Psychopathology.html

PSYCHOPATHOLOGY IN OLDER ADULTS

General Information

Mental health is the absence of mental disorders and the ability to deal effectively with life events; the latter part includes the utilization of the many of the coping strategies already discussed

- Estimates of developing some kind of mental disorder in one’s lifetime: 1 in 3
- Number of adults currently suffering from a mental disorder: 1 in 4 or 5

Possible pathways to psychopathology in later adulthood:

1) having the same disorder at one more earlier points in one’s life
2) having a problem earlier in life that gets more serious with age
3) no evidence of a mental disorder earlier, but one develops later

Age comparison of psychopathology:

- Twice as prevalent in the young (18-24 years) as in the old (based on those living in the community)

It is possible that community studies underestimate both the current face and the future pace of psychopathology in the elderly.

Utilization of mental health services

Fewer older adults use mental health services, often due to stereotypes about such services (may be a cohort effect):

were not socialized to self-disclose
may believe therapy is only for "crazies"
may believe their problems are not serious enough
may believe therapy is expensive and takes a long time
may be embarrassed to admit a problem for personal or family reasons

The underutilization of mental health services may be most problematic for ethnically diverse elderly who because of financial considerations and physical health needs are more at risk for the adverse effects of mental disorders.

Acculturation (ease with interacting within the majority culture) is an important aspect to consider with regard to mental health services: For example, Latino elderly who are more acculturated are more likely to use such services. Less acculturated are more likely to rely on family members and even traditional, folk healing for intervention.

In all minority groups, the use of professional services is usually a last resort and reserved for when the situation is at its most severe — may require inpatient rather than outpatient treatment which is more expensive, longer term, and possibly less successful.

Important to consider are the possible barriers to mental health services for minority elderly. These include:

Overt discrimination and prejudice
Lack of bicultural understanding
Professionals speaking only in English
SES differences between client and therapist
Geographic inaccessibility to services
Lack of transportation
Lack of health insurance and/or income to cover services
Lack of minority mental health professionals or role models
Physical and social isolation of the ethnic minority community itself

Specific Disorders

I. Phobias

These are the most common of all anxiety disorders and the top-ranking emotional problem in old age. Can be classified as simple phobias (e.g., fear of flying, etc.), social phobias (anxiety about performing in front of others); and agoraphobia (literally fear of open spaces).

Agoraphobia

• is often accompanied by intense panic attacks which often weaken in severity with age

• more common in women (14.2% of elderly women) than men (7.6%)

• tend to first appear in one’s teens or 20s; illness rates decline in old age

• is chronic, affecting all areas of one’s life

Possible causes: physiological abnormality (e.g., higher levels of lactate in the blood), dysfunctional, shallow breathing may lead to panic attacks --> learned response

Age considerations — agoraphobia may be underdiagnosed in older adults because of stereotypes about aging (e.g., disengagement theory); also it may be less severe because panic symptoms may be less intense

II. Depression & Suicide

Depression

A general unhappiness with life. Two kinds: major depression which must last at least two weeks and is characterized by 5 or more symptoms beyond a general low mood; dysthymia which must last for 2 years or more and with only two of the DSM-IV symptoms.

• some research estimates that as high as 20-40% of elderly suffer from clinical depression at some time during late life; others put the incidence at about 4-7% of community living elderly and 20-50% of institutionalized elderly

• 70-80% improve significantly with adequate treatment

• Elderly, white males are the largest demographic group to die from suicide

• Of that group, 80% have diagnosis of depression

Depression seems to be more prevalent in the old-old, but healthy older people are no more likely to be depressed than their younger counterparts. With regard to suicide, 12.5% of the population are responsible for 20% of the suicides, much more prevalent than for teens. White males are especially at risk; after the age of 85, they are three times as likely to commit suicide.

Depression may be particularly difficult to diagnose in the elderly because:

• it may be masked with physical complaints such as gastrointestinal problems or sleep disturbances

• often times the individual does not even recognize that he or she is depressed, thinking that such symptoms are normal for anyone that age

• many grew up when it was not socially acceptable to verbalize feelings of sadness or guilt

• depression may also appear to be cognitive impairment such as indecisiveness, muddled thoughts, and inability to concentrate

• symptoms can overlap with dementia, substance abuse, medication side effects

Causes: genetic predispositions, stressful events may also trigger a tendency towards depression - e.g., loss of a spouse/loved one, loss of control

Treatments: intensive, brief therapy (e.g., cognitive-behavioral therapy), drug treatments, or their combination; in extreme cases, ECT may be used

Suicide

Older adults with depression are more likely to successfully carry out suicide; estimates that 1 in 6 of those with severe depression will actually bring on their own death

