Mental Health and Mental Illness

Changes in mental capabilities are among the most feared aspects of aging. As Mark E. Williams states in "Mild Cognitive Impairment: Who Is Confused?" (Conference Report Highlights of the American Geriatrics Society 2005 Annual Meeting, May 2005), mental health problems that impair functioning are among the most common age-related changes—their prevalence doubles every five years, increasing from an estimated 1% among those aged sixty years old, to 20% at age eighty, and 50% or higher among people aged eighty-five and older.

The aging population has spurred interest in age-related problems in cognition—the process of thinking, learning, and remembering. Cognitive difficulties much milder than those associated with organic brain diseases, such as Alzheimer's disease or dementia, affect a significant proportion of older adults. Organic brain diseases, often referred to as organic brain syndromes, refer to physical disorders of the brain that produce mental health problems as opposed to psychiatric conditions, which may also cause mental health problems. A landmark study supported by the National Institute on Aging (NIA) and summarized by Frederick W. Unverzagt et al. in "Prevalence of Cognitive Impairment: Data from the Indianapolis Study of Health and Aging" (Neurology, November 2001) estimates that in 2001, 23.4% of community-dwelling older adults and 19.2% of nursing home residents suffered some degree of cognitive impairment, besides those who suffered from much more serious cognitive impairment. The prevalence of this mild cognitive impairment grew significantly with age, with rates increasing by about 10% for every ten years of age after age sixty-five. Unverzagt et al. conclude that "cognitive impairment short of dementia affects nearly one in four community-dwelling elders and is a major risk factor for later development of dementia."

Because the number of people with mental impairments such as dementia is anticipated to increase as the population ages, and older adults with mental impairment are at risk for institutionalization, the financial costs to individuals and to society are expected to escalate. As such, the mental health and illness of older adults is an increasingly important public health issue.

MENTAL HEALTH

Mental health may be measured in terms of an individual's abilities to think and communicate clearly, learn and grow emotionally, deal productively and realistically with change and stress, and form and maintain fulfilling relationships with others. Mental health is a principle component of wellness—self-esteem, resilience, and the ability to cope with adversity influences how people feel about themselves.

When mental health is defined and measured in terms of the absence of serious psychological distress, then older adults fare quite well when compared to other age groups. The 2006 National Health Interview Survey conducted by the Centers for Disease Control and Prevention questioned whether respondents had experienced serious psychological distress within the thirty days preceding the interview. Adults aged sixty-five and older were the least likely to have experienced serious psychological distress (2.1%), compared to those aged forty-five to sixty-four (3.8%) and adults aged eighteen to forty-four (2.6%). (See Figure 8.1.)

Experience Shapes Mental Health in Old Age

One theory of aging, called continuity theory and explained by Robert Atchley in The Social Forces in Later Life: An Introduction to Social Gerontology (1980), posits that people who age most successfully are those who carry forward the habits, preferences, lifestyles, and relationships from midlife into late life. This theory has gained credence from research studies that find that traits measured in midlife are strong predictors of outcomes in later life and that many psychological and social characteristics are stable across the lifespan. For most people, old age does not represent a radical departure from the past; changes often occur gradually and sometimes unnoticeably. Most older adults adapt to the challenges and changes associated with later life using well-practiced coping skills acquired earlier in life.

Not surprisingly, adults who have struggled with mental health problems or mental disorders throughout their life often continue to suffer these same problems in old age. Few personal problems disappear with old age, and many progress and become more acute. Marital problems, which may have been kept at bay because one or both spouses were away at work, may intensify when a couple spends more time together in retirement. Reduced income, illness, and disability in retirement can aggravate an already troubled marriage and strain even healthy interpersonal, marital, and other family relationships.

Older age can be a period of regrets, which can lead to mutual recriminations. With life expectancy rising, married couples can now expect to spend many years together in retirement. Most older couples manage the transition, but some have problems.

Coping with losses of friends, family, health, and independence may precipitate mental health problems. Hearing loss is common, and close correlations have been found between loss of hearing and depression. Visual impairment limits mobility and the ability to read and watch television. Loss of sight or hearing can cause perceptual disorientation, which in turn may lead to depression, paranoia, fear, and alienation.

A constant awareness of the imminence of death can also become a problem for older adults. Even though most older adults resolve their anxieties and concerns about death, some live in denial and fear. How well older adults accept the inevitability of death is a key determinant of satisfaction and emotional well-being in old age.

