Transcript Mental health and older people

Mental health and older
people
prepared by hassan abu rahma
Supervised by :
Dr. Abd Al Kareem Radwan
Background and epidemiology •
AGEING AND HEALH
•
Older people mental health prevalence and impact of •
mental health problems
Prevalence 0f mental disorder 1n relation to demographic •
factors Inter-relation between physical and
mental disorder
Inter-relation between disability and mental disorder •
Older hospital setting patient in general •
Older people in nursing and residential homes •
Background and epidemiology
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
•
STAGE POPULATION •
POPULATION
STRUCTURE
1-THE FIRST AGE OF •
SOCIOLIZATION
2- SECOND AGE OF •
WORK AND CHILDREARING
2_THIRD AGE POST •
EMPLOYMENT
FIRT
AGE
1900
21
1950
21
BIRTH
DECAD
E
1990
24
SECON
D AGE
THIRD
AGE
76
67
3
11
55
21
ACENTURY OF CHANGE PRECNTAGE
DISTRIBUTION BY AGES OF LIFE
FOR THE BRITISH POPULATION
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‫•‬
‫يشير تقرير إحصائي صادر عن الجهاز المركزي لإلحصاء‬
‫الفلسطيني بمناسبة اليوم العالمي للمسنين تحسن طرأ على أوضاع‬
‫المسنين الفلسطينيين أدى الى ارتفاع معدالت البقاء على قيد الحياة إلى‬
‫نحو ‪ 6-5‬سنوات خالل العقد ونصف العقد الماضيين‪.‬‬
‫وارتفع عمر المسنين من نحو ‪ 67.0‬سنة لكل من الذكور واإلناث‬
‫عام ‪ 1992‬إلى ‪ 71.8‬سنة للذكور و ‪ 73.3‬سنة لإلناث لعام‬
‫‪ ،2006‬وقد أدى ارتفاع معدل توقع البقاء على قيد الحياة عند‬
‫الوالدة إلى ارتفاع أعداد كبار السن في األراضي الفلسطينية‪.‬‬
‫• ففي منتصف العام ‪ 2009‬حسب اإلحصاء الفلسطيني‪ ،‬بلغت‬
‫نسبة كبار السن (األفراد ‪ 60‬سنة فأكثر) ‪ %4.4‬من مجمل‬
‫السكان في األراضي الفلسطينية (بواقع ‪ %4.9‬في الضفة‬
‫الغربية و‪ %3.7‬في قطاع غزة)‪ ،‬مع العلم أن نسبة كبار‬
‫السن في الدول المتقدمة مجتمعة قد بلغت حوالي ‪%16.0‬‬
‫من إجمالي سكان تلك الدول‪ ،‬في حين تبلغ نسبة كبار السن‬
‫في الدول النامية مجتمعة حوالي ‪ %6.0‬فقط من إجمالي‬
‫سكان تلك الدول‪.‬‬
AGEING AND Health
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
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 disorder 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
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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
Prevalence 0f mental disorder 1n relation to
demographic factors
1- •
gender
1male to2 •
female
2-MARITAL •
STATUS
Marital disruption is consistently associated with higher rate of common
mental disorder UK 7%MEN 12%FEMAL divorced status and separation
associated mental disorder
proportion divorce in Palestine 11.65 %
3-socio-economic status •
problem increase after 29 yrs that effects income ,social class
unemployment
•
•
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
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1-reduce motivation
•
2-psychomotorretardation
•
3- poor sleep
4-lack of energy
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•
•
•
•
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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
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
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 

homes scored adequately in respect of •
non-restrictive care practice ,standard
Of décor and cleanliness and facilities •
For activity and recreation
•
•
Mental disorder are common when
residential facilities is poor ,limited social
interaction and daily activity
Challenges
1-staffing levels and skill mix match the type
and complexity of client needs “support”
2- training of staff
3- absence of policy intervention
4-costs
mental health and older people specific disorder
1234-
depression •
anxiety disorder •
dementia •
delirium •
depression
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 •
Marital status •
Loneliness cause to increase depression •
and caused increased mortality rate
Suicide and depression
Elderly people have
the highest rate of
completed suicide
rate of any age group
•
Assessment of depression and
suicide risk in older people
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 pleasuer in doing things ?yes or
no
•
•
Depression management
Ani depression treatment •
Psychological treatment •
Cognitive treatment •
Problem solving therapy •
Antidepressant treatment
50% to60% of older people improved •
Studies have indicated that older patient •
treated with antidepressants should stay
12 month to two year's
Older patient are have more side effect •
because of higher levels of multiple drug
prescribing
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 •
Other antidepressant substance
Folk remedies
•
Extract of st john wort
•
5-hydroxytryptophan and tryptophan •
Is amioacde available as dietary supplement and •
alternative treatment {conventional } difficult conclusion
about efficacy
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
•
Problem solving therapy
Defining the problem and goal selecting •
and Appling means of achieving the goal
Model of care :community mental
health team for older people
The involvement of community mental health •
teams for older people in depression
management is associated with improved
outcomes
