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Discussion, Thursday

On seniors and mental health

Expert takes your questions

Globe and Mail Update

Mental illness knows no age. It can strike children, but it can also strike seniors.

And like so many things affecting mental health issues, society has its share of prejudices, including those around mental illness in the aging population. There are no major "runs for the cure" or gala fundraisers in this field. The very few health-care professionals who understand both geriatric and mental-health care are stretched thin.

But there are those working to change that, including Dr. David Conn, co-chair of the Canadian Coalition for Seniors Mental Health and a geriatric psychiatrist, who will be joining us Thursday at 12:30 p.m. ET for a live discussion on the subject of mental health and the aging population.

Do you worry about the mental health of an elderly parent? Are you confused about medications? Do you want to know more about the health of the aging brain? Send your questions now and read Dr. Conn's answers, which are being posted at the bottom of this page.

Dr. David Conn is currently the Vice-President of Medical Services and Academic Education and Psychiatrist-in-Chief at Baycrest Centre for Geriatric Care and Associate Professor in the Department of Psychiatry, University of Toronto. He is the Co-Chair of the Canadian Coalition for Seniors' Mental Health and Chair of the Coalition's National Guidelines Project. He is Past President of the Canadian Academy of Geriatric Psychiatry.

Dr. Conn completed his Medical Degree at Trinity College, Dublin, and his training in psychiatry was carried out at the University of Toronto. He subsequently completed a Fellowship in Consultation-Liaison Psychiatry at the Massachusetts General Hospital in Boston. He joined the Department of Psychiatry at Baycrest in 1983 and has been the Department Head since 1992. He has a keen interest in telemedicine and is currently the Medical Director of Telehealth Services at Baycrest. He is also Medical Director of the Mood and Related Disorders Clinic and Co-Director of the Brain Health Centre.

His academic interests include nursing home psychiatry, the psychiatric consequences of brain disease in the elderly and late life mood disorders. He is the co-editor of three textbooks including "Practical Psychiatry in the Long-Term Care Home: A Handbook for Staff". He received the 2005 Canadian Academy of Geriatric Psychiatry Award for Outstanding Contributions to Geriatric Psychiatry in Canada.

Editor's Note: editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Christine Diemert, Thanks for joining us today Dr. Conn. This is a subject that has a particular interest for me because I, like many people in my generation, have an aging parent whose care at times has become a central cause for concern in the family.

I get the sense depression is something many seniors battle. Is this true? Are depression and anxiety issues fairly common among the elderly?

How often are seniors prescribed anti depressants and how well is their progress monitored when they are taking these drugs? Also, how well does that type of medication mix with others many seniors take, such as blood thinners or heart pills? Is it possible they become a toxic cocktail?

Dr. David Conn: Depression occurs frequently among seniors. It is important to note that there are different types of depression ranging from transient depressive symptoms which can occur as a reaction to a loss or stressful situation to serious Clinical Depression (or major depression) which is more severe and persistent and is often accompanied by physical symptoms such as sleep and appetite disturbance and low energy & motivation. Depression can also be chronic, even lifelong in some individuals (called dysthymia).

Antidepressants are frequently prescribed especially in settings where depression is more common such as nursing homes. About 25 per cent of nursing home residents are receiving an antidepressant. These medications may be prescribed for depression or serious anxiety or sometimes for agitation or insomnia.

It is important that they be monitored regularly especially early during a course of treatment. Drug interactions can occur for example the level of blood thinners can increase so it is very important to monitor for this.

I also want to stress that psychosocial interventions can be very effective for some individuals eg psychotherapies (talk therapies). For example There is lots of evidence that CBT (cognitive behaviour therapy) works very well. However - it may be hard to find qualified therapists in many areas.

Gregory Alan Elliott from Canada: When all is said and done, if they have a life partner who loves them, all of these challenges seem unimportant. I'd rather lose my mind and be truly loved by someone who I love, than be perfectly sane and alone.

Dr. David Conn: Thanks for your comment. Certainly having support makes experiencing mental health issues a lot easier than facing these challenges alone. I do think it is important to recognize that the challenges of mental health and dementia can have an impact on family caregivers, and in fact can increase their risk for depression. If you are supporting someone with mental health issues it is important to make sure you get support too!

Jenny charbonneau from Canada: In my opinion, seniors need professional, experienced, non-judgemental, non religious, caring, supportive, firm care from intelligent, caring, concerned, talented educated mentally well non violent experienced workers. They are hard to find.

