Health Status of Older Adults(Mental Disorders)

Lecture 6 – Chapter 6

Mortality

Chronic Health Conditions

Sensory Impairments and Oral Health

Percent of Medicare Beneficiaries Reporting Difficulty with IADLs or ADLs by Age, 2004

Data Source: Medicare Current Beneficiary Survey

Per

cent

(%

)

0

5

10

15

20

25

30

35

65-74 75-84 85 years and over

IADL Only 1 to 2 ADLs 3 to 6 ADLs

Dietary Quality

Cigarette Smoking

Drinking

Respondent-Assessed Health Status

Compression of Morbidity Hypothesis (Fries, 1980):

As life expectancy increases the onset of chronic disease, infirmity or disability are not only postponed but

compressed into a shorter time period nearer the end of life

years2 4 6 8 10 12 14 16 18 20

Onset of illness Death or disability

2006: 2.66% decrease in disability /year

20-22%

Mental Disorders in Late Life

1. MD continues or reoccurs

2. Life time of stressors MD

3. Develop disorder in later life

Problems with Diagnosis

PolypharmacyIs it the drugs or a

real mental disorder???

Medical Condition or real mental

disorder???

Side effects, interactionsIssue re: adipose tissue (lipophillic drugs),

dosage

Alzheimer’s, PD

Mental Health Among Persons Age 65 and Over by Race/Ethnicity (2004-2005)

0 1 2 3 4 5 6

Visited a mental healthprofessional during the past

12 months

Serious mental illness

Hispanic White non-Hispanic Black non-Hispanic

Percent (%)

Data Source: National Health Interview Survey

¾!!

¾!!75%!!!

75%!!!

Poor Quality of Care for Older Adults with Mental Disorders

• Increased risk for inappropriate medication treatment (Bartels, et al., 1997, 2002)

1 in 5 older persons given an inappropriate prescription (Zhan, 2001)

• Less likely to be treated with psychotherapy (Bartels, et al., 1997)

• Lower quality of general health care and associated increased mortality (Druss, 2001)

Expenditures on NIMH Newly Funded Grants

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000Fiscal Year

Total NIMHGrants

AgingGrants

8% 7% 8% 8% 9% 6%

NIMH, 2001

Mill

ions

of

Dolla

rs

What is most commonly diagnosedmental disorder among older adults???

More mental illness than other age groups???

2:1 females to males

Specific anxiety disorders include the following:

general anxiety disorder (GAD)panic attacks

phobias obsessive compulsive disorder post-traumatic stress disorder

Anxiety:

-- Necessary part of life! (transitional: adjustment)

-- Warns of danger-- Can stimulate and lead to productivity

Persistent anxiety …not good

Transitional AnxietyTransitional Anxiety:

-- decreased self-confidence-- fearfulness-- mild concentration decline-- worry related to home, belongings, friends, pets Couple of days to couple of weeks

Transitional Anxiety Disorder

-- interferes with ADL-- intensity is out of proportion to the event-- duration of anxiety episode is out of proportion to the event Couple of days to couple of weeks

Anxiety Disorder

FACTORS COMPLICATING THE DIAGNOSIS OF ANXIETY IN OLDER ADULTS

Comorbidity of Mental Illness-- Older Adults

Panic Attacks (???)sudden, distinct episodes of intense anxiety

• usually a hx of attacks when younger• relatively rare for attacks to begin for the first time after age 55

(usually milder with fewer panic symptoms and less agoraphobia:

fear of open spaces)Phobias (.5%)

specific phobia: fear of a specific person, animal, place, object, event, or situation that results in symptoms of anxiety.

social phobias: fears associated with social situations. The usual fear is of behaving inappropriately in a certain situation and feeling

incompetent or embarrassed.

obsessive compulsive disorder (1.5%)having persistent thoughts (obsessions) that cause anxiety, and then

behaving (compulsions) in ways to decrease the anxiety (< than 1 hr a day).

post-traumatic stress disorder (???)experienced (either as a witness or a victim) a traumatic event and

reacted with feelings of fear and helplessness.

