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Table 3: Co-occurrence of mental disorders by gender and age strata.

Other psychiatric symptoms

Psychotic symptoms emerged in 33 (7.2%) participants. Within these symptoms, 6 were self-reported visual hallucinations, 4 auditory hallucinations, and 3 paranoid delusions. The remaining symptoms were referred from the informant or directly observed from the interviewer. In ten participants, psychotic symptoms seemed to be isolated whereas they co-occurred with other mental disorders in 23 subjects (18 affected by dementia, 3 by MDE, 3 by GAD). Psychotic symptoms covered 20.5% of Dementia and 10.5% of MDE cases. Cognitive Impairment No Dementia was present in 13.9% of the nondemented sample (7.9% of men vs. 14.2% of women; p=0.031) and it increases with increasing age (p for trend <0.001). CIND occurs in 6 (7.1%) persons affected by GAD and no overlap is observed between CIND and MDE. In three subjects CIND and psychotic symptoms cooccurred. Fifty-one participants (13.1%) felt that living was not worthy (95% CI: 8.0-14.0%) and 29 (7.3%) had suicidal thoughts (95% CI: 4.0- 8.0%). No gender differences neither age groups difference emerged in suicidal ideation (Table 4). Only 92 years old men acknowledged that he attempted suicide in the past. He committed it with high death wish and avoided thanks to a lucky rescue.

Table 4: Suicidal ideation by gender and age strata.

Discussion

Currently the number of people aged 60 and over is more than 800 million and by 2050 this figure is projected to increase to over two billion [31].

Findings on the prevalence of mental disorders in older people are heterogeneous. The most of the epidemiological studies carried on in late-life are mainly centered on dementia [13], mood disorders [14] and alcohol use disorders [15,16,17,20]. At the same time, few studies have investigated the prevalence rates of psychotic disorders [32,33] among the elderly population, even if paranoid psychoses in old age are much more common than previously thought [34].

Our study aims to describe mental disorders occurrence in the Faenza population, one mental disorder is diagnosable in one out of 3 community-dwelling elderly.

In our sample the most prevalent diagnosis were GAD and dementia, with almost one out of 5 participant suffering of one of them.Also CIND was highly prevalent with 13.9% of the sample showing these symptoms.

Among people older than 65 years total prevalence of major depression and dysthymia varies widely from 2% to 25% [35], with some studies reporting higher rates among older people compared to younger adults [36,37], whilst others describing lower frequencies of depressive [16,38] and anxiety disorders [39] among older persons. In the former meta-analysis [40] rates for current and lifetime GAD were 2.30% and 6.36% respectively, and differed from previous findings that reported a much higher rate for current GAD (10.8%) and a lower rate for lifetime GAD (4.6%) [41]. Although GAD has been posed as the most common anxiety disorder in old age [42], there is much controversy about whether GAD is a diagnosis in its own right [43] or lies on a continuum of depression [44]. In fact anxiety is a warning sign for depression in the elderly. Unsurprisingly, fear for the future, and in particular ‘dependency anxiety’ was commonplace among older [45]. The excess costs of depression and anxiety in community-dwelling elderly are just as significant as those observed for adults even when productivity losses are not considered.

Also in our sample the most frequent overlap was between GAD and MDE (8 persons equal to the 1.9% of the sample, to the 9.6% of the persons affected by GAD and to the 42.1% of the persons affected by MDE). Anxiety disorders could be a risk factor for late-life depression as well as a predictor of persistence and relapse, even if evidences in this direction are not univocal [8]. This comorbidity request a particular warning anxious depression in older adults predicts more cognitive decline [46] and greater suicide risk [47] than nonanxious depression. Adequately managing depression and anxiety in the older adult population may lead to important healthcare cost savings for society [48]. In fact the presence of depressive disorders can lead to impairments in physical, mental, and social functioning and often affects the onset, the course and the complications of other chronic diseases. Mortality risk of older depressed subjects has been estimated to be 2-3 fold higher than that of non-depressed elderly individuals, with suicide as well as complications of cardiac diseases accounting for a significant proportion of the increase in risk [49].

According to a recent meta-analysis assessing the prevalence of mental disorders in older people in Europe and North America [40] the overall random-effects estimate for the 13 included studies was 3.29% for current major depression (MD) and 16.52% for lifetime MD, with high variability within study entered the meta-analysis. Large heterogeneity has been reported in a previous review [41], between 3.1% and 26.9%. Among factors the variability or possible underestimation of prevalence rates of depression may be associated with the fact that depressive symptoms in older adults may often manifest through somatic symptoms and may be confused with these symptoms [50].

