Affective disorders and other common disorders in old age Flashcards
What characterises the increase in ageing population?
> Population aged +60 years worldwide
- 2015: 12%
- 2020: 22%
> Old age population growth is 3.5 times more rapidly than general population
What is the impact of the ageing population on society?
> Increasing socio-economic burden
> Increases demands on
- social care
- healthcare
- pension
> Need for
- larger and better trained workforce
- more age-friendly environments
=> old age psychiatry gains significant relevance
What are the valuable contributions of the ageing population to society?
- Carers for families’ grandchildren
- Volunteers in their local community
What does the demographic transition model proposed in 1929 by Warren Thompson consist of?
Observed changes in birth and death rates in industrialised societies over previous 200 years:
> Stage 1: high birth rate, high death rate
- stable or slow increase of population
> Stage 2: high birth rate, rapid fall of death rate
- very rapid increase of population
> Stage 3: falling birth rate, slower fall of death rate
- slowing increase
> Stage 4: low birth rate, low death rate
- stable or slow increase
> Stage 5: very low birth rate, low death rate
- stable or slow decrease
What is observed between developed countries (HICs) and developing countries (LMICs) in the demographic transition model of Warren Thomspon?
- Most developed countries (HICs) are either in late stages or have completed the transition
- most developing countries (LMICs) are still in process of transition
In the demographic transition model, what were the historical events and associated population growth between the 18th and 21st century?
> Stage 1: 18th century
- infectious diseases, periodic epidemics (plague, cholera) -> high death rates
- high fertility + high mortality = slow population growth
> Stage 2: 19th century
- improvements in medicine, nutrition and sanitation -> lower death rates
- high fertility + lower mortality = higher population growth
> Stage 3: 20th century
- social changes (e.g. increased access to contraception) -> low fertility rates
- low fertility + low mortality = imbalance of births over deaths -> rapid increase of pop. growth
> Stage 4: 21st century
- extended lifespan and low fertility rates -> older population
- low fertility + low mortality = increase of adult population
> Stage 5: 21st century and future
- birth rate drops below replacement levels
- very low fertility + very low mortality = reduction of overall population
What is epidemiology, as defined by WHO (2010)?
Study of the distribution and determinants of health-related states or events (including disease),
AND the application of this study to the control of diseases and other health problems
Why is further epidemiological research needed in old age psychiatry?
Cognitive and non-cognitive disorders represent a burden for health, social and economic systems
What is the worldwide prevalence of adults over 60 that suffer from a mental disorder?
15%
What is are two main factors explaining why mental health problems in old age continue to be under-identified by healthcare professionals and old people themselves?
> Cognitive and non-cognitive problems considered normal in old age
> Stigma
- limits help-seeking behaviour
What is the most frequent affective disorder in old age population?
Depression
- approx. 15-25% of general population experience mild depressive symptoms
- > distress and loss of functioning
- unipolar major depression occurs in 7% of general older population
- > 5.7% of YLDs in people aged +60
What is depression associated with in old age?
- Functional disabilities
- Cognitive impairment
- Lower self-related QoL
- Increased mortality
- Poorer functioning compared to those with physical chronic conditions
- Increased self-perception of poor health and use of health care services
In which cases do we commonly see depression in older age?
In older adults recovering from major medical conditions
What characterises late-onset depression in terms of recurrence and persistence?
Late-onset depression shows higher rates of recurrence and/or persistence
Which types of symptoms are frequently observed in depression in old age?
- Somatic and psychotic symptoms
- Suicide is common
What are the available treatment options for depression in old age?
> Psychotropic medication (e.g. antidepressants) and psychotherapy (e.g. CBT, interpersonal psychotherapy)
> Antipsychotics
> Electroconvulsive therapy (ECT), reserved exclusively for very severe psychotic or life-threatening depression
What is the first-line treatment for mild depression in old age?
Psychotherapy, not antidepressants
What is subsyndromal depression?
2 or more symptoms of depression that last for at least 2 weeks
BUT aren’t severe enough for a depression diagnosis
- more common than MDD in older age population
What is the prevalence of subsyndromal depression in older adults in primary and long-term care settings?
> 6-10% of older adults in primary care settings
> 30% in medical and long-term care settings
What is associated to increased age and depression severity?
Greater cognitive impairment
What could explain the complex relationship between depression and dementia?
- Depressive symptoms as prodromal to dementia
- Depression as causative factor in dementia
- Potential shared risk factors
- Cerebral white matter hyperintensities may increase risk of cognitive impairment in depression
- Cardiovascular risk factors (e.g. smoking, hypertension) increase risk for dementia and depression
- Several cognitive domains may be affected in depression
- Cognitive impairment often persists even after remission of depression (40% of affected individuals develop dementia)
What is a prodrome?
Premonitory symptom of a disease
What is the role antidepressants in cognitive impairment?
