!Mental Health Issues in Later Life

Mental Health Conditions

• Determinants of healthy cognitive aging include

  • Socialization

  • Physical health

  • Cognitive stimulation

• Older adults with mental illness are often isolated and have limited financial and human resources, affecting opportunities for participation in health aging activities

• Aging with mental illness can intensify challenges in maintaining health, performing daily activities, and managing social interactions

Mental Health in Later Life

• Older adults with mental illness were found to have

  • Less physical activity

  • Unhealthy diets

  • More use of medications

  • Sleep disorders

  • Agitation

Support

• Individuals with mental illness often rely on close relatives and friends to assist with everyday activities and to provide socialization

• With aging, the death of these supports is a source of great stress and trauma for persons with mental illness

  • This loss of support often results in the initialization of person, leading to further problems with isolation

***Aging persons with mental illness are more likely to experience insufficient and inappropriate support due to lack of trained professionals and target programs addressing the complexity of aging and mental illness

Depression

• One of the most common illnesses in older adults

• Factors contributing to depression in older adults include

  • Chronic illness

  • Loss of socialization

  • Hearing loss

  • Stressful life events

  • Low resilience

  • Decreased mobility

  • Loss of loved ones

  • Limited income

• Depression is linked to decreased functioning and decreased life satisfaction in older adults

• About 2% of adults older than 55 years have major depression, and 10% to 15% have clinical depression

• The rate of major depression increases with age, and for older adults who are in nursing homes or hospitalized

Symptoms of Depression

• Range from

  • Loss of interest and pleasure in activities

  • Change in appetite

  • Sleep disturbances

  • Feeling agitated, fatigued, and low self-worth

  • Difficulty concentrating

  • Suicidal thoughts

  • Hopelessness

  • Sadness

  • Loss of energy

  • Can also impact an individual’s cognitive abilities, resulting in memory loss, difficulties in concentration and attentional processes, problems with learning, and problems with executive functioning

Assessing Depression

• Commonly used Depression Scales

  • Geriatric Depression Scale

  • Center for Epidemiological Studies-Depression (CES-D)

  • Beck Depression Scale

    • most commonly used in OT

  • Zung’s Depression Rating Scale

  • Cornell Scale for Depression in Dementia

  • Need to ask about suicide

Treatment for Depression in Older Adults

• Pharmacological and behavioral components

• Antidepressants are beneficial in treating depression

  • However, older adults often have comorbidities, such as heart disease, demanding attention to drug interactions

  • Monitoring changes in cognition, hypotension, or other issues (e.g. electrolyte imbalance) can assist clinicians

  • Older adults metabolize or excrete many medications slower than younger individuals and because these medications can cause cognitive changes, careful monitoring is essential

Evidence-based Programs for Treatment of Depression

• Promoting the use of Depression Care Management Model

  • e.g., restorative models, day programs, ACL (Administration of Community Living) programs, etc.

• IMPACT

  • Improving Mood, Promoting Access to Collaborative Treatment

  • treatment intervention for adults w/ major depression, often paired with other conditions

  • collaborative step-care approach w/ a depression team that helps to administer the course of treatment

• PEARLS

  • treatment program designed to reduce symptoms of depression and improve QoL among older adults and adults w/ epilepsy

  • 6-8 home counseling sessions

  • help to schedule enjoyable activities + incorporates physical movement

Communication Strategies when working with Older Adults with Depression

• WARK

  • Warmth, Acceptance, Respect & Kindness

    • establish rapport, actively listen, communicate hope, etc.

• Maintain eye contact

• Acknowledge what the person is saying

• Permit expression of strong emotions

• Be non-judgmental

• Communicate acceptance of the person’s sadness

• Help identify the things he/she is sad about

• Reinforce a person’s worth

• Use touch if appropriate

Occupational Therapy Interventions

• Need to break the “Inactivity Cycle”

• Use of Life Review/ Reminiscence

• Mindfulness/Meditation

• Problem-solving social skills

• Importance of physical activity

Group Ideas for Older Adults with Depression

• Self Management

• Interpersonal & Social Skills

• Leisure Skills

• Goal Setting

• Exercise

• Task/Work Skills

• Discussion Groups

• Intergenerational programs

  • e.g., older adults read books to children

• Consider outpatient vs. inpatient focus

Pseudodementia vs. Dementia

• Pseudodementia

  • Short duration of symptoms

  • Strong sense of distress

  • Many detailed complaints of cognitive loss

  • Memory gaps common

  • Emphasizes disability

  • Makes little effort to perform

• Dementia

  • Long duration of symptoms

  • Often unconcerned

  • Few, vague complaints of cognitive loss

  • “near miss" answers common

  • Conceals disability

  • Struggles to perform

Anxiety Disorders

• Generalized anxiety disorders are the most prevalent mental illness among older adults

• Studies of anxiety and depression have found relationships between life stressors, loneliness, and health to exacerbate mental illness

• Adults ages 50 to 59 years were found to have high rates of anxiety, possibly due to life transitions