Furthermore, the consequences of symptoms may not affect the daily life of elderly people as much as they affect younger age groups [51]. Hence, current diagnostic criteria and instruments may not adequately assess depressive disorders in the elderly and the wide spectrum and severity of cognitive symptoms in elderly patients impairs the reliability of diagnosis and the differential diagnosis.

The common belief that persons with cognitive impairment cannot provide accurate, reliable self-report on their depressive symptoms has been questioned by Snow and colleagues, who suggested that among those who can self-report, severity of cognitive impairment (as measured by a cognitive screening measure) is not itself a significant predictor of self-reported depression accuracy and that main effects on patient-reported depression scores is for deficit awareness and depression diagnosis but not for dementia diagnosis [52]. However, when self-report is unreliable or unavailable due to cognitive dysfunction, observation of behaviors that are suggestive of depression and caregiver/clinician evaluation of depression are recommended [53].

Gender differences affect mental disorders in younger adults as well as in older. In late-life men and women have different health and morbidity patterns and women generally have lower income but better family support networks [54]. On the other hand both depression and Alzheimer’s disease are more prevalent among women [55]. In our sample women were more likely to be affected by at least one mental disorder than men (42.5 46.7% vs. 28.3% p<0.001). Nevertheless multivariate logistic regression analyses demonstrated that the association between female gender and increasing number of mental disorders is confounded by age (data not shown), and each subject was affected by an increasing number of mental disorders with increasing age (p=0.002). These figures are controversial because the prevalence rates of DSM-IV mood and anxiety disorders in late life were found tending to decline with age. Nevertheless these disorders were found as very common, especially in women [23], and our findings are in line, with dementia and GAD significantly more frequently found in women than in male, as well as Cognitive Impairment No Dementia.

The risk of suicide is very high among older men in almost all cultures [56] and suicidal ideation is a core phenomenon in all psychiatric diseases in elderly persons. In our sample 7.3% had suicidal thoughts, in line with those found by other studies [57-59] that share similar characteristics regarding methodology and population sample. No gender differences neither age group differences were found in our study regarding suicidal ideation, although most findings concluded that older males had a higher risk of suicide than older females [60].

Psychotic disorders, characterized by a loss of contact with reality, may be common in people in their later years, causing hallucinations, abnormal beliefs, and impaired insight. The symptom presentation of this condition is heterogeneous and empirical findings are scarce, so it remains unclear whether the prevalence of psychosis increases with age

They may be caused by many medical conditions such as dementia, infections, metabolic or hormonal disorders, sensory impairments, and substance abuse. According to our finding and figures in previous report psychotic symptoms may trouble up to five percent of the elderly in the community [32,61,62] and much higher numbers in nursing homes.

With the exponential aging of the population, the numbers of older individuals experiencing psychosis will likewise expand. Some studies have argued that the prevalence of psychosis may increase due to its combined occurrence with dementia [62,63] or due to age-related changes in symptom presentation [64]. Late-life psychosis is associated with decreased quality of life, caregiver distress, institutionalization, and increased healthcare costs. Existing pharmacotherapy for late-life psychosis is far from ideal in light of its risky side effect profile, especially for the psychosis of dementia. Existing psychosocial therapies for psychosis of dementia are promising, but more evidence-based data on these therapies are needed to merit widespread implementation [10].

Our study acknowledges some limitations: first our data are generalizable only to an urban area of northern Italy whereas a multicentric design would have been more informative. Second the cross-sectional design of our study does not allow us to have a perspective framework of our sample. Third we used the diagnosis of GAD according to Byrne [28], as GAI-SF was validated and recommended as a short form of the Geriatric Anxiety Inventory for use in epidemiological studies. At last DSM-IV and ICD-10 diagnostic criteria may not sufficiently consider important age-related changes [40].

In spite of these limitations, in a society with a rapidly aging population, implementing innovative strategies to promote successful aging in older adults is imperative.

There is a need to improve the awareness about mental disorders in late-life both at the community level and among health professionals and epidemiologic studies demonstrating the improvement of appropriate health care for the elderly with mental illness will open the way to Collaborative care, one promising model for improving geriatric mental health care delivery in primary care. Public policy should reflect the essential role of psychiatry in geriatrics and promote the integration of geriatric psychiatry with primary care [22].

Conclusion

Mental health problems can have a high impact on an older person’s ability to carry out the basic activities of daily living, reducing their independency, autonomy, and quality of life and a prompt recognition and treatment could lead to significant improvements in each of these issues. Moreover mental disorders may exacerbate the symptoms and functional disabilities associated with medical illnesses and increase the use of healthcare resources, length of hospital stay and overall cost of care. Four themes crucial to understanding mental disturbances among older adults are: 1) Sub-syndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment [65].

Studies specifically designed on older persons with mental disorders are needed to promote a successful mental aging our study, even with some limitations, might have implications for policy makers and primary care providers.

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