Emerging Mental Health Issues in Aging

1
Emerging Mental Health Issues in Aging

• Louis D. Burgio, PhD
• Distinguished Research Professor
• Director, Center for Mental Health Aging
• The University of Alabama

2
Emerging Mental Health Issues in AgingGoals

• Serious Mental Illness
• Depression
• Alzheimers Disease
• Background and treatment
• Caregiving

3
Population Trends and Prevalence of Mental
Illness

• Trend toward living longer
• Greater percentage of lifespan spent in old age
• (see population pyramid, next slide)
• Many people are living with chronic illness,
  including mental illness, in their later years
• (see slide on prevalence rates)

4
Population Pyramids for United States
5
Estimate of Prevalence Rates Age 55(U.S.
Department of Health and Human Services Office
of the Surgeon General)
National Prevalence ()
6
Serious Mental Illness (SMI)

• Refers to the most debilitating mental illnesses
  such as . . .

• Schizophrenia
• Schizoaffective disorder
• Bipolar disorder

7
Serious Mental Illness

• Typically appears between late teens early 30s
  
• (early onset)
• SMI can first appear in later life
• (late onset)

8
Serious Mental Illness

• Key feature of SMI Severe functional impairment
  in major areas of life
• Late onset SMI often associated with less
  impairment partly because the disease does not
  interrupt critical developmental periods

9
Serious Mental Illness

• SMI carries with it a high economic burden,
  partly due to higher use of inpatient services
• However, there is a continuing trend to decrease
  institutional care ? shift to community-based
  care
• For those unable to reside with family, older
  adults with SMI often end up in nursing homes
  rather than psychiatric facilities

10
Serious Mental IllnessCaregiver Issues

• Families often provide care assistance
• Estimated 1/3 of SMI patients live with family
  members on an ongoing basis
• Those that live separately are often dependent on
  family for social support and assistance

11
Serious Mental IllnessCaregiver Issues

• With the increasing life expectancy of people
  with SMI, and the reduction in institutionalizatio
  n, families will be carrying an increasing burden
  of care
• Caring for a loved one with a serious mental
  illness involves a unique set of stressors

12
Serious Mental IllnessCaregiver Issues

• Stressors
• Cyclical trajectory (waxing waning)
• Periods of wide swings in symptomatology levels
  of functionality
• Such changes in symptoms are often unpredictable
• The relationship with an SMI family member is
  often fraught with conflict

13
Serious Mental IllnessCaregiver Issues

• Family caregivers often feel isolated must deal
  with stigma of mental illness
• Often the caregivers are parents
• Parent caregivers have genuine concerns for the
  future care of their children when the parents
  become disabled or deceased

14
Serious Mental IllnessCaregiver Issues

• Care for persons with SMI often involves
  vigilance and oversight, rather than help with
  activities of daily living (ADLs)
• Caregivers often deal with inadequate service
  delivery systems they are on their own to make
  up for the gaps

15
Serious Mental IllnessCaregiver Issues

• Problems faced by caregivers (Biegel and Schulz,
  1999)
• Coping with problem behaviors
• Dealing with feelings of isolation
• Interference with household routines
• Interference with meeting personal needs of other
  family members
• Not having adequate information about the illness
• Problems in medication management and compliance
• Coping with impaired role performance/functioning
• Disruptions to family life
• Lack of a respite from caregiving
  responsibilities
• Insufficient help from our service systems

16
Depression

• Depression in older adults causes . . .
• Emotional Distress
• and impairments in . . .
• Physical, Mental, and Social functioning

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Depression in older adults is . . .

