Demography and Epidemiology of Psychiatric disorders in Elderly

Dr Ravi SoniSenior Resident

Dept. of Geriatric Mental HealthKGMC

Demography and Epidemiology of Psychiatric disorders in Elderly

• What is Geriatric Psychiatry?• Demography of Aging• Geriatric statistics• Epidemiology of psychiatric disorders in India• Epidemiology of psychiatric disorders worldwide• Details about main psychiatric problems in elderly

Discussion over following

What is Geriatric Psychiatry?• Fastest growing field of psychiatry

– branch of medicine concerned with prevention, diagnosis, and treatment of physical and psychological disorders in the elderly and with the promotion of longevity

• Managing elderly patients requires ‘special’ knowledge: – Possible differences in mental health presentations, – Frequent co-exiting and complicating chronic medical

diseases, – Multiple medications (drug-drug interactions,

pharmacodynamics and pharmacokinetics) and – Aging specific issues

What age makes you a geriatric patient? What makes you ‘elderly’?

• In developed countries with higher life expectancies older adults are generally categorized in three age segments: – Young old: aged 55-65 years; – Old: aged 66-85 years, – Oldest old: aged 85 years and above (Carey, 2003).

• In India age categorizations have been done as following : – young-old: 60 to 70 years;– old-old: 70 to 80 years and – oldest-old: 80 years and above

(Venkoba Rao, 1993; Irudaya Rajan, 2003)

Geriatric statistics• Life expectancy at birth in India

• The most rapidly growing segment of the population is the age group 85 years and older, the group with the highest morbidity and the highest rate of psychiatric and medical comorbidities.

• This age group grew 40-fold, from 100,000 in 1900 to more than 4 million in 2005, and is projected to reach 19.4 million by 2050.

Life expectancy at birth in India

Female Male Combined

1960 41.54 43.31 42.45

2011 67.08 63.95 65.48

The Ageing India

≥ 60 aged have increased from 83.6 m in 2006 to 98.47 m in 2011

Projected increase by 2016 is 118.1 m, by 2021 143.25 to 173.18 m by 2026.

No. in million

Population India.Chapter-2.Census of India 2010. Vital statistics. SRS report.

The Aging Imperative

• Persons aged 60y and older constitute 13% of the population and purchase 33% of all prescription medications

• Many are ‘Frail Elderly’

• By 2040, 25% of the population will purchase 50% of all prescription drugs

Epidemiology of Psychiatric Disorders in India[Tiwari SC et al. 2012]

Epidemiology and profile of Mental Health Problems in India

• In Pondicherry (South India), psychiatric disorders among older adults were found to be 17.4%.

• Another epidemiological study from Uttar Pradesh (North India) reported 43.3% of the elderly to be suffering from one or the other mental health problems as against 4.7% adults

• 17.3% urban and 23.6% rural older adults aged 60 years and above suffer from syndromal mental health problems

• 4.2 urban and 2.5% of rural older adults suffer from sub-syndromal mental health problems

• Prevalence of dementia in India has been reported to be variable, from 1.4% to 9.1%

• Depression was thrice more common than mania, occurring for the first time after 60 years

• Prevalence of neurotic depression in the rural elderly was found to be 13.5%. A recent report indicates that 5.8% of the urban and 7.2% of the rural older adults primarily suffer from mood (affective) disorders

Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: An evidence-based commentary. Indian J Psychiatry 2012;54:8-14.

• Enormous psychiatric morbidity:Author(s) & year Population (Study area) RateDube, 1970 Rural & urban community (UP) 2.23%

Nandi et. al, 1975 Rural community (WB) 33.3%

RamChandran et. al.,1979 Urban community (TN) 35.0%

Venkoba Rao, 1990 Semi urban (Madurai) 8.9%

Natrajan et al, 1993 Rural & urban community (TN) 17.3- 29.6%

The Burden of Mental Health Morbidity In Older AdultsThe Burden of Mental Health Morbidity In Older Adults

• Enormous psychiatric morbidity:Author(s) & year Population (Study area) Rate Tiwari, 2000 Rural Eld. Pop. (UP) 43.3%Prakash, 2004 Urban Eld. Pop. (Rajsthan) 42.0%Malik & Banerjee, 2005 Rural Eld. Pop. (W. B.) 32.0%Tiwari, 2009 Urban Eld. Pop. 17.3%Tiwari, 2010 Rural Eld. Pop. 23.6%

Neuropsychiatric illnesses cause significant morbidity in elderly (GOI & WHO, 2007). Elderly are highly prone to mental morbidity (Ingle & Nath, 2008).

