HEALTH PROMOTION AND AGING
    "MENTAL HEALTH"

Barry J. Gurland,  M.D.* and Barnett S. Meyers, M.D.+

* Director and Borne Professor of Clinical Psychiatry, Center for
Geriatrics,  Columbia University and NYS Office Of Mental Health.
+ Associate Professor of Clinical Psychiatry, New York Hospital
and Cornell Medical Center.

Intgoduction: The emphasis in this paper is on the direction that
health promotion efforts might take to enhance the mental   health
of   the  elderly  by building on the established effectiveness of
primary,  secondary and tertiary health care interventions.   This
approach  accepts  that health promotion strategies should invoke
the capacity of elderly persons to take responsibility for   their
health  style   and  care decisions and should thus make available
the requisite information and a social   and   service   environment
which  allow8 a   proper   role in   such decisions;   and that in-
dividuals at high risk for mental health problems should be   tar-
geted  for special efforts in health promotion as well as screen-
ing,  risk appraisal and early intervention programs.

Partly because of space limitations,   this paper does not do JUS-
tice to   the  complexity   and  activity  of developments in this
field.  A supplement will be available to address two substantial
limitations in the coverage of this review:

1.   The   set of   conditions which are discussed here are not in-
tended to be exhaustive: The specific   mental   health   conditions
chosen to illustrate the discussion are in the realm of dementia,
delirium,  schizophrenia,  depression,  and anxiety.  Taken together,
these   conditions  constitute the great maJority of severe mental
health problems among the elderly (alcoholism is omitted   because
it  is covered in another background paper).   Notably missing are
problems which lie in the range   between   severe   conditions   and
normal    states:    Low  morale,   grief  reactions,    loneliness,
diminished  self-esteem,   age   related  slowing of   intellectual
processes,   loss  of creativity and productivity,   reduced social
engagement   and  activities,   lack of. friendly  relationships,
changes in sexual performance with aging, and the like. These are
not less important or less accessible to preventive interventions
than the more severe conditions which are discussed, although ar-
guably,  their consequences appear to be less devastating   and the
urgency of the need for interventions less pressing.

2.   The  types of   interventions   which   are   described   are not
restricted to classical health promotion  techniques:   Biomedical
treatments   are   covered on   the  grounds   that   these   are main
reference points in the content of health education,  in decisions
on mental health care that the elderly are called upon to  make,
in  restructuring of  social emvironments to foster autonomy and
self-care,  in the purposes of screening and in selecting modes of
early intervention.   However,   some widely used interventions do
not receive the space they deserve in this review: Such as stress

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management  including  relaxation exercises,  autogenic training,
biofeedback,  assertiveness training and self-hypnosis;   bereave-
ment  counselling,   easing   relocation  stress,   resocialisation,
memory training,  cognitive-behavioral methods of redressing self-
defeating ways of responding to perceived experiences, and skills
training in coping with problems;  and methods of empowering   the
elderly  through   involvement in   service to   others,   advocacy
groups,  resident's councils and the like. The central reasons for
the omission of discussion on these and many other   interventions

are   lack of   space   and   (in   some   instances)   their uncertain
relevance to the severe mental conditions that serve as the focus
of the paper.

Severe mental health problems:  Interventions aimed at  promoting
the   mental   health of  the elderly should be built on an under-
standing of   certain   characteristics of   severe   mental   health
problems among the elderly:

I.  The effects of age on mental health and its treatment;    as an
indication of what knowledge can be transferred   from  experience
with   youger   persons   and   what  is unique to old age. II.   The
frequencies of specific conditions and the sites at   which  they
may be   found; to  show the size and distribution of the public
health problem.   III.   The consequences of specific conditions in
terms of the distress,   disability and danger to the patient, and
disturbance to others;  as a gauge of the urgency of the need for
health promotion and preventive intervention. IV. The etiology of
mental health conditions;  as a guide to the potential for health
promotion and preventive   intervention. V.   The  ways in   which
problems  are amenable to prevention;  with respect to the onset,
relapse or consequences of disease. VI.   The barriers to seizing
the  opportunities   that   may   arise   for   intervention;   and the
strategies and needed resources   for  enhancing   the   chances of
successful intervention.

I-The effects of sue on mental health and its treatment.

There   are   three   broad   groups  of elderly patients with mental
health problems: 1.   Those who  developed   their  problem  during
adult -life and have since grown old.   2. Those who have a problem
which more commonly presents in adult life but in   this   instance
is   of late onset. 3.   Those whose problem typically presents in
old age.

The fact that the person is chronologically elderly reveals   very
little   about   the   circumstances  surrounding a   mental   health
problem because the elderly are a differentiated group.   Only in
some  elderly do   mental   health  problems acquire a distinctive
'geriatric character';  that is show the effects of age:

1.  On the clinical presentation:  The picture of mental illness in
old age is largely similar to   that in   younger  patients;   the
specific   conditions   should  therefor be readily recognizable by
professionals familiar with adult psychiatry.   Exceptions to this
rule  are of significance to health promotion in that potentially

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treatable conditions may be overlooked: for  example,   depression
in   the  elderly is  often overshadowed by complaints of somatic
symptoms,  Or masked by ambiguous descriptions of distress such as
complaints of emptiness,  anxiety or unease.  SUbJeCtiVe report8 or
ObJective signs of memory impairment dominate the   clinical  pic-
ture in about 10% of severe depressions;  phobic anxiety is often
disguised as disability.

2.   On outcomes:  There is a tendency to underestimate the  poten-
tially good spontaneous and treated outcomes Lhat can be obtained
with  most mental conditions occurring in old age;   even relative
to the outcomes in younger patients. For example,   schizophrenic-
like   states   which  begin in old age (paranoias or paraphrenias)
even if untreated are less likely to show  progressive   emotional
deterioration,   inability to express thoughts coherently, or loss
of iniative than is typical for younger schizophrenics (Kay 1963)
The symptoms of adult onset schizophrenia become less troublesome
to the patient and others if the patient   survives to   old   age.
However,    some  aspects of mental illness become more severe with
agei  suicidal efforts are more determined,   delusional depression
is frequently a serious problem  (Meyers and Greenberg 1986).

Paranoia   tends to  respond well to pharmacological treatment if
the compliance of the patient is   maintained   (Post   1984b3);   the
proportions  of elderly with depressions who return to normal and
symptom free function after treatment are not substantially   less
than in   younger  patients  (Georgotas et al 1985;   Godber et al
1987).  While it is true that the prognosis for the primary demen-
tias is generally gaurded at the present,   a small but  importamt
proportion of  suspected   cases turn out to be treatable and re-
versible conditions.

The successfulness of intervention in the elderly   may   sometimes
be  obscured and overlooked because of the complexity of adequate
treatment and the care required in its   administration.   Compared
with   younger   cases,   depressions  in the elderly maybe somewhat
more difficult to treat  because of physical complications   which
frequently  accompany it   and   the   age   associated  adJustments
required in medication regimes.

