will bounce back with treatment. Treatment for dementia will also improve you or your loved ones quality of life. And in some types of dementia, symptoms can be reversed, halted, or slowed.Depression self-help for older adults and the elderlyDealing with depressionYou cant beat depression through sheer willpower, but you do have some controleven if your depression is severe and stubbornly persistent. Read Dealing with Depression Its a myth to think that after a certain age you cant learn new skills, try new activities, or make fresh lifestyle changes. The truth is that the human brain never stops changing, so older adults are just as capable as younger people of learning new things and adapting to new ideas. Overcoming depression often involves finding new things you enjoy, learning to adapt to change, staying physically and socially active, and feeling connected to your community and loved ones.If youre depressed, you may not want to do anything or see anybody. But isolation and inactivity only make depression worse. The more active you arephysically, mentally, and sociallythe better youll feel. Exercise. Physical activity has powerful mood-boosting effects. In fact, research suggests it may be just as effective as antidepressants in relieving depression. The best part is that the benefits come without side effects. You dont have to hit the gym to reap the rewards. Look for small ways you can add more movement to your day: park farther from the store, take the stairs, do light housework, or enjoy a short walk. Even if youre ill, frail, or disabled, there are many safe exercises you can do to build your strength and boost your moodeven from a chair or wheelchair. Connect with others, face to face whenever possible. Getting the support you need plays a big role in lifting the fog of depression and keeping it away. On your own, it can be difficult to maintain perspective and sustain the effort required to beat depression. You may not feel like reaching out, but make an effort to connect to others and limit the time youre alone. If you cant get out to socialize, invite loved ones to visit you, or keep in touch over the phone or email. And remember, its never too late to build new friendships. Start by joining a support group for depression, a book club, or another group of people with similar interests. Bring your life into balance. If youre feeling overwhelmed by stress and the pressures of daily life, it may be time to learn new emotional management and emotional intelligence skills. Watch the short video clip and consider following Helpguides free Bring Your Life Into Balance toolkit.Other self-help tips to combat and prevent depression in older adults Get enough sleep. When you don't get enough sleep, your depression symptoms can be worse. Aim for somewhere between 7 to 9 hours of sleep each night. Maintain a healthy diet. Avoid eating too much sugar and junk food. Choose healthy foods that provide nourishment and energy, and take a daily multivitamin. Participate in activities you enjoy. Pursue whatever hobbies or pastimes bring or used to bring you joy. Volunteer your time. Helping others is one of the best ways to feel better about yourself and expand your social network. Take care of a pet. A pet can keep you company, and walking a dog, for example, can be good exercise for you and a great way to meet people. Learn a new skill. Pick something that youve always wanted to learn, or that sparks your imagination and creativity. Create opportunities to laugh. Laughter provides a mood boost, so swap humorous stories and jokes with your loved ones, watch a comedy, or read a funny book.Depression treatment options for older adults and the elderlyDepression treatment is just as effective for elderly adults as it is for younger people.However, since depression in older adults and the elderly is often the result of a difficult life situation or challenge, any treatment plan should address that issue. If loneliness is at the root of your depression, for example, medication alone is not going to cure the problem.Also, any medical issues complicating the depression must be also be addressed.Antidepressant treatment for older adults and the elderlyOlder adults are more sensitive to drug side effects and vulnerable to interactions with other medicines theyre taking.Recent studies have also found that SSRIs such as Prozac can cause rapid bone loss and a higher risk for fractures and falls. Because of these safety concerns, elderly adults on antidepressants should be carefully monitored.In many cases, therapy and/or healthy lifestyle changes, such as exercise, can be as effective as antidepressants in relieving depression, but without the dangerous side effects.Alternative medicine for depression in older adults and the elderlyHerbal remedies and natural supplements can also be effective in treating depression, and in most cases, are much safer for older adults than antidepressants. However, some herbal supplements may cause interactions with certain medications or occasionally carry side effects, so always check with your doctor before taking