Our grandparents, our parents, ourselves … Why care about mental health and addiction in later life?

CrossCurrents

By Dr. Benoit Mulsant

Addressing addiction and mental health problems in late life is a demographic imperative and a clinical possibility. Canada is one of the youngest developed countries, but its aging population is growing. In 2011, the baby boomers will start to turn 65. As a result, the proportion and number of adults 65 and older are increasing more rapidly than those of all other age groups. Older adults will comprise 20 per cent of the population by 2026 and 25 per cent by 2041, compared to 12 per cent in 2001. The fastest population growth is occurring among the oldest: Canadians who are 85 and older are expected to number 1.6 million in 2041 (representing four per cent of the overall population), compared to 430,000 in 1981. This is due in large part to the increase in life expectancy, expected to reach 81 for men and 86 for women in 2041.

As the proportion of older adults doubles and their number almost triples, the healthcare system will experience an unprecedented influx of older adults with substance use and mental health problems. Most will also have various age-related comorbidities, making their care more complex but also more necessary.

While most older adults live independently in the community, free of behavioural, psychological or cognitive problems, a substantial minority face significant challenges associated with addiction or mental health problems. For instance, five per cent of community-dwelling adults 65 and older suffer from a dementia (Alzheimer’s disease in most cases) and a similar proportion experience clinical depression. However, due to the inseparability of physical and mental health in old age, the proportions of older adults with depression or dementia increase dramatically in care settings. Prevalence is about 10 per cent in outpatient primary care clinics and general hospitals and 25 to 50 per cent in long-term care homes.

Fortunately, major advances over the past three decades have led to a dramatic increase in knowledge. Clinicians can now diagnose, treat and, in some cases, prevent mental health problems in late life. We now know that when left untreated, late-life depression is associated with suffering, low quality of life, disability and increased mortality due to comorbid physical illness or suicide. In North America, older white men constitute the demographic group most at risk for completed suicide. We also know that almost none of these suicides are the result of a rational decision to die with dignity. Rather, they are caused by depression, alcohol misuse or a combination of both.

Suicidality associated with late-life depression can resolve completely when the depression is treated adequately. We have learned from more than 100 scientific studies that late-life depression can be treated at least as effectively as depression occurring earlier in life with antidepressant medications, standardized psychotherapies and electroconvulsive therapy. This is true even among the oldest olds, those in their 80’s and 90’s.

Some recent studies are also demonstrating that depression can even be prevented in selected groups of older adults at high risk for depression, such as those suffering from stroke or macular degeneration. Similarly, other mental disorders occurring in late life such as schizophrenia, anxiety disorders, alcohol abuse or cognitive impairment and behavioural disturbances associated with dementias can be treated effectively. Like most common physical ailments afflicting older adults – hypertension, diabetes, heart failure – these mental disorders cannot be “cured,” but their symptoms can be alleviated and the associated morbidity and disability can be prevented.

Unfortunately, despite these advances, data show that many physicians are unlikely to recognize and diagnose addiction and mental health problems in older adults. Older adults presenting to their primary care providers complaining of depressive symptoms are half as likely as younger adults to receive a diagnosis of depression. More than half of older adults in the early stages of Alzheimer’s disease are not diagnosed. When diagnosed with depression or dementia, most older patients do not receive treatment, or when they are treated, it is typically inadequate. When a “happily married” 40-year-old woman who has “nothing to be depressed about” reports to her physician that she feels miserable and is crying all the time, she will be promptly started on an antidepressant or referred for counselling. When the same complaints are reported by a frail widow in her 70’s, her physician will typically think “I would also be depressed in her situation.” Her depressive symptoms, having been “explained away,” will remain untreated. She will continue to suffer for weeks or months unless she kills herself, or more often, lets nature follow its course and lets herself die by neglecting her physical needs. Why is this older person less deserving of treatment than a young adult? Why is her depression less deserving of treatment than a hip fracture? If she had fallen down a flight of stairs and broken her hip, the orthopedic surgeon would not have ignored her because her fracture “made sense.”

Older adults battling with mental health problems or addiction face a double stigma. Contemporary Western society is obsessed with youth and health. It fears, or at best ignores, mental illness and aging. This has to change. Why should we care? Today, these older persons are our grandparents, our parents, our aunts and uncles. In 20 to 40 years they will be us.

Dr. Benoit H. Mulsant is physician-in-chief of the Centre for Addiction and Mental Health in Toronto, as well as clinical director of its Geriatric Mental Health Program. He is also a vice-chair of the Department of Psychiatry at the University of Toronto.

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