• . . . not uncommon in late life
• . . . often unreported
• . . . often unrecognized
• . . . related to loss of physical
  functioning and
• independence
• . . . very treatable

18
Depression may be . . .

• Acute
• Remitting and relapsing
• Chronic

19
Depression Comorbidity

• Depression is comorbid with medical conditions
  such as heart disease and stroke
• For older adults, who generally experience an
  increase in medical problems, this can be a
  significant issue

20
Depression Comorbidity

• Many other psychiatric conditions occur with
  depression, such as anxiety disorders, substance
  abuse, dementia, and psychosis
• Depression can be related to medication use

21
Depression Differential Diagnosis

• Often difficult to determine whether cognitive
  symptoms (e.g., disorientation, apathy,
  difficulty with concentration, memory problems)
  are due to dementia or depression
• If possible, conduct a thorough clinical
  evaluation in order to make an accurate diagnosis

22
Depression Suicide

• Depression is associated with suicide
• (In a study of suicides among people 75 years
  and older, 60 75 were depressed Conwell,
  1996)
• Older adults, especially white males, have the
  highest suicide rate of any age group in U.S.
• Prevention/Intervention consists of awareness,
  accurate diagnosis, and proactive treatment for
  depression in older adults

23
Depression Prevalence

• Although current studies show lower rates of
  depression among older adults, this may be a
  cohort effect
• The higher rates of depression among Baby Boomers
  
• Thus, rates of depression among older adults may
  be expected to increase

24
Depression Prevalence

• Major depression prevalence rate (1-year) for
  older adults is 5 or less
• However, 8 20 of community dwelling older
  adults suffer from depressive symptoms
• Up to 37 of older adults in primary care
  settings suffer from depressive symptoms

25
Depression Treatment

• Medication
• Psychotherapy (CBT)
• Hospitalization (for acute treatment of
  moderate to severe depression)
• Electroconvulsive therapy (for refractory
  depression)

26
Depression Treatment

• Older adults may be more sensitive to the effects
  of drugs
• Susceptible to drug interactions

27
Golden Treasures Louis D. Burgio, Ph.D

• The University of Alabama
• Department of Psychology
• Center for Mental Health and Aging

28
Goals

• Discuss some new treatments for dementing
  illness.
• Discuss successful aging preventing dementia
  (Alzheimers Disease) as well as other health
  problems.

29
Facts

• 4.5 million Americans have Alzheimers Disease.
• 65 75 year old age group about 1 in 10
  people have the disease.
• 85 year old age group about half have
  Alzheimers Disease.
• Do all Alzheimers patients end up in nursing
  homes? NO! 7 out of 10 patients are cared for
  in the home.

30
The Normal Aging Brain

• If there is no illness present, there will be no
  significant memory problems.
• The mind may not work as quickly as we are used
  to, but we will not have trouble remembering old
  information or learning new things.

31
DeliriumSome Conditions that Affect the Brain
are Reversible

• Medication Complications
• Urinary Tract Infection
• Other Infection
• Dehydration
• Poor nutrition
• Depression
• Anxiety
• Numerous medical problems can cause reversible
  memory loss.

32
Dementia

• Significant memory impairment
• One or more of the following
• Language disturbance
• Impaired motor ability
• Unable to identify familiar objects
• Problems with planning, organizing, sequencing,
  and abstract thinking

33
DementiaSome Conditions that Affect the Brain
are Irreversible

• Alzheimers Disease
• Vascular Dementia
• Parkinsons Disease
• Lewy Body Disease
• Picks Disease
• Chronic substance abuse

• Head Trauma (dementia pugilistica)
• Untreated syphilis
• HIV Disease
• Creutzfeldt-Jacob Disease

34
Alzheimers Disease

• Characterized by Cerebral Atrophy
• i.e., loss of brain cells and important brain
  systems like the cholinergic system
• At autopsy, AD brains contain
• Neurofibrillary tangles (intracellular)
• Senile plaques (extracellular)

35
Compare

• This is the brain of a 70 year old with
  Alzheimers Disease

• This is the brain of a normal 70 year old

36
Causes of AD

• Genetic Influences
• A Defective Protein
• Biochemical Imbalance
• A Slow Virus

37
Genetic Influences

• Currently, there are four known genes associated
  with AD.
• Three of the genes are associated with the
  early-onset form of the disease (rare). This
  form of AD is inherited in an autosomal dominant
  pattern, meaning that the disease develops in
  family members in multiple generations.
• The fourth gene associated with Alzheimers
  Disease is the apolipoprotein E gene (APOE),
  which is referred to as a risk-factor or
  susceptibility gene. The e4 variant is
  associated with an increased risk of developing
  AD.