them. Omega-3 fatty acids may boost the effectiveness of antidepressants or work as a standalone treatment for depression. St. Johns wort can help with mild or moderate symptoms of depression but should not be taken with antidepressants. Folic acid can help relieve symptoms of depression when combined with other treatments. SAMe may be used in place of antidepressants to help regulate mood, but in rare cases can cause severe side effects.Counseling and therapy for older adults and the elderlyTherapy works well on depression because it addresses the underlying causes of the depression, rather than just the symptoms. Supportive counseling includes religious and peer counseling. It can ease loneliness and the hopelessness of depression, and help you find new meaning and purpose. Therapy helps you work through stressful life changes, heal from losses, and process difficult emotions. It can also help you change negative thinking patterns and develop better coping skills. Support groups for depression, illness, or bereavement connect you with others who are going through the same challenges. They are a safe place to share experiences, advice, and encouragement.Helping a depressed older adult or seniorThe very nature of depression interferes with a person's ability to seek help, draining energy and self-esteem. For depressed seniors, raised in a time when mental illness was highly stigmatized and misunderstood, it can be even more difficultespecially if they dont believe depression is a real illness, are too proud or ashamed to ask for assistance, or fear becoming a burden to their families.If an elderly person you care about is depressed, you can make a difference by offering emotional support. Listen to your loved one with patience and compassion. You dont need to try to fix someones depression; just being there to listen is enough. Dont criticize feelings expressed, but point out realities and offer hope. You can also help by seeing that your friend or family member gets an accurate diagnosis and appropriate treatment. Help your loved one find a good doctor, accompany him or her to appointments, and offer moral support.Other tips for helping a depressed elderly friend or relative: Invite your loved one out. Depression is less likely when peoples bodies and minds remain active. Suggest activities to do together that your loved one used to enjoy: walks, an art class, a trip to the museum or the moviesanything that provides mental or physical stimulation. Schedule regular social activities. Group outings, visits from friends and family members, or trips to the local senior or community center can help combat isolation and loneliness . Be gently insistent if your plans are refused: depressed people often feel better when theyre around others. Plan and prepare healthy meals. A poor diet can make depression worse, so make sure your loved one is eating right, with plenty of fruit, vegetables, whole grains, and some protein at every meal. Encourage the person to follow through with treatment. Depression usually recurs when treatment is stopped too soon, so help your loved one keep up with his or her treatment plan. If it isnt helping, look into other medications and therapies. Make sure all medications are taken as instructed. Remind the person to obey doctor's orders about the use of alcohol while on medication. Help them remember when to take their dose. Watch for suicide warning signs. Seek immediate professional help if you suspect that your loved one is thinking about suicide.Depression in Older PersonsFact SheetHow common is depression in later life?Depression affects more than 6.5 million of the 35 million Americans aged 65 years or older. Most people in this stage of life with depression have been experiencing episodes of the illness during much of their lives. For others, depression has a first onset in late lifeeven persons in their 80s and 90s. Depression in older persons is closely associated with dependency and disability and causes great suffering for the individual and the family.Why does depression in the older population often go untreated?Depression in elderly people often goes untreated because many people think that depression is a normal part of aging and a natural reaction to chronic illness, loss and social transition. Elderly people do face noteworthy challenges to their connections through loss and also face medical vulnerability and mortality. For the elderly population depression can come in different sizes and shapes. Many elderly people and their families don't recognize the symptoms of depression, aren't aware that it is a medical illness and don't know how it is treated. Others may mistake the symptoms of depression as signs of:DementiaAlzheimers DiseaseArthritisCancerHeart diseaseParkinsonsStrokeThyroid disordersAlso, many older persons think that depression is a character flaw and are worried about being made fun of or of being humiliated. They may blame themselves for their illness and are too ashamed to get help. Others worry that treatment would be too costly. Yet research has also shown that treatment is effective