Seminars in Old Age Psychiatry: Second Edition

Healthy Ageing

Complex Definition: Healthy ageing is complex, involving biological, mental, and social aspects, with physical function peaking in mid-twenties.
Increased Longevity: Life expectancy has increased significantly (e.g., to 80 years for men and 83 for women in England), but often with more years spent in poor health.
Leading Causes of Morbidity: Low back/neck pain, skin diseases, and depressive disorders are major causes; morbidity rates increase with age.
Risk Factors for Disability: Obesity, diabetes, physical inactivity, and low socioeconomic status are key contributors.
Risk Factors for Morbidity: High BMI and high blood sugar are primary risk factors, along with smoking and alcohol use.
Ageing Theories:
- Genetics: Ageing is partly genetically controlled (e.g., species-specific lifespans, premature ageing disorders like Progenia and Werner Syndrome).
- Longevity Genes: Genes like daf-2, pit-1, aak-1, and SIR2 may extend lifespan by optimizing survival.
- Telomeres: Cell division limit (Hayflick Limit) is regulated by telomere shortening, influenced by replication, free radicals, stress, inflammation, and vitamin D deficiency.
- DNA Damage: Oxygen free radicals and errors in cell replication contribute to ageing, with DNA repair capacity linked to longevity.
- Disposable Soma Theory: Proposes an evolutionary trade-off between self-maintenance, reproduction, and lifespan.
- Calorie Restriction: May extend lifespan and improve health in various animals, potentially by altering metabolism.
- Sugar: Advanced glycation end products (AGEs) from sugar binding to proteins may cause cataracts and atheroma.
- Gender: Women generally live longer, possibly due to two X chromosomes and hormonal effects; lifestyle factors also play a role.
Assessment of Healthy Ageing: No standard battery; tests like grip strength and balance are predictive of mortality. Proposed biomarkers include physical, cognitive, physiological, immune, and endocrine measures. Hierarchy of functional loss begins in the forties.
People with Severe Mental Illness:
- Mortality Gap: Patients with schizophrenia and bipolar disorder die significantly earlier, largely due to physical ill health (especially cardiovascular disease), exacerbated by antipsychotics, high BMI, and socioeconomic disadvantage.
- Clinical Actions: Clinicians should ensure primary care enrollment, promote health education, and monitor physical health (BMI, BP, HbA1c, lipids, ECG) before and during antipsychotic treatment, and advocate for lifestyle interventions.
Seven Healthy Lifestyle Choices:
- Be Social: High levels of social interaction correlate with healthy ageing and well-being, though quality is often more important than quantity.
- Be Loving: Remaining sexually active is linked to longevity and satisfaction, with partner availability and biological changes being factors.
- Exercise: Regular physical activity balances growth/repair processes, prevents frailty, and harnesses inflammatory benefits (moderate exercise leads to best outcomes).
- Eat Healthily and Stay Trim: Nutrition is crucial; high BMI is a major risk factor. Healthy diets vary (fish, vegetables, grains); moderate overweight may be associated with longevity, but obesity reduces survival.
- Keep Stimulated: Mental and social stimulation (e.g., new challenges, spirituality) is beneficial for brain plasticity and overall well-being; early retirement is linked to earlier death.
- Sleep Well: Adequate sleep (at least $6$ hours) supports mental/physical health by boosting the immune system, reducing cancer/Alzheimer's risk, and positively impacting psychiatric conditions.
- Don't Smoke or Drink Too Much Alcohol: Smoking severely damages cardiovascular health and accelerates ageing. Excessive alcohol intake is increasing in older populations and can lead to various health issues even at moderate levels.
Lifestyle Change: Knowledge alone is insufficient; motivational interviewing, goal-setting, and person-centered approaches are effective for promoting lifestyle changes, which are crucial for reducing years lived in poor health.
Cohort Studies: Important longitudinal studies informing healthy ageing include Framingham Heart Study, National Health and Nutrition Survey, Nun Study, Swedish Adoption/Twin Study of Ageing, Lothian Birth Cohort Studies, HALCyon, Dunedin Multidisciplinary Health and Development Study, and Newcastle $85+$ Study.

Clinical Assessment

Old Age Psychiatry: An adaptation of general adult psychiatry for later life, necessitated by increased longevity and age-related health changes.
Core Principles: Good assessment principles remain consistent, but risk assessment and outcome measurement are increasingly emphasized, as is cultural competence.
Unique Aspects in Older Adults: Assessment is modified by high frequency of physical illness, sensory deficits, coexisting organic and functional illness, and presentation of emotional distress as physical symptoms. Collateral history from relatives/carers is crucial due to dependency and potential lack of self-reporting.
Location of Assessment:
- Domiciliary Visits: Often preferred for initial assessment to observe the patient in their natural environment, identify assets/liabilities, and note signs of dysfunction (e.g., squalor, medication issues, family support). Though time-consuming, decisions can be made promptly.
- Outpatient Departments: Can be unsettling for patients due to transport; information may be less rich than home visits.
- Day Hospital: A good compromise for multidisciplinary assessment, allowing observation of daily living activities and medical assessment under less pressure.
- Inpatient Admission: Provides a safe environment, continuous nursing observation, and a break for patient/carer.
Interviewing Relatives and Carers: Essential for establishing rapport, gathering comprehensive information, and understanding the patient's context and care needs.
Cultural Competence: Clinicians need awareness of the older person's culture, their own culture, and the cultural setting, especially for migrants, to interpret symptoms accurately.
History Setting: See patients alone first, respecting their autonomy. Address sensory deficits (deafness, dysarthria) and create a comfortable, non-intimidating environment.
History of Presenting Complaint: Determine if it's a new or exacerbated problem, focusing on feelings, cognition (memory), and activities of daily living (ADL), including reliance on others.
Family History: Inquire about psychiatric illness (dementia, depression) and early deprivation, as these can be relevant.
Personal History: Gather details on education, occupation, and war experiences for context on interests, coping, and resilience. Note that education levels can influence cognitive test performance.
Past Psychiatric History: Seek information on previous psychiatric illnesses, acknowledging it may be difficult to obtain.
Medical History: Recognize that current GPs may lack full awareness of past disorders; the mere presentation of symptoms may be highly significant.
Medications: Assess for polypharmacy, patient understanding, adherence, and potential iatrogenic effects (falls, drowsiness, confusion), including over-the-counter drugs.
Alcohol History: Always inquire about alcohol use (e.g., using CAGE questionnaire), as misuse is increasing and often not volunteered, especially with medication interactions.
Activities of Daily Living (ADL): Determine independence, environmental cleanliness, nutritional status, and the extent of support relied upon.
Social History: Explore financial situation (poverty, savings, property ownership) and leisure activities/social network. Isolated individuals are at high risk, and loneliness impacts mental health.
Premorbid Personality: Difficult to establish reliably, but insights (e.g., from others) can inform therapeutic approach.
Mental State Examination:
- Appearance and Behaviour: Note signs of neglect, grooming, confidence,