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What are some signs that it is time for a
dementia evaluation?

• Forgetting meetings or appointments
• Forgetting why you are in a specific location,
  e.g., grocery store
• Reading a short newspaper story and then
  forgetting what you just read
• Asking the same question several times in the
  same conversation
• Often appearing tongue-tied
• Excessively calling something or someone by the
  wrong name or a made up name
• Having difficulty finding the right word several
  times during the course of one conversation

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What are some signs that it is time for a
dementia evaluation?

• Notes to remember simple information such as
  ones own birthday
• Confusion regarding the day or date (more than
  just off one day)
• Losing the ability to balance a checkbook
• Losing the ability to do chores such as cooking,
  laundry, or cleaning without instruction or help
• Getting lost in very familiar places
• Not being able to find the way home

40
Diagnosing AD

• Medical and Psychiatry History
• Physical Exam (e.g., blood tests)
• Neuroimaging (e.g., CT Scan, MRI)
• Neuropsychological Testing (e.g., cognition,
  functional tests)

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Stages of Alzheimers Disease

• Mild Alzheimers
• Asking the same questions repeatedly
• Getting lost in conversations and having problems
  finding the right word
• Not being able to complete familiar tasks, such
  as following a recipe
• Not remembering recent events
• Misplacing items in inappropriate places, such as
  putting a wallet in the refrigerator
• Having less interest in their surroundings
• Disorientation to time and place

42
Stages of Alzheimers Disease

• Moderate Alzheimers
• Consistently forgetting to take medications
• Having difficulty with tasks involving
  calculation and planning
• Problems with communication, including reading
  and writing
• Exhibiting behaviors such as aggressiveness,
  outburst of anger, or withdrawal
• Sleeping for long periods of time or hardly
  sleeping at all
• Having hallucination or delusions

43
Stages of Alzheimers Disease

• Severe Alzheimers
• Having little or no memory
• Having difficulty speaking and understanding
  words
• Having difficulty recognizing others, or even
  themselves in the mirror
• Needing assistance for all personal care
• Increasing weakness and being susceptible to
  infections

44
Prevalance of Dementia in the U.S.

• National prevalence is estimated to be 4.5
  million (i.e., the number of people at any
  particular time who have the disease using
  population projections from the Census and death
  rates from the National Center for Health
  Statistics).
• 7 of those with AD were age 65-74,
• 53 of those with AD age 75-84, and
• 40 of those with AD age 85 and older.
• By 2050, it is projected that 60 of people with
  AD will be 85 and older.
• Declines in death rates after age 65 mean that
  more people will survive to the oldest ages,
  where risk of AD is greatest.

45
Older Individuals Experience NORMAL Changes in
their Memory

• Young have sharper vision and hearing.
• Young have quicker reaction time.
• Young have better short-term memory.
• Young are better at learning that requires
  perceptual speed, physical coordination, and
  strength.

46
Bad News/Good News/Better News

Bad News Currently there is no cure for
dementia. Good News Currently there are
things one can do to prevent or delay dementia
there are helpful medications available. Better
News Scientists are developing additional drugs
and they are working on a vaccine.
47
Tricks and Strategiesfor Better Memory

• Use of external memory aids calendars, signs
  (reminders), lists
• Imagery
• Chunking
• Relaxation Training

48
Six Factors Associated with Maintaining High
Mental Functioning

• Regular physical activity
• Strong social support system(stay engaged!)
• Belief in ones abilities(can-do attitude)
• Positive spirituality
• Keep your mind active
• Good nutrition

49
Medications for Alzheimers Disease

• Cholinesterase Inhibitors(prevent breakdown of
  chemical messenger in brain)
• Aricept (1996)
• Exelon (2000)
• Reminyl (2001)
• Cognex (rarely prescribed due to side-effects)
• Half of individuals taking these drugs,
  prescribed for mild dementia, show show some
  improvements.

