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Myths and Realities About Old Age
The number of Americans age 65 and older is projected to comprise about 20% of the nation’s population by the year 2030. With a growing elderly population, greater attention has been devoted to the lives of seniors and toward ensuring the physical and mental health of individuals as they move toward later life. Unfortunately, beliefs typically ascribed to older persons about their mental health tend to be myths. For example, the elderly are assumed to experience greater psychological problems in comparison to younger adults, and are thought to be plagued by sadness and loneliness, tormented by fears of death and dying. It is also commonly assumed that American families abandon their older relatives and that the elderly almost always suffer from dementia. Given that none of these assertions are substantiated, debunking common myths about old age is a necessary first step to gain a better understanding of psychological disorders among the elderly and within the context of aging. The vast majority of older people are happy and satisfied with their lives. Some surveys show that older people display less fear of and more acceptance of death in comparison to younger and middle-aged people. Families also typi cally remain geographically and emotionally close to their older relatives — even when they live in nursing homes. While dementia is more common in old age than in youth, it is not typical. Changes in thinking that occur with normal aging are largely harmless, characterized by mild forgetfulness and wordfinding difficulty in conversational speech.
Thus, when older people experience marked psychological distress and impairment, the aging process itself cannot be held accountable. Rather, changes in the social or physical surroundings, the absence of supportive relationships, or longstanding difficulties should be considered as contributing factors to the development and maintenance of distress among the elderly. Appreciating the normal changes that occur in the aging process paves the way to proper assessment and treatment when problems do arise.
In general, psychological disorders are less common in old age than middle age. The incidence of major depression, anxiety, and drug abuse all decrease with age. Some core symptoms of chronic psychological disorder s may even improve with age. For example, hallucinations and delusions among individuals with schizophrenia tend to decrease with age. Unfortunately, older people who do suffer from psychological distress are far less likely than younger people to receive effective treatment for mental health problems. They are less likely to seek treatment and, if they do, their problems are less likely to be treated aggressively. Older persons are more likely to receive diagnoses of intractable conditions and pharmaceutical rather than behavioral treatment. These facts highlight the importance of understanding the various treatment options available for older people who experience mental health problem.
While temporary feelings of sadness, grief, and loss are typical in old age, persistent depression that interferes significantly with functioning is not a normal part of aging. In fact, recent studies have found the incidence of major depression to be relatively low among the elderly. Nevertheless, it is the most common psychological disorder in old age and the principal reason for psychiatric hospitalization in the elderly. Estimates of major depression in the elderly population living in the community range from about 1 percent to about 5 percent. These estimates rise to approximately 13.5 percent among elderly persons who require home healthcare and to 11.5 percent in elderly hospital patients. In addition, about 5 million older people have subclinical depression, symptoms that fall short of meeting the full diagnostic criteria for the disorder.
The risk of depression in the elderly increases when other medical problems are present including heart disease, stroke, diabetes, and cancer. Other risk factors for depression in the elderly include certain medications or combinations of medications, being female, single status (especially if widowed), social isolation, chronic or severe pain, stressful life events, lack of a supportive social network, past suicide attempts, and personal or family history of depression.
Left untreated, depression can seriously reduce quality of life. When depression co-occurs with a physical illness, depression can delay recovery from or worsen the course of other illnesses. The risk of suicideis also a serious concern among elderly patients with depression. Untreated depression can be deadly as demonstrated by the fact that Americans over the age of 65 are disproportionately likely to die from suicide, accounting for an estimated 18 percent of suicide deaths in the year 2000. Elderly white men are particularly at risk, with suicide rates in people ages 80 to 84 more than twice that of the general population.
Unfortunately, only about 10% of elderly persons with depression receive treatment. Given that older persons tend to have medical illnesses and face other problems, health care providers sometimes erroneously assume that depression is a normal consequence of these problems or overlook depression. This misunderstanding is one of the many factors that contribute to underdiagnosis of depression among the elderly.
Proper assessment is critical when depression is suspected. A correct diagnosis is beneficial because elderly persons with depression typically respond well to treatment. Antidepressant medications or psychotherapy, or a combination of the two approaches, can be effective treatments for depression later in life. For older adults who are in good physical health, psychotherapy in conjunction with medication appears to be the most successful treatment approach. If medication is clinically indicated, consulting with a geriatric specialist about the most appropriate medication(s) is recommended. There are a variety of medications for depression including antidepressants, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs). It is important to note that different medications work for different people. Typically, medications take about four to eight weeks to work. If one medication is not helpful, research findings indicate that another might. Those who are taking medication for depression the first time should discuss with their health care physicians about continuing medication even if symptoms disappear because there is some evidence that older adults who continue to take their medications even after symptoms remit are less likely to relapse. In psychotherapy, people work with a trained professional to deal with symptoms of depression, thoughts of suicide, and related problems. Research shows that certain types of psychotherapy are effective treatments for late-life depression.
Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities. The most common form of dementia in senior citizens is Alzheimer’s disease, also referred to as senile dementia/Alzheimer’s type (SDAT). SDAT currently affects about 5 million Americans. This number is expected to triple by the year 2050 because people are living longer. The number of people with SDAT doubles with every decade past the age of 70. Approximately 5 percent of people ages 65 to 74 have SDAT, and nearly half of those age 85 and older may have the disease. While the risk of SDAT increases with age, it is important to keep in mind that this disease is not a normal part of the aging process. SDAT is a degenerative brain disease with a slow, progressive course. Although memory impairment is the core feature for the diagnosis of dementia, this disease also affects language, judgment, attention, emotions, decision-making, and other behaviors. In the early stages, the symptoms of SDAT may be more subtle and resemble characteristics that are often mistakenly attributed to the aging process with symptoms initially involving disruptions in thought, memory, and language.
Early symptoms include repeating questions, misplacing personal items, having difficulty finding objects, getting lost in familiar places, losing interest in activities that used to be enjoyable, and experiencing difficulty performing tasks such balancing a checkbook or playing games. Later, disorientation, wandering, and profound memory loss characterize the disease. During advanced stages of the illness, symptoms include forgetting details about current events, forgetting aspects of personal history and identity, experiencing hallucinations, delusions, feeling agitated, difficulties selecting appropriate clothing, and difficulties performing daily tasks such as cooking. Eventually, victims do not recognize long-time friends and relatives, no longer understand language, and lose the capability to perform basic self-help skills such as bathing and dressing.
There are two types of SDAT, which are distinguished by the timing of disease onset. In early-onset SDAT, the less common version, symptoms appear before the age of 60 and the disease tends to progress rapidly. In late-onset SDAT, the symptoms typically emerge and progress at a slower rate. The cause of SDAT is unknown but it is believed to result from both genetic and environmental factors. Genes are hypothesized to play a causal role in early-onset SDAT, but lateonset dementia appears unrelated to family history. Neuropsychological testing can be highly valuable in the differential diagnosis of reversible conditions, like depression, from dementia. It is extremely important to rule-out drug side-effects as the cause when dementia is in question.
The rate of disease progression is different for different people. However, some research suggests that SDAT will continue to progress at the same rate at which it develops. Thus, rapid development of the disease will likely lead to rapid progression of the illness and slow development will likely be followed by a slower progression of deterioration in memory, language, and other areas of impairment.
When elderly persons exhibit signs of SDAT, the first step is to establish the presence of dementia. Health care physicians should be consulted for a diagnosis of the type of dementia experienced. Physicians will help to determine whether the cause of the dementia is treatable. For example, conditions such as thyroid deficiencies, brain tumors, chronic infections, anemia, and depression may sometimes lead to dementia. There is no known cure for SDAT. Both pharmaceutical and behavioral treatments have had limited success. Thus, treatment focuses on slow ing the progression of the disease, managing problems such as confusion, changing the home environment to control problematic behavior, and supporting caregivers course of deterioration. The treatments with the most promise and success are medications that affect the neurotransmitter acetylcholine, lifestyle changes, and antioxidant supplements (i.e., ginkgo biloba and vitamin E). As with any medical condition, it is recommended that individuals interested in taking medication consult with a physician. Lifestyle changes may include incorporating regular activities such as walking into the daily routine, practicing relaxation techniques, using bright light therapy, and listening to calm music. Although research has not substantiated the effect of antioxidant supplements such as ginkgo biloba and vitamin E, these supplements have demonstrated some promise in reducing dementia symptoms. Individuals taking blood-thinning medications or monoamine oxidase inhibitors
Caregivers and family members of individuals with SDAT should be prepared to provide both support and supervision in the home as the disease progresses. It can also be helpful to simplify the environment of those with this
Aging per se does not increase the incidence of psychological disorders. If anything, the prevalence of most psychological disorders decreases with the aging process. It is essential to appreciate that most older people are psychologically resourceful and competent. When mental health problems do occur in the elderly, however, these problems are often overlooked. Thus, only a fraction of elderly persons with psychological distress receive effective treatment despite evidence that interventions can be effective for the elderly. It is important to be aware of mental health symptoms, particularly depression and dementia, and to be knowledgeable about the various treatment options available and effective for adults in later stages of life.