epidemiology of psychiatric disorders in elderly

1. Demography and Epidemiology
of Psychiatric disorders in Elderly
Dr Ravi Soni
Senior Resident
Dept. of Geriatric Mental Health
KGMC

2. Demography and Epidemiology of Psychiatric
disorders in Elderly
Discussion over following
• What is Geriatric Psychiatry?
• Demography of Aging
• Geriatric statistics
• Epidemiology of psychiatric disorders in India
• Epidemiology of psychiatric disorders worldwide
• Details about main psychiatric problems in elderly

3. What is Geriatric Psychiatry?
• Fastest growing field of psychiatry
– branch of medicine concerned with prevention, diagnosis,
and treatment of physical and psychological disorders in
the elderly and with the promotion of longevity
• Managing elderly patients requires ‘special’
knowledge:
– Possible differences in mental health presentations,
– Frequent co-exiting and complicating chronic medical
diseases,
– Multiple medications (drug-drug interactions,
pharmacodynamics and pharmacokinetics) and
– Aging specific issues

4. What age makes you a geriatric patient?
What makes you ‘elderly’?
• In developed countries with higher life expectancies older
adults are generally categorized in three age segments:
– Young old: aged 55-65 years;
– Old: aged 66-85 years,
– Oldest old: aged 85 years and above (Carey, 2003).
• In India age categorizations have been done as following :
– young-old: 60 to 70 years;
– old-old: 70 to 80 years and
– oldest-old: 80 years and above
(Venkoba Rao, 1993; Irudaya Rajan, 2003)

5. Geriatric statistics
• Life expectancy at birth in India
Life expectancy at
birth in India
Female Male Combined
1960 41.54 43.31 42.45
2011 67.08 63.95 65.48
• The most rapidly growing segment of the population is the
age group 85 years and older, the group with the highest
morbidity and the highest rate of psychiatric and medical
comorbidities.
• This age group grew 40-fold, from 100,000 in 1900 to more
than 4 million in 2005, and is projected to reach 19.4 million
by 2050.

6. The Ageing India
No. in million
 ≥ 60 aged have increased from 83.6 m in 2006 to 98.47 m in 2011
 Projected increase by 2016 is 118.1 m, by 2021 143.25 to 173.18 m by 2026.
Population India.Chapter-2.Census of India 2010. Vital statistics. SRS report.

7. The Aging Imperative
• Persons aged 60y and older
constitute 13% of the
population and purchase
33% of all prescription
medications
• Many are ‘Frail Elderly’
• By 2040, 25% of the
population will purchase
50% of all prescription
drugs

8. Epidemiology of Psychiatric Disorders in India
[Tiwari SC et al. 2012]

9. Epidemiology and profile of Mental Health
Problems in India
• In Pondicherry (South India), psychiatric disorders among older adults
were found to be 17.4%.
• Another epidemiological study from Uttar Pradesh (North India) reported
43.3% of the elderly to be suffering from one or the other mental health
problems as against 4.7% adults
• 17.3% urban and 23.6% rural older adults aged 60 years and above suffer
from syndromal mental health problems
• 4.2 urban and 2.5% of rural older adults suffer from sub-syndromal
mental health problems
• Prevalence of dementia in India has been reported to be variable, from
1.4% to 9.1%
• Depression was thrice more common than mania, occurring for the first
time after 60 years
• Prevalence of neurotic depression in the rural elderly was found to be
13.5%. A recent report indicates that 5.8% of the urban and 7.2% of the
rural older adults primarily suffer from mood (affective) disorders
Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: An evidence-based commentary.
Indian J Psychiatry 2012;54:8-14.

