Intoduction .ps



Introduction

Mental health and emotional well-being are as important in older age as at any other time of life. Most older people have good mental health, but older people are more likely to experience events that affect emotional well-being, such as bereavement or disability. The Department of Health estimates that perhaps 50 per cent of older people in general hospitals, and 60 per cent of care home residents, have a mental health problem.

Assessing the mental health needs of older people requires an understanding of the complex interaction between specific medical conditions and social circumstances. To be able to offer effective support, practitioners need to keep up-to-date with the latest research methods and legislation.

Improved living standard and success in combating many diseases have led to increase life expectancy. industrialized societies people are living healthier and longer than ever before

In the UK between 1971and2003 the number of people over 65 changed 28% and 2002 life expectancy for female 81 years and 76 for male

People aged 85 are fastest rising population

England currently over6000 people over 100 yrs asESRC

Added life to years not just more to life

A growing body of evidence counter the stereotype that ageing is inevitable associated with sickness

The optimistic some of studies factor such as diet, ,marital stability, exercise,education,mental stimulation

And social involvement are associated with longevity a

And quality of the life

Some study in Sweden for people aged 85.more than three quarters were identified as having high levels of subjective well being measured by high and moderate levels on morale scale

The combination of this higher frequency of the physical ill health

And disability with other factor associated with ageing cognitive

Impairment ,socio economic deprivation and social support deficit

This factor increase incidence of commonest metal health problem

Depression,anxiety disorders among oldest old

Trends for increasing proportion of older people in population and having less disability and independent . Depend on continuing social

,economic ,and health care improvement

Older people live alone without family support structure present a special challenge and need for innovation by health care providers

Older people mental health prevalence and impact of mental health problems

Mental disorder are common in general population affecting more than a quarter of all people at some time in their life WHO 2001.

Mental disorder accounted for four of 10 leading cause of the of disability,.

Point prevalence rate for adult experiencing any mental disorder are 10 %

To 15% .

The frequency of mental illness in elderly may be under-reported" make diagnosis in the presence of physical co-morbidity “

Depressive and anxiety disorder affect between 1-7 people1-10

Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham 2004}.

SOME study in UK lower levels of common mental disorder in aged 60

And older these community studies are individual living in private house

Exclude people in situation ,temporary hospitalized or homeless

UK 1996 33200 people living in hospital and 350000 older people having care in homes as mental disorder

One in ten people aged 60 to 74 living in private households in

Great Britain (10 per cent) had a common mental disorder (such

as anxiety, depression and phobias) according to a survey report∗

published today by the Office for National Statistics.

Common mental disorders were strongly associated with

disability. Over a third of people interviewed (37 per cent) had

difficulty with one or more of seven common activities of daily

living (ADLs), (for example, personal care, household work,

getting out and about), and the likelihood of reporting difficulties

rose steadily with increasing severity of symptoms of common

mental disorder.

Difficulties with ADLs increased were also associated with longterm

physical health problems. However, at every level of

physical ill-health those with mental disorder were more likely

than those without to have difficulty with at least one ADL.

This report is also the first in the UK to examine systematically

cognitive impairment in older people. One sixth of those aged 60

to 64 rising to one quarter of those aged 70 to 74 were relatively

impaired in standard tests of memory and concentration. While

very few would be suffering from dementia, those with impairment

were much more likely than others to experience difficulties with

most ADLs.

This report is also the first in the UK to examine systematically

cognitive impairment in older people. One sixth of those aged 60

to 64 rising to one quarter of those aged 70 to 74 were relatively

impaired in standard tests of memory and concentration. While

very few would be suffering from dementia, those with impairment

were much more likely than others to experience difficulties with

most ADLs.

The report is part of a series based on a survey of psychiatric

Inter-relation between physical and mental disorder

Inter-relations between physical and psychological health are evident with in all age however the frequency of negative association –co-morbidity rise with age . The frequency of interaction and severity of its effects are magnified in older

Much research has explored the relationship between depression and cardiac

patient’ compare with non depressed cardiac patient .the mortality rate

threefold increased in cardiac patient have major depression

Epidemiological study has explored the dynamic of the interaction between

Physical illness and mental disorder .