50
Medications for Alzheimers Disease

• NMDA Receptor Agonist(boosts the actions of a
  special chemical messenger, glutamate)
• Memantine (Namenda) (February 2004)(moderate to
  severe dementia).
• Exciting new strategy Combine Namenda with
  Cholinesterase Inhibitor (e.g., Reminyl).
• More exciting Developing new drugs to boost
  additional chemical messengers Drug cocktail.

51
Vitamins

• Vitamin E protects against oxidative stress.
• Also Vitamin C?
• Check with your physician if taking aspirin or
  other blood thinners first.

52
Vaccine Update

• Beta-amyloid protein that destroys nerve cells.
• Vaccinate against Beta-amyloid.
• Stopped clinical trial some got better some
  developed brain inflammation.
• Recently restarted trial part of molecule
  causing inflammation not a necessary part of
  vaccine.
• If it works, when available? 10-15 years

53
Treatments forAlzheimers Disease

• Promising Statins drugs to lower cholesterol
  (e.g. Lipitor, Prevachol)
• Not so promising Hormones, anti-inflammatory
  drugs (e.g. Motrin, Advil)

54
Exercise

• Forms of Exercise
• Stretching/warm up
• Balance-related exercise
• Strength training
• Aerobic training
• Exercise has physical, social and psychological
  benefits

55
Three Points About Exercise

• Need to fit it into every-day schedule
• Many age-related reductions in physical
  performance are avoidable and many are
  reversible.
• Exercise dramatically increases physical fitness,
  muscle size, and strength in older individuals.

56
Exercise your Mind

• Crossword puzzles and other word games
• Read
• Learn a new skill (hobby)

57
Caring for family members with Alzheimers
disease and other dementias

• Alan B. Stevens, PhD
• Associate Professor of Medicine,
• Director, Dementia Care Research Program
• Division of Gerontology and Geriatric Medicine
• UAB

58
Normal Aging

• What is normal?
• Is illness normal?

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The Normal Aging Brain

• The brain loses volume as we age.
• This loss in volume does not necessarily
  correspond to memory decline or mental slowing.
• Memory loss that causes a problem with daily
  functioning or caring for ones self, is not
  normal aging.

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Number of People with AD, by Age Group (in
millions)
61
Religiosity/Spirituality

• A large proportion of published empirical data
  suggest that religious commitment plays a
  beneficial role in
• preventing mental/physical illness,
• improving how people cope with mental and
  
• physical illness, and
• facilitating recovery from illness.
• Arch Fam Med 1998 Mar 7(2) 118-124

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Caregiving in the U.S.National Alliance for
Caregiving and AARP(April 2004-Funded by MetLife
Foundation)

• National survey of 6,139 adults in the U.S., from
  which 1,247 caregivers were identified.
• The 1,247 caregiver interviews include a total of
  approximately 200 African-American, 200 Hispanic,
  and 200 Asian-American caregivers obtained
  through over-sampling.
• Caregivers were identified by self report and by
  verifying that he or she assists another with at
  least one ADL or IADL.

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How Many Caregivers are there in the U.S.?

• 21 of the U.S. population age 18 and older
  provides unpaid care to friends or relatives 18
  and older. This translates into 44,443, 800
  caregivers in the U.S.
• 16 of the population, or 33,861,900 adults,
  provide unpaid care to a recipient who is 50 or
  older.
• 21 of U.S. households contain at least one
  caregiver, reflecting approximately 22,901,800
  households (Table 2).
• 17, or 18,539,500 households in the U.S. contain
  at least one caregiver who provides care to
  someone age 50 or older.