Dr. David Conn: Hi Jenny. (I would like to mention that Kim Wilson the Executive Director of the Canadian Coalition for Senior's Mental Health is assisting me with some of these responses.) It can be a challenge to find health care providers who are trained to work with seniors with mental health issues. There are some groups working to improve the training of professionals, including the CCSMH, the National Initiative for the Care of the Elderly, and the Geriatric Education and Recruitment Initiative.

You may also want to explore the Canadian Academy of Geriatric Psychiatry, the Canadian Gerontological Nursing Association, and the Canadian Geriatrics Society. There is also a 'Care of the Elders' program that is offered by the College of Family Physicians. Certainly those who work in the field recognize that there is a shortage of trained professionals and are advocating to ensure there are more trained to work with older adults with mental health issues.

Nicole Campbell from Canada: Can you please comment on the role of physical activity and mental health. Does strength training and aerobic training improve mental health?

Dr. David Conn: There have been many positive studies of the effects of exercise on mental health and especially depression, including a variety of studies of older adults. Many of these studies suggest very good benefits.

A recent scientific review of these studies was published as a Cochrane Review (a process that tries to integrate all of the best scientific studies). I'm inserting a summary below.

Overall it suggests modest benefit for depression. I believe that for severe depression exercise can help but additional interventions are generally necessary.

1: Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004366.

Exercise for depression.

Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA.

School of Clinical Sciences and Community Health, University of Edinburgh, Room F1424, Royal Infirmary, Little France Crescent, Edinburgh, UK, EH16 4SA.

BACKGROUND: Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychotherapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression.

OBJECTIVES: To determine the effectiveness of exercise in the treatment of depression.

SEARCH STRATEGY: We searched Medline, Embase, Sports Discus, PsycLIT, the Cochrane Controlled Trials Register, and the Cochrane Database of Systematic Reviews for eligible studies. In addition, we hand-searched several relevant journals, contacted experts in the field, searched bibliographies of retrieved articles, and performed citation searches of identified studies. We also searched

SELECTION CRITERIA: Randomized controlled trials in which exercise was compared to standard treatment, no treatment or a placebo treatment in adults (aged 18 and over) with depression, as defined by trial authors. We excluded trials of post-natal depression.

DATA COLLECTION AND ANALYSIS: We calculated effect sizes for each trial using Cohen's method and a standardised mean difference (SMD) for the overall pooled effect, using a random effects model. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis.

MAIN RESULTS: Twenty-eight trials fulfilled our inclusion criteria, of which 25 provided data for meta-analyses.

Randomisation was adequately concealed in a minority of studies, most did not use intention to treat analyses and most used self-reported symptoms as outcome measures.

For the 23 trials (907 participants) comparing exercise with no treatment or a control intervention, the pooled SMD was -0.82 (95% CI -1.12, -0.51), indicating a large clinical effect. However, when we included only the three trials with adequate allocation concealment and intention to treat analysis and blinded outcome assessment, the pooled SMD was -0.42 (95% CI -0.88, 0.03) i.e. moderate, non-significant effect. The effect of exercise was not significantly different from that of cognitive therapy. There was insufficient data to determine risks and costs.

AUTHORS' CONCLUSIONS: Exercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant.

Further, more methodologically robust trials should be performed to obtain more accurate estimates of effect sizes, and to determine risks and costs.

Further systematic reviews could be performed to investigate the effect of exercise in people with dysthymia who do not fulfill diagnostic criteria for depression.

Lawrence Braul from Calgary: Dr. Conn, My name is Lawrence Braul and my organization in Calgary (Trinity Place Foundation of Alberta - operates a 70 bed facility for older adults who have exhausted their housing options due to concurrent disorders; typically addictions and/or mental illness and chronic physical conditions that impact mobility.

Approximately 40 out of 70 have a persistent mental illness and a lengthy history of homelessness.

I wonder if you could comment on the impact of stable affordable housing and the need for facilities that provide appropriate supports for the older adult living with a chronic mental illness?

We employ a harm reduction methodology and offer a wide array of services including medication prompting, regular physician rounds, recreation therapy, personal care, light house keeping, and meals.

Treatment is not required but offered and encouraged. In the past year one surprising result was that 11 residents transferred to a more independent setting after spending six to twelve months in the residence.

I would be interested in your comments about the efficacy of a harm reduction approach to treating chronic mental illness among older adults. Are you aware of programs that are particularly effective using other methods?

Dr. David Conn: Hi Lawrence, It sounds as though your program has had some impressive results. It sounds as though you offer a full array of positive supports and interventions.

Harm reduction is certainly a critical component in a care plan. It is wonderful to hear that many of your residents have been able to move to a more independent setting!

