women, aging, and mental health
DESCRIPTION
From our Conversations lecture in March 2012.TRANSCRIPT
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Women, Aging and
Mental Health Dr Cathy Shea
Associate Professor
Chair, Division of Geriatric Psychiatry
University of Ottawa
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Topics we will cover
Demographics of aging
Growing older with early onset mental illness
Stigma
Changes with “normal” aging
Late onset mental illness – the three D’s
Recovery
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Demography of Aging
The Baby Boomers are coming!
Babies born in 1946 turned 65 in
2011.
13% of Canadian population now over
65 and will double in by 2041to 23%
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Demography of Aging
There are 147 women for every 100
men over age 65
Most older men are married (75-78%)
(and therefore have/will have familiar
caregivers when they are ill)
Most older women are widowed (52%)
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If you have a mental illness of early
onset and live to grow old
“normal” biological changes might affect your treatment with medication and the expression of side effects of that treatment
Aging itself makes you vulnerable to develop mental illness’ particular to old age (maybe in addition to your early onset mental illness)
Aging itself makes you vulnerable to develop physical illnesses which affect your mental illness and the treatment of both
Aging itself brings psycho-social issues which affect your access to care and services
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The triple whammy for stigma!
1. You have a mental illness (any age)
2. You are old (so you must be frail/confused!)
3. You are a woman (so complain a lot and express your emotions easily)
All three will affect your ability to obtain
diagnosis, treatment and to access services
for physical and mental illness
Note: Quadruple whammy if you are also a member of a visible minority!
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Mental disorders commonly
diagnosed earlier in life
Depression
Anxiety Disorders
Bipolar Disorder
Schizophrenia
Substance Use Disorders
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Mental disorders commonly
diagnosed earlier in life All can be diagnosed for the first time in individuals over 65
years of age and are then typically called “late onset” or “late life” disorders
Depression: 10-15 % of community dwelling elderly have significant depressive symptoms. Rates are higher in hospitals and long term care facilities. Female gender is a major risk factor
Bipolar Disorder: M=F in late onset
Schizophrenia: 3% diagnosed after age 70, mostly women
Substance use disorders: 1.5% alcohol abuse in older women. Problem drinking however can be as high as 27%.
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What happens to us
with “normal” aging?
And why does it matter?
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Physiologic changes with normal
aging
Cardio-vascular changes (meds & dementia) Increased blood pressure (noradrenergic (antidepressant) drugs can
worsen)
Increased susceptibility to develop heart failure if heart rate is increased (e.g. by certain drugs with anti-cholinergic properties)
Increased (cumulative) vascular risk factors for dementia
Endocrine changes (metabolic complications) Increased insulin resistance
Menopausal changes
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Physiologic changes with normal
aging
Respiratory (lung) changes Decreased vital capacity and decreased forced expiratory volume (can be
improved by aerobic exercise training)
Decreased pulmonary defense mechanisms & increased risk for pneumonia (e.g. depressed patients who stay in bed)
Gastro Intestinal changes Gum retraction + increased risk to lose teeth (ECT consideration)
Decreased acid secretion in stomach + decreased intrinsic factor (increased risk of B12 deficiency)
Decreased absorption of calcium, osteoporosis (fractured bones with falls from poor balance)
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Pharmacokinetic changes with normal aging
(What the body does to the medications)
Absorption
Distribution *
Protein binding
Metabolism *
Renal (kidney) clearance *
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Drug distribution changes with
normal aging
Aging results in an increased fat over muscle ratio:
So for fat soluble drugs in an aging body:
increased distribution volume of drug
decreased initial blood levels of drug
increased risk of accumulation of drug
Aging result in a decrease in total body water:
So for water soluble drugs in an aging body:
decreased distribution volume of drug
increased blood levels of drug
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Drug Metabolism with normal aging
Decreased liver mass and blood flow
Decreased de-methylation and decreased
hydroxylation
Decreased rate of elimination = increased levels
of the drug
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Renal (kidney) clearance of drugs with
normal aging
Decreased glomerular filtration rate, tubular
secretion and decreased renal blood flow
Decreases clearance of drugs eliminated by the
kidney = increased levels of these drugs (eg
lithium)
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Brain changes with normal aging:
Neuronal loss (<1% per year after age 60)
Greater neuronal loss or loss of connections in:
frontal/prefrontal cortex (executive function)
hippocampus (memory)
locus ceruleus (sleep)
substantia nigra (gait)
olfactory bulbs (smell / taste)
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Neuro-imaging in normal aging
C.T. brain scan:
shrinkage/atrophy
(increased CSF space/decreased brain volume)
M.R.I scan:
Shrinkage/atrophy
decreased gray-white density
up to 30% white matter abnormalities ?