Memory

Because memory is a key component of cognitive functioning, declining memory that substantially impairs older adults' functioning is a major risk factor for institutionalization. In 2002, 34% of men and 31% of women aged eighty-five and older had moderate to severe memory impairment, compared to 8% of men and 3% of women aged sixty-five to sixty-nine. (See Figure 8.2.) The Federal Interagency Forum on Aging-Related Statistics reports in Older Americans Update 2006: Key Indicators of Well-Being (May 2006, http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2006_Documents/OA_2006.pdf) that older men are slightly more likely than older women to suffer memory impairment—14.9% of men aged sixty-five and older, compared to 11.2% of women of the same age.

According to "Many Americans Worried about Brain Health, but Only Half Keep Their Brains Fit, According to New Survey" (November 15, 2004, http://www.redorbit.com/), a national survey conducted in October 2004 by the Alzheimer's Association, Americans aged fifty-five to sixty-four ranked brain and memory health as their second-greatest health worry, after heart health. Thirty-one percent named heart health as their greatest worry, followed by brain and memory health (23%) and cancer (19%).

Despite the reported high levels of concern, the survey finds that only 52% of the survey respondents said they engaged in activities aimed at exercising their brains and building capacity for memory. When asked about the specific activities they engaged in to exercise their brains and build memory, more than half (53%) named reading and almost one-third (31%) said puzzles or games. Even though the respondents did not necessarily associate their activities with boosting brain health, many reported engaging in activities that exercise and build brain memory. For example, 77% said they "make a special effort to choose foods that are healthier," 76% said they "read a book," and 57% claimed they "walk a mile or more."

ORGANIC BRAIN DISEASES—DEMENTIAS

Dementia refers to a range of mental and behavioral changes caused by cerebrovascular or neurological diseases that permanently damage the brain, impairing the activity of brain cells. These changes can affect memory, speech, and the ability to perform the activities of daily living.

Occasional forgetfulness and memory lapses are not signs of dementia. Dementia is caused by disease and is not the inevitable result of growing older. Many disorders may cause or simulate dementia, which is not a single disorder—dementia refers to a condition caused by a variety of diseases and disorders, a small proportion of which are potentially reversible.

Multi-infarct Dementia

In the "Multi-infarct Dementia Fact Sheet" (August 30, 2006, http://www.nia.nih.gov/Alzheimers/Publications/dementia.htm), the NIA indicates that multi-infarct dementia is the most common form of vascular dementia and accounts for 10% to 20% of all cases of progressive dementia. It usually affects people between the ages of sixty and seventy-five and is more likely to occur in men than in women. Multi-infarct dementia is caused by a series of small strokes that disrupt blood flow and damage or destroy brain tissue. Sometimes these small strokes are "silent"—they produce no obvious symptoms and are detected only on imaging studies, such as computerized tomography or magnetic resonance imaging scans of the brain. An older adult may have a number of small strokes before experiencing noticeable changes in memory, reasoning, or other signs of multi-infarct dementia.

Because strokes occur suddenly, loss of cognitive skills and memory present quickly, although some affected individuals may appear to improve for short periods of time, then decline again after having more strokes. Establishing the diagnosis of multi-infarct dementia is challenging because its symptoms are difficult to distinguish from those of Alzheimer's disease. Treatment cannot reverse the damage already done to the brain. Instead, it focuses on preventing further damage by reducing the risk of additional strokes. This entails treating the underlying causes of stroke, such as hypertension, diabetes, high cholesterol, and heart disease. Surgical procedures to improve blood flow to the brain, such as carotid endarterectomy, angioplasty (a procedure to open narrowed or blocked blood vessels of the heart), or stenting (using wire scaffolds that hold arteries open), as well as medications to reduce the risk of stroke, are also used to treat this condition.

Alzheimer's Disease

Alzheimer's disease (AD) is the most common form of dementia among older adults. It is characterized by severely compromised thinking, reasoning, behavior, and memory, and it may be among the most fearsome of age-related disorders because it challenges older adults' ability to live independently. The disease was named after Alois Alzheimer (1864–1915), the German neurologist who first described the anatomical changes in the brain—the plaques and tangles that are the characteristic markers of this progressive, degenerative disease.

