Maria Margarita Reyes, MD Aging and Mental Health: What’s Normal and When to Seek Professional Assessment Maria Margarita Reyes, MD

Facts vs Myths Older patients are more likely than younger cohorts to be referred to mental health specialists (false) Major depression in later life is closely correlated with poorer self-perceived health (true) Men ages 65 and older have twice the rate of completed suicide than men ages 15-24 years of age (true) Memory loss and significant cognitive decline are a normal and expected part of aging (false) The general approach to treating depression and anxiety in the older population should mirror that of treating younger adults (false)

Depression: Normal vs Abnormal Feeling sad or irritable from time to time Grief Occasional insomnia Feeling sad or irritable most of the time Losing interest in people/activities Pervasive, self deprecating thoughts Change in cognitive function (concentration, planning, memory) Change in appetite and/or sleep patterns Suicidal thoughts

Anxiety: Normal vs Abnormal Worrying from time to time Fear of things that present an eminent danger Mild nervousness when meeting new people, public speaking, etc “Fear of fear” -avoidance of situations/activities because you’re afraid of appearing anxious/having a panic attack “Worrying yourself sick” (somatization)

Cognitive decline: Normal vs abnormal Forgetting names of people or an appointment and remembering it later Occasional difficulty finding the right word Occasional fender bender Misplacing items but being able to retrace steps Getting lost in unfamiliar places Forgetting recent conversations Forgetting appointments w/o any recollection of having made them Forgetting common words (eg watch = “hand clock”) Inability/difficulty performing IADLs (pay bills, cooking meals, grocery shopping, using the phone) Frequent car accidents or “near misses” Frequently misplacing items w/o ability to retrace steps Getting lost in familiar places

Types of Major Neurocognitive Impairment Alzheimer’s Vascular Lewy body Parkinson’s plus dementia Frontotemporal lobular dementia Huntington’s, Creuzfield-Jacob, HIV, Alcoholism Mixed

Mild Cognitive Impairment vs Major Neurocognitive Disorder (aka dementia) Minor Neurocognitive Impairment Major Neurocognitive Impairment Modest cognitive decline in > 1 domains Domains = memory, executive function, language, visual/special reasoning Cognitive deficits do not interfere with independence in daily activities Independent Activities of Daily Living (IADLS) are preserved but may require greater effort, compensatory strategies or accommodation No severity specifier Significant cognitive decline in ≥ 1 domains Cognitive deficits interfere with independence in daily activities Requires assistance with IADL’s Severity specifier (mild, moderate, severe)

Prevalence of Major Neurocognitive Impairment (aka dementia) with Advanced Age Krasuski, 2016

Medical Contributions to Dementia Infection (HIV/AIDS, even a bladder infection!) Medication toxicity/unintended drug effects/ interactions Over/under active thyroid Vitamin deficiencies Uncontrolled diabetes Cancer Stroke, heart attack, high blood pressure, high cholesterol

Is it depression or dementia? Krasuski, 2016

Geriatric Psychiatry Evaluation Review of medications Review of health history Basic labs MMSE/MoCA (cognitive screening) +/- Brain imaging +/- Psychometric testing