Co ordinate by a multi-disciplinary team •
compared with normal primary care delivered
improvement for disable elderly receiving home
care
Regular monitoring physical health review, •
antidepressant prescribing and promotion of
social involvment
Collaborative and case
management
approaches
Primary care occupies a strategic potion in the •
management of late life depression and more
feasible treatment setting for all except the
sever and complex presentation
Approaches applies •
Chronic disease model to care, uses evidence •
based guideline, adherence program telephone
support, with rapid direct access to specialist
advice and support
Anxiety disorder
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 •
Physical illness
•
Other factors induce anxiety
Aspect of environment •
Medication side effects {table 17.3} •
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
Commonly used •
Beneficial effect on symptoms of panic •
and general anxiety disorders
Side effect drowsiness {driving accident •
risk}
Psychological treatment
CBT IS EFFECTIVE for older people •
Situational exposure , relaxation technique •
,self control desensitization and cognitive
restructuring
dementia
Major health public problem •
It is neurodegenerative syndrome characterized
by global ,progressive impairment of cerebral
function .it is primary disturbs higher brain
function such as memory ,thinking, orientation ,
comprehension, calculation learning , language
and judgment
Manifests in loss memory {resent event } and •
loss executive function such as ability to
organise complex tasks or make decision
Demintia affect about 7%of people aged over 65
years and 30% aged over 90 years
•
•
Subtype of dementia
1- Alzheimer disease •
2- vascular dementia •
3- lewy bodies and frontal lobe dementia •
Alzheimer disease is the commonest 50% of cases slow
onset slow deterioration
Vascular dementia abrupt onset step –wise deterioration
,early gait ,seizure, urinary disturbance and history of
stroke
[greater prevalence of hypertension and stroke •
Important risk factor for dementia age and family
history
•
•
•
Cerbrovaccular disease
Risk factor •
1- raised blood pressure •
2- DM •
3- HIGH CHOLESTROL •
4- High fat in take •
5- obesity
6- smoking
assessment
and secondary •
,social services voluntary organization……
Stigma can effect on treatment so patient •
and family need education
Clinical assessment memory impairment •
aphasia agnosia, apraxia function
disturbance {instrumental activities of
daily living}
Physical examination is very important •
Patient need to link primary health care
Mini-mental state examination
25-30 normal •
18-24 mild to moderate impairment •
17 or less impairment in daily activity •
treatment
Prevention strategies and interventions to slow disease progress •
1- blood pressure and vascular factor •
2- nutrition ,diet and dietary supplement •
1-omega 3 polyunsaturated fatty acid {oily fish •
3- limits vitamin C and E
•
4-limit green tea •
5- ginkgo biloba {leaf decorative tree}
3- life style social involvement , physical exercise and cognitive
activities
Drug treatment
1- Cholinesterase inhibitor •
1- donepezil •
2- rivastigmine •
3- galantamine •
2-atypical neuroleptic drug treat behavioral •
manifistation of demintia {lewy bodeis}
Psychosocial intervention
1-enviromental modification aroma, music, reduce noisy , exercise
2-oriantation places time person
3-reminiscence therapy {talked about past }
carer support
1-professional and organization practice
2-communty mental health old age services
delirium
know as confusional state ,is a common and •
serious of mortality and morbidity among older
hospitalized patient, the core diagnostic criteria
for delirium are acute generalized impairment
of consciousness and attention, global
disturbance of cognition and perceptual
abnormalities
Key features rapid onset ,fluctuating course , •
disturbance of the sleep walk disturbance
Delirium may be mistaken for avarity o other •
disorder including mood
disorder,demintia,psychotic illness
Aeti0logy is multifactorial
1- head injury
2- renal, hepatic failar
3- hypoglycemia
4-heart failar ,shock
5- electrolyte imbalance
6-substance intoxication
7- infection
tow and six factor may present
single patient
in
Prevention and early intervention
The prompt detection of delirium is •
important as it is potentially reversible
Patient risk factor need •
Good nurse practitioner ,team work •
Encourage patient to exercise .walking •
,mental stimulation ,discussing current
event, reduce hypnotic
drug,relaxation,treatment medical problem
management
Environmental and supportive •
intervention are a crucial part of
management of distress and disturbed
behavior of the delirium
Delirium rating scale item
Temporal onset , perceptual disturbance , •
psychomotor behavior , cognition status,
physical disease , sleep wake disturbance ,
mood and fluctuation of features
Pharmacological approache
Anti-psychotic drug especially that are •
less sedative ,ant cholinergic
Benzodiazepines related alcohol •
withdrawal
Thanks for Your Attention!!!