10 - Old people Flashcards
1
Q
What are the common issues with older people with mental health problems?
A
- less likely to be correctly diagnosed
- more likely to receive biological tx
- rate estimates widely vary
- more likely to experience sub-threshold sx
- is DSM appropriate? older people often fail to meet full crit + impairment focuses on occupation/academia + crit not age-friendly
- problems distinguishing mental from physical health
2
Q
What are the risk factors for depression in later life? (7)
A
- life events
- lack of social support
- female
- lower SES
- nursing home (39-83% MDD; bidirectional effect)
- lack of physical activity
- physical health: physical illness, inflammatory processes/amyloid/HPA dysregulation, vascular disease
3
Q
Describe the 4 key features of the symptom profile of depression in older adults
A
- depression without sadness (depletion syndrome: withdrawal, apathy, lack of vigour) > must drill down more into effect on functioning
- psychomotor disturbances
- depression-executive dysfunction syndrome (psychomotor retardation, amotivation, reduced interest/planning)
- highly comorbid with physical illness
4
Q
Explain the relationship b/w depression and physical health
A
- old age diseases often chronic and fluctuating
- health events most common in later life
- MDD: increase length of hospital stay, increase disability, increase mortality
HEALTH CONSEQUENCES OF MDD
- mortality
- increased propensity to illness (heart disease most evidence)
- affect outcome of existing illness (increase disability, decrease tx compliance)
NEUROLOGICAL DISEASE
- up to 45% Parkinson’s = MDD
- high MDD (+anxiety) rates after stroke
5
Q
Describe the Vascular Depression Hypothesis including neuroimaging, clinical observations, neuropsych, outcomes, and the 6 key arguments against it
A
- clear link b/w stroke + mood dx
- subset of MDD in older people that is related to vascular disease > typically LATE ONSET depression
- post-stroke: emotional lability common
- HYPOTHESIS: some late-onset MDD is a consequence of structural brain damage secondary to ischemia that creates vulnerability to MDD precipitated by psychosocial risk factors (eg. -ve life events/lack of social support)
- NOT just psychosocial: left frontal cortex involved in MDD severity (social factors may increase risk of MDD though)
- neuroimaging: atrophic changes, deep white matter hyperintensitites)
- clinical observations: apathy, anhedonia, less insight, gait abnormalities, fewer cog sx (eg, guilt/burden/suicidal)
- neuropsych: impaired delayed recall, poor exec functioning, poor performance on lang tasks
- outcome: resistance to anti-dep meds, more delirium, poorer outcomes, higher mortality
ARGUMENTS AGAINST
- elusive clinical phenotype
- no consensus on diagnostic crit
- cause or effect?
- DWMH not uniquely associated with MDD (also BP)
- DWMH present in >50% in >50yrs
- cog impairment + disability associated with MDD at all ages
6
Q
What are the differences between early and late onset MDD?
A
EARLY
- early life risk factors (SES, parent death etc.)
- less cog impairment
- comorbidities (anxiety, substance use)
- less organic pathology
LATE
- medical comorbidity
- high risk of dementia
- comorbidity + family hx less common
- organic pathology
7
Q
Explain the links b/w MDD and cognitive impairment
A
Many ways they can be linked:
- vascular MDD: common causal factor
- any MDD can lead to cog impairment in older people (or anyone)
- MDD secondary to cog impairment as reaction to declining cog function
- older depression patients: attentional diffs, poor motivation, low confidence, excessive anxiety, reduced response speed
- report subjective memory issues (may/may not be backed up by tests)
8
Q
Is grief depression?
A
NO
- DSM exclusion criteria
- acute grief NOT an illness (despite intense emo, cog preoccupation, disruption)
- grief has a purpose (processing, life reconfiguration) + a natural process
- when derailed > can trigger/worsen MDD, anxiety or suicidality
- widows at higher risk of MDD 2mths post-bereavement
- poorer adjustment if: excessive crying, intense wish for own death, feeling confused, not try to keep busy
9
Q
Explain anxiety in older adults and the 4 consequences of anxiety
A
- often unrecognised, untreated and not remit
- tx based on extrapolating from younger adults
- too often rely on benzos
- seek help less
- very high rates in clinical samples (OCD and panic rare though)
CONSEQUENCES OF ANXIETY
- poorer outcome of stroke/COPD/knee surgery
- heavier health service use
- sudden cardiac death
- in healthy, high-functioning: predicts onset of disability, leads to avoidance
10
Q
Explain PTSD in older adults and the 6 risk factors
A
- general trend toward reduction in existing sx
- more likely to have sub-threshold sx
- protective factor = learned coping skills
- age-related factors (physical/cog limitations) may increase impact of sx
- trauma exposure: combat veterans/civilians, holocaust survivors, natural disasters
RISK FACTORS
- female
- perceived health
- relocation
- personal injury
- family death
- property loss
11
Q
Explain psychotic disorders in older people (include symptom presentation and risk factors)
A
2 CATEGORIES
- Long hx of SCZ
- stabilisation with age
- poor social outcome, more -ve sx, less +ve sx, less acute episodes, cog/exec deficits - Late-onset (LOS 40+, VLOSLP 60+)
VLOSLP 1-2%
- less strong genetic component
- mostly paranoid (persecutory) delusions
- no thought dx
- no clear-cut -ve sx
- hallucinations (auditory, somatic, olfactory)
- risk factors: female, premorbid ‘unusual’ personality, social isolation/social cog deficits, sensory impairment
- do not seek tx (call police usually about paranoia, then police refer)
12
Q
Explain personality dx in older people
A
- likely under-recognised + under-treated
- DSM-4 limited relevance to older people (social/occupational impairment)
- assessment difficult (MMPI = 550 items) + physical illness complicates ax (eg. dependent traits)
- with age: cluster B decrease (impulsivity)
PERSONALITY CHANGE AS A RED FLAG
- warning of impending disease
- frontotemporal lobar degeneration: personality change first sx (disinhibition, aggression, traffic offences, verbal/physical threats etc.)
- ALZ (apathy, anxiety)
- pituitary disease (apathy, hostility)
- diogenes/senile squalor syndrome: PD masquerading as dementia (high distress, hoarding, self-neglect, domestic squalor, social withdrawal, lack of concern about living environment)
13
Q
Explain the prevalence depression in later life
A
- lower rates than younger adults(?) > but studies exclude high rate pops (eg. nursing homes)
- more sub-threshold BUT this is just as important as full-threshold bc impact of a few MDD sx has greater impact on functioning than in younger people (much higher distress)
- POTENTIAL FOR DISPROPORTIONATE IMPACT FOR SMALLER NO. OF PEOPLE
- MDD rates slowly drop until ~70yrs then increase
14
Q
What is pseuodementia?
A
- dementia syndrome arise in context of psych illness and subsides when condition is treated
- NOW know that impairment only tends to partly resolve (i.e. impairment is real)
- some go further: depression can be a prodrome of dementia
15
Q
Explain depression in ALZ
A
- high risk of MDD (up to 83% MDD in ALZ)
- often untreated (but evidence for effective tx, especially in early stages)
- associated with: wandering, aggression, impaired ADLs
- can occur in any stage (mood disturbance in early stages; motivation diffs in later stages)
