Health Status of Older Adults

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Health Status of Older Adults Mental
Disorders Lecture 6 Chapter 6
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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
2 4 6 8 10 12 14
16 18 20
years
Onset of illness
Death or disability
2006 2.66 decrease in disability /year
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20-22
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DSM-IV-TR (2000)

• Publisher APA
• covers all mental health disorders (children
  adults) (over 300)
• lists known causes of these disorders
• stats gender, age at onset, prognosis, optimal
  tx approaches

• symptoms that must be present (and for how long)
  (called inclusion criteria)
• ? symptoms that must not be present (called
  exclusion criteria)

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Mental Disorders in Late Life

• MD continues or reoccurs
• Life time of stressors ? MD
• Develop disorder in later life

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Problems with Diagnosis
Polypharmacy Is it the drugs or a real mental
disorder???
Medical Condition or real mental disorder???
Side effects, interactions Issue re adipose
tissue (lipophillic drugs), dosage
Alzheimers, PD
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¾!!
75!!!
¾!!
75!!!
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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)

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Expenditures on NIMH Newly Funded Grants
Millions of Dollars
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NIMH, 2001
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What is most commonly diagnosed mental disorder
among older adults??? More mental
illness than other age groups???
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21 females to males
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Specific anxiety disorders include the
following general anxiety disorder (GAD) panic
attacks phobias obsessive compulsive disorder
post-traumatic stress disorder
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Anxiety -- Necessary part of life!
(transitional adjustment) -- Warns of danger --
Can stimulate and lead to productivity
Persistent anxiety not good
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Transitional Anxiety
Transitional Anxiety -- decreased
self-confidence -- fearfulness -- mild
concentration decline -- worry related to home,
belongings, friends, pets Couple of
days to couple of weeks
Anxiety Disorder
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
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FACTORS COMPLICATING THE DIAGNOSIS OF ANXIETY IN
OLDER ADULTS
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Comorbidity of Mental Illness -- Older Adults
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• 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)

Others
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 (lt 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.
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General anxiety disorder (GAD)

• 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
• Chronic anxiety that persists for more than 6
  months
• be accompanied by decreases in activities or some
  sort of impairment
• 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)

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Howard Hughes
1905 - 1976)

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

The Aviator Draws Attention to Anxiety
Disorders in Older Adults Until recently, anxiety
disorders were believed to decline with age
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Depression
Reactive-Exogenous triggered by an obvious event
Endogenous No trigger No obvious event
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• Anhedonia (experience pleasure)
• Weight gain or loss
• Hypersomnia, insomnia
• Fatigue, loss of energy
• feelings of worthlessness guilty
• difficulty concentrating

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• 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
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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)
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• Attitudes Of Older Adults Towards Depression
• Americans 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
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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
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Leading Causes of Suicide Among females, 2001
Source National Vital Statistics System -
Mortality, NCHS, CDC.
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Leading Causes of Suicide Among Males, 2001
Source National Vital Statistics System -
Mortality, NCHS, CDC.
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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)

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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)

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Decrease by 50
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