The Alzheimer's Association reports in Alzheimer's Disease Facts and Figures, 2007 (2007, http://www.alz.org/national/documents/Report_2007FactsAndFigures.pdf) that an estimated 5.1 million Americans were afflicted with AD in 2007. The overwhelming majority of AD sufferers—4.9 million—were aged sixty-five and older. Approximately 2% of the population aged sixty-five to seventy-four, 19% of those aged seventy-five to eighty-five, and 42% of those over age eighty-five—the fastest-growing segment of American society—have the disease, and its prevalence doubles every five years beyond age sixty-five.

The U.S. Government Accountability Office, in Alzheimer's Disease: Estimates of Prevalence in the United States (January 1998, http://www.gao.gov/archive/1998/he98016.pdf), projects that the number of AD cases will likely increase by more than 12% every five years through 2015. According to Gloria Dal Forno et al., in "APOE Genotype and Survival in Men and Women with Alzheimer's Disease" (Neurology, 2002), the prevalence of AD is anticipated to increase not only because of the growing numbers of older adults but also, to a lesser extent, because the average length of time people live with AD—about a decade—has increased and will likely continue to increase in response to advances in care and treatment.

The Alzheimer's Association asserts in Alzheimer's Statistics (2006, http://www.alztex.org/aboutAD/statistics.asp) that if a cure or preventive measure is not found by 2050, the number of Americans with AD will range from 11.3 million to 16 million. In contrast, the NIA, in Alzheimer's Disease Fact Sheet (August 29, 2006, http://www.nia.nih.gov/Alzheimers/Publications/adfact.htm), indicates that the identification of effective treatment to delay the onset of AD by five years could reduce the number of individuals with the disease by nearly 50% after fifty years.

SYMPTOMS AND STAGES.

In general, AD has a slow onset, with symptoms such as mild memory lapses—forgetfulness and disorientation that initially may not be identified as problematical beginning between the ages of fifty-five and eighty. As the disease progresses, memory loss increases and mood swings are frequent, accompanied by confusion, irritability, restlessness, and problems communicating. AD patients may experience trouble finding words, impaired judgment, difficulty performing familiar tasks, and changes in behavior and personality.

In "Stages of Alzheimer's" (2006, http://www.alztex.org/aboutAD/stages.asp), the Alzheimer's Association discusses the Global Deterioration Scale, which outlines the seven stages that describe the progress of AD and AD patients' deteriorating abilities. The stages range from the first and second, in which there is no and then little apparent cognitive decline, to stage 3, which is marked by mild lapses and is often discernable to friends, family, and coworkers. Stage four is called mild or early stage Alzheimer's disease, and during this stage moderate cognitive decline is observed. For example, in stage four AD patients may have diminished recall of recent activities or current events and compromised ability to perform tasks such as paying bills or shopping for groceries. In the fifth and sixth stages memory impairment continues along with personality changes, sleep disturbances, and, if left unsupervised, a dangerous tendency to wander off and become lost.

Ultimately, the disease progresses to stage seven, when patients are entirely unable to care for themselves. In their terminal stages, AD victims require round-the-clock care and supervision. They no longer recognize family members, other caregivers, or themselves, and they require assistance with such daily activities as eating, dressing, bathing, and using the toilet. Eventually, they may become incontinent, blind, completely unable to communicate, and have difficulty swallowing.

AD is the seventh-leading cause of death in adults of all ages. (See Table 8.1.) In 2004 it claimed 65,188 lives and was the fifth-leading cause of death among adults aged sixty-five and older.

GENETIC ORIGINS OF AD.

AD is not a normal consequence of growing older. It is a disease of the brain that develops in response to genetic predisposition and non-genetic causative factors. Scientists have identified some genetic components of the disease and have observed the different patterns of inheritance, ages of onset, genes, chromosomes, and proteins linked to the development of AD.

In "The mec -4 Gene Is a Member of a Family of Caenorhabditis elegans Genes That Can Mutate to Induce Neuronal Degeneration" (Nature, February 14, 1991), Monica Driscoll and Martin Chalfie reported their discovery that a mutation in a single gene could cause AD. The defect was in the gene that directs cells to produce a substance called amyloid protein. Researchers also found that low levels of acetylcholine, a neurotransmitter involved in learning and memory, contribute to the formation of hard deposits of amyloid protein that accumulate in the brains of AD patients. In healthy people the protein fragments are broken down and excreted by the body.

