Mental Problems in Geriatric Age

Older people are the largest and most progressive growing population group. According to WHO, the next 50 years, the relative share of the adult population is expected to increase fourfold. Worldwide, for over half a century, the number of people aged over 60 has grown more than threefold to reach nearly two billion in 2050, according to estimates. 

In 1990, the WHO (World Health Organization) developed the concept of “active aging” as a possible response to the challenge of “global aging”. Active aging is a process of optimizing health, safety and active lifestyle opportunities to improve the quality of life of the elderly. This requires for the society to address the medical and social needs of an aging population. In the foreground increasingly exposed problems of patients in geriatric age associated with type and characteristics of their illness and the need of competent health care [1-3].

Human mental activity begins and develops in its ontogenesis under the influence of its social and natural environment. Psychological changes occurring in physiological and pathological aging are different and depend not only on age and on changes in the body, but also on a number of social factors, including family and professional background [4]. Many social, demographic and psychological factors contribute to the formation of the mental status. Poverty, social isolation, loss of independence and loneliness accompany the lives of elderly people, which significantly affects their mental health and overall health. Practice shows that patients who have never reported psychopathological problems in earlier stages of their lives, in the elderly show psychiatric symptoms. 

When ranking the importance of mental disorder in the elderly, the first places go to depression, dementia and paranoid psychoses [5]. Epidemiological studies have found wide variations in the frequency - from 2.8% to 22% of the depression [6]. 10-15% of adult patients have depression which requires clinical intervention. More common are the unipolar depression and the reactive depression, both developed as a consequence of major life changes. For example, the presence of concomitant depression in people with diabetes is associated with mandatory adherence to a specific treatment regimens, poor metabolic control, frequent complications, reduced quality of life, and increased use of health services, which increases the risk of death. 

With women it is more common to have a higher chance of depression or depressive states in their early senior years, whereas in men such states are more common in individuals above 80 years of age. Depression is a major cause of suicide among older people, especially among men. The increased risk of suicide among adults reinforces the need for family and health professionals to know and react swiftly to the signs of depression and eventual suicide attempt [7]. Elderly people living alone have a 50% higher risk of depression, as this risk increases over the age of 75 [8]. 

In other studies, it is confirmed that widowhood is the most stressful and severe life event for an individual and can impact severely on the physical and mental health [9,10]. Widowhood is a prerequisite for social isolation for both male and females, as the feeling of loneliness is a major problem. Another study indicates that depression, suicide, and mortality are higher for widowed men who doesn’t a sufficient support network, and especially for those without a best friend [11]. Diagnosing elderly people with depression is often difficult. A lot of adults deny the presence of symptoms, while others attribute it to concomitant medical conditions. Studies dedicated to determine depression among the elderly require the use of specific tools [12,13]. 

Experts are unanimous that dementia is one of the most significant health and social problems of the 21^st century, along with the cardiovascular and the oncological diseases. The extreme medical and social significance of this devastating human intellect is a result of both the high morbidity and the progressive loss of patient autonomy and the specific care required for exceptional health, moral and financial costs [14]. Dementia usually affects the elderly, although it can be perceived as a natural aging process. People with intellectual disabilities who reach old age are more likely to develop dementia. This syndrome is characterized by a deterioration in memory, thinking, behavior and ability to perform daily activities such as dressing, nutrition, personal hygiene and toilets [15,16]. 

According to WHO data, the relative share of mental illnesses is higher than in other groups of diseases. Approximately one quarter of adults have mental illness, and nearly half have developed at least one mental state during their lifetime [17-20]. The prevalence of dementia is about 5% for older people over the age of 65, a total of 600,000 cases of dementia in the UK. More than one third of the 1.3 million disabled adults in England and Wales have one cognitive disorder or a combination with physical disorder [5]. 

Severe dementia makes elderly people completely dependendent on someone’s help in their daily activities, and this is related to cohabitation with other people or institutionalization. It is more common for elderly people who live alone to develop mild and moderately severe dementia. A majority of these people receive day-to-day support from their friends or relatives, but one part remains without support [21]. In one of her studies P. Balkanska notes that some of the leading problems in the care of the mentally ill adults are: lack of specialized knowledge and skills when you have to work with older people, which pose considerable difficulties for the medical staff and aggravate the quality of the geriatric assistance; the early detection and diagnosis of late dementia is extremely unsatisfactory due to ignorance or misconception of the manifestations of the disease; the functional capabilities of patients with dementia syndrome are limited not only by the development of the destructive brain process but also by the ignorance and lack of caregivers' skills to develop and support their potential capacity [22,23]. 

Older people hardly recognize the presence of mental health problems and have a negative attitude towards the demand for psychiatric help. This phenomenon is particularly pronounced among men. On the other hand, in a number of studies it is reported that older people transform their psychological problems into somatic complaints and turn to the general practitioner for help [22]. The number of elderly people with mental illness, according to the psychiatric institutions in Bulgaria is decreasing, but this is most probably the result of the lack of a single registration of mental illness. Depressive disorders are the first in our country, the most common mental illness in the elderly (Table 1). 

Table 1: Elderly people in Bulgaria admitted and discharged from psychiatric facilities (clinics, wards, outpatient clinics). 

