Introduction

Do you worry that your "golden years" will be tarnished by sharply declining mental abilities?

Do you think it is inevitable that all older people eventually lose their intellect and their ability to "think on their feet"?

Do you believe that as you age you are destined to be depressed?

A recent landmark report on mental health by U.S. Surgeon General David Satcher should help put your concerns at rest¹. The report suggests that due to advances in nutrition, physical fitness, public health, and health care, more adults are reaching the age of 65 in better health---and better mental health---than ever before.

Contrary to common stereotypes, extreme mental impairment is not an inevitable part of the "normal" aging process. While some changes in mental functioning do occur with age, the report notes that the extent of age-related mental changes vary from person to person and can be modified by lifestyle.

In fact, there is accumulating scientific evidence to suggest there are some steps you can take to maintain good mental health, reduce the risk of mental disability, and keep your body and mind strong and active.

Scope of the Report

"Mental Health: A Report of the Surgeon General" provides a comprehensive, up-to-date review of what is known about nearly every facet of mental health and mental illness. By summarizing what has been learned about the brain and behavior---through scientific research and clinical experience over the past fifty years---the report helps to dispel myths and misperceptions about mental illness that have persisted for generations.

The report stresses the importance of treating and preventing mental disorders, which can occur at any phase of life. One chapter of the report focuses specifically on older adults and their mental health; the findings below are distilled from that chapter.

Promoting Mental Health and Preventing Mental Illness

Certain factors place older adults at greater risk for mental conditions. These include:

• co-existing medical problems
• loss of social status and self-esteem associated with aging
• side effects of taking multiple prescribed medications, and
• the loneliness and isolation that may follow the death of friends and significant others

There is good news to report, however. In spite of these stress factors, the majority of older adults cope constructively with the limitations and losses of late life. Some of the hallmarks of sound "mental health" among older persons include stable intellectual functioning, the ability to change with changing circumstances, and productive engagement with life.

With advancing years, there are often marked declines in memory, problem-solving abilities, and concentration. Yet, many high-level functions are spared and certain adaptations---such as memory training techniques, repetition, and slowing the pace of learning---can help overcome these deficits.

Several studies show that age-related memory losses aren't as significant as they are perceived to be and when they occur, are often a product of depression rather than an actual decline in memory performance.

One longitudinal study suggests that four factors account for sustaining high cognitive functioning among older persons. These include:

• Number of years of prior education
• Performance of strenuous activity in the home
• Pulmonary flow rate (the rate of blood flow through the lungs)
• Self-efficacy ( the confidence in one's own ability to plan and carry out future activities)

Mental Disorders among Older Persons: Challenges in Diagnosis

One out of five persons over the age of 55, however, experiences some type of mental disorder that is not associated with "normal" aging. Common mental disorders among older adults include depression, Alzheimer's disease, alcohol and drug misuse and abuse, anxiety, and late-life schizophrenia.

While many of these disorders are similar to those affecting younger persons, the prevalence, nature, and course of each may be different. For example, the first symptoms of depression or anxiety disorders among older persons often take the form of physical complaints.

The recognition of mental disorders in this group, therefore, raises some unique diagnostic challenges. For example, an individual may go to their doctor complaining about chest pains, palpitations, or fatigue, or other physical problems that may actually be symptoms of anxiety or depression.

Second, older people often have co-existing physical problems that mimic or mask mental disorders. Physical disorders can cause cognitive, emotional, and behavioral symptoms that also make diagnosis difficult and confusing.

If left unchecked, however, the early symptoms of mental disorders can progress to more serious ones. While there is evidence that early diagnosis and treatment leads to better outcomes and reduced impairment, many family physicians still tend to overlook mental disorders. Additionally, barriers posed by the health care system, such as reimbursement policies and time pressures faced by most physicians, further interfere with accurate diagnosis and treatment.

Recognizing the Signs of Depression

Clinical depression is a mental disorder that is very common among older adults. It is estimated that between 8 to 20 percent of older adults in the community, and up to 37 percent of older adults in primary care settings experience symptoms of depression. This group also has the highest rate of suicide, with older white men having a suicide rate that is six times that of the general population.

Depression and hopelessness are not natural conditions of old age. Depression causes distress and suffering that can lead to impaired physical and social functioning and even death. Some of the symptoms of late-life depression include depressed mood, loss of interest in activities, unexplained weight loss or weight gain, sleep disturbances, feelings of restlessness or agitation, fatigue, psychomotor retardation (slowed movements), feelings of worthlessness, concentration problems, and thoughts of death and/or suicide.

Stressful life events such as the loss of a spouse, declining health, or diminished income and resources often occur among older people. However, persistent grieving or serious depression is not a consequence of normal aging and requires treatment. Too often, depression goes unrecognized and untreated. Without treatment, the disorder can become chronic resulting in mortality either from physical illness or suicide. This is unfortunate because there are an array of effective treatments for late-life depression including medications and psychosocial interventions.

Reducing the Toll of Alzheimer's Disease

Alzheimer's disease affects between 8 and 15 percent of the population over the age of 65. Because of the devastating effects of the disease on memory, cognition, and behavior, it is one of the most feared and dreaded of all mental disorders. The causes of the disease are still not well understood, and seem to involve a complex combination of genetic and environmental factors.

Diagnosis of the disease requires:

• the presence of a memory impairment;
• evidence of difficulty in thinking clearly, either in using language or in the capacity to plan and make meaningful decisions; and
• significant impairment in carrying out the daily tasks of life (e.g. keeping house or maintaining relationships with family or friends)

Behavioral symptoms of Alzheimer's disease include obvious mental disturbance, depression, agitation (hyperactivity) and wandering away.

Diagnosis of Alzheimer's disease is often tricky because of its gradual onset and the similarity of its symptoms to those of other causes of dementia. Family members often dismiss or ignore the early signs of Alzheimer's, attributing its deficits to the normal course of aging. Accurate diagnosis of the disease depends on a full history of the patient's symptoms and a careful assessment of the individual's rate of mental decline.

With the availability of new medications that can slow the progression of the disease, early recognition and treatment is vitally important. These treatments are most successful when they are used early on in the course of the illness. And their impact can be significant, both in human and economic terms. For example, by delaying the onset of the disease by five years, overall rates of Alzheimer's disease can be reduced by as much as 50 percent.

Conclusions

When unrecognized or untreated, mental disorders among older people can result in unnecessary impairment, disability, and even death. Conversely, early recognition and treatment helps improve overall health and quality of life by enabling individuals to take care of themselves for longer periods of time.

This bold message of the Surgeon General's Report needs to be conveyed loudly and clearly to older persons---and to their families, their friends, their caregivers, their doctors, and to all policymakers whose decisions affect them on a day-to-day basis.

If you are feeling blue a lot of the time or if you have concerns about significant memory loss, raise these issues with your doctor. If you notice these or other signs of a mental disorder in a partner or other family member, take these concerns seriously and encourage them to seek medical attention. Remember---regardless of age--- most mental problems are treatable, especially when recognized early on.