and in fact changes the brain when it works.What are the consequences of untreated depression in older persons?Late-life depression increases risk for medical illness and cognitive decline. Unrecognized and untreated depression has fatal consequences in terms of both suicide and nonsuicide mortality. The highest rate of suicide in the U.S. is among older white men. Depression is the single most significant risk factor for suicide in the elderly population. Tragically, many of those people who go on to die by suicide have reached out for help20 percent see a doctor the day they die, 40 percent the week they die and 70 percent in the month they die. Yet depression is frequently missed. Elderly persons are more likely to seek treatment for other physical aliments than they are to seek treatment for depression.Are symptoms of depression different in older persons than in younger persons?Symptoms in older persons may differ somewhat from symptoms in other populations. Depression in older persons is at times characterized by: Memory problems Confusion Social withdrawal Loss of appetite Weight loss Vague complaints of pain Inability to sleep Irritability Delusions (fixed false beliefs) HallucinationsOlder individuals who are depressed often have severe feelings of sadness but these feelings frequently are not acknowledged or openly shown; sometimes, when asked if they are "depressed," the answer is "no." Some general clues that someone may be experiencing depression are: Persistent and vague complaints Help-seeking Moving in a more slow manner Demanding behaviorHow can clinical depression be distinguished from normal sadness and grief?It's natural to feel grief in the face of major life changes that many elderly people experience, such as leaving a home of many years or losing a loved one. Sadness and grief are normal, temporary reactions to the inevitable losses and hardships of life. Unlike normal sadness, however, clinical depression doesn't go away by itself and lasts for months. Clinical depression needs professional treatment to reduce duration and intensity of symptoms. Any unresolved depression can affect the body. For example, depression, if left untreated, is a risk for heart disease and can suppress the immune system raising the risk of infection.What causes depression in older persons?Although there is no single, definitive answer to the question of cause, many factorspsychological, biological, environmental and geneticlikely contribute to the development of depression. Scientists think that some people inherit a biological make-up that makes them more prone to depression. Imbalances in certain brain chemicals like norepinephrine, serotonin and dopamine are thought to be involved in major depression.While some people become depressed for no easily identified reason, depression tends to run in families and the vulnerability is often passed from parents to children. When such a genetic vulnerability exists, other factors like prolonged stress, loss or a major life change can trigger the depression. For some older people, particularly those with lifelong histories of depression, the development of a disabling illness, loss of a spouse or a friend, retirement, moving out of the family home or some other stressful event may bring about the onset of a depressive episode. It should also be noted that depression can be a side effect of some medications commonly prescribed to older persons, such as medications to treat hypertension. Finally, depression in the elderly population can be complicated and compounded by dependence on substances such as alcohol which acts as a depressant.Are some older persons at highest risk for depression?Older women are at a greater risk because women in general are twice as likely as men to become seriously depressed. Biological factors like hormonal changes may make older women more vulnerable. The stresses of maintaining relationships or caring for an ill loved one and children also typically fall more heavily on women, which could contribute to higher rates of depression. Unmarried and widowed individuals as well as those who lack a supportive social network also have elevated rates of depression.Conditions such as heart attack, stroke, hip fracture or macular degeneration and procedures such as bypass surgery are known to be associated with the development of depression. In general, depression should be assessed as a possibility if recovery from medical procedure is delayed, treatments are refused or problems with discharge are encountered.How is depression in older persons diagnosed?A physical exam can determine if depressive symptoms are being caused by another medical illness. Medical concerns and their treatment are common in this population. A review of the individuals medications is important as a simple medication change can reduce symptom intensity in some cases. A clinical and psychiatric interview is a key aspect of the assessment. Speaking with family members or close friends may be helpful in making a diagnosis. Blood tests and imaging studies (like a CT scan) are helpful insofar as they rule