Mental health problems among elderly people

Internationally, populace is ageing speedily. According to WHO report, it is anticipated that the number of persons aged 60 or over is expected to more than triple by 2100. Neuropsychiatric disorders among the older adult are more prevalent. Statistical reports indicated that 15% of adults aged 60 and over experience mental ailment.

Older people who cross 60 years of age undergo numerous health problems. These adults are highly important for healthy society and contribute a lot as family members, volunteers and as active participants in the workforce. Though some elderly people maintain good health through exercise, nutritious diet but many older adults are at risk of developing mental disorders, neurological disorders or substance use problems as well as physical illness or disability. Major neuropsychiatric disorders in this age group are dementia and depression.

Reports indicated that anxiety disorders affect 3.8% of the elderly population, substance use problems affect almost 1% and around a quarter of deaths from self-harm are among those aged 60 or above. Substance abuse problems among the elderly are often ignored or misdiagnosed.

Risk factors for mental health problems among the older adults:

In global society, there are manifold social, psychological, and biological factors determine the level of mental health of a personas well as the typical life stressors common to all people.Manyelderly peopleunable to live independently because of restricted mobility, long-lasting pain, infirmity or other mental or physical problems, and they need long-term care from their family members. Additionally, older people sometimes experience feeling of bereavement, lower social status in society with retirement, or a disability. These factors leads to isolation, loss of independence, loneliness and psychological anguish in elderly people.

Psychologists stated that mental health has great impact on physical health and vice versa. It can be established in medical reports that elderly people who experienced physical health conditions such as heart disease may develop feeling of depression as compared to people who are healthy.On the other hand, depressive elderly people with heart disease can negatively affect the result of the physical disease.

It has been observed that elderly people are physically neglected and sometimes they are treated badly in family as well as in society. Elder maltreatment can lead to physical injuries, as well as serious long-lasting psychological problems such as depression and anxiety.

Causes for Senior Mental Illness:

One of the continuing problem with diagnosis and treatment of mental illness in elderly people is that they are more likely to report physical symptoms than psychiatric complaints. Though, even the normal physical and emotional stresses that go along with agedpeople can be risk factors for mental illnesses such as anxiety and downheartedness. The Geriatric Mental Health Foundation observed numerous triggers for mental illness in the old people:

Physical disability.
Long-term illness such as heart disease or cancer.
Dementia-causing illness such as Alzheimer’s disease.
Physical illnesses that can affect thought, memory, and emotion such as thyroid or adrenal disease.
Change of environment, like moving into assisted living.
Illness or loss of partner of close family member.
Medication interactions.
Alcohol or substance abuse.
Poor diet or undernourishment.

Symptoms of Mental Illness:

There are numerous warning signs, which could indicate a mental health concern in older people:

Sad or miserable mood lasting longer than two weeks.
Social withdrawal, loss of interest in things that used to be pleasurable.
Unexplained fatigue, energy loss, or sleep alterations.
Confusion, disorientation, problems with concentration or decision-making.
Increase or decrease in hunger, changes in weight.
Memory loss, especially recent or short-term memory problems.
Feelings of insignificance, inappropriate guilt, powerlessness,feeling of suicide.
Physical problems that cannot otherwise be explained like aches, constipation.
Changes in appearance or dress, or problems maintaining the home or yard.
Difficulty to manage finances or working with numbers.

Type of mental health problems in elderly people:

Dementia and depression among the elderly as public health issues.

Dementia:

Dementia is a type of disorder that affects person’s brain works. Dementia is a syndrome in which patient’s condition is deteriorated in terms of memory, thinking, behaviour and they have difficulty to perform everyday activities. It mainly affects older people, although it is not a normal part of ageing.It is predictablein reports that 35.6 million people worldwide are living with dementia.

The total number of people with dementia is projected to almost double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050, with majority of sufferers living in low and middle income nations.

Medical experts affirmed that Dementia is a common condition of the elderly people characterised by manifold cognitive deficits resulting in a decline from previous level of function. In the older person, multiple pathologies contribute, including changes dementia with Lewy bodies in addition to vascular changes. Comorbid factors, such as depression, delirium and polypharmacy can contribute to cognitive decline. The most common of effect of dementia is Alzheimer’s disease. Another is vascular dementia which can develop following a stroke or if there is blood vessel damage that disrupts the supply of blood to brain. Dementia is not a normal consequence of growing old.

There are important social and economic problems in terms of the direct costs of medical, social and informal care associated with dementia. Furthermore, physical, emotional and economic stresses can lead to great pressure to families. It is necessary that the health, social, financial and legal systems must support people with dementia and their caregivers.