3.   On pharmacological treatment:   Pharmacological   interventions
for  elderly patients are given in a context of geater complexity
than for younger patients.   The elderly patient  frequently   has
multiple   conditions  and correspondingly is often found to be on
four,   five or more medications;   probably   from   more   than   one
prescriber and several other sources such as over-the-counter and
stocks   of hoarded medications.   There age related alterations in
metabolism,  protein binding, distribution,  and sensitivity to and
excretion of psychotropic medications which demand  greater   care
and  special  experience with administration of medications.   The
elderly are particularly vulnerable to anticholinergic   side   ef-
fects  of psychotropics and to medication induced delirium.   With
certain medications (e.g.   tertiary tricyclic antidepressants) it
takes  longer  than in younger patients to achieve a steady state
of the blood levels of the parent medication and its active meta-
bolites,  and smaller daily doses are needed to obtain therapeutic
blood levels.  It is not surprising that there is a higher risk of

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drug interactions and side-effects in the elderly: toxic or in-
teractive side effects are relatively common.

Accordingly,   dosage   and  administration of psychotropic medica-
tions must be adJusted to allow for age   related  changes.   Usual
practice is to   start   low   and  increase dosage slowly but the
clinician must avoid falling over backwards through giving overly
cautious treatment.  Although there are a few studies  suggesting
that    moderate  dosages  may be  effective,     a  high   rate of
therapeutic success will depend   upon a  willingness to   pursue
treatment   with  intensity   and   duration   where  necessary;   the
cooperation of the patient  (and in many cases the family or other
caregiver) is crucial to the success of such treatment.

4.  On service patterns: The elderly may be   reluctant to  bring
their  incipient  mental health problems to sites offering expert
treatment (for example,  community   mental   health   centers). To
address   rather   than  overwhelm these resistances,   the services
need to reconsider their own organization, attitudes,   procedures
and location as well as channels for better informing the elderly
about the resources and benefits which are being offered.

Since many elderly patients with mental health problems have mui-
tiple conditions which cut across disciplinary boundaries,   their
use of services differs from that in   younger  patients.   Mental
health problems are likely to present in medical and social serv-
ice  settings:  psychiatrists  may have to expand their skills to
include  primary   medical   care   and  conversely,    primary   care
physicians   may  have to acquire psychiatric skills;  bridges be-
tween social and medical settings are vital.

The elderly patient will on average require the spending of   con-
siderable time for screening,  comprehensive or multidisciplinary
evaluation of their problems,  the eliciting of appropriate   com-
munity   resources,   and  the arranging of referrals as necessary.
Coordination of services (case management) becomes  important in
order  that the patient does not become lost or receive redundant
and possibly deleteriously interacting treatments.

5,  On the base rates of specific psychiatric disorders.   Preven-
tive  services to the elderly must be matched to the age specific
probamlities of specific mental health problems.   The   dementias
and   deliria   become   much   more  common with advancing age while
schizophrenic syndromes decrease.  The rates of depression remain
considerable in   clinical  populations   but  despite stereotypes
about the adversities of old age there is not an excessively high
rate of maJor  depression   and   nor   other  types of  depression
(Robins et al.  1984) among the general elderly population; it is
clear that it is not normal for the elderly to be  depressed   and
the goals of health promotion should take this into account.

6. On the person's support system.  Most elderly are women, tradi-
tionally   the   heaviest   users of   mental health services at all
ages.  Very old women are likely to be widowed;  they can be dif-
ficult, to reach with health promotion information or to draw into
treatment  and maintain in the community,  especially if there is
no family to act as a line of communication or to  replace   the

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care and attention formerly given by the spouse.   However,   about
two thirds of the elderly live with someone else in the household
and around 80% have a family member or friend who is  willing to
help   look  after them.  Thus there is usually an opportunity for
health promotion efforts to draw upon the assistance of   the in-
formal  support   network.   Nevertheless,   there is a call for ex-
traordinary determination on the part of   health  promotion   and
prevention services to reach the needy segment of the elderly who
are truely isolated.

Comment:  Age induced alterations in mental health and its treat-
ment are sometimes for the better,   not  always   for   the   worse;
either   way  they  require   new  understanding of the biolcgical,
psychological   and   social  processes of  aging in    order    to
adequately  plan   for   health  promotion and preventive interven-
tions.

Some older patients   are   like   younger  patients   and   some   are
different; it  is these latter who require special geriatric ap-
proaches.  The principles of geriatric interventions to  improve
mental   health  are modifications of those governing adult mental
heath strategies.  Mental health professionals who are interested
in  reaching the elderly must master an additional knowledge base
and set of skills,  and expand the organization of their referral
network for health promotion,   screening,  consultation,  community
services and relocation;   and  will need a deep interest in,   and
empathy with,  the problems of the aged.

There is no Justification for setting the goals of treatment at a
lower level for the elderly than for younger patients; either be-
cause of a presumed lesser ability to respond to treatment or the
even   more   dubious  grounds that they have a briefer life expec-
tancy or less need to be optimally functional.

II.  The frequencies of specific conditions and the sites at which
they may be found.

DEMENTIAS AND DELIRIA: The   dementias   are a   set of  typically
chronic  syndromes in   which  the most striking features involve
deterioration of memory,   orientation,   general intellectual   and
specific  Cognitive capacities and social functioning;   occurring
in clear consciousness and  arising  usually   after   intellectual
maturity has been reached.

Among   dementias in  the general elderly population about 60% or
more are Alzheimer's disease type,   10% or less are a  relatively
pure   multi-infarct   (or   other  cerebra-vascular) type and 1.5% a
mixture of the last two;   the  remaining   15%   are  secondary to
neurological   diseases   such as  Huntington's   Chorea or Parkin-
sonism,  or a so-called reversible secondary dementia arising from
such     causes     a6    intracranial   lesions,     normal    pressure
hydrocephalua,  a systemic condition or depression.

Persons with primary or secondary dementia who reside in the com-
munity   constitute   about 5%  of the elderly (i.e.   65 years and
over) population;  persons with these dementias who reside in long

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stay institutions are a further 2 l/2% of the elderly  population
(although  they  constitute up to 50% of the long stay residents)
(Gurland and Cross 1982). Therefore,   most dementias live outside
institutions.

Rates of   dementia  rise steeply with age and reach 20% over age
80.   Incidence varies from less than 1% annually at  age 70 to
around 4% at age 85.  The lifetime risk of dementia is around 1 in
3 for males who survive to 85 years.   Women are probably not more
prone to develop dementia but many more of them   survive to   ex-
treme old age where the risk is highest.

