W4 T3 P1

• The lecture provides an overview of affective disorders in older adults, covering the demographic context of an aging population, common disorders like depression and bipolar disorder, and aspects of psychiatric assessment in old age.

Aging Population

• Globally, the population aged 60 and over is projected to nearly double from 12% in 2015 to 22% by 2050, growing 3.5 times faster than the general population.
• Aging populations present economic challenges related to social care, health, pension demands, and labor markets.
• Older individuals contribute to families, communities, and the workforce as carers, volunteers, and employees.
• The demographic transition model explains population aging through stages of high/low birth and death rates. This was proposed in 1929 by the American demographer Warren Thompson.
• Most developed countries have completed the demographic transition with low birth rates, while developing countries are still in transition.
• Mental health and well-being are important at all ages, with approximately 15% of adults over 60 suffering from a mental disorder.
• Mental health stigma can deter older adults from seeking help and these disorders account for 6.6% of disability-adjusted life years (DALYs) and 17.4% of years lived with disability (YLDs) in this age group.

Epidemiology in Old Age Psychiatry

• Epidemiology is defined as the study of the distribution and determinants of health-related states or events, including disease, and its application to the control of health problems.
• Approximately 15-25% of the general older population experiences at least mild depressive symptoms that cause significant distress and interfere with daily functioning.
• Unipolar major depression occurs in 7% of the general older population, accounting for 5.7% of years lived with disability in those over 60.
• Depression is commonly seen in older adults recovering from major medical conditions like heart attack, stroke, diabetes, and hip fracture.
• Late-onset depression shows higher rates of recurrence and/or persistence compared to younger adults
• Subsyndromal depression, defined as two or more depressive symptoms for at least two weeks that aren't severe enough for a depression diagnosis
• This affects 6-10% of older adults in primary care and 30% in medical/long-term care settings, has significant medical or social ramifications
• Somatic and psychotic symptoms are frequently observed in severe cases of depression among hospitalized older adults, so special attention should be given to somatic symptoms in old age, as these can easily be missed or confused with physical complaints, leading to unnecessary treatments or medications.
• Suicide is frequent in older adults, especially in old age, making risk assessment crucial
• First-line treatment for recent onset mild depression should usually center around CBT, physical activity, and self-help methods instead of antidepressants

Treatment Options, Depression and Cognition

• Psychotropic medications like selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, such as CBT, are effective treatments for depression
• Antipsychotics and electroconvulsive therapy (ECT) can be considered suitable in special circumstances
• The use of ECT is reserved for very severe psychotic, treatment-resistant, or life-threatening depression after other treatments have not been helpful
• The impact of treatment is limited by things like stigma of psychotropic medication and non-adherance to treatments
• There is an association between depression and cognition with increased age and depression severity being associated with greater cognitive impairment
• Depression and dementia share a complex relationship, potentially sharing risk factors or depressive symptoms may be a prodromal sign of dementia
• Cardiovascular risk factors like smoking and hypertension can increase risk
• Cognitive impairment can persist after remission of depression, potentially increasing risk for dementia, 40% develop dementia

Old Age Bipolar Disorder (OABD)

• Old age bipolar disorder (OABD) is defined as bipolar disorder that's diagnosed in people aged 60 and over, and old age bipolar represents 25% of bipolar diagnoses
• Older adult patients with bipolar disorder may have late onset or continuation of undiagnosed early illness
• Types one and two of bipolar disorder affect 0.5 to 1% of older adults accounting for 6% of old age psychiatry outpatient visits and 8 to 10% of old age inpatient admissions
• 5 to 10% of individuals with bipolar disorder will be aged 50 and over at the time of the first manic or hypomanic episode
• In old age, bipolar disorder has a similar presentation, but less severe manic symptoms, which tends to be associated with disability.
• Mania in old age tends to be associated with disability.
• Cognitive impairment is seen in persons with bipolar disorder, even when euthymic
• Most mood stabilizers show a good response, like sodium valproate, but the use of lithium remains controversial due to risk of toxicity and it requires blood monitoring

Psychiatric Assessment

• Inquiring about present illness, and conducting interviews with carers is key to clarifying a diagnosis, exploring background history is helpful in psychiatric assessments
• Acute delirium can sometimes be observed, in which patients become confused, and in some cases even psychotic and agitated as a result of underlying organic causes, such as infections, which can easily be confused with psychiatric disorders
• Progressive onset, such as cognitive impairment in Alzheimer's disease, is important to take note of when assessing a patient, and the interplay between psychiatric symptoms and physical conditions is also an important variable to take into account
• Secondary effects of physical or psychotropic medication is important to take into account, because it may seem like primary symptoms
• Most primary psychiatric illnesses, other than cognitive disorders, happen at earlier stages of life, meaning onset after 40 should increase concern for a medical problem

Reviewing Medical History

• Important to explore medical history, it is also key to explore alcohol, prescribed medications and over the counter drug use/abuse
• Consider if substance intoxication, especially after post-surgery abuse, could be the cause of psychological symptoms, and underlying medical conditions can increase the risk of mental disorders
• Important to assess sexual functioning and reluctance to take sexual history reflects an ageist attitude
• Reviewing medication is particularly important, a thorough Mental State Examination (MSE) should be conducted and this is a structured process of observing/describing a patient's state of mind under categories like appearance, attitude, behavior, modd, cognition, etc
• Mini mental state examination or Addenbrooke's Cognitive Examination (ACE) screening tools can be used, with a detailed evaluation on suicidal ideation or attempts.

Additional Considerations in Older Adults

• A minimal physical examination needs to be conducted for every patient
• Medical investigations (bloods and urine tests) are usually requested to rule out organic causes, and an electrocardiogram (ECG) to assess cardiac risk
• Ongoing loss in capacities such as reductions in mobility, chronic pain, or other illnesses, drop in socioeconomic standing with retirement, or events such as bereavement can all impact mental health, with some leading to things such as isolation
• Ageism includes discriminatory stereotyping against older people and mental health stigmas are also risk factors for mental health
• Risk assessments need to cover personal, environmental, and risk relating to mental state
• Assessments should be conducted to make sure the manifestations/symptoms do not pose risk.
• Finally, the risk assessment should consider invisible threats like social isolation