Lecture 4: Psychological Distress in Old Age II

Does the prevalence of depression increase with age?

Yes!

What is major depression?

Occurs when 5 or more of these symptoms are present:

• depressed/sad mood

• loss of interest intrest in routine activities (PA, games)

• loss of appetite

• hypersomnia/insomnia

• agitation

• fatigue/loss of energy

• cannot concentrate

• suicidal thoughts

• guilt

In addition, presence of these symptoms must be:

• experienced over a 2-week period or more

• functionally impairing

What is a minor depression?

Symptoms are fewer than 5 or experienced over a period shorter than 2 weeks

In what populations are late-life depression higher?

Women than men

Institutionalized populations (long term care) than community-dwelling populations

Oldest-old (75+ years than young-old (65yrs or less))

Common factor = loneliness and isolation

What is late-life depression a combination of?

Biological/genetics factors

Psychological factors

Social factors

What are some biological factors that influence late-life depression?

This view suggests a genetic predisposition to depression (gene inheritance), as seen in twin studies

Other suggest cerebrovascular disease as primary cause of depression

Physical comorbidity (stroke, vision/hearing impairment, cardiac disease, lung disease) have been linked to depression in late-life

What are some psychological factors?

Fewer pleasurable engagements increase the risk of depression

Maladaptive cognitions (irrational thoughts, over-internalization of adverse events) are risks factor for depression

Catastrophic events (war killings, rape) increase the risk of depression

What are some social factors?

Stress (financial strain, caregiving responsibilities, relationship stress) is a risk factor for depression

Life events (death of a spouse) are associated with depression

Lack of social supports (loneliness) is a risk factor

What are the effects of late-life depression?

Late-life depression can lead to:

• poor cognitive performance (memory, processing speed)

• low life satisfaction

• poor QOL

• suicide ideation

What are some protective factors against late-life depression?

Despite adverse experiences, some older adults do not experience late-life depression, suggesting the role of protective factors:

1. Available resources (good health, high SES)

2. Positive life orientation (optimism/hope vs pessimism)

3. Meaningful social engagements as opposed to social isolation and loneliness

4. Spirituality/religious faith (confers sense of life purpose, hope)

What are some treatments of late-life depression?

• anti-depressant medications

  • have side effects such as nausea and weight gain

• Psychotherapy

  • Cognitive Behaviour Therapy (CBT)

  • Problem-Solving Treatment (PST)

  • Interpersonal therapy (IPT)

What is CBT?

A form of talk therapy to alter negative thoughts and behaviour

What is PST?

Teaches to identify problems and implement solutions

What is IPT?

Addresses problems in everyday relationships

Do older adults worry more than younger adults?

No, nonetheless late-life anxiety is still prevalent

What do older adults tend to worry about more?

Work, finances and romantic relationships are less important to older adults

Worry about health and welfare of loved ones (children and grandchildren)

What are normal everyday “anxiety” symptoms for older adults?

Fear, worry and panic attacks

When does it become anxiety disorder?

When the symptoms have reached clinical significance

• the point where the symptoms impair social functioning, QOL and life satisfaction

What are the types of late-life anxiety?

1. Phobic disorders

2. Generalized anxiety disorder

3. Panic disorder

4. Post-traumatic stress disorder (PTSD)

What is Phobic Disorder?

The most common form of anxiety disorder in late-life:

• characterized by fear of people, objects or activities (walking due to fear of falling; social phobia)

What is Generalized Anxiety Disorder?

The second most common form of late-life anxiety. It is characterized by:

• excessive worry

• motor tension (restlessness, fatigue)

• hypervigilance (insomnia, concentration problems)

• depressive symptoms

What is Panic Disorder?

Characterized by recurrent panic attacks lasting approx. 10 mins (dizziness, choking)

What is Post-traumatic Stress Disorder (PTSD)?

Characterized by recollection of traumatic experiences in the form of dreams, flashbacks (war situations and rape)

What are some treatments for anxiety?

• Exposure Therapy for phobic anxiety:

  • supports people to conquer their fear (in a graded fashion)

  • The assumption is that they overestimate the danger(s)

• Pharmacologic treatments":

  • anxiety shares many symptoms with depression

  • so, anti-depressant medications are also used to treat some anxieties

What is psychosis characterized by?

Characterized by delusions and hallucinations (hearing voices, seeing things others do not see)

Often have disorganized thoughts and cannot differentiate between what is real and what is not (disconnection from reality)

Exhibit disruptive behaviour (aggression) and incoherent speech

What is the prevalence of psychosis?

Increases with age

Very common in ages 90+ age group

What are some common psychotic disorders?

Schizophrenia

Bipolar disorder

How is schizophrenia categorized in older adults?

1. Schizophrenia acquired in early life and carried into old age

2. Schizophrenia acquired in late adulthood (age 40-60 years) —> late-onset schizophrenia

What does late-onset schizophrenia look like?

Accounts for 15-20% of the prevalence in older adults (most cases of schizophrenia occur before age 40)

Characterized by persecutory delusion; fear of being harmed or accused of a horrible crime (paranoia)

Auditory hallucinations are more common in late-onset schizophrenia than early-onset schizophrenia

What do those with late-onset schizophrenia have less of?

Less thought disorder (only 2% of cases) than early-onset schizophrenia (28%)

Experience less emotional flattening (blunted emotions)

What do those with late-onset schizophrenia have more of?

More female representation in late-onset schizophrenia (and more men in early-onset schizophrenia)

What is late-onset schizophrenia associated with?

Social isolation and sensory impairments

Cognitive impairment

Poor physical health

What is the treatment of schizophrenia?

• Anti-psychotic medications are effective for treating positive symptoms (delusion, hallucinations)

  • however, anti-psychotics are less effective in treating negative symptoms (emotional flattening)

  • Anti-psychotics have side effects (delirium, metabolic syndrome- obesity, diabetes, high BP) which increase with age

• Psychosocial therapy (cognitive behavioural therapy, social skills therapy, SST)

What is bipolar disorder?

Also called manic depression; is characterized by extreme mood swings

Alternating periods of stable mood (euthymia), deep sadness (depression), and over-excitement (emotional lows and highs)

The mood swings affect energy levels, sleep, judgement and behaviour

Is there a distinction between early and late-onset bipolar disorder?

yes

Onset differences; before and after age 50 years

Approx. 90% of bipolar patients are under 50 years

How to diagnose late-onset bipolar disorder?

It is difficult to diagnose due to symptomatic overlap with depression and dementia

Must rule out other psychiatric conditions with similar symptoms (depression, anxiety, substance use disorder)

Relies mainly on sustained episodes of mania and depression

What does late-onset bipolar disorder look like?

Associated with less severe symptoms, compared to early-onset bipolar disorder (fewer episodes of depression, delusions)

Factors associated with late-onset bipolar disorder:

• family history of bipolar disorder

• traumatic events

• medical conditions (diabetes, CVD)

• medications

What are some treatments of bipolar disorder?

• Multiple drug therapies may be taken at a tie (anti-psychotics, mood stabilizers, anti-depressants)

  • however, there is concern for side effects of polypharmacy (delirium, death)

• psychosocial therapies

  • CBT to change negative thoughts and behaviours

  • Emotional management training