out other medical conditions that would require a different path of intervention.Can depression in older persons be treated?Fortunately, the treatment prognosis for depression is good. Once diagnosed, 80 percent of clinically depressed individuals can be effectively treated by medication, psychotherapy, electroconvulsive therapy (ECT) or any combination of the three. A novel treatment transcranial magnetic stimulation (TMS) has been cleared by the FDA and may be helpful for mild depression that has not been helped by one medication trial. Medication is effective for a majority of people with depression. Four groups of antidepressant medications have been used to effectively treat depressive illness: selective serotonin re-uptake inhibitors (SSRIs) and norepinephrine and serotonin reuptake inhibitors (NSRIs), and less commonly, tricyclics, monoamine oxidase inhibitors (MAOIs), Medication adherence is especially important, but can present challenges among forgetful individuals.It is important to note that all medicines have side effects as well as benefits., and the selection of the best treatment is often made based on tolerability of the side effects.ECT (also known as shock treatment) may be very useful in the treatment of severe depression in older adults. For carefully selected people, ECT can be a lifesaving intervention. For example, an 80 year old man who lives alone, has been depressed for months, lost 60 pounds and has delusions about his body as a kind of presentation that may improve quickly with ECT. ECT can impact memory so that is an important consideration in comparing it to other interventions.Medications can be beneficial for elderly individuals in treating the symptoms of depression. Medications are frequently combined with supportive psychotherapy or cognitive behavioral therapy to improve their effectiveness. Research has shown that some depressed individuals may need to try more than one medication to get an optimal response.Psychosocial treatment plays an essential role in the care of older patients who have significant life crises, lack social support or lack coping skills to deal with their life situations. Because large numbers of elderly people live alone, have inadequate support systems or do not have contact with a primary care physician, special efforts are needed to locate and identity these people to provide them with needed care. Natural supports like church or bridge friends should be encouraged. There are services available to help older individuals, but the problem of clinical depression must be detected before treatment can begin.Like diabetes or arthritis, depression is a chronic disease. Getting well is only the beginning of the challengestaying well is the real goal. For people experiencing their first episode of depression later in life, most experts would recommend treatment for six months to one year after acute treatment that achieves remission. For those that have had two or three episodes during their lifetimes, treatment should extend up to two years after remission. For peopled with more than three recurrences of depression, treatment may be life-long. The treatment that gets someone well is the treatment that will keep that person well.Delirium Delirium is characterised by a sudden behavioural change, with agitation, inattention, disorientation and memory changes which fluctuate as the day progresses. To the family, the person affected may appear episodically confused. Eg. a person who is independent and well can suddenly appear perplexed and restless, sometimes acting normal, only to become restless and agitated again hours later. Sometimes, there is drowsiness. The sleep-wake cycle is usually disrupted, and the fluctuations are usually more prominent in the evenings and at night.Delirium requires urgent medical attention as it is associated with higher health risks. It may be caused by infections, a minor stroke, undiagnosed or poorly controlled diabetes, hypertension (high blood pressure) etc. Side effects of certain medications can sometimes cause delirium. The person presenting with delirium for the first time often requires hospitalisation in order to identify and treat the underlying cause. Most patients improve with treatment. If left untreated, delirium may progress to dementia or deathDeliriumElderly patients, and especially women, are extremely sensitive to things such as surgery and anesthesia, drug toxicity, and infections like urinary tract infections (especially in women). The symptoms of delirium are often misdiagnosed as relating to other conditions. Common symptoms include: Sudden reduced ability to focus, sustain, or shift attention Disturbed consciousness Sudden onset of misperceptions Impaired judgement Increased or decreased motor activityIf the symptoms develop over a short period of time, fluctuate over the course of the day, or can be caused by a general medical condition, it is quite possible that the patient is suffering from delirium. A diagnosis of delirium can be made if the patient's EEG (electroencephalogram) findings show a slowing of activity in the brain.