The  dementias must be distinguished from the deliria (acute con-
fusional states),  which share some of the main symptoms of demen-
tia but are relatively acute in onset   and   course,   and   show a
clouded or  hyperaroused   alteration   of consciousness.   Deliria
typically result from  systemic   disorders  arising   outside   the
cranium.

Deliria    are  frequent in medical settings,   especially where the
prevailing physical illnesses are acute and severe; some level of
cognitive  impairment   (not  necessarily  meeting   criteria    for
delirium)  has been reported in as much as 25% or more of elderly
patients in such settings  (McCartney and Palmateer 1985).

SCHIZOPHRENIA: Symptoms of schizophrenia occur in old age in   two
main   contexts: 1. As a  result of the aging of schizophrenics
whose condition began prior to old age. 2.   As part of a late on-
set  primary  psychiatric disorder known as late-life paraphrenia
in European psychiatry and as paranoia in DSM-III.

Up to half the long stay patients in  large  psychiatric   centers

are  elderly   (Goodman and Siegel,   1986) and about half of these
are-schizophrenics of earlier onset who have grown old;  many of
these aged schizophrenics are placed in nursing homes, especially
if chronic medical problems have supervened.

Paranoia is  chronic but not progressive,   has a predominance of
paranoid delusions and often hallucinations and leads to  supris-
ingly little impairment of affect,   volition or intellect.   Among
psychiatric first admissions with symptoms of schizophrenia,   10%

or  mor'e begin after middle age (Rabin,s 1984,   Volavka and Cancro
1986 1.  Paranoia is found in about 10% of psychiatric first admis-
sions after the age of 60;   in upwards of 3% of  elderly  nursing
home residents and less than 2% of the community residing elderly
population.  Paranoia is predominantly a disorder of women, partly
because  this gender is the maJority group in the elderly popula-
tion but also because of a much higher risk for this disorder in
elderly women than in elderly men;  in contrast to the gender risk
for adult schizophrenia.

DEPRESSION:   The   cluster of  depressions of  all types,   major
depression, dysthymia,  cyclothymic disorder and atypical depres-
sion   but  including also dysphorias considered to be of clinical
interest,   is in   the  region of   13% of   the  general  elderly
population;   with  maJor depressions accounting for l-2%.   In in-
patient settings  the depressions of all types usually   constitute

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about half the admissions,  with maJor depressions the predominant
type-  Depressions of clinical interest are also frequent in out-
patient psychiatry and in primary medical   care; in   the   latter
site   the  maJor depressions are a minority of cases  (Sireling et
al.  1985) while masked and atypical depressions are common.

ANXIETY:  It is perfectly reasonable to expect   that   the  elderly
would suffer high rates of anxiety given the frequency with which
their   life   situations   appear  precarious.    Nevertheless,   the
prevalence of anxiety disorders in   the  general  population is
around   10% of  elderly    women  with the maJority of these being
phobias,   especially agoraphobias (Turnbull and   Turnbull   1985) ;
prevalence in males is around half that in females.   Anxiety dis-
orders in the elderly are seen more frequently in  primary   care
practice than in psychiatric settings;  reflecting the observation
that sedatives and hypnotics are widely dispensed by primary care
physicians.

III.   The  consequences of   specific   conditions in terms of the
distress,   disability and danqer to the patient,   and disturbance
to others.

DEMENTIA AND DELIRIUM:  The primary dementias are invariably disa-
bling  as the disorder involves first the higher order tasks such
as work,   handling finances,   finding the way in  public  places,
shopping or doing household chores;   at a later stage,  the simple
self care   tasks   such as  bathing,   dressing,   use of  toilet,
mobility,  continence and feeding.  Dependence on others for assis-
tance  and supervision increases over time.   Parietal dysfunction
(difficulties in  naming or  understanding   the   use of   common
ObJects)   obtrudes as   the disease advances and,   in the closing
stages,  seizures,  spasticity,  profound weight loss,   intercurrent
infections and coma.  Life expectancy is considerably shortened by
dementia  unless assiduous nursing and medical care keep the com-
plications (e.g. undernutrition,   aspiration of food,   infections
and   other  overlooked medical illness,   contractures,   bedsores,
overmedication,  and falls) under control.

Disturbing behaviors are   very  frequent:   Aggression,   nocturnal
restlessness,   wandering,   and incontinence are particularly dis-
ruptive a6d add to the heavy demands on  the caregiver's time   and

energy.   The  family may be devastated also by a profound erosion
of the patient's personality,   a dropping of standards of decency
and  a patient's apparent indifference to the caregiving.   Family
members are more often depressed than is the patient (Gurland and
Birkett 1983).

The consequences of deliria depend on whether   the   condition is
recognized   and  the underlying cause promptly identified and ap-
propriately treated. If so,   the   delterious   consequences   are
usually   limited   and   transient;   if not,   the mortality rate is
high,   and avoidable morbidity may   arise as a   result of   the
patient's confusion (e.g. falls and fractures).

SCHIZOPHRENIA:  The maJority of adult onset schizophrenics achieve
old   age.   About    one   third of   the   survivors  to old age have

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recovered virtually completely but the remainder   are   left   with
impaired  functioning;  including   around a   third  of the whole
cohort who have chronic or relapsing symptoms (Ciompi 1985).  With
age and the passage of time the person tends to   become  quieter
and   easier  to supervise or live with.   Nevertheless,  although
patients may have few troublesome symptoms,  poor social function-
ing or supports may make living in   the  community or  discharge
from  hospital difficult;  the promotion of health among this de-
pendent population can be facilitated by access to   enriched   al-
ternative environments in the community such as group homes.

The   onset of  paranoia is  usually fairly slow.   The person is
preoccupied by experiences of harassment, assault,   and intrusion
of  privacy;   and  eventually responds to the psychotic phenomena
with vigor,  making persistent complaints to authorities,  striking
back at  neighbors   because of  imagined   grievances,   trying
desperately to escape through flight or suicidal actions,    or en-
tering a state of withdrawn siege.   Emaciation,   shouting at hal-
lucinations,   pacing   and  moving  furniture around an apartment,
furtive nocturnal sorties and eccentric appearance may arouse the
concern of others;  leading to hospitalization or eviction   which
swells the ranks of the homeless.

DEPRESSION:  The distress of a depressive disorder is worse by an
order of magnitude than that of   normal  depression.   Other   mood
changes that accompany depression,  such as irritability,   apathy
and loss of interest in social roles may damage the interpersonal
and supportive relationships which are   vital to   the  patient's
tenure in the community.  The consequential costs are not only to
be measured in human terms;  there are also expenditures   due to
increased and inappropriate use of physicians services.

A  prolonged  episode of depression can lead to undernourishment,
dehydration,  inactivity and self neglect;   with serious undermin-
ing of   the  patient's physical health.   Mortality rates are in-
creased by depression in excess of that  explainable by   suicide
and declines in health behaviors;  one possible mechanism being an
alteration of immune mechanisms.