In 1995 three more genes linked to AD were identified. Two genes appear to be involved with forms of

early onset AD, which can begin as early as age thirty. The third gene, known as apolipoprotein E (apoE), is involved in important physiological functions throughout the body. It regulates lipid metabolism and helps to redistribute cholesterol. In the brain, apoE participates in repairing nerve tissue that has been injured. According to the article "Cortex Area Thinner in Youth with Alzheimer's-Related Gene" (Science Daily, April 24, 2007), 40% of late-onset AD patients have at least one apoE-4 gene, whereas only 10% to 25% of the general population has an apoE-4 gene. Deborah Blacker et al. report in "Alpha-2 Macroglobulin Is Genetically Associated with Alzheimer Disease" (Nature Genetics, August 1998) that the apoE-4 gene seems to influence when a person may develop AD, not whether the person will develop the disease, whereas another gene, A2M-2, appears to affect whether a person will develop AD.

Despite groundbreaking genetic research and advances in understanding and detecting AD, the proportion of cases attributable to genetic factors remains unknown. According to Wim Dekkers and Marcel Rikkert, in "What Is a Genetic Cause? The Example of Alzheimer's Disease" (Medicine, Health Care, and Philosophy, December 2006), researchers concur that AD is not a specific disease entity with one specific cause, and certainly not a single "genetic cause."

DIAGNOSTIC TESTING.

In "New Techniques Help in Diagnosing AD" (August 29, 2006, http://www.nia.nih.gov/Alzheimers/Publications/UnravelingTheMystery/Part2/subpage02.htm), the NIA indicates that the only sure way to diagnose AD is to examine brain tissue under a microscope, during an autopsy. Examining the brain of a patient who has died of AD reveals a characteristic pattern that is the hallmark of the disease: tangles of fibers (neurofibrillary tangles) and clusters of degenerated nerve endings (neuritic plaques) in areas of the brain that are crucial for memory and intellect.

Even though it does not provide as definitive a diagnosis as an examination of the brain, a complete physical, psychiatric, and neurological history and examination can usually produce an accurate diagnosis of AD. Diagnostic tests for AD may also include analysis of blood and spinal fluid as well as the use of brain scans (computed tomography and magnetic resonance imaging) to detect strokes or tumors and to measure the volume of brain tissue in areas of the brain used for memory and cognition. Such brain scans assist to accurately identify people with AD and to predict who may develop AD in the future.

The NIA delineates the following "probable" criteria for AD:

• Dementia confirmed by clinical and neuropsychological examination (neuropsychological tests examine cognitive abilities such as speed of information processing, attention, memory, and language).
• Progressive worsening of memory and other mental functioning.
• No disturbances or loss of consciousness.
• Symptoms begin between ages forty and ninety.
• No other disorders that might account for the dementia are present.

In "Nanoparticle-Based Detection in Cerebral Spinal Fluid of a Soluble Pathogenic Biomarker for Alzheimer's Disease" (Proceedings of the National Academy of Sciences, February 4, 2005), Dimitra G. Georganopoulou et al. discuss a new diagnostic test for AD that detects small amounts of a protein in the brain called amyloid-beta-derived diffusible ligand (ADDL). ADDLs are small soluble proteins that may be indicative of AD. The test is called a bio-barcode assay and is much more sensitive than other tests.

A simple and accurate test that could distinguish people with AD from those with cognitive problems or dementias arising from other causes would prove useful for scientists, physicians, and other clinical researchers. An accurate test would allow the detection of AD early enough for the use of experimental medications to slow the progress of the disease, as well as identify those at risk of developing AD. However, the availability of tests to predict who may develop AD raises ethical and practical questions: Do people really want to know their risks of developing AD? Is it helpful to predict a condition that is not yet considered preventable or curable? Will health insurers use genetic or other diagnostic test results to deny insurance coverage?

TREATMENT.

There is still no cure or prevention for AD, and treatment focuses on managing symptoms. Medication may slow the appearance of some symptoms and can lessen others, such as agitation, anxiety, unpredictable behavior, and depression. Physical exercise and good nutrition are important, as is a calm and highly structured environment. The object is to help the AD patient maintain as much comfort, normalcy, and dignity for as long as possible.