A modest estimate – 20% psychiatric morbidity

The Burden of Mental Health Morbidity In Older Adults (Contd.)The Burden of Mental Health Morbidity In Older Adults (Contd.)

Late Life Stressors that place older adults at risk of

mental health disorders

• Chronic physical health condition(s)• Death of a loved one• Caregiving• Social isolation/lack or loss of social support• Significant loss of independence• History of mental health problems

– Old age – even though older adults are more likely to experience life stressors – old age is NOT a risk factor for an increasing risk for a mental health disorder;

– in fact, ‘most’ older adults are able to cope with late life stressors without developing significant mental health disorders

Major mental health problems of older adults

Organic DisordersLate Life Functional Diseases:

Mood (Affective) DisordersNeurotic, Stress Related and Somatoform DisordersSchizophrenia, Schizotypal and Delusional Disorders

(Functional Psychoses)Psychoactive Substance Use DisordersSuicidal Behaviors in the Elderly

2nd most common cause of disability among people age 65 and older (second only to arthritis)

Dementia: Statistics DAT (Dementia of Alzheimer’s Type)

• Incidence: – 5-8% ……….over age 65– 15-20%……..over age 75– 25-50+%……..over age 85

• Women > Men (1.2-1.5 to 1.0)

• If trends continue, population with DAT will quadruple within the next 50 years……..

• New Cases/Year=360,000=40 new cases/hour

Elderly population and Prevalence of Dementia: INDIA-EUROPE-WORLD

TOTAL POPULATION

ELDERLY PERCENTAGE

ELDERLY POPULATION

DEMENTIA PREVALENCE

PEOPLE WITH DEMENTIA

WORLD 7 BILLION1 8% 600 MILLION 5.9% 35.6 MILLION

EU 27 502.5 MILLION1 17.5% 97 MILLION 7.65% 7 MILLION

UK 62.5 MILLION1 16.7% 10.4 MILLION 7.65% 0.8 MILLION

INDIA 1.21 BILLION2 8% 96.8 MILLION 3.6% 3.5 MILLION

1U S CENSUS BUREAU, International program center, international database2Indian Census 2010

Dementia will be a big challenge….1- The Global Catastrophe Estimated 35.6 million people have dementia today 7.7 million new cases annually By year 2040

81.1 million will be affected71% in developing nations

Between 2001 – 2040100% increase in developed countries300% increase in India

2- The Indian Catastrophe India–Census 2011: Elderly 60 years and above = 97 m. in India, 13.5

million in UPAt an average prevalence rate of 36/1000 - Dementia = 3.49

million (34.9 lacs) in India In state of Uttar Pradesh–13.5 million elderly : Dementia=0.49

million (4.9 lacs) In 2040: @ 300 % increase-10.76 million (107 lacs) in India; 3.87

million (38.7 lacs) in UP

Dementia :The Indian catastrophe Prevalence of Dementia in India*

Study Year Location Population Rate

Rajkumar S et al 1997 Madras Urban 60>; Dementia

3.5%

Tiwari SC et al 2000 Lucknow Rural 60>;

Mental Health morbidity

Senile dementia - Simple= 5.35% - With Depression = 2.8% - Arteriosclerotic = 0.82%

Chandr V et al 2001 Ballabgarh Rural; 65>; AD 3.2%

Vas CJ et al 2001 Mumbai Urban 65>; Dementia

2.4%

Shaji KS et al 2002 Kerala Rural 60>; Dementia

2.6%

Shaji KS et al 2005 Cochin Urban 65>; Dementia

3.4%

Tiwari SC et al 2009 Lucknow Urban 60>; Dementia

4.4%

Tiwari SC et al 2010 Lucknow Rural 60>; Dementia

2.8%

* Calculated at avg. 36/1000 app. 3.5 m pts of dementia in India

Behavioral and Psychological Symptoms of Dementia (BPSD)

• A heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology.

• Any verbal, vocal, or motor activities not judged to be clearly related to the needs of the individual or the requirements of the situation.

• An observable phenomena (not just internal)

Prevalence of BPSD• 90% of patients affected by dementia will experience

Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled as a problem during the course of their illness.

