Women, Aging and

Mental Health Dr Cathy Shea

Associate Professor

Chair, Division of Geriatric Psychiatry

University of Ottawa

Topics we will cover

Demographics of aging

Growing older with early onset mental illness

Stigma

Changes with “normal” aging

Late onset mental illness – the three D’s

Recovery

Demography of Aging

The Baby Boomers are coming!

Babies born in 1946 turned 65 in

2011.

13% of Canadian population now over

65 and will double in by 2041to 23%

Demography of Aging

There are 147 women for every 100

men over age 65

Most older men are married (75-78%)

(and therefore have/will have familiar

caregivers when they are ill)

Most older women are widowed (52%)

If you have a mental illness of early

onset and live to grow old

“normal” biological changes might affect your treatment with medication and the expression of side effects of that treatment

Aging itself makes you vulnerable to develop mental illness’ particular to old age (maybe in addition to your early onset mental illness)

Aging itself makes you vulnerable to develop physical illnesses which affect your mental illness and the treatment of both

Aging itself brings psycho-social issues which affect your access to care and services

The triple whammy for stigma!

1. You have a mental illness (any age)

2. You are old (so you must be frail/confused!)

3. You are a woman (so complain a lot and express your emotions easily)

All three will affect your ability to obtain

diagnosis, treatment and to access services

for physical and mental illness

Note: Quadruple whammy if you are also a member of a visible minority!

Mental disorders commonly

diagnosed earlier in life

Depression

Anxiety Disorders

Bipolar Disorder

Schizophrenia

Substance Use Disorders

Mental disorders commonly

diagnosed earlier in life All can be diagnosed for the first time in individuals over 65

years of age and are then typically called “late onset” or “late life” disorders

Depression: 10-15 % of community dwelling elderly have significant depressive symptoms. Rates are higher in hospitals and long term care facilities. Female gender is a major risk factor

Bipolar Disorder: M=F in late onset

Schizophrenia: 3% diagnosed after age 70, mostly women

Substance use disorders: 1.5% alcohol abuse in older women. Problem drinking however can be as high as 27%.

What happens to us

with “normal” aging?

And why does it matter?

Physiologic changes with normal

aging

Cardio-vascular changes (meds & dementia) Increased blood pressure (noradrenergic (antidepressant) drugs can

worsen)

Increased susceptibility to develop heart failure if heart rate is increased (e.g. by certain drugs with anti-cholinergic properties)

Increased (cumulative) vascular risk factors for dementia

Endocrine changes (metabolic complications) Increased insulin resistance

Menopausal changes

Physiologic changes with normal

aging

Respiratory (lung) changes Decreased vital capacity and decreased forced expiratory volume (can be

improved by aerobic exercise training)

Decreased pulmonary defense mechanisms & increased risk for pneumonia (e.g. depressed patients who stay in bed)

Gastro Intestinal changes Gum retraction + increased risk to lose teeth (ECT consideration)

Decreased acid secretion in stomach + decreased intrinsic factor (increased risk of B12 deficiency)

Decreased absorption of calcium, osteoporosis (fractured bones with falls from poor balance)

Pharmacokinetic changes with normal aging

(What the body does to the medications)

Absorption

Distribution *

Protein binding

Metabolism *

Renal (kidney) clearance *

Drug distribution changes with

normal aging

Aging results in an increased fat over muscle ratio:

So for fat soluble drugs in an aging body:

increased distribution volume of drug

decreased initial blood levels of drug

increased risk of accumulation of drug

Aging result in a decrease in total body water:

So for water soluble drugs in an aging body:

decreased distribution volume of drug

increased blood levels of drug

Drug Metabolism with normal aging

Decreased liver mass and blood flow

Decreased de-methylation and decreased

hydroxylation

Decreased rate of elimination = increased levels

of the drug

Renal (kidney) clearance of drugs with

normal aging

Decreased glomerular filtration rate, tubular

secretion and decreased renal blood flow

Decreases clearance of drugs eliminated by the

kidney = increased levels of these drugs (eg

lithium)

Brain changes with normal aging:

Neuronal loss (<1% per year after age 60)

Greater neuronal loss or loss of connections in:

frontal/prefrontal cortex (executive function)

hippocampus (memory)

locus ceruleus (sleep)

substantia nigra (gait)

olfactory bulbs (smell / taste)

Neuro-imaging in normal aging

C.T. brain scan:

shrinkage/atrophy

(increased CSF space/decreased brain volume)

M.R.I scan:

Shrinkage/atrophy

decreased gray-white density

up to 30% white matter abnormalities ?