10. The Burden of Mental Health MMoorrbbiiddiittyy IInn OOllddeerr AAdduullttss
• Enormous psychiatric morbidity:
Author(s) & year Population (Study area) Rate
Dube, 1970 Rural & urban community (UP) 2.23%
Nandi et. al, 1975 Rural community (WB) 33.3%
RamChandran et. al.,1979 Urban community (TN) 35.0%
Venkoba Rao, 1990 Semi urban (Madurai) 8.9%
Natrajan et al, 1993 Rural & urban community (TN) 17.3- 29.6%

11. The Burden of Mental Health Morbidity IInn OOllddeerr AAdduullttss ((CCoonnttdd..))
• Enormous psychiatric morbidity:
Author(s) & year Population (Study area) Rate
Tiwari, 2000 Rural Eld. Pop. (UP) 43.3%
Prakash, 2004 Urban Eld. Pop. (Rajsthan) 42.0%
Malik & Banerjee, 2005 Rural Eld. Pop. (W. B.) 32.0%
Tiwari, 2009 Urban Eld. Pop. 17.3%
Tiwari, 2010 Rural Eld. Pop. 23.6%
 Neuropsychiatric illnesses cause significant morbidity in elderly (GOI & WHO, 2007).
 Elderly are highly prone to mental morbidity (Ingle & Nath, 2008).
A modest estimate – 20% psychiatric morbidity

12. Late Life Stressors
that place older adults at risk of
mental health disorders
• Chronic physical health condition(s)
• Death of a loved one
• Caregiving
• Social isolation/lack or loss of social support
• Significant loss of independence
• History of mental health problems
– Old age – even though older adults are more likely to
experience life stressors – old age is NOT a risk factor for an
increasing risk for a mental health disorder;
– in fact, ‘most’ older adults are able to cope with late life
stressors without developing significant mental health
disorders

13. Major mental health problems of older adults
Organic Disorders
Late Life Functional Diseases:
Mood (Affective) Disorders
Neurotic, Stress Related and Somatoform Disorders
Schizophrenia, Schizotypal and Delusional Disorders
(Functional Psychoses)
Psychoactive Substance Use Disorders
Suicidal Behaviors in the Elderly
2nd most common cause of disability among people age 65 and
older (second only to arthritis)

14. Dementia: Statistics
DAT (Dementia of Alzheimer’s Type)
• Incidence:
– 5-8% ……….over age 65
– 15-20%……..over age 75
– 25-50+%……..over age 85
• Women > Men (1.2-1.5 to 1.0)
• If trends continue, population with DAT will
quadruple within the next 50 years……..
• New Cases/Year=360,000=40 new cases/hour

15. Elderly population and Prevalence of Dementia:
INDIA-EUROPE-WORLD
TOTAL
POPULATION
ELDERLY
PERCENTAGE
ELDERLY
POPULATION
DEMENTIA
PREVALENCE
PEOPLE WITH
DEMENTIA
WORLD 7 BILLION1 8% 600 MILLION 5.9% 35.6 MILLION
EU 27 502.5 MILLION1 17.5% 97 MILLION 7.65% 7 MILLION
UK 62.5 MILLION1 16.7% 10.4 MILLION 7.65% 0.8 MILLION
INDIA 1.21 BILLION2 8% 96.8 MILLION 3.6% 3.5 MILLION
1U S CENSUS BUREAU, International program center, international database
2Indian Census 2010

16. Dementia will be a big challenge….
1- The Global Catastrophe
 Estimated 35.6 million people have dementia today
 7.7 million new cases annually
 By year 2040
81.1 million will be affected
71% in developing nations
 Between 2001 – 2040
100% increase in developed countries
300% increase in India
2- The Indian Catastrophe
 India–Census 2011: Elderly 60 years and above = 97 m. in India, 13.5
million in UP
At an average prevalence rate of 36/1000 - Dementia = 3.49
million (34.9 lacs) in India
In state of Uttar Pradesh–13.5 million elderly : Dementia=0.49
million (4.9 lacs)
In 2040: @ 300 % increase-10.76 million (107 lacs) in India; 3.87
million (38.7 lacs) in UP