There are exceptionally high rates of suicide among elderly white
males.  This is a generational  (cohort) phenomenon and not due to
aging,(Gurland and Cross 1982);  future groups of  elderly   white
males   will  probably   have  lower rates as do current cohorts of
females,   and non whites.   Nevertheless,   the elderly tend to be
deadly  serious in their suicidal actions (their first attempt is
likely to be their last).  Behaviors which are potentially harmful
to the self (eg.  non compliance with medical regimes,   failing to
report warning symptoms of illness,  neglect of diet,  fighting, or
falling)   may  sometimes be analagous to suicide attempts.   These
behaviors are seen quite often among the elderly in nursing homes
and call for a search for an underlying depression.

ANXIETY:  Anxiety disorder has both an emotional   component   (e. g.
fear,   tension,   dread,  irritability and worried apprehension), a
behavioral component (e.g. distractibility,   complaints and reas-
surance seeking),   and,  especially in the elderly a somatic com-
ponent. The somatic symptoms of anxiety are both SubJective (e.g.

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feelings of respiratory restriction, palpitations, feeling shaky,
dizziness and headache or chest pains ) and ObJective (e.g. sigh-
ing and rapid breathing,  trembling, diarrhea, vomiting, coughing,
rapid pulse,  and sweating).  These'symptoms are not only distress-
ing but also can be disabling and exhausting.   Self medication or
inappropriate  presribing for relief of symptoms can lead to drug
dependence and other serious side effects.   Unnecessary and   even
harmful hospitalization may be precipitated by the presentaion of
the  anxiety  symptoms in   the  guise  of an acute medical (e.g.
cardiac) crisis.

IV.  The etiology of mental health conditions.

DEMENTIA AND DELIRIUM:  In Alzheimer's Disease   the  frequency of
microscopically visible senile plaques around nerve terminals and
neurofibrillary  tangles   inside   neurones in the cerebral cortex
(parietal,  temporal and occipital regions especially)   and  hip-
pocampal  region of  the limbic system,   is increased beyond age
norms (Blessed et al.   1968,   Katzman et al   1983 1 i   dendritic
processes and spines waste away.  There is still uncertainty as to
whether   these  neuropathological changes are the cause or result
of brain dysfunction,   and whether they are reversible up to a
point.

The   locus   coeruleus   and   Nucleus   Basalis  of Meynert are par-
ticularly  affected by   Alzheimer  changes,   and  through   their
proJections,   large   areas of   the   cerebral   cortex.   There is
degeneration of cholinergic neurotransmitter  pathways   essential
to memory processes;  choline acetyl transferase is decreased and
the  production of    the    neurotransmitter   acetylcholine    is
presumably   reduced.   The muscarinic receptors situated after the
neural Juncture (post-synaptic) are not affected. There are other
relevant structural and neurotransmitter changes but   this   basic
model  provides a rationale for the efforts to develop treatments
which would enhance acetylcholine neural transmission in dementia
through   use of   precursors   (e. g.   choline),    extenders  (e. g.
physostigmine) and agonists (i.e.   substitutes such as arecoline)
(Lauter 1985).

The fundgmental cause of Alzheimer's Disease is   not  known,   and
there is probably more than one.   In surveys of precursors,   head
trauma occurs more often than expected by chance. The presence of
amyloid and immunoglobulins in plaques in the brain   has   led to
the  suggestion of a brain tissue autoimmune disease;  changes in
brain antibody levels and the HLA histocompatibility System   have
given some support to this avenue of research.   Possibly a break-
down in the blood brain barrier allows access to  damaging   sub-
stances   such as  aluminum along the lines of dialysis dementia;
however the latter differs in important  respects  including   the
neuropathology. A   transmissible  slow virus has been sought but
found consistently only in kuru and Creutzfeldt-Jacob disease. A
familial  pattern   consistent   with an autosomal dominant mode of
inheritance has been reported  particularly in   the   severe   and
younger   cases  and those with focal signs;  penetrance increases
with age but may be complete by the age of 90.   There   are   also
clues   that  there may be a link with Down's syndrome (Heston and

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Maatri 1977) leukemia and an older age of the mother (and perhaps
tbe father) at time of the patient's birth;   abnormal   microfila-
ments   may be  implicated in   this  triad of disorders.   Recent
studies have linked one form of familial patterning with  trisomy
and a subsection abnormality on chromosome 21; thus adding to the
genetic    and  neuropathological  overlap   with   Down's  syndrome
(Delabar 1987).

Multi infarct dementia is characterized by   arteriosclerosis of
the blood vessels supplying the brain and numerous, usually small
cerebral infarcts.  Cognitive impairment rather than stroke is the
predominant presentation.   Presumably,  the well known predisposi-
tions to arteriosclerosis may play a role in multi infarct demen-
tia as well.

The causes of the reversible secondary dementias and of   deliria
are to   some   extent  overlapping:   intracranial lesions such as
hematomata (trauma induced  pockets of   blood  pressing on   the
brain) or tumors,   systemic conditions such as pernicious anemia,
or metabolic and endocrine disturbance.   Deliria may additionally
arise   from   toxic  states,   septic  agents,   drug  side effects,
anoxia,   or an intracranial infection.   Reversible dementias   can
further be  due to normal pressure hydrocephalus (enlargement of
the cerebral ventricles probably due to  inadequate  reabsorption
of cerebrospinal fluid).   or even depression.   Dementias may also
be secondary to  alcoholism,   Parkinson's  disease,   Huntington's
chorea,   Creutzfeldt-Jacob   disease  (caused by   a transmissible
agent that can be carried in transplanted   tissue)   and  repeated
head   trauma.   Neurosyphilis is currently still a possibility and
the AIDS virus may one day increase its attack on the   older   age
groups.

SCHIZOPHRENIA:  Among families of elderly patients with paranoia,
the risk of a schizophrenia is raised   but   not as  high as in
families of   earlier   onset  schizophrenics   (Funding 1961,   Kay
1963).  The risk among relatives is raised for both adult and late
onset types but with some loading towards the latter (Bridge   and
Wyatt 1980b).   It has also been suggested that the mode of trans-
mission is   recessive.   Women   are  particularly   vulnerable to
paranoia.   The   life  long personality is usually abnormal: Unso-
ciable,  cold hearted and prone to take offense;  isolated,   single
or divorced,  or with few sibs and few children (Kay et al.  1976).
        .J

In spite of an abnormal personality,  patients with paranoia main-
tain competence in the running of their own lives until the onset
of the illness in old age.  Socially evident deafness precedes the
psychosis in a  higher  proportion of cases than for depressive
disorder;   a severe degree of  hearing   loss   (as  indicated by
audiometric   tests   and   social  function) occurs more frequently
than in depressives or the general elderly population (Cooper et
al.  1976).  The deafness usually dates back several decades and is
of   the  type  (conductive or mixed) caused by chronic middle ear
disease and not by aging.

