Women, Aging and Mental Health. Dr Cathy Shea Associate Professor Head, Division of Geriatric Psychiatry University of Ottawa

Transcription

1 Women, Aging and Mental Health Dr Cathy Shea Associate Professor Head, Division of Geriatric Psychiatry University of Ottawa

2 Objectives To discuss the course of early onset mental illness and issues to consider for women who age To touch on stigma of mental illness for older women To review late life mental illness for women who develop problems after age 65

3 Topics we will cover Demographics of aging Changes with normal aging Growing older with early onset mental illness Stigma Late onset mental illness the three D s D s + Treatment and recovery

4 Demography of Aging The Baby Boomers are here! Babies born in 1947 turned 65 in % of Canadian population now over 65 and will double in by 2041to 23%

5 Demography of Aging There are 147 women for every 100 men over age 65 Most older men are married (72%>65) (46%>85) and therefore have/will have familiar caregivers when they are ill Most older women are widowed/single (56%>65) (90%>85)

6 What happens to us with normal aging? And why does it matter?

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8 Physiologic changes with normal aging Cardio-vascular changes Endocrine changes Respiratory changes Gastrointestinal changes

9 Pharmacokinetic changes with normal aging (What the body does to the medications) Absorption Distribution * Protein binding Metabolism * Renal (kidney) clearance *

10 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 (arousal, sleep) substantia nigra (gait, movement, posture) olfactory bulbs (smell / taste) Increased blood brain barrier susceptibility

11 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?

12 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)

13 Early Onset Mental Illness

14 If you have a mental illness of early onset and live to grow old normal biological changes will affect your treatment with psychotropic medication and the expression of side effects of that treatment Aging itself makes you vulnerable to develop mental illness particular to old age (perhaps 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 social issues which affect your access to care and services

15 The triple whammy for stigma! 1. You have a mental illness (any age, young or old) 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 accurate diagnoses, effective treatment and to access services for physical and mental illness Note: Quadruple whammy if you are also a member of a visible minority!

16 Mental disorders commonly diagnosed earlier in life Major Depression Anxiety Disorders Bipolar Disorder Schizophrenia Substance Use Disorders

17 So what about the woman with early onset mental illness who is aging? Expect to lower doses of some psychiatric meds to reduce side effects/obtain same treatment effect as when this woman was younger Eg Lithium for Bipolar Disorder lower geriatric therapeutic range for blood levels Eg Antipsychotics for psychotic disorders EPS such as parkinsonism, tardive dyskynesia Eg Anticholinergic med traditionally added to counteract EPS from antipsychotics Eg Antidepressants such as SSRI s and prolonged QTC

18 So what about the woman with early onset mental illness who is aging? Expect medical conditions might be caused by or worsened by psychiatric meds metabolic syndromes such as diabetes, increased cholesterol, weight gain with antipsychotics Hypothyroidism with lithium parkinsonism with antipsychotics, some antidepressants postural hypotension with antipsychotics poor balance, falls and fractures from all Hyponatremia from SSRI s

19 So what about the woman with early onset mental illness who is aging? New onset of confusion is not normal aging increasing risk of developing dementia as we age increasing risk of delirium from both medications and medical problems

20 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) Financial changes/challenges Medical illness/physical disability/functional decline Changes in family relationships Caregiver role (whether wanted or not)

21 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

22 Caregiver role Our health care system depends on unpaid caregivers Most caregivers of elderly disabled individuals are women (wives, daughters, daughters-in in-law, sisters, sisters-in 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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24 Late Onset Mental Disorders

25 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 : % 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%.

26 Dementia / Delirium /Depression The 3 D s D s of Geriatric Psychiatry Dementia: : A condition of acquired cognitive deficits, sufficient to interfere with functioning, in a person without depression (pseudo-dementia) 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

27 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.

28 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

29 Medical problems often co-occur 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)

30 Dementia is Common % 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: CSHA CMAJ 1994; 150: ; CSHA. Neurology 2000; 55: 66-73

31 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 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

32 How many drivers have dementia? 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

33 Delirium Delirium: : An acute,, potentially reversible, condition characterized by fluctuating attention & level of consciousness, disorientation, disorganized thinking, disrupted sleep/wake cycle

34 Delirium Recognition Low rate of recognition by health care professionals why? Hospitals are organized around one-thing-wrong- at-once 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

35 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

36 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

37 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

38 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

39 FEMALE Risk factors for late life depression Major life events such as widowed or divorced Structural brain changes Peripheral body changes such as major physical or chronic debilitating illness

40 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

41 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

42 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

43 Suicide rates in Canada Highest rates for men: age group and age group (30/100,000) 85+ highest with 35/100,000 Highest rates for women: age group (9/100,000) Ratio of attempts: completed suicide after 65 much lower than younger adult 2:1 men; 4:1 women.

44 Improving recognition of late life Clinician factors depression Incorrectly attribute depressive symptoms to the aging process ( I d( d be depressed too! ) More focus on concurrent medical conditions Time pressures/fee-for for-service payment Problems in integration of mental health and primary care systems

45 Improving recognition of late life Patient factors depression Stigma (patient and caregivers) Ageism (patient and caregivers) Misinformation More comfortable to report physical symptoms Dementia may color the picture

46 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

47 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

48 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!

49 Thank you Any questions?