Depression often remains unrecognizable and hence untreated. The vast majority of suicide attempts on a global scale are due to affective disorder. Suicide in adults in Bulgaria is 38.7%. Bulgaria ranks 12^th in the world when it comes to suicide. Prof. Milanova notes that there is no register in Bulgaria, there is no absolute data on the prevalence of mental illness among the population. Unfortunately, the mentally ill in Bulgaria suffer more severely because of the crisis in the social sphere and the possibilities of our healthcare system [24]. 

In the process of providing long-term care for people with mental disorders, the psychiatric nurse plays a key role. Nurses working in psychiatric hospitals are subject to a number of specific requirements. The function of the psychiatric nursing caregiver for elderly people implies flexibility and application of a variety of professional approaches. Behavior towards such patients requires an individual approach and dynamic monitoring of the patient’s condition. The nurse, like no other member of the multidisciplinary team, has the opportunity to get a detailed acquaintance with the patient, observing it at different times in a formal and informal setting. She should have communicative skills combined with good theoretical knowledge in psychology, psychotherapy, also have a high level of empathy, kindness, responsiveness.

The elderly population is a specific contingent of the general human population for which medical care should be shaped in such a way that it is possible to meet the individual needs of the elderly, taking into account their specific needs and desires. It is therefore of the utmost importance that a single system of medical protection should be available for adults and elderly people. The task of bringing together all specialists and scientists in the field of geriatrics and gerontology worldwide, including in Bulgaria, seems to be necessary as well as the need of close collaboration between specialists and workers in this field.

1. Golubeva EY, Danilov RI (2009) Assessment of the need for care / maintenance as a key component in the planning of services for the elderly. Clinical Gerontology 12: 23-27.
2. Maksimova TM, Lushkina NP (2012) State of health and problems of medical care for the elderly. Moscow, Russia.
3. Messinger-Rapport B, Dumas LG (2009) Falls in the nursing home: a collaborative approach. Nurs Clin North Am 44: 187-195.
4. Balkanska P (2012) Psychosocial and Health Perspective of Aging - Realities and Opportunities for Successful Aging. Science & amp Technologies 2: 164-169.
5. Reeves WC, Strine TW, Pratt LA, Thompson W, Ahluwalia I, et al. (2011) Mental illness surveillance among adults in the United States. MMWR Suppl 60: 1-29.
6. Evans S, Katona C (1993) Epidemiology of depressive symptoms in elderly primary care attenders. Dementia 4: 327-333.
7. Li G (1995) The interaction effect of bereavement and sex on the risk of suicide in the elderly: An historical cohort study. Soc Sci Med 40: 825-828.
8. Lish JD, Zimmerman M, Farber NJ, Lush D, Kuzma MA, et al. (1995) Psychiatric screening in geriatric primary care: should it be for depression alone? J Geriatr Psychiatry Neurol 8: 141-153.
9. Ghesquiere A, Shear MK, Duan N (2013) Outcomes of bereavement care among widowed older adults with complicated grief and depression. J Prim Care Com Health 4: 256-64.
10. Rozenzweig A, Prigerson H, Miler M, Reynolds CF (1997) Bereavement and late life depression: Grief and its complications in the elderly. Annu Rev Med 48:421-428.
11. Umberson D, Wortman CB, Kessler RC (1992) Widowhood and depression: Explaining long-term gender differences in vulnerability. Health Soc Behav 33: 10-24.
12. Atanasova P, Masaldjieva R, Calakova N (2005) Dementia and depression in later age - a diagnostic problem of growing importance for medical practice. Bulgarian Neurology 5: 68-73.
13. Masaldjieva R, Raycheva M, Atanasova P (2007) Cognitive Disorders in Dementia Syndrome at Late Age- The "New" Challenge to Psychometry: Comparing Mini-Mental State Examination with Raven's Standard Progressive Matrix and Benton Test. Medicine, Pharmacy, Dentistry 8: 219-224.
14. Wetle T (1998) Challenges and Directions for Gerontological Research Beyond 2000. The Australian J on Aging 17:107-110.
15. Masaldjieva R (2009) Visual impairment of mild cognitive impairment and dementia syndrome in the late age and & quot; Draw a person & quot; test as a visual-constructive test. PhD Thesis, Medical University of Plovdiv, Plovdiv, Bulgaria.
16. WHO (2010) mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. WHO, Geneva, Switzerland.
17. Kessler RC, Chiu WT, Colpe L (2006) The prevalence and correlates of serious mental illness in the National Comorbidity Survey Replication. In: Manderscheid RW, Berry JT (eds.). Substance Abuse and Mental Health Services Administration (15thedn). Rockville, USA.
18. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE, et al. (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych 62 : 617-627.
19. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych 62: 593-602.
20. World Health Organization (2005) Promoting mental health: concepts, emerging evidence, practice. WHO, Geneva, Switzerland.
21. Jacobs H (1994) His and her aging: Differences, difficulties, dilemmas, delights. J Geriatric Psych 27: 113-128.
22. Balkanska P, Georgiev N, Mladenova S (2008) Educational Needs of Healthcare Professionals in Gerontology. Health Policy and Management 6: 54-61.
23. Balkanska P (2010) Management in of person with Dementia syndrome-problems and perspectives. J of Nursing Case 2-3: 23-27.
24. Madjirova N (2011) Psychology and Medicine (1stedn). Raykov Medical Publishing House, Bulgaria.