  • starting to think about retirement

• Diagnosis and detection of generalized anxiety disorder in later life can be complicated by chronic medical conditions, cognitive decline, life changes, and medication side effects

Potential Anxiety Triggers for Older Adults

Worries about their

• health

• disability

• dependence

*pretty different from the anxiety triggers that younger adults have (e.g., work, finances, family)

Symptoms of Anxiety

• Can be manifested cognitively, emotionally, and/or physically

• Examples of such manifestations include

  • Ruminating

  • Excessive worry and fear

  • Difficulty concentrating or focusing

  • Restlessness

  • Irritability

    Fatigue

  • Body aches/pains

  • Insomnia

  • Increased cardiovascular and respiratory responses (i.e., pounding heart, irregular breathing)

Risk Factors for developing an anxiety disorder as an older adult

• Loss of a spouse or loved one

• Physical illness

• Social isolation

• Low quality of life

• No religious affiliation

Evidence Based Treatments for Anxiety Disorders

• Psychotherapy including

  • CBT,

  • medications, and

  • complementary health approaches for stress reduction and relaxation

  • Benzodiazepines and anxiolytics can have negative effects on older adults and may not be recommended (must be closely monitored if using)

• Psychosocial interventions, including

  • relaxation training,

  • CBT,

  • cognitive restructuring, and

  • supportive therapy

Schizophrenia

• Considered a severe mental illness, affecting about 1 in 300 people worldwide (WHO, 2022)

• Characterized by disturbances in thought processes, hallucinations, delusions, cognitive impairments, and deficits in daily functioning

• Typically diagnosed in young adults and is a chronic condition with premature mortality and characterized by severe dysfunction

• Older adults with schizophrenia often have comorbidities and dementia

• often leads to institutionalization (e.g., long-term care facilities)

Bipolar Disorder

• A serious mood disorder characterized by alternating elevated periods of mania (bipolar I mood disorder) and depression (bipolar II mood disorder)

• Some individuals experience a mixed state in which manic, hypomanic, and depression are present concurrently

• Older adults with bipolar disorder with severe mixed symptoms may present with

  • disorders in language and thought, with irritability during the manic state,

  • and with concentration problems, sadness, and anxiety during the depressive state

• While the prevalence of bipolar decreases with age, about 25% of persons with bipolar disorder are older than 60 years

Functional Impact of Bipolar Disorder

• Older adults with bipolar disorder, especially mixed symptoms and frequent episodes, are likely to be more dependent in daily activities and cognitive functioning

• Older adults with bipolar disorder presented with difficulty with attention, inhibition, immediate memory, work memory (storing and retrieving), processing speed, cognitive flexibility, verbal fluency, psychomotor function, executive functions, and recognition

Substance Use Disorders (SUDs)

• Refer to the misuse of substances that result in physical and/or psychological addiction

• These substances include alcohol, prescription drugs, nonprescription medications, and illicit drugs

• Although older adults do have SUDs, relatively little is known about prevalence, etiology, or treatment

Cohort Information

• Between 2008 to 2018, older adults’ rate of seeking first-time treatment for SUDs was proportionally higher than that of younger adults

• The primary substances misused at admission by older adults were illicit drugs including opioids, heroin, and methamphetamine

  • There were fewer admissions for alcohol use compared with those for illicit drug use

• This population is defined by the baby boomer generation, which had early exposure to drug and alcohol culture

Risk Factors Contributing to SUD

• Chronic pain

• Poor overall health

• Polypharmacy

• Social isolation

• History of abuse

• Loss of loved ones

• No religious affiliation

• Single or divorced

• Avoidant coping strategies

Treatment of SUDs in Older Adults

• Must consider the physiological changes associated with aging

  • Older adults are at risk of decline in renal and liver functions caused by SUD

• Treatment programs such as detoxification must consider underlying medical conditions

• Nonpharmacological treatments for SUD include

  • Psychotherapy, including CBT, self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous)

  • Motivational interviewing

  • Group therapy

Suicide in the Elderly

• People 65 & older have highest suicide rate of any age group

• Caucasian men aged 85 years and older have the highest suicide rate

  • This rate is nearly 6 times the rate of suicides of other ages

  • men typically are more successful bc they use more violent forms of harm (guns vs women who are more likely to use medication)

While we often think of suicide as an act of the young, the highest incidence of completed suicide is in the older adult population

Suicide Risk Factors

• Depression

• Medical Illness

• Intense feelings of hopelessness

• Single or widowed

• Recent major loss of a loved one

• Hx of psychiatric illness, drug or ETOH abuse

• Previous suicide threats/ attempts

• Diagnosis of a terminal illness in self or spouse

How does Suicide in the Elderly differ from Suicide in the Young

• Older individuals make fewer suicide attempts

• The ratio of attempts to suicide complete is ~4:1 compared to 8- 20:1

• Older people are less likely to directly communicate their intent to die and what signals they do give are more likely regarded as a normal part of aging

• Suicides are often long planned