Others

unrealistic or excessive worry not related to a particular problem or event

Related to vague fears about losing control, fear of failure, fear of death

• fatigue • muscle tension • trouble sleeping through the night panic attacks• difficulty concentrating on a task • feeling irritable or on edge

1) Chronic anxiety that persists for more than 6 months2) be accompanied by decreases in activities or some sort of

impairment3) be caused by more than one worry (ex: intense worry over

financial matters or a medical illness alone, even with all the associated symptoms, does not mean someone has GAD)

General anxiety disorder (GAD)

• Hughes’ OCD was not treated• Became a recluse• Died– largely of starvation - 71 yrs old,

1905 - 1976)

Howard Hughes

“The Aviator” Draws Attention to Anxiety Disorders in Older AdultsUntil recently, anxiety disorders were believed to decline with age

Depression

Reactive-Exogenous triggered by an obvious event

Endogenous No trigger No obvious event

•Anhedonia (experience pleasure)•Weight gain or loss•Hypersomnia, insomnia• Fatigue, loss of energy• feelings of worthlessness guilty• difficulty concentrating

Indicator 18 - Depressive Symptoms

Clinical Depression ~ 5%:

• Depressed mood most of the day, nearly everyday • Loss of pleasure in daily activities • Significant weight loss or gain • Change in mobility (slowing down or nervous gestures)• Feelings of worthlessness, self reproach, excessive guilt • Diminished ability to concentrate • Suicidal thoughts

Steffens et al. (2000) : depression in older adults was 4.4% in women and 2.7% in men

When depression occurs in late life:

1. relapse of an earlier depression

2. If first time occurrence may be triggered by another illness, hospitalization, or placement in a nursing home

3. Unlike the onset of depression in younger adults depression is thought to be a psychological disorder triggered by specific life stressors (loss of loved one)

Attitudes Of Older Adults Towards DepressionAmericans aged 65:

• 68% know little or almost nothing about depression

• 38% believe that depression is a "health" problem

• more likely than any other group to "handle it themselves“

• 42% would seek help from a health professional

National Mental Health Association, 1996

Peak suicide rates: goes up continuously for men / at midlife for women, then declines

1/3 of older men saw their primary care physician in the week before completing suicide; 70% within the prior month

Leading Causes of Suicide Among females,

2001

0

10

20

30

40

50

60

70

80

90

100

10-14 15-19 20-64 65+

Pe

rce

nt

of

all

su

icid

es

by

ag

e

Firearm Suffocation Poisoning Fall-jump Drowning Cut/pierce

Source: National Vital Statistics System - Mortality, NCHS, CDC.

Leading Causes of Suicide Among Males, 2001

0

10

20

30

40

50

60

70

80

90

100

10-14 15-19 20-64 65+

Pe

rce

nt

of

all s

uic

ide

s b

y a

ge

Firearm Suffocation Poisoning Other

Source: National Vital Statistics System - Mortality, NCHS, CDC.

Nursing Homes: The Primary Provider of Institution-Based Care for Older Persons with Mental Disorders

• 65-80% of Nursing Home Residents-A Diagnosable Mental Disorder(vs 20% in older adults at home)

• Among the Most Common Disorders– Dementia – ***Depression (as high as 50%!!!)– Anxiety Disorders and Psychotic Disorders

(Burns & Taube, 1990, 1991, Rovner et al., 1990)

Unmet Need for Mental Health Services

in Nursing Homes

• Over one month: 4.5% of mentally ill nursing home residents received mental health services (Burns et al., 1993)

• Over one year: 19% in need of mental health services receive them. – Least likely: Oldest and most physically impaired

(Shea et al., Smyer et al., 1994)

Decrease by 50%