In 2007 there were five FDA-approved prescription drugs for the treatment of AD, and the National Institutes of Health affiliates and pharmaceutical companies were involved in clinical trials of more than twenty new drugs to treat AD. All the drugs being tested are intended to improve the symptoms of AD and slow its progression, but none is expected to cure AD. The investigational drugs aim to address three aspects of AD: to improve cognitive function in people with early AD, slow or postpone the progression of the disease, and control behavioral problems such as wandering, aggression, and agitation of patients with AD.

CARING FOR THE AD PATIENT.

AD affects members of the patient's family. Even though medication may suppress some symptoms and occasionally slow the progression of the disease, eventually most AD patients require constant care and supervision. Until recently, nursing homes and residential care facilities were not equipped to provide this kind of care and, if they accepted AD patients at all, admitted only those in the earliest stages of the disease. Since 2000 a growing number of nursing homes have welcomed AD patients, although they are more difficult and costly to care for than older adults without AD. Even though this change was primarily financially motivated, as nursing home occupancy rates dropped in response to the growth of alternative housing for older adults, it does offer families with ample financial resources—the average annual stay ranges from $46,000 to $75,000, depending on the location of the facility in the United States and the intensity of services—an alternative to caring for the AD patient at home.

Many children and other relatives of AD patients care for the affected family member at home as long as possible because they cannot afford institutional care or they feel a moral obligation to do so. No matter how willing and devoted the caregiver, the time, patience, and resources required to provide care over a long period are immense, and the task is often overwhelming. As the patient's condition progresses, caregivers often find themselves socially isolated. Caregiving has been linked to increased rates of depression, compromised immune function, and a greater use of medication and psycho-tropic drugs—medications used to improve mood and relieve symptoms of mental distress.

Caregivers who participate in support groups, and make use of home health aids, adult day care, and respite care (facilities where patients stay for a limited number of days), not only feel healthier but also are better able to care for AD patients and maintain them at home longer than those who do not.

MENTAL ILLNESS

Older people with mental illnesses were once considered senile—that is, mentally debilitated as a result of old age. Serious forgetfulness, emotional disturbances, and other behavioral changes do not, however, occur as a normal part of aging. They may be caused by chronic illnesses such as heart disease, thyroid disorders, or anemia; infections, poor diet, or lack of sleep; or prescription drugs, such as narcotic painkillers, sedatives, and anti-histamines. Social isolation, loneliness, boredom, or depression may also cause memory lapses. When accurately diagnosed and treated, these types of problems can frequently be reversed.

Mental illness refers to all identifiable mental health disorders and mental health problems. Mental Health: A Report of the Surgeon General, 1999 (1999, http://www.surgeongeneral.gov/library/mentalhealth/home.html) defines mental disorders as "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning." The report distinguishes mental health disorders from mental health problems, describing the signs and symptoms of mental health problems as less intense and of shorter duration than those of mental health disorders, but it acknowledges that both mental health disorders and problems may be distressing and disabling.

The Surgeon General's report observes that nearly 20% of people aged fifty-five years and older experience mental disorders that are not part of normal aging. The most common disorders, in order of estimated prevalence rates, are anxiety (11.4%), severe cognitive impairment (6.6%), and mood disorders (4.4%) such as depression. The report also points out that mental disorders in older adults are frequently unrecognized, underreported, and undertreated.

Diagnosing mental disorders in older adults is challenging, because their symptoms and presentation may be different from that of other adults. For example, many older individuals complain about physical as opposed to emotional or psychological problems, and they present symptoms that are not typical of depression or anxiety disorders. Accurate identification, detection, and diagnosis of mental disorders in older adults are also complicated by the following:

• Mental disorders often coexist with other medical problems.
• The symptoms of some chronic diseases may imitate or conceal psychological disorders.
• Older adults are more likely to report physical symptoms than psychological ones, because there is less stigma associated with physical health or medical problems than with mental health problems.

Depression

Symptoms of depression are an important indicator of physical and mental health in older adults, because people who experience many symptoms of depression are also more likely to report higher rates of physical illness, disability, and health service utilization.