Physical illness appear to be an important risk factor for development of

several mental agoraphobia in older people may be commonly precipitated

By stork and falls rather than associated with panic disorder. patient with

Chronic medical illness have increased risk of depressive illness

Older people have vascular disease prescribed medication may make mood disorder

Inter-relation between disability and mental disorder

study appear disability resulting from physical illness are associated with common mental disorder especially depression

The disability arising from physical ill health has been estimated to be

Cause of up 70%of new cases of depression in older people

Depression cause disability features

1-reduce motivation

2-psychomotorretardation

3- poor sleep

4-lack of energy

5- avoidance and anhedonia

Are likely to limit activity and physical disability . They are mutual reinforcement process

Older hospital setting patient in general

older people occupy tow –third of general hospital beds

And exhibit a high prevalence of co-morbid mental disorder

Predominantly delirium dementia and depression

Level of patient with depression 50% {ames 1994}

Co-exist with medical condition especially chronic illness sush as ischemic heart disease

,stroke ,cancer ,chronic lung disease ,Alzheimer's ,and Parkinson disease likely to be prevalent At levels three time in the community

Problem affect mental disorder in hospital

1-length of stay

2- use of resource

3- cost of care

4- prognosis

the complex range of physical and emotional and social problems

are demand high level of skill from care staff and resource,

the recognition of mental problems in physical ill older people is made more difficult by the inter action of illness feature ,example such as

depression symptom of anorexia .poor sleeping , and weight

loss result from variety of physical condition

physical feature such as aches pains fatigue may be aspect

of mental disorder

should be have screening measure in the hospital to identify

mental health problem such as geriatric depression scale

Older people in nursing and residential homes

You may be living at home and finding it difficult to cope because you are disabled or because you are getting more frail, or you might be in hospital and know that returning to live at home will be difficult. Moving into a residential care home is one possibility that might make your life easier.

Another setting is high prevalence of mental disorder among older people with absence optimal management Is residential care . Care home are differentiated on the basis of whether they provide personal and social car

Research indicate that new admissions to all types of care homes in the UK increasingly old . Residents are more disabled than previously with higher level of cognitive impairment , Prevalence level of dementia 50% . Depression in USA PREVALENCE 20% TO 40% of residents. Advantage of home care

• homes scored adequately in respect of non-restrictive care practice ,standard

• Of décor and cleanliness and facilities

• For activity and recreation

mental health and older people specific disorder

1- depression

2- anxiety disorder

3- dementia

4- delirium

Depression

Definition: Unipolar depression is another name for major depressive disorder. It is a mood disorder characterized by a depressed mood, a lack of interest in activities normally enjoyed, changes in weight and sleep, fatigue, feelings of worthlessness and guilt, difficulty concentrating and thoughts of death and suicide. If a person experiences the majority of these symptoms for longer than a two-week period they may be diagnosed with major depressive disorder.

The term unipolar depression is used to distinguish it from depression which occurs within the context of bipolar disorder, a disorder in which a person experiences alternating periods of depression and mania.

Type of depression

1. Major Depressive Disorder

When people use the terms depression or clinical depression, they are generally referring to major depressive disorder. Major depressive disorder is a mood disorder characterized by a depressed mood, a lack of interest in activities normally enjoyed, changes in weight and sleep, fatigue, feelings of worthlessness and guilt, difficulty concentrating and thoughts of death and suicide. If a person experiences the majority of these symptoms for longer than a two-week period, they may be diagnosed with major depressive disorder.

Dysthymic Disorder

The terms dysthymia and dysthymic disorder refer to a mild, chronic state of depression.