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Other changes with “normal” aging that
affect older patients
Decline in mineralization of bones (8-10% per year for
post-menopausal women = fracture with falls)
Impaired postural reflexes and increased sway, poor
balance (falls from side effects of prescription meds or
OTC drugs)
Hearing loss in up to 60% over age 70 ( may appear to
be cognitive problems)
Decreased perception of acute pain
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So what about the woman with
mental illness who is aging?
Expect to lower doses of psychiatric meds to reduce side effects/obtain same treatment effect as when this woman was younger
Expect medical conditions might be caused by or worsened by psychiatric meds (metabolic syndromes, parkinsonism, postural hypotension (low BP), falls and fractures)
New onset of confusion is not “normal” aging – increasing risk of developing dementia as we age, increasing risk of delirium from medications and medical problems
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Frequent Problems / Common Stresses
of Aging for all Women:
Dealing with death and loss of family/friends
Retirement from work and other active roles
Housing & relocation (planned or unplanned)
Medical illness/physical disability/functional
decline
Changes in family relationships
Caregiver role (whether wanted or not)
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Caregiver role
Our health care system depends on unpaid caregivers
Most caregivers of elderly disabled individuals are women (wives, daughters, daughters-in-law, sisters, sisters-in-law, nieces)
Many are themselves elderly
Caregivers of elderly individuals with mental and/or physical disorders are twice as likely to develop depression
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Additional frequent problems
/common stresses for older women
with mental illness Poverty
Social isolation
Lack of transportation
Exclusion from criteria for home care services
Multiple medications with complex instructions
Triaged with a “different lens” in ER and
primary care settings
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Late Onset Mental
Disorders
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Dementia / Delirium /Depression
The 3 D’s of Geriatric Psychiatry
Dementia: A condition of acquired cognitive deficits,
sufficient to interfere with functioning, in a person
without depression (pseudo-dementia) or delirium
Delirium: An acute, potentially reversible, condition
characterized by fluctuating attention & level of
consciousness, disorientation, disorganized thinking,
disrupted sleep/wake cycle
Depression: Alteration in usual mood with sadness,
despair, lack of enjoyment in previously enjoyed
activities and vegetative symptoms sufficient to
interfere with functioning
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Common psychiatric disorders
in those over 65 years old
Dementia: estimates are that 8% of
population over 65 and 30% over 85 is
affected by dementia.
Delirium: approx. 30% of general in-pts in
medicine and rehab. More frequent in
neurology and common after surgery,
especially orthopedic procedures.
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Psychiatric disorders often co-
exist in the elderly Dementia is often complicated by delirium,
depression, anxiety and psychotic symptoms (hallucinations and delusions)
Late onset depression is associated with high risk of developing dementia.
Anxiety symptoms common in early dementia, depression, substance use withdrawal…
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Medical problems often co-occur
in elderly with mental illness
Medical problems can mimic psychiatric illness (e.g.
Parkinson disease); cause or precipitate psychiatric
illnesses (thyroid, strokes causing depression or mania)
or cause anxiety or depressive symptoms.
Medication for medical problems may interact with
psychiatric drugs or can cause depression, delirium.
Psychiatric drugs can worsen some medical problems
(BP problems, weight gain, blood sugars, falls and
fractures, confusion, visual problems, urinary retention)
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Dementia
Dementia: A condition of acquired cognitive
deficits, sufficient to interfere with functioning,
in a person without depression (pseudo-
dementia) or delirium
Cognitive deficits: can be a decline compared
to previous levels in language, executive
function, memory, orientation, visuo-spatial
abilities etc.
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Dementia is Common
2.411.1
34.5
0
5
10
15
20
25
30
35
65-74 75-84 85+
% Prevalence
Age related risk: > 65: Overall:
Incidence: 2 %
Prevalence: 8 %
Prevalence doubles every ~5 years
An intervention that would delay onset by 5 years would
decrease prevalence by 50%
Females>Males
Lindsay et al. Can J Psychiatry 2004;49:83-91. CSHA CMAJ 1994;
150: 899-913; CSHA. Neurology 2000; 55: 66-73
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Warning signs of Dementia
10 Warning Signs for Caregivers*
Difficulty performing familiar tasks
Problems with language
Disorientation to time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood and behaviour
Changes in personality
Loss of initiative
Memory loss that affects day-to-day function
Behavioural Flags for Health Care Professionals
Frequent phone calls
Poor historian, vague
Poor compliance: meds /instructions
Change in Appearance / hygiene / makeup
Word finding / decreased interaction
Appointments - missing / wrong day
Confusion: surgery, meds
Weight loss / dwindles
Driving: accident / problems
“Head turning sign”
*Adapted from the Alzheimer Society of Canada: www.alzheimer.ca
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How many drivers have
dementia?