Other changes with “normal” aging that

affect older patients

Decline in mineralization of bones (8-10% per year for

post-menopausal women = fracture with falls)

Impaired postural reflexes and increased sway, poor

balance (falls from side effects of prescription meds or

OTC drugs)

Hearing loss in up to 60% over age 70 ( may appear to

be cognitive problems)

Decreased perception of acute pain

So what about the woman with

mental illness who is aging?

Expect to lower doses of psychiatric meds to reduce side effects/obtain same treatment effect as when this woman was younger

Expect medical conditions might be caused by or worsened by psychiatric meds (metabolic syndromes, parkinsonism, postural hypotension (low BP), falls and fractures)

New onset of confusion is not “normal” aging – increasing risk of developing dementia as we age, increasing risk of delirium from medications and medical problems

Frequent Problems / Common Stresses

of Aging for all Women:

Dealing with death and loss of family/friends

Retirement from work and other active roles

Housing & relocation (planned or unplanned)

Medical illness/physical disability/functional

decline

Changes in family relationships

Caregiver role (whether wanted or not)

Caregiver role

Our health care system depends on unpaid caregivers

Most caregivers of elderly disabled individuals are women (wives, daughters, daughters-in-law, sisters, sisters-in-law, nieces)

Many are themselves elderly

Caregivers of elderly individuals with mental and/or physical disorders are twice as likely to develop depression

Additional frequent problems

/common stresses for older women

with mental illness Poverty

Social isolation

Lack of transportation

Exclusion from criteria for home care services

Multiple medications with complex instructions

Triaged with a “different lens” in ER and

primary care settings

Late Onset Mental

Disorders

Dementia / Delirium /Depression

The 3 D’s of Geriatric Psychiatry

Dementia: A condition of acquired cognitive deficits,

sufficient to interfere with functioning, in a person

without depression (pseudo-dementia) or delirium

Delirium: An acute, potentially reversible, condition

characterized by fluctuating attention & level of

consciousness, disorientation, disorganized thinking,

disrupted sleep/wake cycle

Depression: Alteration in usual mood with sadness,

despair, lack of enjoyment in previously enjoyed

activities and vegetative symptoms sufficient to

interfere with functioning

Common psychiatric disorders

in those over 65 years old

Dementia: estimates are that 8% of

population over 65 and 30% over 85 is

affected by dementia.

Delirium: approx. 30% of general in-pts in

medicine and rehab. More frequent in

neurology and common after surgery,

especially orthopedic procedures.

Psychiatric disorders often co-

exist in the elderly Dementia is often complicated by delirium,

depression, anxiety and psychotic symptoms (hallucinations and delusions)

Late onset depression is associated with high risk of developing dementia.

Anxiety symptoms common in early dementia, depression, substance use withdrawal…

Medical problems often co-occur

in elderly with mental illness

Medical problems can mimic psychiatric illness (e.g.

Parkinson disease); cause or precipitate psychiatric

illnesses (thyroid, strokes causing depression or mania)

or cause anxiety or depressive symptoms.

Medication for medical problems may interact with

psychiatric drugs or can cause depression, delirium.

Psychiatric drugs can worsen some medical problems

(BP problems, weight gain, blood sugars, falls and

fractures, confusion, visual problems, urinary retention)

Dementia

Dementia: A condition of acquired cognitive

deficits, sufficient to interfere with functioning,

in a person without depression (pseudo-

dementia) or delirium

Cognitive deficits: can be a decline compared

to previous levels in language, executive

function, memory, orientation, visuo-spatial

abilities etc.

Dementia is Common

2.411.1

34.5

0

5

10

15

20

25

30

35

65-74 75-84 85+

% Prevalence

Age related risk: > 65: Overall:

Incidence: 2 %

Prevalence: 8 %

Prevalence doubles every ~5 years

An intervention that would delay onset by 5 years would

decrease prevalence by 50%

Females>Males

Lindsay et al. Can J Psychiatry 2004;49:83-91. CSHA CMAJ 1994;

150: 899-913; CSHA. Neurology 2000; 55: 66-73

Warning signs of Dementia

10 Warning Signs for Caregivers*

Difficulty performing familiar tasks

Problems with language

Disorientation to time and place

Poor or decreased judgment

Problems with abstract thinking

Misplacing things

Changes in mood and behaviour

Changes in personality

Loss of initiative

Memory loss that affects day-to-day function

Behavioural Flags for Health Care Professionals

Frequent phone calls

Poor historian, vague

Poor compliance: meds /instructions

Change in Appearance / hygiene / makeup

Word finding / decreased interaction

Appointments - missing / wrong day

Confusion: surgery, meds

Weight loss / dwindles

Driving: accident / problems

“Head turning sign”

*Adapted from the Alzheimer Society of Canada: www.alzheimer.ca

How many drivers have

dementia?