Most common:• Agitation (75%) • Wandering (60%) • Depression (50%) • Psychosis (30%)• Screaming and violence (20%)

Mild Cognitive Impairment (MCI)

• MCI (mild cognitive impairment): – Cognitive impairment in elderly persons not of sufficient

severity to qualify for a diagnosis of dementia

• Patients have complaints of – Impairment in memory or other areas of cognitive

functioning usually noticeable to them or to those around them

– Performance on ‘memory or cognitive’ tests are usually below that expected for their age and education

• A ‘precursor’ to DAT in 50% of patients over 3-4 years

MCI Prevalence Rate in the Community

• Normal aging MCI early DAT

• Prevalence rate for >60 years of age: 3%

• Prevalence rate for >75 years of age: 15%

• Annual conversion rate to DAT: 6-25%/year

Depressive disorders in Elderly

• Prevalence of depression in healthy independent community-dwelling elderly is lower than the general adult population.

– In general population over age of 65 years, the estimated prevalence of LOD is 2% and of subsyndromal depressive symptoms (minor depression) is 10-15%.

– Prevalence rates rise to 25-40% in hospital sub-populations and residential homes; and to 40% for patients with stroke, myocardial infarction or cancer.

– LLD [Late life depression] is most common psychiatric disorders in inhabitants of old age/nursing homes, followed by anxiety disorders (13.3%) and dementia (11.1%).

Depressive disorders in Elderly (cont..)

• Most depressive episodes occurred in persons with a prior history of depression, with a recurrence rate of 25.5 per 1,000 person years.

• Clinically significant but subthreshold depressive symptoms occurred at twice the rate of depressive syndromes

• The ratio of male to female with MDD remains stable with higher prevalence in women across the age spectrum

• With advancing age, the gender gap in depression prevalence narrows

Risk Factors and Etiology

• Female sex, • Bereavement, • Sleep disturbances, • Disability, • Prior depression, • New medical illness, • Less education, • Cognitive impairment, • Poor social support, • Poor health status, • Poor self-perceived health and • Vision or hearing impairment.

• In addition, following are also noted to be significant risk factors.

– recent onset of physical illness – greater severity of physical illness – functional disability and limited

mobility– poorly treated pain – multiple illnesses

• Insomnia is risk for development of LOD and its persistence and recurrence further aggravate the likelihood

Phenomenology • DSM-IV TR and ICD-10 do not include specific diagnostic criteria for LLD, there are differences

in presentation of depression in older adults• Depressed or sad mood, is usually less prominent or absent in elderly subjects• More likely to report irritable mood• Emotional reactivity and responsiveness to external positive events are usually preserved• Other differences from adult depression include

– Higher rate of somatisation, – Weight loss, – Guilt feeling, – Melancholia, – Hypochondriasis and – Psychosis

• Elderly more commonly present with – Symptoms of psychomotor change (usually seen in conjunction with melancholic features or vascular depression)– Anhedonia, and – Cognitive impairment

• ‘Gastric Symptoms’– gas ascending to head– gas not being cleared– constipation

• ‘Low blood pressure’• ‘Non-recordable Fever’

Anxiety Disorders

• Usually begins in early or middle adulthood but may appear after age 60

• Prevalence rate: 5.5% -11.4*

• With the elderly - up to 20% with – 37% co-morbidity with depression, dementia and

medical illnesses such as CHF, CAD, diabetes

*U.S. Department of Health and Human Services. Mental Health: Report of Surgeon General; 1999

Anxiety Disorders: Prevalence(among older community-dwelling individuals)

• GAD = 7.3%• Phobias = 3.1%• Panic D/O = 1.0%• Obsessive-compulsive disorders = 0.6%

Bipolar Disorders: in Older Adults

• True prevalence is unknown (elderly underutilize mental health services, underreport mental health problems, receive care in other settings)

• Co-morbidity is the rule rather than the exception (neurological illness, diabetes….7 or more co-morbid diagnoses in 20% of elderly BMD)*

• Lifetime rate of substance abuse: 20-30%

• Mania is usually associated with medical conditions

* Depp & Jeste 2004; Regenold, et al.

