According to the National Institute for Mental Health in England (2005), “The presence of Mental Health problems [for the elderly], is a strong independent predictor of poor outcomes, such as increased mortality, length of stay, institutionalism, and resource use.”
In North America an estimated 20% of seniors living on their own, and 80-90% of those living in institutions have Mental Health issues or illness. In addition, dementia cases are expected to double in the next 30 yrs. Over the next 25 years, the US will have a large growth in the population of older adults age 65 and over. This population will double, and the proportion of this sector of the American population will grow to 13-20%.
The mental disorders discussed are not a part of normal aging. Unrecognized and untreated Mental Health conditions can be severely impairing, even fatal. In the US, the rate of suicide, a consequence of Depression, is highest among older adults. The largest prevalence rate for people 55 and over of Mental Health disorders are the following: Depression and Anxiety, Dementia, Drug and Alcohol Abuse, and other Mental Health Disorders.
Mental Health problems can lead to or exacerbate other physical conditions, by decreasing the ability of older adults to care for themselves, by impairing their capacity to rally social support, and impairing physiological functions. Depression and anxiety can increase mortality from coronary disease and cancer.
Many older adults experience loss with aging: loss of social status and self-esteem, death of friends and loved ones. Loss of a spouse is common. Bereavement may increase the probability of, or cause/exacerbate mental disorders. Bereavement is a risk factor for depression. Ten to twenty percent of widows/widowers develop Major Depression during the first year of bereavement. Some succumb to Depression and suicidality, while others find new adaptive strategies. The reason for this is unknown, but one could speculate that it has to do with the person’s previous coping strategies and attitudes toward living.
According to a study done by Texas A&M University, people 65 years and older are unlikely to receive mental health services. Data from a National Survey on Drug Use and Health found that older adults were three times less likely than younger adults (ages 16-64), to receive Outpatient Mental Health treatment. Only 2.5% of older adults, compared to 7% of younger adults utilized any Outpatient treatment. There may be several reasons for this which includes: The elderly may have difficulty with mobility and transportation, and the commonly held misconception that Depression, Dementia, and Anxiety is a normal response to aging.
Older people with Mental Health needs are at greater risk for abuse than other groups of older people. The risk is greater for abuse under the following circumstances. When older people: (1) have cognitive impairment (2) people who are depressed (3) caregiver drinks alcohol heavily (4) poor relationships within the household (5) when the older person is physically or mentally abusive, or has behavior problems. Older people, especially those with mental illness, need to be examined periodically for suspicious bruises, scratches, and potential fractures induced by caregivers. General practitioners need to be more aware of elderly patient’s mental status and mood, and inquiring about recent functioning and losses.
Cognitive impairment, which is loss of brain function, is seen in varying degrees in older patients, which is often memory loss. Memory complaints are reported in 50-80% of these patients. These complaints may not actually correspond to actual performance. Long- and short-term memory declines along with recall, slowing of information processing, selective attention, problem solving, and fluid intelligence.
Males and females have different risk factors for age-related cognitive impairment. Risk factors for females are more relationship focused. They lacked a strong social network and are dependent (3.5 times greater than those that are independent. Females with Depression are 2 times more likely to progress to dementia, than those who are not depressed. Males with mild cognitive impairment were likely to be overweight, have Diabetes and/or CVA (stroke), a 3 time increase in developing dementia. There is also a genetic factor (ApoE), which is seen frequently in patients with Dementia.
A French study also revealed that, in a 4-year period, 42% of 7,000 people showed mild cognitive impairment initially. At the end of 4 years, 6.5% developed Dementia, while 37% returned to normal, implicating that people can drift in and out of mild impairment. Some suggestions from this study included: (1) maintain good relationships with friends and family (2) prevent or treat Depression (3) maintain a healthy weight (4) prevent or manage Diabetes (5) prevent a CVA (stroke). These suggestions highlight the fact that cognitive decline may be prevented to some degree, through lifestyle changes.