1. Dementia: Irreversible Causes:

Dementia has numerous causes. Many medical conditions can cause dementia symptoms, especially in older people. The causes of dementia include various diseases and infections, strokes, head injuries, drugs, and nutritional deficiencies.

All dementias reveal dysfunction in the cerebral cortex, the part of the brain that controls perception, memory, thoughts, language, and consciousness. Some disease processes harm the cortex directly while others disturb subcortical areas of the brain that normally regulate the function of the cortex.

When the fundamental process does not permanently damage the cortical tissue, the dementia may sometimes be stopped or retreated.

To classify dementias, medical specialists may either separate the causes into cortical or subcortical dementias or into reversible and irreversible dementias.

Alzheimer's disease:

This is major reason of having dementia in elderly people. Alzheimer's disease is partly hereditary. It can be said that it runs in families. In this disease, abnormal protein deposits in the brain destroy cells in the areas of the brain that control memory and mental functions. People with Alzheimer's disease also have lower than normal levels of brain chemicals called neurotransmitters that control important brain functions. Alzheimer's disease is not reversible, and as on date there is no treatment for this severe disease. However, certain medications are prescribed to slow down its progress.

Vascular dementia:

Another common cause of dementia is vascular dementia which is triggered by atherosclerosis, or "hardening of the arteries," in the brain. Deposits of fats, dead cells, and other debris form on the inside of arteries, partially (or completely) block blood flow. These blockages cause several strokes, or interruptions of blood flow, to the brain. Vascular dementia is related to high blood pressure, high cholesterol, heart disease, diabetes, and related conditions. If treatment to these problem is given then it can slow the progress of vascular dementia, but functions do not reverse once they are lost.

Parkinson's disease:

In this medical ailment, elderly people typically have limb stiffness (which causes them to shuffle when they walk), speech problems, and tremor (shaking at rest). Dementia may develop late in the disease, but it is said that people who have Parkinson, do not experience symptoms of dementia. Reasoning, memory, speech, and judgment are most likely to be affected.

Lewy body dementia:

This disorder is due to abnormal microscopic deposits of protein which destroy nerve cells. These deposits can cause symptoms typical of Parkinson's disease, such as tremor and muscle rigidity, as well as dementia similar to that of Alzheimer's disease. Lewy body dementia affects thinking, attention, and concentration more than memory and language. Lewy body dementia is not reversible and has no cure.

Huntington's disease:

This congenital disease causes deteriorating of certain types of brain cells that controls movement as well as thinking. Dementia is common and occurs in the late stages of the disease. Personality changes are observed in this disease. Huntington's disease in elderly people may affect reasoning, memory, speech, and judgment.

Pick disease (frontotemporal dementia):

This is infrequent disorder that damages cells in the frontal part of the brain. Behaviour and personality changes usually precede memory loss and language difficulties.

Multiple sclerosis:

In this medical condition, brain and spinal cord cells are damaged by an autoimmune process. Dementia can result in some people.

Untreated brain infections such as HIV, Lyme disease damage brain cells by forming lesions and trigger inflammatory responses that damage or kill brain cells.

Symptoms of dementia:

Symptoms of dementia differ significantly by the individual and the original cause of the dementia. The first sign of dementia is usually loss of short-term memory.

The person repeats what he just said or forgets where he put an object just a few minutes ago. Other symptoms and signs are as follows:

Word-finding difficulty: May be able to compensate by using synonyms or defining the word.
Patent forget names, appointments, or whether or not the person has done something; losing things.
Difficulty in performing familiar tasks such as driving, cooking a meal, household chores, managing personal finances.
Personality changes (for example, sociable person becomes withdrawn).
Uncharacteristic behaviour.
Mood swings, often with brief periods of anger or rage.
Poor judgment.
Behaviour disorders: Paranoia and suspiciousness.
Decline in level of functioning but able to follow established routines at home.
Confusion, disorientation in unfamiliar surroundings: May wander, trying to return to familiar surroundings.
Difficulty or inability to perform multiple task.

When to visit doctor: Elderly people who are experiencing dementia may not be aware of problem. Most people with dementia are brought to medical attention by a caring relative. Patients must seek medical attention in following conditions.