Techniques: starvation, auto accidents, misuse or disuse of medications (overdose, mixing with other medications or with alcohol, discontinuing use), use of firearms (especially among elderly white males with lower SES)

Risk factors: living alone, being male, experiencing the loss of a spouse, and failing health

Signs (prevalent at all ages):

extreme mood or personality changes
discussion of suicide and death
preoccupation with the futility of the continuing the struggle of daily life
giving away cherished possessions
sleep or eating disturbances
severe threat to identity and self-esteem
death of loved ones and/or long term friends

III. Alcoholism

Alcohol dependence is indicated by signs of addiction, blackouts or withdrawal symptoms, and an impairment in the ability to function in life. Alcohol abuse is the diagnosis given for those who use alcohol repeatedly and it interferes with work or home.

The AMA estimates alcoholism is misdiagnosed in about 70 percent of cases. Of the estimated 10 million alcoholics in the United States, probably 3 million are over the age 60 years.

Men are five times more likely than women to be alcoholics; widowers over the age of 75 have been reported to have the highest incidence of alcoholism of any group.

Statistically the elderly alcoholic is:

• less likely to have various problems with the legal system,

• less likely to attempt suicide,

• more likely to be living alone whether divorced or separated,

• usually not employed and therefore unlikely to have a job-related referral for alcohol abuse.

There are two major groups of elderly alcoholics

1. Early onset group.

This group is defined as showing problem drinking younger than 60 years of age. People in this "survivor group," which encompasses 50-75% of older alcoholics, have numerous chronic alcohol-related medical problems (Korsakoff’s syndrome, liver disease) as well as other health problems. These early onset patients generally have a family history of alcoholism, are less well adjusted, and have had alcohol-related problems with the law. Many in the early onset group actually die before they get to old age.

For men in the early onset group, there may be two types of alcoholics (Cloninger, 1987):

hereditary type — chronic alcohol abuse with physical abusiveness when drunk, criminal behavior, driving while intoxicated, jail

nonhereditary type — abuse starts at around 25 with problems appearing in middle age, includes periods of bingeing and abstinence, usually better social adjustment and fewer job problems, BUT still can be highly problematic and is considered alcohol abuse

2. Late onset group, or "reactor group". Patients in this group tend to begin problem drinking after the age of 60 years. These patients are thought to have a more favorable treatment response. In this group the alcohol abuse may be secondary to the stresses and losses associated with aging. May make up from 1/3 to 1/2 of elderly alcoholics with women and those of high SES being at risk. The alcoholism often begins as a response to chronic, multiple stressors as opposed to one catastrophic event.

Treatment; May include the use of older "peer" counselors, Alcoholics Anonymous, social support and training in coping skills, etc.

Advice for doctors (and caregivers):

• Consider problem drinking as a factor when treating a patient for falls, appetite and memory problems, trouble sleeping, and depression.

• Use open, non-judgmental questions such as "Do you use alcohol?''

• Watch for possible interactions between alcohol and prescription drugs, especially anti-anxiety, barbiturate and sedative medications.

Therapeutic Interventions in Late Adulthood

Goals of intervention (at all ages!): alleviation, compensation, enrichment, and prevention

Evaluation: first step in treatment — involves assessment of the situation (symptoms, stressors, length of time that the problem was experienced, coping styles used in the past, major life events), the person (physical appearance — clean and well-groomed, judgment, insight, mood, and interpersonal skills), additional information for older adults might be physical examination, functional assessment (how well does one do with ADLs), family interview, and mental status exam

Intervention for the elderly may include service delivery, exercise, education.

Mental health needs are underserved in nursing home populations. Emphasis on management with medication, rather than behavioral intervention. Especially as the baby boomer population increases, there is a huge need for therapists specially trained to work with older adults.

Types of therapy (described above):

Cognitive-Behavioral — probably the most useful for healthy, cognizant older adults; problem-focused, education- oriented; flexible and may be able to be done in the home
Psychoanalytic — emotion-centered; may need to focus more on the here and now
Chemotherapy — though drug regimens and drug interactions are a major concern: drugs are metabolized more slowly à toxicity, possible drug interactions are often ignored, regimens may be hard to follow, etc.

1/3 of all hospitalizations among the elderly are due to adverse medication effects!

Some other types of therapeutic interventions used with older adults:

Behavior Therapy — often used in institutional settings
Reality Orientation — may be used with dementia patients
Life Review or Reminiscence Therapy — used to deal with "unfinished" business
Milieu Therapy — modifies the living situation for institutionalized elderly, especially used for those with dementia
Pet Therapy — often directed at nursing home residents