Mental Health Treatment Approaches for Older Adults

Overview of mental health issues in the elderly

Old age is a natural occurrence for every human being, a stage in growth accompanied by several changes, which can be negative and identified as problems. Some of these problems are a rise in morbidity, mortality, hospitalization, and functional status loss. A large number of evidence associates these problems with common mental disorders to which the elderly are prone. A combination of depression and anxiety is a very common occurrence in the elderly, being so prevalent, one-half of elderly patients report significant anxiety or depressive symptoms (Parkar, 2015). The changing nature of current society has redefined the social role of the elderly within the family and community, eliminating the traditional life-sustaining and fostering influences the elderly contributed. As a result of these, the elderly are socially isolated. Many are committed to a nursing home or an institution where the only available social links are other equally alienated older adults.

The contributions of the elderly to families and society, while limited, are not irrelevant. Older adults aged 60 and above still make valuable contributions as family members, volunteers in the community, and active part of a societys workforce. However, the effectiveness of the elderlys contribution can be limited by the individuals mental health condition. While most elderly have good mental health, there is a high risk of an aged individual developing mental disorders. As age advances, the risk of suffering a mental disorder rises. Over 20% of adults the age of 60 and over suffer from a mental or neurological disorder (excluding headache disorders), and mental and neurological disorders account for 6.6% of all disabilities (disability-adjusted life years DALYs) in persons aged 60 and over (WHO, 2017). The three most common mental and neurological disorders in the worlds older population are depression, dementia, and anxiety, conditions that affect 7%, 5%, and 3.8% of the worlds older population.

Mental health conditions are often unrecognized by healthcare professionals and the elderly themselves who suffer these conditions. In the eventuality of accurate identification, many sufferers of such conditions are reluctant to seek professional help due to the stigma linked with the conditions. This paper focuses on dementia as a mental health issue that affects the elderly.

Dementia

Dementia is considered to be a syndrome (a group of symptoms), either chronic or progressive, which interfere with cognitive function (the ability to process thought) and exhibit mental ability deterioration beyond what might be expected from normal aging. Dementia affects several mental faculties, including thinking, memory, orientation, calculation, learning capacity, comprehension, language, and judgment, but consciousness is not affected. Symptoms such as deterioration in emotional control. Social behavior and motivation commonly precede cognitive impairment manifestation but occasionally occur in accompaniment (WHO, 2020). The resulting lack of personal ability caused by dementia is recognized as the leading cause of dependency among the elderly worldwide. The poor understanding of this mental health issue has led to the association of stigma with dementia, a social factor that can interfere with diagnosis and care. The situation created by this condition can be overwhelming for everyone involved, including the patient, the carer of the patient, and the family. The resultant impact of dementia on the patient, the family, and society can be physical, psychological, social, and economic.

Dementia, although not a normal aspect of aging, is most prevalent in older adults. An estimated number of 50 million people worldwide live with dementia, with 60% of that population distributed in low- and middle-income countries. The total number of dementia patients worldwide is projected to rise to 82 million in 2030 and 152 million in 2050 (WHO, 2017). In addition to the high economic cost of medical, social, and informal care required for dementia patients, the families and carers for the patients are also subject to great physical and emotional stress. As such, support from the health, social, financial, and legal systems is required for the dementia patient and the carers, and the family.

Possible causes

The following factors are recognized as the most common causes of dementia (Livingston et al., 2020):

Degenerative neurological diseases: Like Alzheimers disease, Parkinsons disease, Huntingtons disease, and some variants of multiple sclerosis. These neurological diseases are characterized by an increase in severity as time advances;

Vascular disorders which impair the circulation of blood to the brain;

Brain injuries caused by trauma during a car accident, fall, concussion, etc.;

Certain infections of the central nervous system such as meningitis, HIV, Creutzfeldt-Jakob disease;

Persistent use of drugs or alcohol;

Certain types of hydrocephalus (a build-up of fluid in the brain).

The risk of developing dementia is also influenced by physical and lifestyle factors such as:

Age;

The history of dementia in the family;

The existence of underlying illnesses such as diabetes, Down syndrome, heart disease, and sleep apnea (Shi et al., 2018);

Poor diet and a lack of exercise;

Cognitive inactivity, social isolation, and depression.