17. Dementia :The Indian catastrophe
Prevalence of Dementia in India*
Study Year Location Population Rate
Rajkumar S et al 1997 Madras Urban 60>;
Dementia
3.5%
Tiwari SC et al 2000 Lucknow Rural 60>;
Mental Health
morbidity
Senile dementia
- Simple= 5.35%
- With Depression = 2.8%
- Arteriosclerotic = 0.82%
Chandr V et al 2001 Ballabgarh Rural; 65>; AD 3.2%
Vas CJ et al 2001 Mumbai Urban 65>;
Dementia
2.4%
Shaji KS et al 2002 Kerala Rural 60>;
Dementia
2.6%
Shaji KS et al 2005 Cochin Urban 65>;
Dementia
3.4%
Tiwari SC et al 2009 Lucknow Urban 60>;
Dementia
4.4%
Tiwari SC et al 2010 Lucknow Rural 60>;
Dementia
2.8%
* Calculated at avg. 36/1000 app. 3.5 m pts of dementia in India

18. Behavioral and Psychological Symptoms of
Dementia (BPSD)
• A heterogeneous range of psychological reactions, psychiatric
symptoms, and behaviors occurring in people with dementia
of any etiology.
• Any verbal, vocal, or motor activities not judged to be clearly
related to the needs of the individual or the requirements of
the situation.
• An observable phenomena (not just internal)

19. Prevalence of BPSD
• 90% of patients affected by dementia will experience
Behavioral and Psychological Symptoms of Dementia (BPSD)
that are severe enough to be labeled as a problem during the
course of their illness.
 Most common:
• Agitation (75%)
• Wandering (60%)
• Depression (50%)
• Psychosis (30%)
• Screaming and violence (20%)

20. Mild Cognitive Impairment (MCI)
• MCI (mild cognitive impairment):
– Cognitive impairment in elderly persons not of sufficient
severity to qualify for a diagnosis of dementia
• Patients have complaints of
– Impairment in memory or other areas of cognitive
functioning usually noticeable to them or to those around
them
– Performance on ‘memory or cognitive’ tests are usually
below that expected for their age and education
• A ‘precursor’ to DAT in 50% of patients over 3-4
years

21. MCI
Prevalence Rate in the Community
• Normal aging  MCI  early DAT
• Prevalence rate for >60 years of age: 3%
• Prevalence rate for >75 years of age: 15%
• Annual conversion rate to DAT: 6-25%/year

22. Depressive disorders in Elderly
• Prevalence of depression in healthy independent community-dwelling
elderly is lower than the general adult population.
– In general population over age of 65 years, the estimated prevalence
of LOD is 2% and of subsyndromal depressive symptoms (minor
depression) is 10-15%.
– Prevalence rates rise to 25-40% in hospital sub-populations and
residential homes; and to 40% for patients with stroke, myocardial
infarction or cancer.
– LLD [Late life depression] is most common psychiatric disorders in
inhabitants of old age/nursing homes, followed by anxiety disorders
(13.3%) and dementia (11.1%).

23. Depressive disorders in Elderly (cont..)
• Most depressive episodes occurred in persons with a prior
history of depression, with a recurrence rate of 25.5 per 1,000
person years.
• Clinically significant but subthreshold depressive symptoms
occurred at twice the rate of depressive syndromes
• The ratio of male to female with MDD remains stable with
higher prevalence in women across the age spectrum
• With advancing age, the gender gap in depression prevalence
narrows

24. Risk Factors and Etiology
• Female sex,
• Bereavement,
• Sleep disturbances,
• Disability,
• Prior depression,
• New medical illness,
• Less education,
• Cognitive impairment,
• Poor social support,
• Poor health status,
• Poor self-perceived health and
• Vision or hearing impairment.
• In addition, following are also
noted to be significant risk
factors.
– recent onset of physical illness
– greater severity of physical illness
– functional disability and limited
mobility
– poorly treated pain
– multiple illnesses
• Insomnia is risk for development
of LOD and its persistence and
recurrence further aggravate the
likelihood