DEPRESSION:  There appears to be a spectrum of association between
old age depression   and  neuropathology;   with   the  majority of
depressive   disorders in  old age being Just as functional as in

F-10


younger persons.  The neurotransmitter (biogenic amine) hypothesis
is as valid for the elderly as for younger depressions; moreover,
there are age related changes increasing   monoamine   oxidase   ac-
tivity  (leading  to increased break down of the biogenic amines)
and decreasing the activity of tyrosine hydroxylase  (with reduced
production of biogenic amines)  which reinforce the rationale   for
biological treatment of some of the depressions in old age.

Life  events are variably related to the precipitation of depres-
sion among the elderly.  Most depressive episodes in old age   are
noted to be preceded by a negative life event, generally bereave-
ment or physical illness and disability;  depression and physical
illness occur together in the elderly at a far higher   rate   than
is expected by chance.  The absence of a confidante predisposes to
depression in   the   face  of a severe adverse life event.   These
facts seem in accordance with the widely held view   that in   old

age  depression is often a consequence of isolation and losses of
close persons,   health,   material resources and  status, as   are
likely to occur at this phase of life.

A   wide  variety of  medications may be depressogenic in elderly
patients:  especially   the  benzodiazepines,   barbiturates,     an-
tihypertensives, digitalis, L-dopa,  or anticonvulsants (Ouslander
1982).

ANXIETY:  Cases of anxiety disorder in the elderly (with persist-
ence of symptoms for at least a month) may fall into any of   the
following    broad    classes:    Panic    states    with or   without
agoraphobia,   other specific phobic states,   generalized  anxiety
disorder,  or adJustment disorder with anxious mood.   These diag-
nostic classes and their  etiologies   are  usually   identical to
those found in younger groups of patients.

V.  The ways in which problems are amenable to prevention.

1.  Prevention of onset.

DEMENTIA AND DELIRIA:  Community resources which can be applied to
supporting  the family have been mentioned as a means of prevent-
ing the onset of reactive mental illness and demoralization among
these ca?egivers.  Patients with dementia are at risk for superim-
posed delirium,   the symptoms of which may be  incorrectly   dis-
missed  as an advance in the dementia process;   cases of dementia
should be kept in mind for active preventive efforts.

Many of the potential causes of deliria can be avoided or treated
prior to their provoking the state of delirium.   Mostly this   in-
volves  providing  good~primary medical care and the early treat-
ment of such conditions as  pernicious   anemia,   thyroid   abnor-
malities (e.g.  hypothyroidism,  apathetic hyperthyroidism),  occult
infections,  malnutrition and dehydration.  Attention must be given
to controlling medications,  especially those with anticholinergic
properties,   and  coordinating prescriptions from all sources in-
cluding multiple service providers,  self medication and over-the-
counter drugs.

F-11


SCHIZOPHRENIA: The role of deafness in precipitating paranoia can
be understood as a paradigm for the effect of   poor   social   com-

munication   and   lack  of opportunity for reality testing in vul-
nerable individuals.   Other causes of poor  communication such as
the development of increased isolation in old age may explain the
late precipitation of paranoia.  The long latent interval between
deafness,  isolation and the onset of paranoia suggests that there
are opportunities for preventive intervention aimed at  improving
hearing impairments and social interaction.

DEPRESSION:   Key   life   events   are   markers  of vulnerability to
depression in the  elderly   person:   bereavement,   the   onset of
physical disability or illness,  and relocation to a venue that is
perceived as undesirable.  These are opportunities for counseling,
and  shoring up   social   networks;  especially involving or sub-
stituting for a confidante,  preparation for relocation (e.g. to a
nursing home) so as to inform and involve the entrant as a   par-
ticipant in  making   choices,   and  help   with  adJustment after
bereavement.  Among other external depressogenic agents,   medica-
tions rank high and should be kept to a minimum routinely.

ANXIETY:   The   exercise of  abilites which lead to experience of
mastery may help to allay general anxiety; continuation of social
activities may prevent the onset of restrictive agoraphobias.

2.  Prevention of consequences.

2.1 THROUGH EARLY RECOGNITION:  Given the highly effective   treat-
ments now available for a wide range of mental health problems of
the elderly,  it is important that remediable conditions be recog-
nized and treated early.  Many consequences of mental illness can
thus be averted:  The deterioration of   the  patient's   health if
deliria   are  not noticed and investigated so that the underlying
condition can be   reversed;   the   dislocation of   the  paranoid
patient   from   the  community  and the breakdown of the patient's
trust in the treatment team;  the loss of independence,   risk of
suicide,  emaciation and deleterious effects on concomitant physi-
cal  disorders in the patient with depression;   the social isola-
tion   and  drug  dependency   that   can   emerge   when  anxiety is
uncontrolled;  and especially the unnecessary distress that may be
inflicted on   the  patient.   In primary dementia as well,   early
recog'nition and intervention   can  prevent a   rift   between   the
patient   and  supporting family and the damage resulting from in-
discretions,  and can permit the patient and family to become edu-
cated about the contingencies for  which they must plan.

The difficulties that must be   overcome to   achieve   the  early
recognition  that paves the way to early intervention involve the
unfamiliarity of many practitioners with geriatric  presentations
of mental disorder,  the mixed and atypical symptom patterns among
the elderly that may make differential diagnosis complex, lack of
adequate testing and investigatory techniques,   insufficient time
given over to taking a history from the patient and  family    mem-
bers,   and  reluctance of patients to report their symptoms early
or to consult specialists where advisable.

DEMENTIA AND DELIRIUM:  Efforts at early recognition in   dementia

F-12


should first be directed at the identification of reversible con-
ditions,   which   are  found in up  to 20% of investigated cases
(Cummings 1983,  NIA Task Force 1980).

The first priority in assessing patients for possible dementia is
a history and a specific inquiry for symptoms of  depression or
delirium.   Next  steps   are  a physical examination and review of
medications as causes of deliria,   and a search for  neurological
signs or a condition associated with secondary dementia.

The  clinical recognition or exclusion of dementia is assisted by
brief clinically feasible tests (e.g. the Mental Status Question-
naire or Mini Mental   Status   Examination)  together   with   other
clinical   information. An   extensive  range of widely accessible
technical investigations of blood, urine, chest and heart are es-
sential to detect hidden causes of deliria;   and so is some   form
of  brain imaging (usually computerized axial tomography) to help
rule out an intracranial mass or normal   pressure  hydrocephalus,
or to  show up brain infarcts.  Neuropsychological batteries can
help to confirm a diagnosis of   dementia;   regional   blood   flow
studies or electroencephalograms can assist the identification of
the subtype of dementia.