- May improve cognitive symptoms BUT cognitive impairment may hinder the effectiveness of certain psychotherapies for depression in older adults
- Antidepressants with anticholinergic side effects should be avoided
What is old age bipolar disorder (OABD)?
> Bipolar disorder in individuals aged 60+
> Similar presentation to early-onset bipolar disorder (EOBD)but usually with less severe manic symptoms
> Good response to most mood-stabilisers
Why is the use of lithium for old age bipolar disorder (OABD) controversial?
- Risks of toxicity
- Need for blood monitoring -> could compromise treatment adherence
How is cognitive impairment associated to bipolar disorder?
Observed in bipolar disorder patients, even when euthymic (stable mood)
What are the five elements important to consider when performing a psychiatric assessment in old age?
- History of present illness
- Onset and time course
- acute (e.g. delirium) vs. progressive (e.g. cognitive impairment in Alzheimer’s)
- symptoms of delirium can be easily confused with psychiatric disorders - Presence of complex reciprocal relationships between medical conditions and psychiatric symptoms
- secondary effects of physical/psychotropic mediation could be interpreted as primary symptoms
- substance abuse might contribute to existing psychological symptoms
- long-standing substance use may lead to multiple comorbidities - Nature and pattern of symptoms
- visual, olfactory or tactile (vs. auditory) hallucinations increase suspicion for medical causes - Relevance to family and carer’s opinions
What is important to check in the medical history during a psychiatric assessment in old age?
- Existence of disorders
- high comorbidity with psychiatric illness (cardiovascular, endocrine, rheumatological)? - Pain
- very common in older adults
- may increase risk of suicide - Sexual history
- interaction of psychotropic medications in sexual functioning - Medication assessment
- iatrogenic psychiatric symptoms
- physical and psychiatric substances
- prevalence of polypharmacy in old age
What does “iatrogenic” mean?
- Caused by medical treatment or by a doctor
- Secondary to medication side effects and drug interactions
What is a mental state examination (MSE)?
Structured way of observing and describing a patient’s current state of mind, under several domains
e. g.
- Mini Mental State Examination (MMSE)
- Addenbrooke’s Cognitive Examination (ACE)
What is the purpose of a mental state examination (MSE)?
To obtain comprehensive cross-sectional description of patient’s state of mind
- allowing the clinician to make an accurate diagnosis and formulation
What characterises a mental state examination (MSE) in older adults?
Similar to younger adults with an additional and more extensive cognitive assessment
What is important to consider when doing a mental state examination (MSE) in older adults?
- Consider delirium as potential differential diagnosis
- Include detailed evaluation for suicidal ideation (higher risk of suicide in older adults)
What does a physical examination for psychiatric assessment in old age usually include?
- Blood and urine tests
- Brain imaging (CT or MRI)
- Electrocardiogram (ECG)
What si the purpose of assessing the cardiac risk of older patients in a psychiatric assessment?
Before prescription of psychotropic medication such as antipsychotics which have increased risk fo cardiac side effects, stroke, and sudden death
What is important to consider during a physical examination for a psychiatric assessment in old age?
- Increased risk of physical illness
- Impact of chronic medical illness on quality of life and functional ability
What are common risk factors for a psychiatric illness in old age, in combination to common life stressors?
> Significant ongoing loss in capacities
> Decline in functional ability
> Reduced mobility
> Chronic pain
> Frailty
> Medical comorbidities that require long-term care
> Bereavement (loss)
> Drop in socioeconomic status with retirement
> Elder abuse: physical, verbal, psychological, financial, sexual, abandonment, neglect, serious loss of dignity and respect
What are the consequences of elder abuse?
Physical injuries and long-term psychological problems including depression and anxiety
What is ‘ageism’?
Term used to describe attitudes that show a degree of stereotyping, prejudice and discrimination against old people based on their age
- marginalises and excludes older people from their communities
- widespread and socially normalised
- > harmful effect on health of older adults
What are the common psychiatric disorders in old age?
- Anxiety disorders (including phobias, OCD, PTSD)
- Psychotic disorders (acute psychosis, schizophrenia)
- Substance use disorders
What are the common cognitive disorders in old age?
- Dementia
- Alzheimer’s disease
- Vascular dementia (VaD)
- Frontotemporal dementia (FTD)
- Dementia with Lewy bodies (DLB)
- Parkinson’s disease dementia
What characterises anxiety disorder?
- Excess worry
- Hyperarousal
- Fear that is counterproductive and debilitating
What is the prevalence of anxiety disorder?
Lower prevalence of all anxiety disorders in older adults when compared to younger adults
What is the common comorbidity to anxiety disorder?
Anxiety symptoms and depression: 30-70%
To which disorder is generalised anxiety disorder (GAD) possibly comorbid?