25. Phenomenology
• DSM-IV TR and ICD-10 do not include specific diagnostic criteria for LLD, there are differences
in presentation of depression in older adults
• Depressed or sad mood, is usually less prominent or absent in elderly subjects
• More likely to report irritable mood
• Emotional reactivity and responsiveness to external positive events are usually preserved
• Other differences from adult depression include
– Higher rate of somatisation,
– Weight loss,
– Guilt feeling,
– Melancholia,
– Hypochondriasis and
– Psychosis
• Elderly more commonly present with
– Symptoms of psychomotor change (usually seen in conjunction with melancholic features or vascular depression)
– Anhedonia, and
– Cognitive impairment
• ‘Gastric Symptoms’
– gas ascending to head
– gas not being cleared
– constipation
• ‘Low blood pressure’
• ‘Non-recordable Fever’

26. Anxiety Disorders
• Usually begins in early or middle adulthood
but may appear after age 60
• Prevalence rate: 5.5% -11.4*
• With the elderly - up to 20% with
– 37% co-morbidity with depression, dementia and
medical illnesses such as CHF, CAD, diabetes
*U.S. Department of Health and Human Services. Mental Health: Report of Surgeon General; 1999

27. Anxiety Disorders: Prevalence
(among older community-dwelling individuals)
• GAD = 7.3%
• Phobias = 3.1%
• Panic D/O = 1.0%
• Obsessive-compulsive disorders = 0.6%

28. Bipolar Disorders: in Older Adults
• True prevalence is unknown (elderly underutilize
mental health services, underreport mental health
problems, receive care in other settings)
• Co-morbidity is the rule rather than the exception
(neurological illness, diabetes….7 or more co-morbid
diagnoses in 20% of elderly BMD)*
• Lifetime rate of substance abuse: 20-30%
• Mania is usually associated with medical conditions
* Depp & Jeste 2004; Regenold, et al.

29. Bipolar Disorders: in Older Adults
Primary vs. Secondary Mania
• Primary:
-onset early in life
-no obvious medical
cause
-higher familial rate of
bipolar illness
-better general
response to lithium
• Secondary:
-onset later in life
-related medical cause
(CNS lesions, metabolic
disease)
-lower familial rate of
bipolar illness
-generally poor response
to lithium

30. Bipolar Disorders: in Older Adults
• Depression usually precedes mania by 20 years
• In general, manic symptoms are milder compared to
younger patients
• May present with mixed, manic, dysphoric or agitated
states
• More likely to have
– Irritability,
– Treatment resistance,
– Higher mortality rate
• Develop dementia at a higher rate than elderly without
bipolar illness

31. BMD – late onset
• Persons age 60 years and older may constitute as much as
25% of the population with BMD*
• New-onset BMD frequency declines with advanced age
– 6 to 8% of all new cases of BMD developing in persons age 60 years
and older*
• Co-morbid Axis I disorders include:
– Alcohol abuse disorders = 38.1%,
– Dysthymia = 15.5%,
– GAD = 20.5%,
– Panic disorder = 19.0%
– Men have greater prevalence of alcoholism; women have greater
prevalence of panic disorder**
* Sajatovic M, et al: New-onset bipolar disorder in later life. Am J Geriatr Psychiatry 2005; 13: 282-289.
* Almeida, OP, Fenner, S: Bipolar disorder. Int Psychogeriatr 2002; 14:311-322.
** Goldstein, BI, et al: Am J Psychiatry 2006; 163:319-321.

32. Psychosis in Elderly: Epidemiology
Up to 23% of older adults:
Will experience psychotic symptoms at some time
Study from lucknow about prevalence of (Tiwari et al. 2009-10):
Study from lucknow about prevalence of (Tiwari et al. 2009-10):
•Psychiatric disorders in elderly:
•Psychiatric disorders in elderly:
Urban:3.1 %
Rural: 7.7%
Urban:3.1 %
Rural: 7.7%
•Cognitive disorders:
•Cognitive disorders:
Urban:3.8%
Rural: 3.9%
Urban:3.8%
Rural: 3.9%
Nearly 40% of these have psychotic symptoms.
Nearly 40% of these have psychotic symptoms.