Noticeable loss of short-term memory
Behaviour or personality changes
Unsuitable or uncharacteristic behaviour
Depressed mood
Marked mood swings
Inability to do daily tasks such as bathing, dressing, feeding, using the toilet, or household chores
Carelessness in personal hygiene
Persistent word-finding difficulties
Persistent or frequent poor judgment
Persistent or frequent confusion or disorientation, especially in familiar situations
Inability to manage personal finances

Diagnosis:

In some elderly people, the signs and symptoms of dementia are easily recognized; in others, they can be very subtle. It is important to perform a careful and thorough evaluation to identify their real cause. Health care provider will conduct a detailed medical interview to develop a picture of the symptoms. A systematic physical examination will look for evidence of illness and dysfunction that might shed light on what is causing the symptoms. An assessment of dementia symptoms should include a mental status evaluation.

Treatment:

People with dementia should always be under medical care. Normally, family members handle daily care of patient but medical examination must be done from time to time.

2. Depression:

Many medical researchers have stated that the progressive changes that occur in later life, such as at the time of retirement, the death of partner, increased isolation, and other medical problems lead to depression. In elderly people, it is most common mental problem. Depression also impacts person’s energy, sleep, appetite, and physical health.

Depression can cause great sorrow and leads to decreased functioning in daily life. Medical reports have signified that unipolar depression occurs in 7% of the general elderly population and it accounts for 1.6% of total disability among over 60 year olds.

Symptoms of depression in older people are often ignored and not treated because they overlap with other late life problems. Depression in the elderly often increases their risk of cardiac diseases and increases their risk of death from disease. Depression also increases the risk of suicide, especially in elderly men.

The suicide rate in people ages 80 to 84 is doubled as compared to other age groups.

Symptoms of depression in older people:

Depression in the elderly people can lead to following symptoms:

Sadness
Fatigue
Abandoning or losing interest in hobbies or other pleasurable pastimes
Social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home)
Weight loss or loss of appetite
Sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness)
Loss of self-worth (worries about being a burden, feelings of worthlessness, self-loathing)
Increased use of alcohol or other drugs
Fixation on death; suicidal thoughts or attempts

There is a responsibility of health care agencies to train health providers and societies to meet the specific requirements of older people such as:

Training for health professionals in old-age care.
Preventing and managing age-associated chronic diseases including mental, neurological and substance use disorders.
Designing sustainable strategies on long-term and palliative care.
Developing age friendly services and settings.

Treatment and care strategies:

There are several treatment procedures for depression. They include medicine, psychotherapy or counselling, or electroconvulsive therapy or other newer forms of brain stimulation (such as repetitive transcranial magnetic stimulation. Sometimes, a combination of these treatments may be used to treat depression of elderly people.

For severe depression, medical practitioners use antidepressant medication.

Antidepressant medication may take longer to work in older people.

Another therapy effective in older people associated depression is electroconvulsive therapy (ECT). It is a useful treatment in melancholic and psychoticdepression when individuals who do not respond to medication, or when thedepression is very severe.

In the non-melancholic depressions, the usual range of psychotherapies is applicable.

Thoughpsychotherapists need to take into account the limitations imposed by poor hearing,poor eyesight and physical discomfort.

Prevention:

Depression can be prevented in older age group through lifestyle changes. There is growing data that cerebrovascular disease may be linked to depression in old age, so controlling the recognized risk factors for vascular disease may also prevent depression.

These include:

Reduction of high blood pressure
Cessation of cigarette smoking
Reduction of cholesterol and lipid levels

Health promotion:

Mental health of elderly people can be enhanced through promoting active and healthy ageing. Mental health-specific health promotion for the older adults involves creating healthy living conditions that allow people to lead integrated lifestyles. Promoting mental health depends on policies which ensure the elderly have the necessary resources to meet their basic requirements, such as:

Providing security and freedom.
Satisfactory housing through helpful housing policy.
Social support for elderly people and their caregivers.
Health and social programmes targeted at susceptible groups such as those who live alone, rural populations or who suffer from a chronic or relapsing mental or physical illness.
Violence or older adult's maltreatment prevention programmes.
Community development programmes.

Interventions:

It is important to quickly recognize and treat mental, neurological and substance use disorders in older adults. Both psychosocial interventions and medicines are suggested.

There is no medication currently available to cure dementia but some steps must be taken to support and improve the lives of people with dementia and their caregivers such as:

Early diagnosis, in order to promote early and optimal management.
Optimizing physical and psychological health, including identifying and treating, accompanying physical illness, increasing physical and cognitive activity and optimizing well-being.
Identifying and managing challenging behavioural and psychological symptoms.
Providing information and long-term support to caregivers.