Bipolar Disorders: in Older AdultsPrimary vs. Secondary Mania

• Primary:-onset early in life-no obvious medical

cause-higher familial rate of

bipolar illness-better general

response to lithium

• Secondary:-onset later in life-related medical cause

(CNS lesions, metabolic disease)

-lower familial rate of bipolar illness

-generally poor response to lithium

Bipolar Disorders: in Older Adults

• Depression usually precedes mania by 20 years

• In general, manic symptoms are milder compared to younger patients

• May present with mixed, manic, dysphoric or agitated states

• More likely to have – Irritability, – Treatment resistance, – Higher mortality rate

• Develop dementia at a higher rate than elderly without bipolar illness

BMD – late onset

• Persons age 60 years and older may constitute as much as 25% of the population with BMD*

• New-onset BMD frequency declines with advanced age– 6 to 8% of all new cases of BMD developing in persons age 60 years and

older*

• Co-morbid Axis I disorders include: – Alcohol abuse disorders = 38.1%, – Dysthymia = 15.5%, – GAD = 20.5%, – Panic disorder = 19.0% – Men have greater prevalence of alcoholism; women have greater

prevalence of panic disorder**

* Sajatovic M, et al: New-onset bipolar disorder in later life. Am J Geriatr Psychiatry 2005; 13: 282-289.* Almeida, OP, Fenner, S: Bipolar disorder. Int Psychogeriatr 2002; 14:311-322.** Goldstein, BI, et al: Am J Psychiatry 2006; 163:319-321.

Psychosis in Elderly: EpidemiologyUp to 23% of older adults:

Will experience psychotic symptoms at some time

Study from lucknow about prevalence of (Tiwari et al. 2009-10):•Psychiatric disorders in elderly:

Urban:3.1 % Rural: 7.7%

•Cognitive disorders: Urban:3.8%Rural: 3.9%

Nearly 40% of these have psychotic symptoms.

Study from lucknow about prevalence of (Tiwari et al. 2009-10):•Psychiatric disorders in elderly:

Urban:3.1 % Rural: 7.7%

•Cognitive disorders: Urban:3.8%Rural: 3.9%

Nearly 40% of these have psychotic symptoms.

• Psychotic symptoms:– More common in populations of elderly persons than in

younger persons. This is due:• Conditions such as DELIRIUM and DEMENTIA

– More commonly associated with psychotics symptoms

• Prevalence of psychotic symptoms increases with advancing age because of many factors:– Age-related cortical atrophy & Neurochemical changes– More co-morbid illnesses– Social isolation– Sensory deficits– Cognitive changes– Polypharmacy & substance abuse– Genetic predisposition– Premorbid personality

Sensory deficit: Brain is:– Dependent on signals from the outer world to function properly.– If spontaneous activity in the brain is not counterbalanced with information from the senses

Loss from reality and psychosis

Sensory deficit: Brain is:– Dependent on signals from the outer world to function properly.– If spontaneous activity in the brain is not counterbalanced with information from the senses

Loss from reality and psychosis

Targum SD, Abbott JL. Psychoses in the elderly: a spectrum of disorders. J Clin Psychiatry.1999;60(suppl 8):4–10

THE MOST COMMON ETIOLOGY:

Webster et al 1998

The prevalence of delirium in elderly (Fann JR, 2000):o At the time of hospitalisation: 11% to 24%o In post surgical patients: much higher [60 to 80%]

Schizophrenia: [Lacro JP et al, 1997; Targum SD et al, 1999]

• Onset after 45 years of age: ‘Late onset schizophrenia’• Onset after 60 years of age: ‘Very late onset schizophrenia’

Constitute for 10% of the total cases of schizophrenia

Risk Factors of Late-Onset Schizophrenia:

Family history of schizophrenia Sensory deficits Social isolation Abnormal premorbid personality Never married/no children Lower socioeconomic status

Characteristics of Late onset schizophrenia: Females>males (reduction of antipsychotic role of estrogens) Less family history More persecutory delusions Auditory hallucinations are more common Cognitive deterioration < less than that in early onset More positive and Fewer negative symptoms Higher prevalence of sensory deficits Pre-morbid functioning less impaired Respond to lower doses of antipsychotics Avoid conventional antipsychotics

MOOD DISORDERS WITH PSYCHOSIS

• Most common psychiatric disorder in older patients:– Depression

• Prevalence (ECA community survey) (Myers JK et al, 1984):– Depression in 27% of the elderly

• Psychotic symptoms in depression:– 40-45% of cases (Nelson et al, 1989; Mayers BS, et al, 1986)– Mostly delusions which usually include persecutory

beliefs, guilt, nihilism, suspiciousness, and sin– Hallucinations

• In contrast to non-psychotic depression, psychotic depression in the elderly (Lacro JP et al, 1997):– Associated with increased risk for relapse, – More persistent symptoms over 1 year, – More suicide attempts, – More hospitalizations, comorbidity, and financial

dependency– Poorly respond to antidepressants alone, require

antipsychotics– Best respond with ECT

• Elderly manic patients:– Irritability, paranoia, and mild confusion more common

than euphoria– Delusion of grandiose, or paranoid delusion

MOOD DISORDERS WITH PSYCHOSIS

DEMENTIA WITH PSYCHOSIS• Elderly patients with dementia:

– High risk for the development of psychotic symptoms and behavioral disturbance

• Psychotic symptoms (Targum SD et al, 1999; Tariot P, 1999):– Alzheimer disease: 50% -70% patients

• Type os Psychotic symptoms in Alzheimer disease (Tariot P, 1999):– Hallucinations: 28%– Agitation: 44%– Verbal aggression: 24%– Delusions: 34%– Wandering: 18%

• Persecutory delusions (Cummings et al,1987):– Alzheimer disease: 30%– Vascular dementia: 40%

• Dementia with Lewy Body:– ~20% of Dementia– Prominent findings (McKeith IG et al, 1996):

• Fluctuations in cognition and alertness (attention) with• Behavioral disturbance (early psychiatric symptoms)• Visual hallucinations• Motor features of parkinsonism

– 90% have visual hallucinations.– Avoid antipsychotics, better respond with Cholinesterase inhibitors

• Vascular Dementia– 50% of multi infarct dementia have delusions– Up to 40% of cases may have delusions before dementia obvious– Low response rate

DEMENTIA WITH PSYCHOSIS

Prevalence: Alcohol Abuse/Dependence

• More than half of people over age 65 do not drink at all

• ‘At risk drinking’ (more than 2 drinks/day for a man and more than 1 drink/day for a woman): 6-9% (minimum)

• Up to 17% of older adults (over age 60) misuse alcohol or prescription drugs (5% - 10% of patients seen in an outpatient setting and 7% - 22% of medical inpatients)*

• Approx. 2/3 of alcohol problems are “long standing” while 1/3 are a late-onset problem appearing for the 1st time later in life POSSIBLY associated with retirement, bereavement or depression

.

*J. Geriatr. Psychiatry Neuro. 2000:13;106-14

Prevalence: Alcohol Abuse/Dependence

• “alcohol abuse” = 15% men/12% women ……..drinking in excess of recommended limits/guidelines

• With women, rapid progression to alcohol-related illnesses such as cirrhosis, sleep problems and cognitive problems

• Alcohol dependence: prevalence is 8 – 14%; most common psychiatric disorder

• Often accompanied by other substance abuse (particularly nicotine) d/o, anxiety/panic, mood disorders and antisocial personality disorder

Clinical Presentation in the Elderly with an Alcohol/SA Problem

• Do NOT present as: – Substance seeking behavior such as characterized by crime,

manipulativeness, and antisocial behavior• Presentations vary but may include:

– marital discord, – falls, – confusion, – poor personal hygiene, – depression, – anxiety, – sleep complaints, – malnutrition, – delirium, – dementia

Elder Abuse, Neglect and Exploitation

• Types of elder abuse: – Physical abuse, – Sexual abuse, – Emotional/psychologic abuse, – Financial exploitation/victimization/undue influence, – Neglect, – Abandonment

• Most common type of elder abuse: – Neglect - depriving an elder of something needed for daily

living• Second most common type of elder abuse:

– Physical abuse• Third most common type of elder abuse:

– financial exploitation

Elder Abuse Statistics

• Prevalence: 1% - 12%

• Women more than men

• 75% of victims are physically frail• 50% are unable to care for themselves • many are confused or disoriented – some or most of the time

• Majority occurs in home setting

• Majority of perpetrators are family members usually a spouse or adult child

STATISTICS: Elderly Abuse

• Can occur in family homes, nursing homes, board and care facilities, and hospitals

• Mistreated by their spouses, partners, children and other relatives and friends

• Elder partner abuse: long standing pattern of marital violence or as abuse originating in old age – as relates to issues in aging/disability, stress and changing family relationships

Risk Factors for Abuse

• Older age (>75)• Female• Unmarried/widowed/divorced• Lack of access to resources• Low income• Social isolation• Minority status• Low level of education• Functional debility/taking multiple medications• Substance abuse by caregiver or elder person• Psychological disorders (depression, anxiety) and personality change• Previous history of family violence• Caregiver burnout and frustration• Cognitive impairment• Fear of change of living situation (home ALF/NH)