Mental Illness in Older Adults: Effective Treatments
Outreach Partnership Program 2005 Annual Meeting
Friday April 1, 2005
Susan Schultz, M.D., Associate Professor of Psychiatry
University of Iowa College of Medicine
Dr. Schultz presented an overview of the major psychiatric disorders of particular relevance to the aging population. She also discussed the challenges of treating aging people who have suffered from schizophrenia throughout their lives, the presentation of depression and anxiety disorders in late life, services to people with late onset illness, and psychiatric difficulties associated with dementia.
Viewing the burden of mental illness over the continuum of life, Dr. Swedo previously discussed the prevalence of depression, anxiety disorders, ADHD and other mental illnesses in childhood and adolescence. In late adolescence and early adulthood, the burden of mental illness rises sharply with the onset of schizophrenia, bipolar illness and substance abuse. In midlife, incidence levels off, although significant numbers of people are diagnosed with depression and anxiety disorders. However, because of the exponential increase in the over-65 population that is anticipated over the next 20 years, we can predict a spike in this group, as more people will be at risk for late-life onset depression and cognitive changes. We will need to deal with the effects of lifelong drug abuse in older persons and will need to face the challenge of care for people who have suffered from chronic mental illnesses for many years. Whereas in the past, this population has been institutionalized or sequestered or exposed to a variety of adversities that reduced lifespan, we now have many aging people who have been living in the community for the duration of their illnesses, and have been taking antipsychotic medications since the onset of their illnesses many years ago. We also need to face the challenges of caring for aging people with mental retardation.
Because the onset of schizophrenia occurs in young adulthood, much research on the disease has focused largely on neurodevelopment abnormalities. Most of the treatments were developed through studies of young adults, and are designed to reduce the “positive” symptoms — delusions, hallucinations, etc. The “negative” symptoms — loss of motivation, loss of verbal interaction, etc. — have chiefly eluded treatment. There is some evidence that the positive symptoms ameliorate over time, and the negative symptoms will constitute the greater burden of symptoms among persons in later life. Negative symptoms do increase in older patients, though the reason is unclear. Previously it was thought that dementia was a common outcome of chronic schizophrenia, but postmortem studies have shown that the brains of these patients are not like those of people with dementia caused by Alzheimer’s.
The burden of disability for schizophrenia changes over the lifespan of the individual. In the first decade, the family, friends and community grieve for the loss of the person and his or her potential, and there is a high risk for suicide. In midlife, we often see relative stabilization and ability to function, if the person receives effective treatment and has adequate supports from parents and/or the community. In late life, however, there are a number of challenges. The mental health and medical systems are not geared to care for people who have both schizophrenia and other chronic illnesses like diabetes or heart disease. The person’s parents, who have provided the support system that has helped the individual to function, die or become disabled themselves. Nursing homes are often not equipped to monitor chronic antipsychotic medication, and the staff is not necessarily educated or experienced in working with the chronically mentally ill. Communities need to prepare for these problems.
We also face the challenge of identifying and implementing appropriate treatment strategies for schizophrenia in late life. We know that schizophrenia typically requires lifelong antipsychotic medications. Given the number of physiologic changes that affect the way medications are metabolized, in concert with a possible stabilization of the illness, we need to consider reducing medication in older patients. A study conducted in Tokyo in persons in long-term care found that when antipsychotic medications were reduced, the overwhelming majority improved or had no change, and only a minority worsened.
The sheer number of new atypical antipsychotics available, and the assumption that they are safer and better than older drugs, present their own challenges to mental health services. It is difficult for psychiatrists, consumers and communities to keep track of these medications and how best to use them. Very frequently, older persons are receiving multiple medications, and are experiencing adverse cognitive effects and other side effects associated with the atypical antipsychotics. Interestingly, an NIMH meta-analysis of treatment studies recently showed that cognitive performance was enhanced in people with schizophrenia who received typical antipsychotics versus placebo or no medication.
The large-scale NIMH CATIE (Clinical Antipsychotic Treatment Intervention Effectiveness) studies are expected to yield helpful information to clinicians regarding use of various atypical antipsychotic medications. One is a study of persons with schizophrenia, and a separate trial is looking at persons with Alzheimer’s dementia with psychosis.
