الفهرس 
Cognitive impairmentOnly 14 pages are availabe for public view
 |  | from | 254 |  |  |
| | | from | 254 | | |
Abstract
According to Cairo Demographic Center, (2003) one of the main features of the Egyptian population over the last few decades is the gradual increase in the absolute and relative numbers of older people. This trend will continue over the next decades. The percent of older people” defined as 60 yrs of age and more” was 6.1% of the total population according to the Egyptian census in 1996. The expected percentage of older people may reach 8.9% in2016 and 10.9% in 2026. Accordingly, the expected rate of total population from 1996 to 2026 is about 57% while the expected rate of increase among older people during the same period is about 79 %.
As the population ages, the number of older adults with severe mental illnesses will increase dramatically over the next several decades (Jeste et al., 1999).
In old age, there are special problems, which are Different from those of younger persons. Isolation from society and feeling of loneliness and hopelessness are the important agonizing problems of the old age. Also the relationship between somatic and psychiatric disorder is closer in old age than in earlier part of the life span.
Older primary care patients are a particularly vulnerable group for the misdiagnosis and mismanagement of psychological symptoms and psychosocial stressors.
Research has suggested that older patients may be more likely than younger patients to report physical symptoms rather than emotional symptoms when psychological distress is present, making it difficult to differentiate the origin of somatic complaints (i.e. disease progression vs. distress). Studies have also documented a greater preference of older patients (relative to younger patients) to seek care for psychological problems from a primary care provider rather than a mental health specialist.
Depression:
Depression is considered as one of the commonest psychiatric disorder in old age. It is associated with morbidity as well as disability among the elderly (Cole and Dendukuri, 2003). It constitutes a major public health problem worldwide and its prevalence rate ranges between 10 and 55% (Sherina et al., 2004; Chi et al., 2005; Tsai et al., 2005; Khattri and Nepal, 2006; Kaneko et al., 2007).
Clinical features normally regarded as more common in elderly depressed patients include: neuro-vegetative symptomatology, somatic preoccupation, agitation, forgetfulness and delusions. However, these stereotypic descriptions and may reflect illness severity. (Blazer et al., 1986).
The prevalence of major depressive disorder appears to diminish as people get older (Mulsant & Ganguli, 1999); however the incidence of clinically significant non major forms of depression increases steadily with advancing age and rises steeply among those older than 80 years(Lavertsky & kumar,2003).
Some studies have reported that depressive symptoms are related to poor health and physical and mental limitations that affect daily life (Wells et al., 1988; Blazer, 1989). Other studies have shown poor physical health and mental distress to frequently be linked in older adults’ lives (Beekman et al., 1995: Geerlings et al., 2000).
The co-occurrence of depression and chronic diseases complicates assessment and treatment in primary care settings and negatively impacts quality of life (Rudisch &Nemeroff , 2003; Bisschop et al., 2004).
The presence of a high level of physical illness in depressed subjects has important implications for their pharmacological management, especially for those treated outside hospital. Elderly patients metabolize and eliminate antidepressants more slowly, are much more susceptible to adverse reactions and tolerate side effects less well. High rates of cardiovascular disorders, glaucoma and prostate disease and associated polypharmacy have an important influence on the potential toxicity of antidepressants and may also effect compliance with treatment and ultimately efficacy. Furthermore admission to hospital may be required for treatment of relatively minor depressive disorders because of the coincidence of physical illness (McWilliam et al., 1992). Stewart (1991) highlight the need for a thorough working knowledge of geriatric medicine and therapeutics in relation to psychogeriatrics especially for those patients treated in long stay facilities or in the community where there is often limited access to specialist medical advice.
In general, the pharmacological treatment of nonpsychotic major depressive disorder in elderly persons is only partially successful: only about half of older adults with depression improve with initial antidepressant monotherapy (Alexopoulos et al., 2001). Many factors may predict a more difficult-to-treat depression, including coexisting anxiety, low self-esteem, poor sleep, and a high coexisting medical burden Being aware of these and other predictors of a difficult-to-treat depression gives the clinician more reasonable expectations about a patient’s likely treatment outcome. Getting well and staying well is the goal of patients; thus, clinicians should treat to remission of depression, not merely to response (Driscoll et al., 2007).
Anxiety:
Anxiety is another common psychiatric disorder in elderly is which is typified by feelings of worry, fearfulness, distress, or panic that seem out of proportion (Manthorpe & Iliffe, 2006). Anxiety symptoms are common place in later life (Girling et al., 1995). Flint (1994) identifies anxiety in as many as 10 per cent of older people living in the community, while (Krasucki et al., 1998) suggested that generalized anxiety disorders affect 14 per cent of the older population, even though the incidence of formally diagnosed anxiety disorders diminishes with advancing age. A third of older people seeking help from primary care professionals also have an anxiety disorder which may be expressed in a variety of forms (Krasucki et al., 1999).