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1986 2000 2028
65+
80+
Combined Ontario
Ministry of
Transportation data
with census data and
dementia prevalence
data to give “best
estimate” of
proportion of drivers
with dementia
F > M
Hopkins et al. Can J Psychiatry 2004
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Delirium
Delirium: An acute, potentially reversible,
condition characterized by fluctuating attention
& level of consciousness, disorientation,
disorganized thinking, disrupted sleep/wake
cycle
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Delirium Recognition
Low rate of recognition by health care professionals – why?
Hospitals are organized around “one-thing-wrong-at-once” principle and delirious patients are complex
Patient is often unable to give a history (a sensitive but non-specific marker!) so viewed as uncooperative, demented or a “poor historian”
Assumptions are made about “usual” functioning
Frequent falls are not recognized as possible important marker
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Delirium – So What?
Patients with delirium have:
- prolonged length of stay in hospital
- worse functional outcomes
- higher rates of nursing home placement
- increased risk of permanent cognitive decline
- higher death rates
- worse rehabilitation outcomes
Delayed recognition → worse outcomes
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Late life depression
Depression: Alteration in usual mood with
sadness or negative mood state (anger,
irritability, despair), lack of enjoyment in
previously enjoyed activities and vegetative
symptoms sufficient to interfere with
functioning
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Late Life Depression
Common (but often undiagnosed)
Costly
Debilitating
Potentially lethal
Aging baby boomers are expected to have
higher rates than the current elderly cohort
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Late Life Depression
View late life depression as a sentinel event
that substantially increases the risk for
decline in general health and function
Frequently heralding the onset of cognitive
decline/dementia
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Risk factors for late life
depression
FEMALE
Major life events such as widowed or
divorced
Structural brain changes
Peripheral body changes such as major physical
or chronic debilitating illness
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Risk Factors for late life
depression
Previous history of depression
Caregiver for person with dementia or other debilitating medical condition
Excessive alcohol consumption
Taking medications, such as centrally acting BP meds, analgesics, steroids, antiparkinsons, benzodiazepines
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Mood Disorder due to Medical
Condition: common in late life
Stroke induced depression or mania
Depression associated with Parkinson's disease
Depression or mania due to endocrine disorders (thyroid, adrenal)
Depression due to infectious illnesses
Substance-induced depressive or manic syndromes (alcohol, benzo)
Depression and cognitive problems due to sleep apnea
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Use of Health Care Services in
Depressed Elderly
Twice the number of medical appointments
Increased number of medications taken
Twice the length of stay in hospital
In Nursing homes:
Increased nursing time
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Suicide rates in Canada
Highest rates for men:
20-24 age group and 80-84 age group (30/100,000)
85+ highest with 35/100,000
Highest rates for women:
45-49 age group (9/100,000)
Ratio of attempts: completed suicide after 65 much lower than younger adult
2:1 men; 4:1 women.
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Improving recognition of late life
depression
Clinician factors
Incorrectly attribute depressive symptoms to the
aging process (“I’d be depressed too!”)
More focus on concurrent medical conditions
Time pressures/fee-for-service payment
Problems in integration of mental health and
primary care systems
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Improving recognition of late life
depression
Patient factors
Stigma (patient and caregivers)
Ageism (patient and caregivers)
Misinformation
More comfortable to report physical symptoms
Dementia may color the picture
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Treatment and recovery/well being
Possible for all (early and late onset) mental
disorders for elderly women
Many recent best practice guidelines to focus on
mental disorders in the elderly
Recent enhancement of training/education for
general psychiatrists, primary care physicians
New Royal College official subspecialty in
Geriatric Psychiatry
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Treatment and recovery/well being
Medication can be an important part of
treatment/recovery
Psychotherapies can be an important part of
treatment/recovery
ECT can be an important part of treatment/recovery
Physical exercise, healthy diet, stable housing, stable
finances, spiritual well being, social connections,
laughter, brain exercise are all important parts of
recovery and well being
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Take Home Messages
Growing old with mental illness is not for sissies !!
Early onset mental illness requires a fresh perspective
by health care professionals as women grow older
Late onset mental illness can be complex
Prevention, early identification, treatment and follow-
up are key to recovery/well being
Mental health services for the elderly can be
fragmented, lack availability and are plagued by stigma
but improvements are happening!
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Thank you
Any questions?