Symptoms

• sleep difficulties

• fatigue

• low self-esteem

• difficulty concentrating or making decisions

• feelings of hopelessness

3. Bipolar Disorder

Bipolar disorder is an illness that consists of alternating periods of elevated moods, called manic episodes, and depression. Mood swings run on a spectrum from mild mania (called hypomania) to more severe, debilitating highs. Periods of mania can last for hours, days, weeks or even months before depression returns.

4. Postpartum Depression

Pregnancy brings about many hormonal shifts. These dramatic shifts can sometimes affect mood. This is commonly known as the "baby blues." Postpartum depression can be more than just a case of the blues, however. It can range from mild symptoms that go away without treatment all the way up to postpartum psychosis, which left untreated, may be responsible for tragic murders of children.

5. Seasonal Affective Disorder

If you experience depression, sleepiness, weight gain and carbohydrate cravings during the winter months, but feel great as soon as spring returns, you may have a condition called Seasonal Affective Disorder (SAD).

Prevelance major depression among older people 1% to 4% and in minor depression 4% to 12% . Increased over aged 80%

Older people with depression have longer duration of episodes and shorter time of relapse than younger persons

30% remain chronicly depressed

• The longer duration of episodes appear

• To be co-existing physical illness

• To be poor self health status

• To be depressed severity

• Inadequacy social support

• Adverse life event

Depression ,loneliness and social support

The social environment plays crucial part in determining the quality of older people lives . Inters personal relationship have been found to act buffer between adverse event and depression . Loneliness is associated with living alone and social isolation . Vulnerability factor for loneliness

Female, Chronic health problem and Marital status. Marital status

Suicide and depression Elderly people have the highest rate of completed suicide rate of any age group. Depression in older people commonly complicates because co-morbid medical illness or dementia

The clinical presentation may be typical and meet full criteria for depressive disorder , Stigma prevent seek help for emotional problem

Useful questions for uncovered depression

• Are you sad?

• Are you sleeping poorly?

• Do you worry to much ?

• What have you enjoyed doing later ?

• Rating scale

• during the past month ,have you often been bother by feeling down ,depressed or hopeless? Yes or no

• During the past month have you often been bothered by little interest or pleasure in doing things ?yes or no

Management

Antidepressant drug

• 1- SSRI fluxetine, fluvoxamine

• 2- tricyclic imipramine , clomipramine

• 3-monoamone oxidase inhibition ,phenelzine,selegiline

• 4- atypical bupropion ,mitrazapine , nefazodone

• 5- SNRI duloxetine ,venlafaxine

Psychological therapies

Is important and enhancing the effect of medication and reducing relapse follow cessation of treatment and it is consistently found to be more acceptable than other treatment

Cognitive behavior therapy

Most establish treatment for depression and the aims to alter dysfunctional beliefs and negative thoughts that characterize depression by sessions

CBT need some adaptation for work with older people because of different life experience and value related ego

Anxiety disorder

(psychiatry) a relatively permanent state of worry and nervousness occurring in a variety of mental disorders, usually accompanied by compulsive behavior or attacks of panic and Is co morbid with depression Anxiety symptom and disorder among older people are associated with disability ,reduce equality of life, increase use health services Prevalence 10% making these mental disturbance in the late life ,The rate of anxiety disorder are around twice a high among women as men

Vulnerability factor Lower level of education , External locus of control , Resent loss of family and Physical illness

Other factors induce anxiety

• Aspect of environment

• Medication side effects Alcohol intoxication or withdrawal

• *factors contribute to poor recognition

• 1-other common mental disorder

• 2- medical co-morbidity

• 3- early age of onest and no treatment

Treatment for anxiety disorder in later life

• Tricyclic antidepressant

1-clomiparmine hydrochloride

2- imipramin hydrochloride

General anxiety improved with anti depressants drug

benzodiazepines

• Beneficial effect on symptoms of panic and general anxiety disorders {diazepam , lorazepam }