Most anxiety disorders in the elderly are chronic and first occur earlier in life (Flint, 1997). The most common late-onset anxiety disorders are generalized anxiety disorder (GAD) and agoraphobia (without panic). GAD usually occurs secondary to major depression, and agoraphobia is typically secondary to a traumatic incident (Manela et al., 1996& Flint, 1999). A first episode of obsessive compulsive disorder (OCD) also may occur in later years for women, but OCD in elderly men typically represents the persistence or recurrence of an earlier- onset disorder (Flint, 1997). The prevalence of posttraumatic stress disorder (PTSD), panic disorder, and social anxiety disorder in the elderly is not known with precision, but is believed to be very low (Flint, 1999). Anxiety disorders may be more common in elderly women than in men (Heun et al., 2000). Other risk factors for the development of an anxiety disorder in late life include major depression, loss of a partner, social or residential isolation, and medical illness (Doraiswamy, 2001).
The anxiety disorders were significantly associated with some but not all types of chronic somatic diseases (Van Balkom et al., 2000). Van Balkom et al (2000) found higher prevalence rates for the coexistence of any anxiety disorder with joint and heart diseases, incontinence, lung disease, atherosclerosis and stroke.
Following a careful diagnostic workup, clinicians must first address the underlying causes of anxiety, that is, through treatment of primary psychiatric disorders, especially depression, modification of environmental factors (such as living in a high crime area), medication review, treatment of medical disease states, and pain relief. While this approach is self evident in the abstract, in practice clinicians often miss co-morbid medical and psychiatric disorders in the elderly (Weiss, 1994).
Dementia:
Dementia is a gradual loss of the previously achieved mental function. Its characteristic changes involve cognition, memory, language and visuospatial functions, but behavioural disturbances are also common and include agitation, restlessness, wandering, rage, violence, social and sexual disinhibition, impulsiveness, sleep disturbances and delusions. Delusions and hallucinations occur in 75% of patients with dementia (Finnema et al., 2000).
A considerable body of research indicates that multiple cognitive abilities decline in parallel with advancing age (Dixon et al., 2004). Of an estimated 24.3 million people with dementia worldwide in 2005, 14.6 million lived in developing countries and this number will increase in the next decades (Ferri et al., 2005).
In randomized clinical trials, cholinesterase inhibitors (donepezil, rivastigmine, and galantamine), antioxidant (vitamin E), anti-inflammatory drugs (rofecoxib), and nootropics (piracetam) failed to prevent progression of MCI to dementia (Jelic et al., 2006).
Primary care physicians can play a problem-solving role in enabling people with dementia to continue to live at home (Bridges-Webb, 2002). People with dementia are more likely to be referred for specialist assessment when behavioral problems or care giver stress are identified (Bruce et al., 2004; Weiner et al., 2005). Between 20-90% of people with dementia will experience behavioral and psychological symptoms (BPSD) at some time, particularly in the middle and later stages (Robinson et al., 2006; Savva, 2009). However while the risks, such as wandering and getting lost, from such behavior are often not as high as care givers fear (Robinson et al., 2007a), they can lead to high levels of care givers stress, curtailment of the person with dementia’s activities and may be the crucial factor that leads to care home moves (Balestreri et al., 2000). Guidelines urge non-pharmacological management for such symptoms (NICE/SCIE, 2006), but in the community this is very difficult to achieve. There is little high-quality evidence for the clinical and cost effectiveness of non-pharmacological treatments (Livingston et al., 2005; Robinson et al., 2006; Robinson et al., 2007b), although research is emerging which illustrates the potential of exercise, behavioral interventions and educational interventions for care givers (NICE/SCIE, 2006).
Psychosis:
Late-onset psychosis can have a variety of symptoms, including frank delusions and hallucinations, but also paranoid misidentifications and other Schneiderian symptoms. Delusions, especially paranoid ones, are most often the focus of treatment in the elderly population. These might be primary, as part of a primary psychotic disorder, or secondary arising directly out of another medical or psychiatric disorder, The delusion may take a variety of forms, from bizarre(common in disorganized schizophrenia) to almost believable and difficult to differentiate from the real-life experiences of the patient. Delusions of late-onset delusional disorder are often plausible at first, consisting of simple delusions of theft, for example, which can delay recognition of the disorder and postpone treatment (Thorpe, 1999).
In the elderly, causes of psychosis may include schizophrenia and schizoaffective disorder, affective illnesses, dementia, delirium, delusional disorders, substance-induced disorders, and Parkinson’s disease. Prevalence estimates of psychotic disorders in the elderly range widely from 0.2% to 4.75% in community-based samples, and are as high as 10–63% in nursing home populations (Desai et al., 2003).
Elderly patients presenting with psychotic symptoms require social, behavioral, and environmental interventions that are necessary for their safety and reorientation. Given the likelihood of co-morbid medical disorders and concomitant medications, the mere presence of delusions or hallucinations is not always an indication for additional medications.