33. • Psychotic symptoms:
– More common in populations of elderly persons than in
younger persons. This is due:
• Conditions such as DELIRIUM and DEMENTIA
– More commonly associated with psychotics symptoms
• Prevalence of psychotic symptoms increases with advancing age because of many factors:
– Age-related cortical atrophy & Neurochemical changes
– More co-morbid illnesses
– Social isolation
– Sensory deficits
– Cognitive changes
– Polypharmacy & substance abuse
– Genetic predisposition
– Premorbid personality
Sensory deficit: Brain is:
Targum SD, Abbott JL. Psychoses in the elderly: a spectrum of disorders. J
Clin Psychiatry.1999;60(suppl 8):4–10
– Dependent on signals from the outer world to function properly.
– If spontaneous activity in the brain is not counterbalanced with information from the senses
 Loss from reality and psychosis
Sensory deficit: Brain is:
– Dependent on signals from the outer world to function properly.
– If spontaneous activity in the brain is not counterbalanced with information from the senses
 Loss from reality and psychosis

34. THE MOST COMMON ETIOLOGY:
Webster et al 1998

35. The prevalence of delirium in elderly (Fann JR, 2000):
o At the time of hospitalisation: 11% to 24%
o In post surgical patients: much higher [60 to 80%]
Schizophrenia: [Lacro JP et al, 1997; Targum SD et al, 1999]
• Onset after 45 years of age: ‘Late onset schizophrenia’
• Onset after 60 years of age: ‘Very late onset schizophrenia’
Constitute for 10% of the total cases of schizophrenia
Risk Factors of Late-Onset
Schizophrenia:
 Family history of schizophrenia
 Sensory deficits
 Social isolation
 Abnormal premorbid personality
 Never married/no children
 Lower socioeconomic status
Characteristics of Late onset schizophrenia:
 Females>males (reduction of antipsychotic
role of estrogens)
 Less family history
 More persecutory delusions
 Auditory hallucinations are more common
 Cognitive deterioration < less than that in
early onset
 More positive and Fewer negative symptoms
 Higher prevalence of sensory deficits
 Pre-morbid functioning less impaired
 Respond to lower doses of antipsychotics
 Avoid conventional antipsychotics

36. MOOD DISORDERS WITH PSYCHOSIS
• Most common psychiatric disorder in older
patients:
– Depression
• Prevalence (ECA community survey) (Myers JK et al,
1984):
– Depression in 27% of the elderly
• Psychotic symptoms in depression:
– 40-45% of cases (Nelson et al, 1989; Mayers BS, et al, 1986)
– Mostly delusions which usually include persecutory
beliefs, guilt, nihilism, suspiciousness, and sin
– Hallucinations

37. MOOD DISORDERS WITH PSYCHOSIS
• In contrast to non-psychotic depression, psychotic
depression in the elderly (Lacro JP et al, 1997):
– Associated with increased risk for relapse,
– More persistent symptoms over 1 year,
– More suicide attempts,
– More hospitalizations, comorbidity, and financial
dependency
– Poorly respond to antidepressants alone, require
antipsychotics
– Best respond with ECT
• Elderly manic patients:
– Irritability, paranoia, and mild confusion more common
than euphoria
– Delusion of grandiose, or paranoid delusion

38. DEMENTIA WITH PSYCHOSIS
• Elderly patients with dementia:
– High risk for the development of psychotic symptoms and behavioral
disturbance
• Psychotic symptoms (Targum SD et al, 1999; Tariot P, 1999):
– Alzheimer disease: 50% -70% patients
• Type os Psychotic symptoms in Alzheimer disease (Tariot P, 1999):
– Hallucinations: 28%
– Agitation: 44%
– Verbal aggression: 24%
– Delusions: 34%
– Wandering: 18%
• Persecutory delusions (Cummings et al,1987):
– Alzheimer disease: 30%
– Vascular dementia: 40%