SCHIZOPHRENIA: The onset of paranoia almost invariably arises out
of a  previously   abnormal  asociable personality,   after a long
prodrome.  There may be signs of an impending episode: The patient
appears at first to be merely embattled and aggrieved; the victim
of an unfriendly environment.  An increase of complaints and rest-
lessness may be noticeable.  As frankly paranoid symptoms   emerge
the   condition  must be distinguished from organic and depressive
syndromes.  A failure to begin treatment early may leave time for
the  patient's delusory suspicions  to include medications and the
health care team and lead to the patient's withdrawal and impreg-
nable resistance to receiving help.

DEPRESSION:  For the most part,  the criteria for diagnosis of the
depression subtypes may be applied to the elderly as is customary
for younger patients.   However,  in a minority of cases there are
special difficulties in diagnosing depression in the elderly   be-
cause of masking,  complication by physical illness,   or presence
of cognitive impairment or striking paranoid or anxiety symptoms.
           J

The masking of depression can be minimized by  routinely  probing
for depressed mood and associated symptoms. Furthermore, patients
who  have previously had a depression and are relapsing can some-
times convey that their previous symptoms are  returning   without
being   able to  pinpoint  a depressed mood.   This underlines the
value of continuing aftercare of recovered patients in   view of
the  high rate and often subtle symptoms of relapse among elderly
depressives.

Distinguishing   between   the   somatic  (vegetative)  symptoms of
depression   and   the  physical symptoms of medical illness or the
aging process is quite a common problem (Gurland and Toner 19821:
The somatic symptoms of depression include those usual for   adult

malor depressions but more often extend to discomforts, aches and
pains   which  may be vague or referred to a specific site such as

F-13


the chest,  abdomen,   urinary tract or oral area.   In medical ill-

ness,  symptoms such as loss of energy and interest,  sleep distur-
bance,   loss  of appetite and weight may resemble the symptoms of
depression;  and may precede   the  discovery of   the  underlying
physical   illness  (particularly with secondary carcinomas in the
brain,  apathetic hyperthyroidism,   carcinoma of the head of   the

pancreas,   uremia,  pernicious anemia,  heavy metal poisoning, or
collagen disease).  Where the differential diagnosis of depression
and physical  illness arises it requires a proper investigation of
evidence for both conditions and a detailed   examination of   the
symptoms  and their chronological sequencing.   Blood level assays
may identify   whether   there is a   medication   which  might be
precipitating the depression.

The  conjunction  of symptoms suggesting depression and cognitive
impairment    calls    for   distinguishing   depressive    dementia
(pseudodementia) from depression in dementia. Depressive dementia
is  discovered in about 4% of patients referred for investigation
of presumptive dementia (Rabins 1985).   These  patients   tend to
recover their normal cognitive functioning when the depression is
relieved   (Bulbena   and Berrios 1986);  although recent work sug-
gests that after an interval of wellness  (which may be lengthy) a
greater than chance proportion of   these   cases   may   emerge as
clearcut   dementia.   Recognition of   the   reversible  depressive
dementia is assisted by neuropsychological testing   (Caine   1981)
and   certain   clinical  features (described by Wells,   1979,   and
Rabins, 1985).

ANXIETY:  Aging produces an increased chance of anxiety being   ac-
companied by a physical disorder;  if the latter is present it may
produce  symptoms   that  overlap with the anxiety symptoms making
differential diagnosis more difficult.   In cases of late onset of
anxiety   disorder a  determined search for a possible underlying
physical condition should be instituted (Lader 1982).   Even where
the anxiety disorder occurs alone the physician may be unduly in-
fluenced by  the age of the patient to interpret the symptoms as
indicating a physical (e.g.   cardiovascular) disorder with a con-
sequently misdirected emphasis in investigation and treatment.

Several physical disorders are particularly likely to be misdiag-
nosed as anxiety because they produce trembling, tachycardia and
hypesexcitability (eg. hypoglycemia, hyper-thyroidism); or dread,
bewilderment,   weakness,   dizziness,   resp-iratory   distress   and
sweating (eg.   silent  myocardial   infarct,   pulmonary   embolism,
small stroke or cerebral ischemic attack).   Other physical condi-
tions mimicking the symptoms of anxiety include excess intake of
caffeine,   sympathomimetic  medications in non-prescription drugs
for colds or allergies,  and the withdrawal symptoms of sedatives,
hypnotics or alcohol.  Probing for a depression underlying anxiety
symptoms is also a high priority since the depression if  present
would then be the main target of intervention.

Phobic anxiety cases may not be recognized when fear or avoidance
of  a situation is rationalized as a disability due to frailty or
chronic physical disorder.   Opportunities for rehabilitation   may
thereby be missed.

F-14


2.2 THROUGH EFFECTIVE TREATMENT:  Most mental health problems of
the elderly offer the prospect of complete return to normality or
at least substantial improvement,  if treated appropriately and in
a timely fashion.  This is in contrast to such physical disorders
as  stroke,   heart   disease or  cancer where permanent damage is
usually incurred at or preceding the time of Onset of  symptoms.
Conditions  such as maJor depression,  dysthymia,   paranoia,   and
general anxiety are for practical purposes as functional (without
permanent structural damage) in the  elderly as in   the  young;
these   conditions  do not in general herald the onset of dementia
or other declines associated with aging.

However,  the functional mental health disorders of   the  elderly
often   have a  long   duration  if neglected,   and may become ir-
retrievably chronic if treated too   late.   Thus,   the  successful
treatment of   these  disorders will truncate the episode,   lower
prevalence rates and prevent years of   individual  suffering   and
disability; as  well as remove the risks to which the patient is
exposed while ill (e-g of suicide).

Treatment of these 'functional'   conditions in   the  elderly is
remarkably   effective if  applied  with skill and determination;
treatment of some organic disorders such as delirium is  equally
effective.  In the case of primary dementia, effective treatments
are currently directed at secondary symptoms;   treatments for the
the basic intellectual changes are still evolving.

DEMENTIA:   The  treatment of a primary dementia should follow the
ruling out of reversible conditions that resemble it.

The specific treatment of Alzheimer's disease is not yet   out of
the   experimental   stage.     Current   understanding of    the
pathophysiology of this condition has led to the  abandonment of
treatments   aimed at  combating  anoxia and has turned attention
away from drugs (such as hydergine) with uncertain   and  marginal
effects   towards  those which fit the rational cholinergic model.
There are several variations on this latter theme: (a) Choline, a
constituent of normal diet,   in the   concentrated   form of   oral
lecithin; to  promote  production of  acetylcholine.    (b)   An-
ticholinepterase  (e.g.physostigmine)  parenterally    (and     more
recently,  orally) with the intention of allowing  accumulation of
acetylcholine at   nerve  endings by  preventing   its breakdown.
Physostigmine is short acting,  but newer drugs of this class are
being tried (e.g.   tetrahydroaminoacridine).  (c) Arecoline or the
longer acting oxotremorine,  in an attempt to bypass the impaired
neuron  and  stimulate post  synaptic receptor sites since these
remain intact.  (d) Piracetam to increase the activity Of  neural
cells and perhaps increase the firing rate.