Choices for pharmacologic intervention for psychotic symptoms generally include anxiolytics, antidepressants, anticonvulsants, and antipsychotic medications (Reisberg and Gershon1979; Mayeux and Sano, 1999).
Organic co-morbid illness becomes more common with old age and may be associated with a poor prognosis for the resolution of psychotic symptoms. The pharmacological treatment of the psychosis can interact with the medications prescribed for medical illnesses and worsen the psychosis or the medical illness. It is important to work closely with the family physician to minimize the total number of concurrent medications and untreated medical or psychiatric illnesses that may be exacerbating psychotic symptoms. Anticholinergic (such as first-generation tricyclic antidepressants) and antiparkinsonian medications must be explored as possible causes of psychotic symptoms. Doses of remaining necessary medications should be reduced as much as is clinically feasible (Thorpe, 1997).
Perceptual functioning, such as hearing or vision, must be optimized. Sometimes modification of the environment may be successful in reducing the burden of psychotic symptoms, for example, improving the lighting to minimize illusions and other misinterpretations (Thorpe, 1997).
Bipolar Disorder:
According to Aziz et al (2006) bipolar affective disorder is fairly common in elderly persons, with a prevalence of 0.1% to 0.43% in the United States. However, between 10% and 20% of geriatric patients with mood disorders have bipolar disorder, as do 5% of those admitted to the geropsychiatric inpatient units. Sajatovic et al, (2005) stated that while late onset bipolar disorder is relative rare, recurrence of remitted disease frequently occurs in late life.
There has been an increased awareness of the burden of general medical co-morbidity in patients with bipolar disorder, especially among older patients with this illness (Khot et al., 2003; Kilbourne et al., 2007a). Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among older patients with bipolar disorder (Sharma & Markar, 1994; Kilbourne et al., 2005). Some of the most common medical conditions (diabetes, hypertension, hyperlipidemia, and obesity) observed in older patients with bipolar disorder are also the leading risk factors for CVD (Khot et al., 2003).
The use of lithium in older adults, complicated by the presence of side effects (Tueth et al., 1998; McDonald, 2000).
Valproate may be a preferred agent for the treatment of some older adults with bipolar disorder (Evans et al., 1995).
The anticonvulsant carbamazepine may be utilized in the management of late life bipolar disorder, although its side effect profile in the elderly appears be less favorable compared to valproate. As with valproate, and in contrast to lithium, carbamazepine may be a preferred agent in secondary mania (Evans et al., 1995).
Antipsychotic medications are widely utilized in clinical settings for management of bipolar disorder, particularly in situations where psychosis is associated with mania or depression, where behavioral agitation is present, or as an adjunct to mood stabilizing medication (Goldberg, 2000).
Among older adults, the atypical antipsychotics are generally well tolerated and effective (Fuller and Sajatovic, 2001). The atypical antipsychotics clozapine, risperidone, olanzapine and quetiapine have all been reported to be of benefit for elderly patients with bipolar disorder (Madhusoodanon et al., 1999; Sajatovic, 1999; Street et al., 1999; Yeung et al., 1999).
The specific aim of this study was to investigate the prevalence, nature, socio-demographic variables and medical co-morbidity correlates of mental disorders among the elderly population. In this study the broad spectrum of mental disorders in the elderly were investigated.
This study aimed at studying the prevalence of psychiatric disorders in a sample of 273 patients aged 60 years and above who attended the outpatient clinic of internal medicine of Damanhour Medical National Institute during the period from the 1st of November 2009 till the 30th of April 2010. For all patients, SCID I was done to identify the profile of psychiatric disorders and MMSE was done as a screening tool for cognitive impairment, while CDR scale was done to diagnose and grade dementia only in patients with cognitive impairment.
43.6% of the study sample had one or more psychiatric disorder; the commonest were affective disorders with a prevalence of 32.2%, followed by anxiety disorders 12.5%, dementia was 5.1% with very mild dementia 3.7% and mild dementia 1.5%, psychotic disorders 1.8% other disorders were also detected, somatoform disorder and hypnotic dependence 3.3%.
We found that psychiatric disorders were significantly more prevalent in females, patients with very low socio-economic level, patients with liver disease and in patients suffering from more than one physical problem.
Affective disorders were the most common psychiatric disorder in our study and in most previous studies all over the world.
We found that affective disorders were more associated with females, very low socio-economic level, and having more than one medical problem.
Anxiety constituted 12.5% of our study sample, we found no relation between anxiety disorders and any of the studied socio-economic variants or medical problems.
The prevalence of dementia was higher with female gender, urban residence, illiteracy and very low socio-economic level, but with no statistical significance. This may be because of the relatively small sample size and small percentage of cognitive impairment. Prevalence of dementia was highest in the age group 70-74 and not in the older age group as was expected.
The prevalence of psychotic disorders was 1.8%. Because of the small number of subject with psychotic disorders, we couldn’t find any relationship between any of the socio-demographic variants.