Beryl Russell from Ottawa: Hello Dr. Conn, my question: Do you consider that elderly patients who present symptoms of confusion are at a disadvantage in terms of accessing rehabilitation after a fall or a stoke? If an elderly patient can be rehabilitated, at minimum in terms of physical gains, is it ethical that they be refused access to rehabilitation on the basis of fluctuating cognition?

Dr. David Conn: Hi Beryl, This is a major issue and a challenge.

Confusional states such as delirium are exceedingly common after a stroke or an orthopedic injury e.g. a fractured hip.

The person is temporarily disoriented and may be agitated and distractible. The rehab staff may feel that they cannot fully participate in the rehab program.

There is a movement now towards Slow Stream Rehab which recognizes a subgroup of patients who will require extra care and time in order to recover.

I agree that this raises some serious ethical and resource issues.

By the way the Canadian Coalition for Seniors' Mental Health published Canadian Guidelines on the care of individuals with delirium as well as 3 other sets of Guidelines on Depression in Seniors, Suicide assessment and prevention and Mental health issues in Long term Care. These Guidelines can be downloaded from

Jane Cayley from Canada: Hello from Kelowna BC Can you pls tell us - what are the key indicators that an elderly person is suffering from dementia?

Dr. David Conn: Hi Jane, The Key indicators include:

a) Some kind of memory impairment (usually short-term memory loss initially).

b) Language impairment e.g. difficulty finding words or understanding certain words.

c) Trouble recognizing certain things such as people's faces.

d) Difficultly carrying out certain basic actions such as trouble dressing oneself (called apraxia).

e) difficulty with certain high level ("executive") functions such as planning or organizing activities.

In addition these changes must represent a distinct change over time and result in problems with functioning socially or occupationally.

Other changes can include personality or behaviour changes which can result in socially inappropriate actions. These changes are common in a disorder called Frontotemporal Dementia.

Brenda Dunn from Canada: When our Aunt had a breakdown 13 years ago at 77 her Dr put her in a nursing home with no anti-depressants. They told the family just to leave her there, she'll get used to it.

It took me months to get her proper treatment. She has been at home with her daughter now for 12 years. She has had a few relapses, again they want to put her in a nursing home. She lives with her developmentally delayed daughter and as long as they can manage she will stay home.

We have to fight to keep her on her anti-depressants, they figure at her age she doesn't need them. How many more people are in nursing homes because people think Drs know best?

Dr. David Dunn: First of all I agree that the decision to enter a nursing home should be carefully considered. For many people staying in their own home for as long as possible with maximum family and community supports is ideal.

On the other hand for some individuals nursing homes offer a good alternative.

When the person is very isolated and has few supports and multiple problems (mental health and physical) the care and support offered in LTC can be very beneficial.

I agree that the role of the physician or health care professional should be to assist in the decision-making process not to impose their views. The issue of risk must also be considered and carefully weighed.

You also note that you had to battle to keep your aunt on antidepressants. For individuals with chronic severe depression staying on antidepressants (often for life) is vitally important and can allow them to live full and productive lives.

Alan McRoberts from Canada:My mother recently had surgery and since returning home has been often confused, angry and depressed. She seems to be doing OK physically but mentally she is acting very strangely.

Dr. David Conn: Hi Alan, As I mentioned previously delirium is very common after surgery. It has multiple possible causes including infections, drugs, anesthetic, changes of blood levels of glucose or electrolytes (like sodium and potassium) or a variety of other illnesses which may be co-existing.

It is important to have your mother assessed to ensure that she doesn't have an underlying illness or complication that needs treatment.

Depression can occur during delirium as well as other mood swings. One common symptom of delirium is day night reversal (insomnia plus day time drowsiness).

It is also important to rule out depression as the primary problem BUT I would start with asking the physician to rule out causes of delirium.

Christine Diemert, Thanks for joining us today Dr. Conn, and thanks to Kim Wilson, executive director of the Canadian Coalition for Seniors' Mental Health, for adding her voice. Before we conclude, is there anything either of you would like to add?

Dr. David Conn: Hi Christine, I would like to thank you and The Globe and Mail for your outstanding advocacy work in creating and developing this series on Mental Health challenges in Canada.

Seniors are particularly vulnerable to developing mental illnesses including mood and anxiety disorders, psychotic illnesses and the complications of many brain disorders such as Alzheimer's Disease and other dementias.

Our health and social services in Canada vary in terms of availability with huge discrepancies across the country.

Many organizations, including the Canadian Coalition for Seniors' Mental Health and the key organizations on our Steering Committee, are trying to advocate for improved services and best clinical practices.

Hopefully we will be able to care for our aging population with excellent care and compassion in the years ahead.

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