Interventions   derived   from   the  cholinergic  hypothesis of the
dementia deficits   have   led to  measurably  improved  cognitive
functioning  in some studies but not yet of a degree and duration
that has clinical significance.   The search will continue for an
effective  drug with a lasting action and tolerable side effects,
which can act at specific cholinergic sites that   mediate   memory
processes   and  can capitalize on the structures that retain some

F-15


functional  potential, at   least in   the   earlier  stages of
Alzhelmer's disease.

There are also treatments specific to other subtypes of dementia.
Removal of  plaques in the external carotid arteries and control
of hypertension may be beneficial in  preventing  progression of
the   multi   infarct  type-   Ventricular   shunts or other means of
aiding the flow of cerebrospinal fluid may relieve some cases of
normal pressure hydrocephalus.

Treatment of  behavioral problems is not specific to the subtype
of dementia.  A superimposed complication of   dementia   such as
delirium or  depression   must first be ruled out.   The patient's
restlessness at night may exhaust the caregivers; simple remedies
are best (eg.   daily activities,  a soft night light) and a short
acting  benzodiazepine at  night  only  if necessary until a non
pharmacological routine is   established.  Anxiety,   irritability,
suspiciousness and repetitive overactivity should also be managed
without    resort    to    chemical   restraints if  possible,    but
psychotropics may be temporarily needed.

The management of the dementias should concentrate on  adJusting
the   demands  on the patient to be engaging but not overwhelming,
easing the introduction to   new  caregivers or  locations,   and
clarifying the information the patient needs to relate to the en-
vironment,   other  people and time through use of signs and other
cues.   Depending on the level of  disability   entailed   and   the
capability  of the family to provide the appropriate personal as-
sistance,  a lengthy list of special services can be   invoked in
the  community or in congregate sites.   Social services and local
chapters of self help societies devoted to this   condition   offer
advice on  obtaining services.   For example,  respite care (e.g.
sitting services,  day care,  or temporary admission to a hospital
or. a  nursing  home) is available in many communities to relieve
overly taxed family caregivers and reduce the risk of  permanent
placement of   the  person in an institution.  Support groups for
families add emotional and practical help.

Modified psychotherapy, remctivation therapy, reality orientation
can be valuable aspects of   care;    even  though   the   measurable
benefits for cognitive functioning are slight, if any, the impact
on sZlf esteem and social activity can be gratifying.

The  underlying   condition in   cases of  secondary   dementia or
delirium is either known,  strongly suspected or can be discovered
by careful clinical investigation.   For those   causes  shared by
secondary   dementias   and  deliria,   or peculiar to deliria,   the
prognosis is good for the intellectual changes if   treated in a
timely fashion.  For some other secondary dementias there are also
helpful interventions.

SCHIZOPHRENIA:  In elderly patients with paranoia it is essential
that compliance with treatment be-obtained although this is   not
easy.   Without   treatment  very few patients will recover whereas
with treatment the great maJority of patients should  improve. A
favorable response is usually quickly evident, and more than half
the   treated  patients  will return completely to their premorbid

F-16


state, Usually an abnormal personality (Post 1964).

DEPRESSION: The importance of treating depression in the  elderly
is supported by the good initial response  (which is comparable to
that   obtained  in younger patients),   the relief of distress and
functional impairment,  the improvement in accompanying  physical
illness,  and the reduction in the risk of suicide that can be ob-
tained.

With  adequate  treatment of maJor depression,   the prognosis for
short term improvement is good where duration is   short   but   be-

comes  very gloomy if the duration is over 2 years;   until other-
wise proved it is safest to infer that early referral and   inter-
vention   will   reduce   the  proportion of refractory cases.   If a
medication is at fault then withdrawing it should be followed by
improvement in the depressive symptoms within a few weeks.

Suicide is  usually  preceded  by a clinical depression or other
psychiatric disorder.   In the great maJority of elderly   suicides
there   has   been  a recent contact with a psychiatrist or primary
care physician  suggesting   that   better   liaison   between   these
professionals  might  create an opportunity for preventive inter-
vention.  The risk of suicide is increased by bereavement,   isola-
tion and concommitant physical illness.

Antidepressants  are indicated for treatment of maJor depressions
and other severe depressions.   Differences in   effectiveness   be-
tween  the commonly used antidepressants are not yet sufficiently
marked or invariant in the elderly to dictate a   rote   choice of
medication;   however,   the  side effects characteristic of a par-
ticular medication require special consideration in   the  elderly
(Neshkes and Jarvik 1986).  The benefits of pharmacological treat-
ment for depression must be weighed against side effects; of most
concern are excessive sedation,  cardiac arrythmias and conduction
defects,   orthostatic  hypotension ( with the risk of falling and
fracturing) or anticholinergic syndromes of the peripheral   (e. g.
urinary   retention or   narrow  angle  glaucoma) or central (e.g.
confusional) types.   Lithium carbonate is used in the elderly for
the   relief of   the  manic phase of bipolar depression,   for the
maintenance control of relapses in unipolar depression and as an
adJuvant to antidepressants in refractory depressions.

           .a
Electroshock  therapy is a   safe   and   effective   treatment for
depression in the elderly.   This treatment is advisable for cases
otherwise refractory to treatment,   rapidly progressive,    severe,
suicidal or losing a high proportion of body weight. The side ef-
fects of confusion or memory impairment are not lagting   and   are
negligible   with   unilateral   administration   to the non dominant
hemisphere and when the total number of treatments is   not   more
than  twelve (which should be sufficient for those who are likely
to respond at all).

Psychotherapy,   either individual or group, is  widely  used by
psychogeriatricians for depressed patients,  either as adJuvant to
physical   treatments or   where   the  latter are not appropriate.
Groups are well accepted by the depressed elderly.

F-17


ANXIETY: Reassurance and explanations to the patient,   supportive
psychotherapy,   strengthening  the involvement of the social net-
work and reducing environmental threats are the first choices for
relief of generalized anxiety in the elderly.  Adequate exercise,
curtailment of   excessive  sleeping  especially  during the day,
regular bedtime rituals,  simple relaxation routines   and   formal
behavioral  strategies   for  reducing  tension should all be con-
sidered prior to and as adJuvants to  pharmacological   interven-
tions.  Psychotherapy and cognitive therapy are also helpful. Ben-
zodiazepines   are  relatively  free of dangerous side effects and
are useful when used in low dosage for short periods; over longer
periods their use can  be troublesome in the elderly who are prone
to drug accumulation and unwanted sedative or central   inhibitory
effects with intellectual changes.

