From our Conversations lecture in March 2012.

1. Women, Aging and
Mental Health
Dr Cathy Shea
Associate Professor
Chair, Division of Geriatric Psychiatry
University of Ottawa

2. 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

4. 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%

5. 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%)

6. 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

7. 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!

8. Mental disorders commonly
diagnosed earlier in life
 Depression
 Anxiety Disorders
 Bipolar Disorder
 Schizophrenia
 Substance Use Disorders

9. 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%.

10. What happens to us
with “normal” aging?
And why does it matter?

12. 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

13. 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)

14. Pharmacokinetic changes with normal aging
(What the body does to the medications)
 Absorption
 Distribution *
 Protein binding
 Metabolism *
 Renal (kidney) clearance *

15. 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

16. 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

17. 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)

18. 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)

19. 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 ?

20. 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

21. 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

22. 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)

23. 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

25. 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

26. Late Onset Mental
Disorders

27. 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

28. 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.

29. 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…

30. 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)

31. 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.

32. Dementia is Common
2.4
11.1
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

33. 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”

34. 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

35. Delirium
 Delirium: An acute, potentially reversible,
condition characterized by fluctuating attention
& level of consciousness, disorientation,
disorganized thinking, disrupted sleep/wake
cycle

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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.

46. 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

47. 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

48. 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

49. 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

50. 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!

51. Thank you
Any questions?