Characteristics or symptoms

There is a variance in the manifestation of dementia in each person, based on factors such as the illnesss impact and the individuals personality before being affected (WHO, 2020). However, the progression of dementia is similar enough for three distinct stages to be identified.

Early-stage: This stage can be difficult to identify as the onset of the illness is gradual. During this time, identifiable symptoms are forgetfulness, a poor consciousness of time, and becoming lost in familiar places.

Middle stage: As dementia advances into this stage, the symptoms become more evident and more serious. The affected individual becomes more forgetful of recent events and peoples nams, becomes lost at home, has greater difficulty communicating, needs help with personal care, and experiences behavioral changes (such as wandering and repeated questioning).

Late-stage: At the late stage, the affected individual will become near totally independent and inactive. Severe memory disturbances will occur, and physical symptoms will become very obvious. At this stage, the affected individual will become unaware of the time and place, have difficulty recognizing relatives and friends, become increasingly dependent, have difficulty walking, and exhibit behavioral changes, including aggression.

Treatment and prevention (if relevant), and a description of screening, assessing, and diagnosing

Assessment

The diagnosis of dementia requires a thorough clinical assessment which will cover medical history, including a cognitive and mental state examination, physical examination, and other relevant investigations (Panegyres, Berry & Burchell, 2016). The patients assessment is to be completed with a knowledgeable informant, as the information produced by an unreliable patient is not admissible. Informant-based assessments provide greater sensitivity than the MMSE (mini-mental state examination) in detecting dementia and changes in biomarker profiles of Alzheimers Disease, particularly in the early symptomatic stages.

Screening

i. Cognitive Testing

Various tests are available to screen for cognitive decline, with the mini-mental state examination (MMSE) being the most widely used (Panegyres et al., 2016). The MMSE takes about 15 minutes to complete, and the result of the test is rated on a scale of 0 to 30. The value obtained indicates the current level of cognitive impairment.

The Montreal Cognitive Assessment (MoCA) is a screening tool used for a similar function of detecting cognitive impairment, but only in mild cases. The test requires 10 minutes to complete.

This paper identifies two other cognitive tests which are as clinically and psychometrically robust as the MMSE, The General Practitioner Assessment of Cognition (GPCOG) screen, and Mini-Cog testing.

ii. Functional Status

The current ability to complete day-to-day activities with no observable impairment has to be determined to assess for dementia. The testing tool used for this observation is The Functional Activities Questionnaire (FAQ). The FAQ is a brief standardized assessment used to obtain objective evidence from an informant, such as a family member or spouse, on the patients competence in completing daily activities.

iii. Review of Medications

Certain medications can interfere with the assessment of dementia in a patient. With the common occurrence of polypharmacy in the elderly, there is a high risk of this interference. Therefore, a full review of all medication, prescribed or over-the-counter, which the patient uses must be completed. From the information contained in the review, drug classes that the patient uses can result in cognitive impairment. Some of the common drug classes that impair the cognitive function are opioids, tricyclic antidepressants, anticholinergics, muscle relaxants, antihistamines, and antiepileptics benzodiazepines, and non-benzodiazepine hypnotics (Panegyres et al., 2016). Information on a history of alcohol consumption, smoking, and illicit drug usage is also very essential.

iv. Neurological Evaluation

The neurological status of a patient is required to diagnose dementia. The neurological status is assessed by completing a neurological evaluation on the patient. This evaluation should include vision, speech, hearing, and movement assessments. The existence of an aberration in any of the mentioned functionalities can indicate a health condition that can cause dementia. A speech impediment might indicate Parkinsonisms presence, while poor motor skills can indicate FTD, Parkinsonism, normal pressure hydrocephalus, or stroke. Any history of head injury or neurological disorder must be acknowledged, like traumatic brain injury and epilepsy are risk factors for the onset of early cognitive decline (Vossel et al., 2017). The patients sleep patterns can also indicate a cognitive decline, especially if the patient suffers from sleep apnea or restless legs syndrome.

v. Social History

An examination of a persons social history can be used to detect a change in cognitive function level....

…2015, the global dementia cost was estimated at US$ 818 billion, 1.1% of the global gross domestic product (GDP). The proportion of each countrys GDP spent on dementia varied from 0.2% in low and middle-income countries to 1.4% in high-income countries.