However, as Dr. Nakamura said previously, we have to manage our expectations. Especially in the elderly, the hope that treatment will result in disappearance of all symptoms must be balanced with the idea that over treating and adding medications increases adversarial risk for that individual. Studies have shown that older persons treated with olanzapine have a greater propensity to weight gain, and those receiving risperidone are more likely to develop tremor and rigidity. For an older person, the risk for Parkinsonism is already heightened, so this serves as a caution. Also, a new FDA warning about the metabolic syndrome associated with the atypical antipsychotics as a class converges with evidence that suggests that schizophrenia in and of itself may predispose individuals to problems such as diabetes mellitus and increased risk of cardiovascular mortality. Thus we need to carefully consider the consequences in deciding what treatments to use for our vulnerable patients and assess function and quality of life before changing or adding medications.
Major depressive disorder has a different profile in older individuals, compared to younger people. Older people are more likely to present to primary care with complaints of pain, insomnia, or other physical symptoms, and perhaps this is attributable to their reluctance to see themselves as mental health consumers. They are more likely to have anxiety, and their symptoms are more likely to be associated with factors like social isolation, loss of a spouse, failing health and loss of independence. The increase in suicides in older Caucasian males may be tied to loss of a sense of contribution to the community and one’s place in society for these individuals. It is important to integrate geriatric mental health care and primary care, internal medicine, and neurology, and to provide appropriate diagnosis and treatment in the medical settings where people are seeking help. Important elements of depression management in older persons include avoiding the use of multiple medications, following up on and monitoring prescription use, caution in increasing dosage, combining medication use with talk therapy, providing social supports, and assessing cognitive decline. In addition, clinicians need to be aware of the common comorbidity with anxiety and the development of phobias in late life.
Emotional changes — apathy, irritability and phobic behaviors — are often the presenting hallmark for dementia and occur before cognition changes are detectable. Antipsychotic and antidepressant (SSRI) medications can be quite effective in patients with dementia. In Alzheimer’s disease, the most common form of dementia, there is gradual loss of memory, particularly short-term recall, associated with real functional impairment. Diagnosis may be missed until late in the disease course if clinicians do not pay close attention to short-term memory loss.
Questions and Answers
A participant asked about the relationship between depression and comorbid medical disorders, such as heart disease or stroke in late life, and whether behavioral interventions might be useful. Dr. Schultz said that studies have shown that myocardial infarction incurs depressive symptoms that then influence cardiac rehabilitation, and that hypoxia from pulmonary disease can incur panic attacks. A fruitful area for future research probably involves developing combined therapies for heart disease and concomitant mood disorders or other mental illnesses. We know that before pharmacologic therapies can help, it is important to intercede in the overall physical health of the person, enhance the social environment and put into place missing psychosocial supports. A number of groups are looking at cognitive therapy as part of the treatment regimen.
A participant asked about training medical students and practicing physicians to raise awareness of depression and the risk of suicide among older people, and to encourage early intervention, citing the study showing that a number of older men have seen a primary care physician in the week just prior to their suicide. Dr. Schultz said that although the Hartford Foundation and HRSA have infused some money into geriatric psychiatry training at the resident level, there is no systematized effort. In general, such training depends on medical colleges’ own initiatives. She also commented that assessing the risk of suicide in older people requires asking questions that will identify feelings of meaninglessness, futility and being a burden to others. Clinicians need to recognize that older people often can more easily identify anxiety or nervousness than depression.
Dr. Nakamura interjected that NIMH has done a fair amount of services research to learn how to change behaviors of primary care physicians, and the only approach that seems to work is placing a mental health or substance abuse clinician in the clinic with the physician so there is a referral system in place. Several major obstacles mitigate against improvement: inadequate reimbursement for the additional time it takes to deal with mental health issues, the overwhelming amount of information that clinicians need to absorb, and the discomfort that many physicians have about dealing directly with mental health issues.
A participant asked whether the requirement for informed consent prevents patients with severe symptoms of schizophrenia from participating in clinical trials, and thus how relevant findings are to treatment of such patients. Dr. Schultz said that many severely ill people can understand treatment protocols, and sometimes those with paranoia are especially able to grasp risks. She acknowledged that in any study, the entire range of a population is not represented, but in the case of schizophrenia, people with real symptoms are participating.
A participant asked about depression in the palliative care setting, and how to provide mental health care for a person who refuses treatment for a terminal illness. Dr. Schultz acknowledged that palliative care providers and mental health providers do not generally work together, but said that it would be beneficial. In related work, Linda Ganzini, an investigator in Portland, Oregon, is conducting research on depression in people with a terminal illness, and asserts that anyone who chooses to end treatment should be evaluated for depression.
Disclaimer
* This document is intended to summarize a speaker presentation at the NIMH Outreach Partnership Program’s Annual Meeting and is not an official statement or opinion of the NIMH. This information is in the public domain and may be used or reproduced for educational purposes without additional permission from the NIMH.