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

1986 2000 2028

65+

80+

Combined Ontario

Ministry of

Transportation data

with census data and

dementia prevalence

data to give “best

estimate” of

proportion of drivers

with dementia

F > M

Hopkins et al. Can J Psychiatry 2004

Delirium

Delirium: An acute, potentially reversible,

condition characterized by fluctuating attention

& level of consciousness, disorientation,

disorganized thinking, disrupted sleep/wake

cycle

Delirium Recognition

Low rate of recognition by health care professionals – why?

Hospitals are organized around “one-thing-wrong-at-once” principle and delirious patients are complex

Patient is often unable to give a history (a sensitive but non-specific marker!) so viewed as uncooperative, demented or a “poor historian”

Assumptions are made about “usual” functioning

Frequent falls are not recognized as possible important marker

Delirium – So What?

Patients with delirium have:

- prolonged length of stay in hospital

- worse functional outcomes

- higher rates of nursing home placement

- increased risk of permanent cognitive decline

- higher death rates

- worse rehabilitation outcomes

Delayed recognition → worse outcomes

Late life depression

Depression: Alteration in usual mood with

sadness or negative mood state (anger,

irritability, despair), lack of enjoyment in

previously enjoyed activities and vegetative

symptoms sufficient to interfere with

functioning

Late Life Depression

Common (but often undiagnosed)

Costly

Debilitating

Potentially lethal

Aging baby boomers are expected to have

higher rates than the current elderly cohort

Late Life Depression

View late life depression as a sentinel event

that substantially increases the risk for

decline in general health and function

Frequently heralding the onset of cognitive

decline/dementia

Risk factors for late life

depression

FEMALE

Major life events such as widowed or

divorced

Structural brain changes

Peripheral body changes such as major physical

or chronic debilitating illness

Risk Factors for late life

depression

Previous history of depression

Caregiver for person with dementia or other debilitating medical condition

Excessive alcohol consumption

Taking medications, such as centrally acting BP meds, analgesics, steroids, antiparkinsons, benzodiazepines

Mood Disorder due to Medical

Condition: common in late life

Stroke induced depression or mania

Depression associated with Parkinson's disease

Depression or mania due to endocrine disorders (thyroid, adrenal)

Depression due to infectious illnesses

Substance-induced depressive or manic syndromes (alcohol, benzo)

Depression and cognitive problems due to sleep apnea

Use of Health Care Services in

Depressed Elderly

Twice the number of medical appointments

Increased number of medications taken

Twice the length of stay in hospital

In Nursing homes:

Increased nursing time

Suicide rates in Canada

Highest rates for men:

20-24 age group and 80-84 age group (30/100,000)

85+ highest with 35/100,000

Highest rates for women:

45-49 age group (9/100,000)

Ratio of attempts: completed suicide after 65 much lower than younger adult

2:1 men; 4:1 women.

Improving recognition of late life

depression

Clinician factors

Incorrectly attribute depressive symptoms to the

aging process (“I’d be depressed too!”)

More focus on concurrent medical conditions

Time pressures/fee-for-service payment

Problems in integration of mental health and

primary care systems

Improving recognition of late life

depression

Patient factors

Stigma (patient and caregivers)

Ageism (patient and caregivers)

Misinformation

More comfortable to report physical symptoms

Dementia may color the picture

Treatment and recovery/well being

Possible for all (early and late onset) mental

disorders for elderly women

Many recent best practice guidelines to focus on

mental disorders in the elderly

Recent enhancement of training/education for

general psychiatrists, primary care physicians

New Royal College official subspecialty in

Geriatric Psychiatry

Treatment and recovery/well being

Medication can be an important part of

treatment/recovery

Psychotherapies can be an important part of

treatment/recovery

ECT can be an important part of treatment/recovery

Physical exercise, healthy diet, stable housing, stable

finances, spiritual well being, social connections,

laughter, brain exercise are all important parts of

recovery and well being

Take Home Messages

Growing old with mental illness is not for sissies !!

Early onset mental illness requires a fresh perspective

by health care professionals as women grow older

Late onset mental illness can be complex

Prevention, early identification, treatment and follow-

up are key to recovery/well being

Mental health services for the elderly can be

fragmented, lack availability and are plagued by stigma

but improvements are happening!

Thank you

Any questions?