Dr. Colin M. Shapiro, MBBCh, PhD, MRCPsych, FRCPC,¹ Co-author: Sharon A. Chung, PhD ²

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Abstract: Nocturia, or the condition where the patient wakes two or more times per night to void the bladder, is linked to a multiplicity of physical and mental health disorders. Whether causal or caused by these disorders, treatment of nocturia and the associated slow-wave sleep disruption is essential to avoid long-term health issues and increased mortality in the individual.

Key Words: nocturia, sleep, physical health, mental health, slow-wave sleep.

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Nocturia is a condition that causes the patient to wake two or more times per night to void the bladder.

Nocturia results in a disruption of restorative slow-wave sleep.

Nocturia results in a disruption of restorative slow-wave sleep.

Desmopressin can prolong or even eliminate time to first awakening, thereby augmenting slow-wave sleep and the associated improved physical and mental health.

Nocturia is associated with a multiplicity of physical and mental disorders.

Nocturia is more prevalent in aging patients.

Physicians should include screening for sleep disorders , particularly in elderly patients who report waking twice or more per night to void the bladder.

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The focus of this month’s journal is Older Adults and Mental Health. This area is one of paramount importance to those who care for older adults, and the greatest challenge lies in managing Alzheimer’s disease and its complications. Our CME article this month, “Paranoid Symptoms among Older Adults” by Dr. Muzumel Chaudhary and Dr. Kiran Rabheru, is on a common syndrome with numerous underlying causes. Dr. Svante Östling contributes an article on “Presentation of Psychosis,” an issue that may not come to mind automatically for the nonpsychiatrist assessing an older adult. Dr. Keri-Leigh Cassidy and Dr. Neil Rector provide an intriguing article “The Silent Geriatric Giant: Anxiety Disorders in Late Life.” This article should force all of us to pause before writing our next prescription for benzodiazepines. We all complain about our memory at times, but Dr. Mario Masellis and Dr. Sandra Black advise us on what to do when our patients similarly complain in their article “Assessing Patients Complaining of Memory Impairment.”

Rounding off this issue we have an article on “Management of Cardiovascular Disease Risk Factors among Older Adults with Peripheral Arterial Disease” by Nicholas Giacomini and Dr. Roberta Oka, and one on a recent pharmacological controversy, “Thiazolidinediones and Cardiovascular Disease: Balancing Benefit and Harm” by Dr. Sonal Singh and Dr. Yoon Loke.

Our journal has consistently focused on practical articles that physicians can immediately use to help their older patients. However, an esteemed colleague of mine (and regular reader of Geriatrics & Aging) recently commented to me that physicians face their own challenges as they age. I am currently trying to find someone with expertise to write an article on the problems that older physicians (myself included) experience. I would appreciate any comments, anecdotes, and experiences that you, our readers, might contribute to this topic. If you have anything you would like to share, please contact our Managing Editor Andrea Németh by email (anemeth@geriatricsandaging.ca), by fax (416-480-9449), or by regular mail (162 Cumberland Street, ste. 300, Toronto, Ontario, M5R 3N5).

Enjoy this month’s articles,
Barry Goldlist

David K. Conn, MB, FRCPC, Psychiatrist-in-Chief, Baycrest Centre for Geriatric Care; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON; President, Canadian Academy of Geriatric Psychiatry; Co-Chair, Canadian Coalition for Seniors' Mental Health.

Shelly Haber, BA, MHSc, Project Director, Canadian Coalition for Seniors' Mental Health.

Ken LeClair, MD, FRCPC, Professor and Chair, Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Kingston, ON.; Co-Chair, Canadian Coalition for Seniors' Mental Health.

A national symposium entitled Canadian Invitational Symposium on Gaps in Mental Health Services for Seniors in Long-Term Care Facilities was held on April 28-29, 2002 in Toronto. The participants, who represented more than 65 organizations from across Canada, included national and provincial associations, policymakers, consumers, service providers, educators, researchers and representatives from private industry. The main outcome of the symposium was overwhelming support for the establishment of the Canadian Coalition for Seniors' Mental Health, the purpose of which is to improve the mental health of seniors through a coordinated national strategy. The Coalition's first priority will focus on the needs of seniors living in long-term care facilities.