The prevalence of clinically relevant depressive symptoms (as distinguished from brief periods of sadness or depressed mood) increases with advancing age. Older Americans Update 2006 reports that in 2002, the most recent year for which data are available, 19.6% of adults aged eighty-five and older experienced these symptoms, compared to 13.1% of those aged sixty-five to sixty-nine. Older women in all age groups reported depressive symptoms more than older men did. Sixteen percent of women aged sixty-five to sixty-nine reported depressive symptoms, compared to 10% of men the same age. (See Figure 8.3.) Among those aged eighty-five and older, 22% of women reported symptoms, compared to 15% of men.

Often, illness itself can trigger depression in older adults by altering the chemicals in the brain. Examples of illnesses that can touch off depression are diabetes, hypothyroidism, kidney or liver dysfunction, heart disease, and infection. In patients with these ailments, treating the underlying disease usually eliminates the depression. Daniel P. Chapman, Geraldine S. Perry, and Tara W. Strine, in "The Vital Link between Chronic Disease and Depressive Disorders" (Preventing Chronic Disease, January 2005), examine the correlation of people who suffer from both chronic diseases and depression. Understandably, people with disabling chronic illnesses such as arthritis, stroke, and pulmonary diseases are likely to become depressed. Some prescription medications, as well as over-the-counter (nonprescription) drugs, may also cause depression.

Research conducted in 2005 at the University of Rochester Sleep and Neurophysiology Research Laboratory and summarized by Alan Mozes in "Insomnia Linked to Depression in Elderly" (HealthDay News, June 27, 2005) finds that depression among older adults may be triggered and fostered by chronic insomnia. One study finds that older patients with a history of depression are more likely to continue being depressed if they also suffered from persistent insomnia. The second study indicates that even without a history of depression, older patients—particularly women—who suffer from chronic sleeplessness are at a higher risk for becoming severely depressed than those who have no trouble sleeping. These findings support the hypothesis that insomnia may be more than a symptom of depression; it may also be a cause. The researchers conclude that older patients with persistent insomnia are six times more likely to experience serious new-onset depression than individuals who do not have problems sleeping.

Depression causes some older adults to deliberately neglect or disregard their medical needs by eating poorly and failing to take prescribed medication or taking it incorrectly. These may be "covert" acts of suicide. Actual suicide, which is frequently a consequence of serious depression, is highest among older adults relative to all other age groups. In 2004 the death rate for suicide among people aged seventy-five to eighty-four was 16.3%, and among adults aged eighty-five and older it was 16.4%. (See Table 8.2.) Older men had the highest rates—34.8% for those aged seventy-five to eighty-four and 45% for those aged eighty-five and older.

TREATMENT OF DEPRESSION.

According to the Surgeon General's report, despite the availability of effective treatments for depression, a substantial fraction of affected older adults do not receive treatment, largely because they either do not seek it or because their depression is not identified, accurately diagnosed, or effectively treated. For example, even though older patients respond well to anti-depressant medications, some physicians do not prescribe them to older patients already taking many drugs for chronic medical conditions because they do not want to risk drug-drug interactions or add another drug to an already complicated regimen. As a result, only a minority of older adults diagnosed with depression receives the appropriate drug dose and duration of treatment for depression.

Common treatments for depression include psychotherapy, with or without the use of antidepressant medications, and electroconvulsive therapy (ECT). Psychotherapy is most often used to treat mild to moderate depression and is prescribed for a limited, defined period, generally ranging from ten to twenty weeks. ECT is used for life-threatening depression that does not respond to treatment with antidepressant drugs.

In "The Effect of a Primary Care Practice-Based Depression Intervention on Mortality in Older Adults: A Randomized Trial" (Annals of Internal Medicine, May 15, 2007), a five-year study of 1,226 older patients, Joseph J. Gallo et al. not only find that depression is independently associated with mortality risk in older adults but also confirm that treatment for depression reduces this risk. Of the total number of subjects, about six hundred were determined to be suffering from major or minor depression. During the five-year follow-up, 223 subjects had died. Subjects who received treatment for depression were 33% less likely to die than those who were not treated.

Anxiety Disorders

Anxiety disorders—extreme nervousness and apprehension or sudden attacks of anxiety without apparent external causes—can be debilitating and destructive. Symptoms may include fear, a "knot" in the stomach, sweating, or elevated blood pressure. If the anxiety is severe and long lasting, more serious problems may develop. People suffering from anxiety over an extended period may have headaches, ulcers, irritable bowel syndrome, insomnia, or depression. Because anxiety tends to create various other emotional and physical symptoms, a cascade effect can occur in which these new or additional problems produce even more anxiety.