Depression in older adults
- prevalence rate approx. 2.2%
What are effective treatments for generalised anxiety disorder (GAD)?
Effective response to SSRIs and CBT for some anxiety disorders in late life
Which psychotropic medication should be avoided in pharmacological treatment?
Benzodiazepines
What characterises phobias in old age?
> Most common type of anxiety disorder in late life
> Lower association with panic attacks when compared to young adults
> Panic disorder is rare in late life; symptoms are often associated to physical diseases
What characterises obsessive-compulsive disorder (OCD) in old age?
> New onset in late life is rare
> Symptoms are similar to those seen in younger adults
Lack of research within older population
What characterises post-traumatic stress disorder (PTSD) in old age?
> Prevalence decreases with age
> However, it may still develop in response to trauma/stress or as part of a chronic lifelong illness
What could explain the lower rates of post-traumatic stress disorder (PTSD) in older age?
- Recovery with age
- Underreporting of symptoms
- Healthy survivor effect
What is the healthy survivor effect?
“selection process whereby healthy workers are selectively retained in the work force while unhealthy workers are removed”
What characterises psychotic disorders in old age?
> Up to 10% of 85 year olds without dementia may exhibit psychotic symptoms
> Approx. 23% of patients with schizophrenia have late disease onset
> Between 15-20% of patient with schizophrenia will show deterioration in their clinical course
> Paranoid ideation is a common clinical symptom
What should be considered in older patients suffering from acute psychosis?
Presence of physical/organic causes
What is the prevalence of substance use disorders in old age?
> Illegal drug use is uncommon
> Abuse of prescription and over-the-counter medications is common
-> understand what medication is being taken during assessment to detect potential misuse
What is dementia?
Syndrome, usually of chronic or progressive nature
- deterioration of cognitive symptoms
- mainly affects older people, although it is not a normal part of ageing
What is the prevalence of dementia worldwide?
50 million people living with dementia
- 60% from LMICs
- 82 million by 2030
- 152 million by 2050
What is the most common type of dementia?
Alzheimer’s disease
- up to 2/3 of cases
What are the risk factors to Alzheimer’s disease?
- Advanced age
- Apolipoprotein e4 genotype
- Cardiovascular risk factors
- Lower education
amongst others
What are major histological hallmarks of Alzheimer’s disease?
Discovery of amyloid plaques and neurofibrillary tangles consisting of tau protein
- beginning especially in hippocampus and entorhinal cortex
What are the major clinical features of Alzheimer’s disease?
> Insidious onset and slow progress over the years post-diagnosis
> Early symptoms include:
- short-term episodic memory loss and for-finding difficulty
> Later-stage symptoms (‘behavioural and psychological symptoms of dementia’ (BPSD):
- depression
- psychosis
- apathy
- sleep disturbance
- agitation/agression
Which tools are used to confirm a clinical diagnosis of Alzheimer’s disease?
> Several validated cognitive and physical screening tests available (e.g. MSE, ACE)
> Blood tests to measure folate and vitamine B12 levels
> Brain imaging (MRI, CT scans)
What are the current treatments for Alzheimer’s disease?
> Pharmacological:
- Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine)
- Memantine (N-methyl-D -aspartic acid glutamate receptor antagonist)
- > to slow the cognitive decline
> Psychosocial interventions for patients AND caregiver psychoeducation
What is the prevalence of vascular dementia among all dementias?
Accounts for 10-15% of all dementias
What are the major clinical features of vascular dementia?
> Classical presentations of large strokes -> sudden and subacute worsening of cognition AND “stepwise” progression
> Chronic microvascular disease often manifest with more “subcortical” dementia profile
> Symptoms may vary and neuropsychological testing results to be patchy
What are the common risk factors for vascular dementia?
Cardiovascular risk factors: smoking, hypertension, diabetes
What is the current treatment for vascular dementia?
No clear indication of benefit with acetylcholinesterase inhibitors
What are the three common subtypes of fronto-temporal dementia?
- Behavioural variant FTD
- Semantic dementia
- Progressive nonfluent aphasia
What is the prevalence of fronto-temporal dementia in all dementias?
Accounts for 5-15% of all dementia diagnoses
What are the major clinical features of fronto-temporal dementia?
> Frequent early onset and strong familial loading
> Behavioural changes dominate the early clinical course
> Possible overlap with extrapyramidal disorders
> Semantic dementia characterised by specific loss of word meaning and comprehension difficulties
> Progressive non-fluent aphasia marked by agrammatic and telegraphic speech
What are the treatment options for fronto-temporal dementia?
Treatment options are limited
What is the prevalence of dementia with Lewy bodies (DLB)?
Thought to be second most common form of dementia
What is a major histological hallmark of dementia with Lewy bodies (DLB)?
Discovery of Lewy bodies (synuclein inclusions) in neocortex, in addition to brainstem (characteristic of Parkinson’s)
What are the major clinical features of dementia with Lewy bodies?