The   treatment of  phobic  anxiety is  basically the same as in
younger persons (e.g.   behavior  therapy)   but   may   have to be
blended    with    the   techniques of   rehabilitation   medicine.
Similarly,    for  panic   disorder   (with or   without   associated
agoraphobia) the approach to treatment is like that used in young
adults;  tricyclic  antidepressants   and   monoamine   oxidase   in-
hibitors are effective.

3. Prevention of relapses.

Elderly patients who have suffered and recovered   from a   mental
health problem remain  at high risk of relapse.   Unless preventive
steps are taken or maintenance treatment is introduced,  disorders
like maJor depression and general anxiety are likely to   show a
pattern of  repeated  episodes;  paranoia is prone to lapse back
into a chronic psychotic state;   delirium may   recur in a   life
threatening manner.  Yet preventive steps or maintenance treatment
can  dramatically  change the frequency of relapse;   can make the
difference between a sick and dependent patient and a person   who
is free of distress and able to function normally or adequately.

DEMENTIA   AND   DELIRIUM:   Preventing   the  relapse   of behavioral
problems in dementia is   crucial to  alleviating   the  patient's
distress,   relieving the burden on family caregivers and reducing
the likelihood of the patient needing admission to a  long   term
care facility.   Techniques for keeping the patient engaged in ac-
tivitiw while keeping challenges within   tolerable   limits   have
been described.

SCHIZOPHRENIA:   The  potential for relapse of paranoia is so high
that maintenance treatment is the rule. Even where maintenance is
attempted,   about a quarter of the patients will   remain in, or
return to a  psychotic   state.   This is in contrast to the aged
adult schizophrenic whose symptoms have generally become so muted
that they often require little in  the way of medication control.

When the symptoms have abated the  neuroleptic   should be   main-
tained but reduced gradually;   efforts at further cautious reduc-
tion should be made every few months and drug free "holidays" at-
tempted twice a year.   At the first sign of relapse the  previous
level of  dosage should be reinstituted.   The goal is the lowest
dose necessary to assist reasonable adJustment of the patient and

F-18


minimize the elderly patient's high risk of   tardive  dyskinesia.
More  general  long  term measures include testing the benefit of
hearing aids and relieving social isolation through day care.

DEPRESSION:  High rates of relapse   are   the   rule   among  elderly
depressives.   Over   70%   will  recover with initial treatment but
about 75% of these will relapse over the long haul   unless   main-
tained on  pharmacological treatment (Post 1984).   Among treated
elderly  depressives   about  equal   thirds  stay   well,    remain
depressed or recover and relapse.   In any event,  the psychiatrist
should see the patient regularly after recovery unless   there is
good   communication  through   the  family or  primary care prac-
titioner.

Cognitive therapy has been systematically evaluated in the   older

age  group with favorable results (Borson and Raskind 1986).   Its

success   seems to   prove   that   the  elderly,   contrary to   the
stereotype,    are  capable of  changing   their   habitual modes of
thinking and reacting.  By learning cognitive schemata less loaded
with negative evaluations of their performance   and  experiences,
they are able to respond with greater satisfaction and mastery to
daily events.

ANXIETY:   Some of   the   measures   recommended  for curtailing an
episode of general or phobic  anxiety,   should   also   reduce   the
chances of a   recurrence;   including  supportive psychotherapy,
strengthening social supports and reducing environmental threats.
Similarly,   the routines described for improving sleep habits and
reducing tension mitigate against relapses.

VI.   The barriers to seizinq the opportunities that may arise for
intervention;  and the stratenies and needed resources for enhanc-
ing the chances of successful intervention.

Conventional and innovative techniques of   health  promotion   can
convey to   the  elderly  and their support network the essential
facts of mental health preventive interventions which   have   been
reviewed here:  The potential for relief of suffering and impaired
functioning;   the importance of seeking treatment early;   the in-
formation,that allows participation in treatment decisions,   self
monitoring of  the need for initiating and cooperating in treat-
ment,   and Judgments on the quality of treatment being   received;
the   effects  of life event stress and the value of interpersonal
relations in coping at those times;   the health  implications of
communicating intimately with significant others; the normal men-
tal   health   standards   that   are   achievable  in old age and the
snares in attributing remediable   mental   health  problems to a
deterioration  brought  on by aging;  methods of maintaining good
mental health through good  physical  health,   rehabilitation of
disability,   and discretion with medications;  simple measures to
regulate sleep and control anxiety; and much else. In addition to
arming the elderly with such facts,  health promotion programs can
put the elderly in a position to   press   for  specific  organiza-
tional changes consistent with the interventions they select.

F-19


Some of the difficulties facing   health  promotion   (and   disease
prevention) interventions are: 1.   There are too few professional
and non-professional service providers who have special  training
in   the   mental   health  problems of the elderly and the means of
preventing them. 2.   There is a discrepancy between the sites to
which   the  elderly in need of intervention tend to gravitate and
the sites at which special skills and treatment are available. 3.
There are attitudes on the part of   the  elderly   which  mitigate
against their explicitly seeking help for mental health problems,
on   the  part  of the public which lead to underestimation of the
effectiveness of current treatments,   and on the part of   service
providers   which  tend to deny the elderly the time and attention
that they need. 4.  Medicare and other reimbursement mechanisms do
not cover enough ambulatory psychiatric visits  (including   those
to   residents  of nursing homes) to permit adequate prevention of
the onset or relapse of mental health problems;   nor to   deliver
the   services  at the sites which would gain optimum contact with
the population at risk;   much less for health promotion for  high
risk groups who are not yet ill. 5.   The knowledge base is still
patchy on the identification of high risk indicators   for   mental
illness   among   the  elderly:  some predictors are strong (e-g of
relapses) and some weak (e.g.  of first onset of depression in old
age).  Similarly,  there is variability in the specification of ef-
fective   interventions:    some   are   proven   effective   (e. g.    an-
tidepressive  medications) and some are very promising but as yet
uncertain in management or effect (e.g.  strengthening social sup-
ports to buffer stress).   Research   can   redress   these  gaps in
knowledge.

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ACKNOWLEDGMENTS: With permission,   this review is based  upon two
papers recently prepared by the same   authors;   the  bibliography
for   the citations in the text of this review is contained in the
two source papers and has not been repeated here because of space
limitations:

Gurland BJ, Mayeux R,   Meyers BS:   The effectiveness of interven-
tion   for  the mental health of the elderly,   in Grimley-Evans J,
Kane R and Macfadyen D.    (eds)   Improvinq the   Health of   Older
People a World View.  Oxford University Press, London, 1988.

Gurland BJ,   Meyers BS:  Geriatric psychiatry,   Talbott JA, Hales
RE,   Yudofsky S   (ed6):   Textbook of   Psychiatry.    American
Psychiatric Press, 1988.

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