Unrelenting anxiety that appears unrelated to specific environments or situations is called generalized anxiety disorder. People suffering from this disorder worry excessively about the events of daily life and the future. They are also more likely to experience physical symptoms such as shortness of breath, dizziness, rapid heart rate, nausea, stomach pains, and muscle tension than people afflicted with other panic disorders, social phobias, or agoraphobia (fear of being in an open space or a place where escape is difficult).

The Surgeon General's report estimates the prevalence of anxiety disorder as about 11.4% in adults aged fifty-five years and older. Phobic anxiety disorders such as social phobia, which causes extreme discomfort in social settings, are among the most common mental disturbances in late life. In contrast, the prevalence of panic disorder (0.5%) and obsessive-compulsive disorder (1.5%) is low in older adults. Generalized anxiety disorder, rather than specific anxiety syndromes, may be more prevalent in older people.

Effective treatment for anxiety involves medication, primarily benzodiazepines, such as diazepam, chlordiazepoxide, and alprazolam, as well as psychotherapy. Like other medications, the length of time that the effect of benzodiazepines lasts may be longer in older adults, and their side effects may include drowsiness, fatigue, physical impairment, memory or other cognitive impairment, confusion, depression, respiratory problems, abuse or dependence problems, and withdrawal reactions.

Schizophrenia

Schizophrenia is an extremely disabling form of mental illness. Its symptoms include hallucinations, paranoia, delusions, and social isolation. People suffering from schizophrenia "hear voices," and over time the voices take over in the schizophrenic's mind, obliterating reality and directing all kinds of erratic behaviors. Suicide attempts and violent attacks are common in the lives of schizophrenics. Many schizophrenics turn to drugs in an attempt to escape the torment inflicted by their brains. The National Institute of Mental Health, in Schizophrenia (January 24, 2007, http://www.nimh.nih.gov/publicat/nimhschizophrenia.pdf), indicates that drug abuse is common with schizophrenics.

The Surgeon General's report notes that the prevalence of schizophrenia among adults aged sixty-five years or older is estimated as 0.6%, less than half of the 1.3% that is estimated for the population aged eighteen to fifty-four. However, the economic burden of late-life schizophrenia is high. Even though the use of nursing homes and state hospitals for patients with all mental disorders has declined over the past two decades, this decline is small for older patients with schizophrenia.

Drug treatment of schizophrenia in older adults is complicated. The medications used to treat schizophrenia, such as haloperidol, effectively reduce symptoms (e.g., delusions and hallucinations) of many older patients, but they also have a high risk of disabling side effects, such as tardive dyskinesia—involuntary, rhythmic movements of the face, jaw, mouth, tongue, and trunk.

MISUSE OF ALCOHOL
AND PRESCRIPTION DRUGS

The Surgeon General's report observes that older adults are more likely to misuse, as opposed to abuse, alcohol and prescription drugs. The report estimates the prevalence of heavy drinking (twelve to twenty-one drinks per week) in the current cohort (a group of individuals that shares a common characteristic such as birth years and is studied over time) of older adults is 3% to 9%. The prevalence rates are expected to rise as the baby boomer (people born between 1946 and 1964) cohort, with its history of alcohol and illegal drug use, joins the ranks of older adults. The current group of older adults is more likely to suffer substance misuse problems, such as drug dependence, arising from underuse, overuse, or erratic use of prescription and over-the-counter medications.

Figure 8.4 shows that in 2006 adults aged sixty-five and older had the lowest rate of excessive alcohol consumption—just 5%—of all age groups. Older men were much more likely than older women to have met the NHIS criteria for excessive alcohol consumption—five or more drinks in one day at least once in the past year—8% versus 2%.

Prevalence of Types of Older Problem Drinkers

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), in "Older Adults and Alcohol Problems: NIAA Social Work Education, Module 10C" (March 2005, http://pubs.niaaa.nih.gov/publications/Social/Module10COlderAdults/Module10C.html), describes the prevalence of three types of problem drinkers: at-risk drinkers, problem drinkers, and alcohol-dependent drinkers.