> Classic symptoms include parkinsonism, fluctuating levels of consciousness, visual hallucinations
> Common symptoms: falls, autonomic instability, REM behaviour sleep disorders
What is parkinsonism?
Symptom characterised by rigidity and bradikenisia
What is the current treatment for dementia with Lewy bodies?
> Use of acetylcholinesterase inhibitors show modest effect
> High sensitivity to motor side effects in DBL patients might affect treatment with antipsychotics
What is the prevalence of Parkinson’s disease dementia among people with Parkinson’s disease?
Affects 30-50% of people with Parkinson’s disease
What is a major histological hallmark of Parkinson’s disease dementia?
Presence of Lewy bodies diffused in cortical regions
What are the major clinical features of Parkinson’s disease dementia?
> Early prominent deficits in visuospatial functioning, attention, and executive functioning
> Presence of psychotic symptoms
> Development of dementia typically slow, and diagnosed at least a year after initial diagnosis of Parkinson’s disease
What is the current treatment for Parkinson’s disease dementia?
Use of rivastigmine is recommended
What are the key elements to consider when prescribing mediation the the elderly?
- Changes in pharmacokinetics and pharmacodynamics of most drugs due to polypharmacy, due to comorbid illnesses
- Risk of increased frequency AND severity of side effects when taking antipsychotics and antidepressants
- higher risk of drug interactions - Possible delayed therapeutic response
- Higher risk of toxicity and therapeutic failure
- > careful management of drugs with low therapeutic index
What are the changes in pharmacokinetics of medications that can occur in older adults, in cases of polypharmacy?
> No significant reduction in metabolism capacity in absence of hepatic (liver) disease
> Slower absorption -> slower onset of action
> Increased volume of distribution AND higher duration of action
> Lower excretion associated with impaired renal function
=> Monitor and reduce dosage
Why is there an increased volume of drug distribution and a higher duration of their action in older adults?
Older adults have more body fat, less body water and less albumen than younger adults
Why is the rate of drug absorption slower in older adults?
Older adults have poorer intestinal motility than younger adults
What is the therapeutic index of drugs?
Range of doses at which a medication is effective without unacceptable adverse events
- narrow TI = minimal change in dose may cause toxicity or loss of therapeutic action
Why are drugs with low therapeutic index not the first treatment option for older adults?
Older adults have a tendency to poorer adherence to treatments and high sensitivity to side effects
-> increasing physical comorbidity (e.g. renal impairment)
What is the concept of the golden rule ‘start slow go slow’ in treatment with older adults?
- Start with small doses
- simple pharmacological regimes (fewer side effects from drug interaction) - Tolerance and response
- expect latency of response to drugs - Side effects
- more likely to result in poor mental health due to higher sensitivity to medication - Routinely perform:
- physical examination medication review for potential drug interactions
- basic blood and urine tests if symptoms occur
What is to avoid in the treatment of older adults?
> Treating side effects with medication
> Increasing dosage
> Antipsychotics in dementia
> Medication with anticholinergic side effects
> Very sedative medications
> Drugs with very long half-life or potent inhibitors of hepatic metabolising enzymes
Why should potent inhibitors or inductors of hepatic metabolising enzymes be avoided for older patients?
They lead to alterations in metabolism of other drugs and potential side effects
Which legal act in the UK refers to cases of patients with impaired decisional capacity?
Mental Capacity Act of 2005
- designed to protect and empower individuals who may lack mental capacity over their own decisions on care, treatment and finances
(applicable to the 16+ year olds)
When should a mental capacity assessment take place?
- In the presence of impairment of mind or brain
- If there’s evidence to show that the impairment prevents the person from making specific decisions
What are the four criteria defined by the Mental Capacity Act (2005) to assess decisional capacity?
- Understanding of information relevant to decision
- Retainment of information
- Use or weighing up of information
- Communicating a decision
What is the most prominent illness for clinicians that raises the subject of impaired decisional capacity?
Dementia
- does not necessarily imply lack in mental capacity
- assessment should be done at specific time points, as the lack of capacity is not static
What are common treatment care strategies for older adults?
> Effective, community-level primary mental health care
> Focus on long-term care
> Education, training and support of caregivers (exposed to burnout)
> Early identification/diagnosis and screening
> Identification of physical comorbidities
> Management of challenging behaviour
> Development of psychosocial interventions (e.g. CBT or social inclusion programmes in community)
> Targeted health and social programmes
> Promotion of active and healthy ageing, with respect to individuals’ freedom and security, and provision of adequate living environments
What are the requirements for the continual improvement of mental health in older people?
> Increasing training for health professionals in providing care for older people
> Enhancing prevention and management strategies of chronic diseases
> Designing sustainable policies
> Developing age-friendly services and settings