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Profile of Caregivers

• A typical caregiver in the U.S. is female (61 ),
  approximately 46 years old, has at least some
  college experience (66), and spends an average
  of twenty hours or more per week providing unpaid
  care to someone 50 or older (79).
• A majority of caregivers are married, and most
  have juggled work with caregiving
  responsibilities at some point during their role
  as caregivers.

65
Employment Status

• Nearly six in ten caregivers are currently
  employed (59).
• Male caregivers are more likely to be employed
  full-time than female caregivers (60 v 41).
• Caregivers between the ages of 35-49 are more
  likely to be working full-time than caregivers
  18-34 years, 50-64 years or 65 (64 35-49 years,
  52 18-34 years, 48 50-64 years 3 65).
• Caregivers with the heaviest caregiving
  responsibility are less likely to be employed and
  more likely to be retired than caregivers with
  less caregiving responsibility.

66
Dementia Caregivers

• Caregivers who say they care for someone who has
  Alzheimers, dementia or other confusion provide
  more than 20 hours of care per week (29) and
  report higher levels of care burden.

67
Caregivers Characteristics by Age of Care
Recipient
Base 1,247 caregivers in the U.S. Source
Caregiving in the U.S., National Alliance for
Caregiving and AARP, 2004
68
Caregivers Most Likely to Report the Use of Any
Paid Help Include

• Upper income (56 of those earning 100,000 v
  37 less than 30,000, 34 34,000-49,000, 43
  50,000-99,000)
• Level 3 (54), Level 4 (53), and Level 5 (50)
  caregivers v 30 Level 1 or 37 Level 2 (i.e.,
  higher burden vs. lower burden)
• Older caregivers (43 50-64 and 50 of 65 v 35
  18-34)
• College educated (51 v 34 high school or less
  and 37 some college)

69
Caregivers Most Likely to Report the Use of Any
Paid Help Include

• Those caring for someone with Alzheimers or
  dementia (50 v 38)
• Those living one hour or more away (50 v 36 of
  those who co-reside)
• Secondary caregivers (50 v 35 primary
  caregivers)
• Those not working while caregiving (47 v 39
  employed) and
• Those whose recipients are 50 or older (46 v 23
  of those 18-49)

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Impact of Caregiving on Work saying yes
Q41-47. IF WORKING WHILE A CAREGIVER In your
experience as both a worker and a caregiver, did
you ever
Base 935 caregivers in the U.S., who are
currently or have worked while caregiving
Source Caregiving in the U.S., National
Alliance for Caregiving and AARP, 2004.
71
Hours of Care
Q27. Thinking now of all the kinds of help you
provide/provided for your ( _ ), about how many
hours do/did you spend in an average week,
doing these things?
Base 1,247 caregivers in the U.S. Source
Caregiving in the U.S., National Alliance for
Caregiving and AARP, 2004.
72
Prevalence and Magnitude of Depression in Family
Caregivers of AD Patients

• CES-D scores commonly average 14.5 to 34.5 in
  study samples
• Studies report 30 to 55 of caregivers scoring
  over 16 on the CES-D.
• Diagnostic interview assessments also suggest
  increased psychiatric morbidity among caregivers.

73
Effects of AD Caregiving on Physical Morbidity

• Caregivers consistently rate their health as
  significantly worse than non-caregivers.
• Some evidence suggests poorer health care
  utilization and immune functioning in caregivers.
• Poor health status in caregivers appears related
  to lower financial adequacy, higher
  psychological distress, low social support and
  severe cognitive impairment in patient.

74
Environmental/Behavioral Treatments

• Environmental/Behavioral treatments attempt to
  reduce contextual demands on the patient so that
  problem behaviors are prevented, or so that the
  negative consequences are reduced.
• Through education and skill training, caregivers,
  can learn to effectively implement treatments.
• structured routines
• appropriate socialization and recreation
• reassurance and comfort from caregivers
• Caregiver use of formal and informal social
  support can assist with patient care and
  caregiver burden.