• At-risk drinking is alcohol use that increases the risk of developing alcohol-related problems and complications. People over age sixty-five who drink more than seven drinks per week (one per day) are considered at risk of developing health, social, or emotional problems caused by alcohol.
• Problem drinkers have already suffered medical, psychological, family, financial/economic, self-care, legal, or social consequences of alcohol abuse.
• Alcohol-dependent drinkers suffer from a medical disorder characterized by loss of control over consumption, preoccupation with alcohol, and continued use despite adverse health, social, legal, and financial consequences.

Figure 8.5 shows the estimated prevalence rates of these different types of drinkers as well as the majority (65%) of older adults that abstains from alcohol consumption.

Types of Older Problem Drinkers

Another way to characterize older problem drinkers is by the duration and the patterns of their drinking histories. The first group is composed of those over age sixty who have been drinking most of their lives. The members of this group are called survivors or early onset problem drinkers. They have beaten the statistical odds by living to old age despite heavy drinking. These are the people most likely to suffer medical problems such as cirrhosis of the liver (a chronic degenerative disease of the liver marked by scarring of liver tissue and eventually liver failure) and mental health disorders such as depression.

The second group, intermittents, has historically engaged in binges or bout drinking interspersed with periods of relative sobriety. These drinkers are at risk for alcohol abuse because they are more likely than others to self-medicate with alcohol to relieve physical pain and emotional distress or to assuage loneliness and social isolation.

Reactors or late-onset problem drinkers make up the third group. The stresses of later life, particularly the loss of work or a spouse, may precipitate heavy drinking. These people show few of the physical consequences of prolonged drinking and fewer disruptions of their lives. According to Katherine A. Carlson of the University of Washington, in The Prevention of Substance Abuse and Misuse among the Elderly (September 1994, http://depts.washington.edu/adai/pubs/tr/elderly/elderly.pdf), about two-thirds of those aged sixty-five and older who suffer from alcoholism have had long-standing alcohol addictions; in the remaining one-third, alcohol abuse develops late in life.

Alcohol-Related Issues Unique to Older Adults

Older adults generally have a decreased tolerance to alcohol. Consumption of a given amount of alcohol by older adults usually produces higher blood-alcohol levels than it would in a younger population. Chronic medical problems such as cirrhosis may be present, but older adults are less likely to require detoxification and treatment of alcohol-withdrawal problems. One possible explanation is that few lifelong alcohol abusers survive to old age.

Because older adults usually take more medication than people in other age groups, they are more susceptible to drug-alcohol interactions. Alcohol reduces the safety and efficacy of many medications and, in combination with some drugs, may produce coma or death. Adverse consequences of alcohol consumption in older adults are not limited to problem drinkers. Older adults with medical problems, including diabetes, heart disease, liver disease, and central nervous system degeneration, may also suffer adverse reactions from alcohol consumption.

SCREENING, DIAGNOSIS, AND TREATMENT.

The NIAAA advocates screening to identify at-risk drinkers, problem drinkers, and dependent drinkers to determine the need for further diagnostic evaluation and treatment. Furthermore, in "Older Adults and Alcohol Problems," it provides a screening protocol that recommends that:

• All adults aged sixty and over should be screened for alcohol and prescription drug use/abuse as part of any medical examination or application for health or social services.
• Annual rescreening should be performed if certain physical symptoms emerge or if the individual is undergoing major life changes, stresses, or transitions.
• These screening criteria apply to any health, social, work, or recreation setting that serves older adults and are not limited to medical care and substance treatment settings.

Diagnosis of problem drinking in the older population is complicated by the fact that many psychological, behavioral, and physical symptoms of problem drinking also occur in people who do not have drinking problems. For example, brain damage, heart disease, and gastrointestinal disorders often develop in older adults independent of alcohol use, but may also occur with drinking. In addition, mood disorders, depression, and changes in employment, economic, or marital status often accompany aging but can also be symptoms of alcoholism. Alcohol-induced organic brain syndrome is characterized by cognitive impairment—memory lapses, confusion, and disorientation. As a result, some older alcoholics may be incorrectly diagnosed as suffering from dementia or other mental illness.

Older problem drinkers make up a relatively small proportion of the total number of clients seen by most agencies for treatment of alcohol abuse. There is little data about the effectiveness of intervention and treatment, which usually consists of some combination of counseling and education, in the older population. Nonetheless, the chances for recovery among older drinkers are considered good, because older clients tend to complete the full course of therapy more often than younger clients.