39. DEMENTIA WITH PSYCHOSIS
• Dementia with Lewy Body:
– ~20% of Dementia
– Prominent findings (McKeith IG et al, 1996):
• Fluctuations in cognition and alertness (attention) with
• Behavioral disturbance (early psychiatric symptoms)
• Visual hallucinations
• Motor features of parkinsonism
– 90% have visual hallucinations.
– Avoid antipsychotics, better respond with Cholinesterase inhibitors
• Vascular Dementia
– 50% of multi infarct dementia have delusions
– Up to 40% of cases may have delusions before dementia obvious
– Low response rate

40. Prevalence:
Alcohol Abuse/Dependence
• More than half of people over age 65 do not drink at all
• ‘At risk drinking’ (more than 2 drinks/day for a man and more
than 1 drink/day for a woman): 6-9% (minimum)
• Up to 17% of older adults (over age 60) misuse alcohol or
prescription drugs (5% - 10% of patients seen in an outpatient
setting and 7% - 22% of medical inpatients)*
• Approx. 2/3 of alcohol problems are “long standing” while 1/3 are a
late-onset problem appearing for the 1st time later in life POSSIBLY
associated with retirement, bereavement or depression
.
*J. Geriatr. Psychiatry Neuro. 2000:13;106-14

41. Prevalence:
Alcohol Abuse/Dependence
• “alcohol abuse” = 15% men/12% women ……..drinking in
excess of recommended limits/guidelines
• With women, rapid progression to alcohol-related illnesses
such as cirrhosis, sleep problems and cognitive problems
• Alcohol dependence: prevalence is 8 – 14%; most common
psychiatric disorder
• Often accompanied by other substance abuse (particularly
nicotine) d/o, anxiety/panic, mood disorders and antisocial
personality disorder

42. Clinical Presentation in the Elderly with an
Alcohol/SA Problem
• Do NOT present as:
– Substance seeking behavior such as characterized by crime,
manipulativeness, and antisocial behavior
• Presentations vary but may include:
– marital discord,
– falls,
– confusion,
– poor personal hygiene,
– depression,
– anxiety,
– sleep complaints,
– malnutrition,
– delirium,
– dementia

43. Elder Abuse, Neglect and Exploitation
• Types of elder abuse:
– Physical abuse,
– Sexual abuse,
– Emotional/psychologic abuse,
– Financial exploitation/victimization/undue influence,
– Neglect,
– Abandonment
• Most common type of elder abuse:
– Neglect - depriving an elder of something needed for daily
living
• Second most common type of elder abuse:
– Physical abuse
• Third most common type of elder abuse:
– financial exploitation

44. Elder Abuse Statistics
• Prevalence: 1% - 12%
• Women more than men
• 75% of victims are physically frail
• 50% are unable to care for themselves
• many are confused or disoriented – some or most of the
time
• Majority occurs in home setting
• Majority of perpetrators are family members usually a
spouse or adult child

45. STATISTICS: Elderly Abuse
• Can occur in family homes, nursing homes, board and
care facilities, and hospitals
• Mistreated by their spouses, partners, children and other
relatives and friends
• Elder partner abuse: long standing pattern of marital
violence or as abuse originating in old age – as relates to
issues in aging/disability, stress and changing family
relationships

46. Risk Factors for Abuse
• Older age (>75)
• Female
• Unmarried/widowed/divorced
• Lack of access to resources
• Low income
• Social isolation
• Minority status
• Low level of education
• Functional debility/taking multiple medications
• Substance abuse by caregiver or elder person
• Psychological disorders (depression, anxiety) and personality change
• Previous history of family violence
• Caregiver burnout and frustration
• Cognitive impairment
• Fear of change of living situation (home  ALF/NH)