• Side effect drowsiness {driving accident risk}

Psychological treatment

CBT IS EFFECTIVE for older people , Situational exposure , relaxation technique ,self control desensitization and cognitive restructuring

provides psychotherapy and/or counseling to help you deal with a variety of life adjustment problems and psychological disorders. Psychotherapy is a process by which you examine your thoughts, feelings, actions and relationships, evaluate where problems exist, and learn how to make whatever changes are necessary to achieve better life adjustment and satisfaction. The terms counseling and psychotherapy are interchangeable because they describe the same process, and have similar goals. Counseling has its roots in personal development and life adjustment, while psychotherapy has its roots in a more medically oriented model of treating a mental disease process. Health insurance companies use a medical disease model, so insurance reimbursement is for "psychotherapy" not "counseling." The distinction is unimportant in applying the process to life management problems

dementia

Definition

• Dementia describes a loss of memory or problems with memory cognition, and reasoning characterized by:

• impairment of short and long-term memory.

• change of personality

• impaired insight and judgment (old age).

• Due to general medical conditions or is substance-induced.

• Dementia is diagnosed only if the cognitive deficits are present for at least several months.

Cortical and subcortical dementias:

The relationship is neuroanatomic lesions to symptoms.

a. Cortical dementia: characterized by the early appearance of aphasia memory loss, and difficulties with calculation. Disturbances of speech and psychomotor behavior are less predominant.

b. b. Subcortical dementia characterized by the early appearance of problems with executive functioning and recall, dysarthria, motor skill impairment, and personality changes.

Epidemiology (Dementias)

• 5% between age 65-85 years of the population

• 20% over 85 years.

• 50 percent in monozygotic twin pairs

• 75% is heritable.

• More than 75% of dementia is caused by Alzheimer disease and cerebrovascular disease.

Diagnostic features (Dementias)

a-impairment. insidious, absent- Memory minded, misplacing objects, learning deficits, and recent memories are lost with progressive forget even their own names, social and occupational even exposed to physical dangers, (fires, falling etc…)

b. Aphasia is an impairment or loss of language. difficult constructing sentences, finding words, naming objects, may aphasia, mutism, communication difficult.

c. Apraxia. (inability to execute complex motor behaviors, bathing, dressing, driving, or drawing, due to impaired sensory (identify objects or position) or motor function.

d. Agnosia. failure to recognize or identify known objects, or familiar persons.

e. Disturbance in executive function. impaired ability to start, stop, think abstractly, plan, sequence, monitor, conceptualizing or problem solving (creating a report, making a grocery list, or adjusting the thermostat in a house).

Associated features (Dementias)

a. Emotional changes. Individuals with dementia often become emotionally uninhibited and labile. They may have outbursts of anger, anxiety, or despair. Depressive symptoms are common and may exacerbate cognitive deficits.

b. Personality disturbances. Even with relatively mild dementia, individuals may undergo marked changes in personality, becoming uninhibited, socially inappropriate, or moody. Irritability and argumentative. Expansiveness and euphoria are sometimes present.

c. Psychotic symptoms. Delusions, especially of a persecutory nature, may be present in individuals with dementia. Hallucinations can also occur.

d. Functional Neuroimaging. Abnormal findings on computed tomography (CT) and magnetic resonance imaging (MRI), Neurodegenerative diseases (generalized or focal cerebral atrophy), Vascular disease, Neoplasm & traumatic injuries (focal lesions), Positron emission tomography (PET) or single photon emission computed tomography (SPECT) or Functional magnetic resonance imaging (MRIf) focal hypometabolic activity.

e. Evidence of general medical conditions or substance use. Substance-induced persisting dementia as prolonged substance abuse, alcohol related, liver disease.

Diagnosis of Dementia

• A complete medical history (medical -thyroid -drug -tumors -etc).

• Examination of patients with mental disturbances.

• Basic medical tests & metabolic homeostasis, levels of electrolytes, pH, hydration, metabolic and endocrine disorders and neoplasms

• Neuropsychological tests (memory -, problem solving -attention -counting -language).

• Brain scans & EEG: (CT -MRI -EEG)

• Mental Status Examination: (Diagnostic Criteria

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