In normal aging, there is a gradual decline of physical and mental functioning, but not as severe as negative stereotypes portray. Trends show that the prevalence of chronic disability is declining, and extreme disability, including mental disorders, is not an inevitable part of aging. There is much variability in individuals,that is dependent on lifestyle and psychosocial factors. According to research, again, lifestyle modifies genetic risk in influencing the outcomes of aging.
Another study postulates that successful aging is contingent upon 3 elements (1) avoiding disease and disability (2) sustaining high cognitive and physical function, (3) and engaging with life- i.e. maintaining interpersonal relationships and productive activities (paid or unpaid). All 3 elements must be included in order to affect aging. Aspects of Mental Health in normal aging include stable intellectual functioning, capacity for change and productive engagement with life.
Erik Erikson, a Developmental Theorist, characterizes the final stage of psychosocial development as “ego integrity versus despair,” the final life crisis. The question a person asks is “Have I lived a full life?” There is a natural slowing of activity, thus allowing one the time to contemplate accomplishments. If one feels we have achieved our goals, one feels contentment and integrity, if one feels dissatisfied with life and in despair, this can lead to Depression.
This stage normally begins before retirement. In the recent years however, the age at retirement has gone steadily up, as well as life expectancy, leaving more years of being productive and more time to achieve life goals. In North America, female current life expectancy is 86, and male is 83-years-old.
Relationships improve life expectancy and bolster cognitive functioning, through social support when life is difficult, by assisting with concrete and emotional issues. Another theory is that the benefit from social support is due to actual biochemical changes in the body that produce chemicals when we are in relationships that protect our health.
Exercise is an important part of a healthy brain while aging. Studies have shown a lower risk of decline in elderly who exercise regularly. Exercise also assists in maintaining a healthy weight, blood pressure, and blood sugar goals as well, and reduces depressive symptoms.
A positive attitude toward aging may add additional years to your life. A study of 660 people revealed that those with a positive perception of aging lived an average of 7.5 years longer. This has implications for retraining society’s image in middle age and senior yrs. Researchers also believe that positive thinking about aging can increase the will to live, and as a result, increase resiliency and proactive behaviors toward health. It is also thought that positiveness reduces mental stress of aging.
There has been much information in recent years regarding improving or maintaining brain fitness. As boomers have entered into this age group, they have clamored for more ways to save brain cells. Again, is biology or lifestyle responsible for the 20% of people over 85 having Dementia? Research has found that remaining engaged in cognitive activities will help maintain brain fitness. Basic principles include: (1) variety and curiosity. Suggestions include: Sudoku, crosswords, and electronic games for 15 minutes per day. (2) Meditation daily (3) Nutrition-include Brain foods: fish oils, nuts, seeds, olive oil, and antioxidant rich foods found in fruits and vegetables. (4) Turn off the TV and use your mind and body! (5) Exercise- vary your workout (6) Reading, but change genre for variety. (7) Learn a new skill- Chinese cooking, needlework etc. (8) Cultivate relationships- stay engaged (9) Live with meaning and purpose- find a passion.
Here, at the VNS of Westchester and Putnam, the average age of our patients is older than the national and state averages. As noted at the beginning of this article, Home Care will experience a doubling of patients over 65 in the coming years. As with other services of the Health Care Continuum, it is vital that we address the issues relevant to maintaining mental and cognitive health, and identifying/diagnosing and treatment of mental illness in the elderly. Education regarding steps one can take to maximize mental health in the golden years should be a part of the Mental Health Home Care visit, and at every point of entry in the Health Care Continuum.
Notes
Friedman, M. B., Williams, K. A. (Jan. 2010) Addressing the Mental Needs of Older Adults in “Age-Friendly communities.” GMHA-NY, p.p. 1-2.
Surgeon General Report. Mental Health: A Report of the Surgeon General. Older Adults and MentaL Health. Ch.5 pp.1-11.