Directions for future research

There are currently several ongoing research on AD and other dementias, as well as over 70 clinical trials of experimental therapies to cure dementia. Some clinical studies on dementia and healthy aging, such as the Memory and Aging Project at Washington University and the nationwide Alzheimers Disease Neuroimaging Initiative, have already provided valuable insight on AD. Information on how AD begins and the progression it follows have been obtained. Through these studies, the pathological process which leads to the development of clinical AD has been identified and shown to begin at least a decade before the manifestation of any symptoms (Musiek & Schindler, 2013). The advent of new biomarkers has improved the potential for diagnosing AD, with very early and even presymptomatic diagnosis now possible. The development of a therapeutic cure for symptomatic AD has, unfortunately, yielded less success. Evidence gathered shows that treatment strategies for AD must be started as early as possible after the onset of the illness to prevent ongoing neurodegeneration. To achieve this, asymptomatic individuals can be tested and treated before symptoms begin to manifest, preventing the eventual manifestation or delaying it. There are currently no therapeutic methods that can perform this function, and as such, presymptomatic screening is not encouraged.

Research on ADs developmental process identified the accumulation of A? as a precursor to neurodegeneration and the manifestation of symptoms. Thus, most current experimental therapeutic strategies focus on eliminating A? to prevent the pathogenic cascade initiation, which causes AD. One therapeutic strategy being tested is the passive immunization of humans with antibodies that bind A?, with several monoclonal antibodies that can already perform this function in various clinical trials (Alzheimers Association. (2012). The inhibition of A? production is also being explored as a possible preventive measure. Using small-molecule inhibitors of beta-and gamma-secretases, A? generation can be altered by influencing the enzymes which produce it. Several of such molecule inhibitors are in late-stage clinical trials.

There have been several failures of anti-amyloid therapies in phas III clinical trials over the past years, therapies such as immunization with A? antibodies and using secretase inhibitors. Several possible reasons why these treatments failed, including the drugs inability to reduce A? levels, initiating the treatment very late in the disease course, and the inclusion of patients with non-AD dementias. The possibility of identifying an effective A?-targeted therapy is increasing as the clinical trial methodology is refined, and a new generation of therapeutic strategies enters phase III trials. Therapeutic methods will provide presymptomatic therapy for rare early onset familial AD patients such as the Dominantly Inherited Alzheimers Network (DIAN) treatment trial. The Alzheimers Prevention Initiative (API) is beginning its first clinical trials this year. The DIAN trials are focused on exploring two distinct anti-A? antibodies, and the API trial will explore another A? antibody (Morris et al., 2012; Musiek & Schindler, 2013).The two trials aim to treat rare autosomal dominant AD, but these trials success may inspire future preventive trials in sporadic (late-onset, non-familial) AD. A third trial, the Anti-Amyloid Treatment in Asymptomatic Alzheimers Disease (A4) study, will evaluate the effect of presymptomatic therapy with anti-A? antibodies in persons over 70 with no cognitive symptoms of AD but who show amyloid imaging evidence of presymptomatic AD.

There are currently other experimental treatment strategies for AD in development that do not use A? therapy. These other treatments explore the reduction of tau aggregation, suppressing neuroinflammation, preventing oxidative injury, augmenting neuronal metabolism, and modulating APOE levels. Small molecule activators of ?7 nicotinic acetylcholine receptor and nasally-inhaled insulin are some of these therapeutic methods that have entered clinical trials. These methods have shown an enhancement in AD cognition in smaller studies and may form the basis for treating symptomatic AD in the future (Craft et al., 2012). Intravenous immunoglobulin (IVIG) has also shown potential as a treatment for symptomatic AD. However, the treatment mechanisms are still not understood, and a large trial of the method has reportedly failed. Other preclinical studies in mouse models have identified different potential treatment methods which are yet to be validated as treatment methods for humans.

Strategies to Create Awareness

Disseminating information to the public in gathering centers such as places of worship, sheltered housing, community centers, day centers, and radio stations.

Contacting family carers using ethnic bilingual professionals in community volunteer centers.

Organizing roadshows in areas with a high population density to reach…