Mental health care in the community:

In community, older people must be given importance. There is a need to support them to maintain good general health and social care in order to prevent disease and manage chronic illnesses. Training all health providers in working with issues and disorders related to ageing is important. Effective, community-level primary mental health care for older people is vital. It is significant to focus on the long-term care of older adults suffering from mental syndromes, as well as to provide caregivers with education, training and support.

Anxiety disorders:

Anxiety disorders are also common in old age and may burden the public health system even stronger than depressive disorders. Anxiety at old age is often silent or difficult to diagnose as older adults tend to somatise psychiatric problems, have multiple psychiatric, medical, and medication issues. When elderly people are diagnosed with anxiety disorders, there is a relatively high probability of comorbid conditions being present. Van Balkometal.found that major depression, benzodiazepine use, and chronic somatic diseases were significantly more predominant in old people with anxiety disorder. Women do have a higher occurrence of anxiety disorders than men but this difference diminishes with growing age.

For treatment of anxiety disorder, effective psychotherapies such as cognitive behavioural therapy (CBT) are applied to the older adult population, and the combination of CBT and medication is more successful.

Delirium:

Delirium is a common manifestation that can affect the health and quality of life for older people. Delirium often accompanied with other diseases, such as dementia, stroke, Parkinson's disease, or depression.People who are affected by this mental disorder exhibit symptoms of acute confessional states which increase mortality and impair long-term outcome of primary illnesses. In the beginning of delirium, elderly people show rapid, typical symptoms include abnormalities of memory, orientation, and attention with an inability to focus and maintain attention and alertness.

Main signs and symptoms are as under.

Reduced awareness of the environment. This may result in:
• An inability to stay focused on a topic or to switch topics
• Getting stuck on an idea rather than responding to questions or conversation
• Being easily distracted by unimportant things
• Being withdrawn, with little or no activity or little response to the environment
Poor thinking skills (cognitive impairment). This may appear as:
• Poor memory, particularly of recent events
• Disorientation, for example, not knowing where you are or who you are
• Difficulty speaking or recalling words
• Rambling or nonsense speech
• Trouble understanding speech
• Difficulty reading or writing
Behaviour changes. This may include:
• Seeing things that don't exist (hallucinations)
• Restlessness, agitation or combative behaviour
• Calling out, moaning or making other sounds
• Being quiet and withdrawn - especially in older adults
• Slowed movement or lethargy
• Disturbed sleep habits
• Reversal of night-day sleep-wake cycle
Emotional disturbances. This may appear as:
• Anxiety, fear or paranoia
• Depression
• Irritability or anger
• A sense of feeling elated (euphoria)
• Apathy
• Rapid and unpredictable mood shifts
• Personality changes

There are three types of delirium:

Hyperactive delirium: Perhaps, it is the most easily recognized type of medical ailment. This may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations.
Hypoactive delirium: This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness or seeming to be in a daze.
Mixed delirium. This includes both hyperactive and hypoactive symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.
Patients usually suffer from delirium when the normal sending and receiving of signals in the brain become impaired. It may be due to combination of factors that make the brain weak and cause a malfunction in brain activity.

Major causes of this mental ailment are as under:

Certain medications or drug toxicity
Alcohol or drug abuse or withdrawal
A medical condition
Metabolic imbalances, such as low sodium or low calcium
Severe, chronic or terminal illness
Fever and acute infection, particularly in children
Exposure to a toxin
Malnutrition or dehydration
Sleep deprivation or severe emotional distress
Pain
Surgery or other medical procedures that include anaesthesia

Medical specialists stated that many cases of delirium can be prevented by addressing modifiable risk factors and integrating environmental and clinical practice strategies in the care of older people. It is significant to involve family members and carers in the process of diagnosing delirium. Older people who affected by delirium are at greater risk of falls, functional decline and cognitive decline. Delirium is also related with higher mortality and morbidity, increased length of hospital stay and admission to residential care.

To treat delirium, Non-pharmacological strategies are used for all patients. The nonpharmaco logical approaches available include reorientation and behavioural intervention. Caregivers should use clear instructions and make frequent eye contact with patients. Sensory impairments, such as vision and hearing loss, should be lessened by use of equipment such as spectacles or hearing aids. Physical restraints should be evaded because they lead to reduced mobility, increased agitation, greater risk of injury, and prolongation of delirium. Other environmental interventions include limiting room and staff changes and providing a quiet patient-care setting, with low-level lighting at night.

It is well established in reports that mental disorders in elderly population are recurrent and they are frequently underdiagnosed. Most mental disorders are treatable once detected. Untreated mental disorders intensely impair life of patients andcare-givers, cost money, promote further ill health and burden for thepublic health system of nation.