In order to effectively treat delirium, the doctor needs to first identify the underlying cause. Haloperidol is commonly given to patients experiencing delirium to try to reduce the symptoms.`DeliriumReliable statistics on delirium are difficult to establish and most estimates are based on studies of patients admitted to hospital. Unquestionably, the actual prevalence of delirium is much higher but is less easy to count when ill elderly who become delirious are treated out of hospital. Further, delirium is often missed because behavioural changes resulting from delirium are too often assumed to be part of a dementia syndrome and are not given suitable attention. Delirium, a reversible condition, is potentially very serious and can result in death. It should, therefore, be promptly recognized and treated.McEwan, et al (1991), report that 13 per cent of all hospitalized elderly develop delirium. Recognizing the potential for delirium is of vital importance and the application of focused delirium intervention protocols with older hospitalized patients can significantly reduce the number and duration of delirium episodes.

DELIRIUMCompared to research on chronic organic brain syndromes like dementia, the field of acute organic brain syndromes is still greatly underinvestigated. Acute confusional states, nowadays synonymously called delirium, are frequent and dangerous events in elderly hospitalized patients. Acute confusional states increase mortality and impair long-term outcome of primary illnesses. Moreover, they are associated with substantial additional costs due to increased need for nursing home placement, home health care, and rehabilization services.

The onset of delirium is characteristically rapid, typical symptoms include abnormalties of memory, orientation, and attention with an inability to focus and maintain attention and alertness.

Etiology of delirium is multifactorial, resulting from the interaction of baseline patient vulnerability (i. e. the presence of predisposing conditions such as advanced age, prior cognitive impairment, underlying comorbidity, hearing or vision impairment) and precipiting factors or hospital-related noxious insults (e. g. certain medications, anesthetic and surgical procedures. The identification of baseline characteristics that indicate a particular vulnerability to delirium could be the basis for behavioral or pharmacological interventions to prevent delirium or to treat it, at least, in the very beginning. Among the causative factors of delirium psychoactive medications are of particular relevance. This is best known as a side effect of anticholinergics, but can also be observed following dopaminergic, noradrenergic or serotonergic medications. Dementia and Alzheimer's DiseasePerhaps the most well-known psychological disorders in the elderly are dementia and Alzheimer's disease. Dementia in certain instances can be attributed to medical circumstances and may be reversible as in the case of vascular dementia. It is important to have a thorough medical exam to rule out physical causes of dementia. Alzheimer's disease is only one of many types of dementia, yet it is often the one most difficult to treat. There are medications that help slow the decline of patients with dementia or Alzheimer's disease, and care should be sought as soon as possible to determine if they may be of benefit.DEMENTIAChronic organic mental disorders, nowadays called dementias, are the main reason for the necessity of geriatric care units. Dementia is defined as a syndrome of acquired impairment of memory and other cognitive functions secondary to structural brain damage. The relative frequency of dementing disorder depends on age of the investigated cohort. We investigated the clinico-pathological correlations in Vienna in a large series of autopsies of 675 cases with a mean age at death of 79.5 years. Patients died at a general hospital, a gerontopsychiatric hospital, and a chronic care hospital. 75 % of dementias were found with pure or combined Alzheimer.s pathology (19). The clinical differentiation between Alzheimer dementia and vascular dementia was made using the Ischemic Scale of Hachinski. Our clinico-pathological validation of this scale led to a large prospective meta-analysis of the Hachinski Ischemic Scale, which is a device in the diagnosis of vascular dementia used worldwide. ]Table 4: DSM IV criteria of Alzheimers type dementia.

A.Development of multiple cognitive deficits manifested by both:1. memory impairment,2. one ore more of the following disturbances: a) aphasia, b) apraxia,c) agnosia, d) disturbances in executive functioning (i.e. planning, organizing,sequencing, abstracting).

B.Cognitive impairments cause significant impairment in social or occupational functioning.

C.The course is characterized by gradual onset and continuing cognitive decline.

D.The cognitive deficits are not due to: a) other CNS conditions that cause progressive cognitive deficits, b) systemic conditions that are known to cause dementia, or