Dr. Scott B. Patten, MD, PhD, Associate Professor, Departments of Community Health Sciences and Psychiatry, Faculty of Medicine, University of Calgary, Calgary, AB.

Introduction
The term depression can refer either to an emotion, such as sadness, or to a set of depressive disorders. As an emotion, depression is a universal experience, which likely explains why people naturally understand feelings of depression, on an intuitive level, as a reaction to undesirable life events. However, intuition tends not to be clinically useful for depressive disorders, and can even act as a barrier to effective communication and clinical decision-making. Of course, when depression really does represent a non-pathological reaction to a negative life event, empathic and intuitive understanding is completely appropriate, but a mental disorder should not be diagnosed in these circumstances. It is critical to be able to distinguish normal emotional reactions from the potentially dangerous and usually destructive manifestations of depressive disorders. This distinction is particularly important in the elderly, who may experience a variety of losses such as financial security, health and loved ones. Bereavement in relation to such losses may be normal and adaptive, whereas the emergence of a mood disorder--even if triggered by such events--is typically destructive and can be dangerous.

It is often difficult for patients and physicians to understand the distinction between normal or adaptive forms of depression and depressive disorders.

At the dawn of the 20th century, psychiatry began to shift away from the rest of medicine, particularly from neurology. Fortunately, that trend was halted and dramatically reversed by the end of the century. My personal feeling is that apartheid policies rarely work, whether applied to political systems or health care systems. I believe that the separation of psychiatry from medicine was harmful to the psychiatrists, who continue to suffer from that legacy in the form of inadequate resources and lower pay as compared to many other specialists. Even more importantly, medical and surgical patients suffer from the lack of attention to their psychiatric and psychological needs.

The necessity of psychiatric expertise in caring for elderly patients is very easy to demonstrate. Medical illnesses are often complicated by depression, and a high level of skill is required to detect and manage depression in sick elderly patients. Geriatricians and geriatric psychiatrists both manage patients with dementia, and cooperation allows more efficient use of scarce resources. In fact, geriatric psychiatry has been in the forefront of demonstrating the degree to which collaboration between psychiatry and medicine can be valuable. Early on in my career, I visited the Department of Health Care of the Elderly at Nottingham University, England. This department combined both geriatric medicine and geriatric psychiatry and was headed by Tom Arie, one of the giants in the history of geriatric psychiatry. In this service, there was no way to say, "that patient is not our responsibility".

In my practice of geriatric medicine, not a day goes by that psychiatric issues do not surface. Not all the cases are complex enough to warrant consulting a psychiatrist, but many are. Unfortunately, psychiatrists with an interest in the problems of the elderly are not that common, despite their importance to geriatric care (the same could probably be said about geriatric medicine specialists). As a result, primary care physicians must develop some expertise in dealing with the psychiatric problems of their elderly patients, and that is the thrust of this month's issue of Geriatrics & Aging. There is an article on personality and mood adaptivity with aging by Dr. Scott Patten, and two articles focusing on sleep issues: Dr. Christina McCrae and Candece Glauser review insomnia in long-term care, and Dr. Daniel Foley discusses the issues of sleep disturbances and dementia.

Depression is a particular challenge to the primary care physician. Drs. Michael Irwin and Jennifer Pike provide a good review of depression screening instruments in primary care, while Dr. Marie-Josée Filteau reviews the important role of physical symptoms in the diagnosis of depression in the elderly. While we have many effective medications for depression, none are as effective and free of side effects as we would like, and so Dr. Kiran Rabheru's article on the new and emerging classes of antidepressant drugs serves as a valuable complement to this issue.

Furthermore, we have our usual collection of articles on topics of interest. Dr. David Gladstone continues his series on neurological examination with a discussion of the motor examination in the context of aging, dementia and cerebrovascular disease. We have articles on osteoarthritis by Dr. Shafiq Qaadri, urinary incontinence by Drs. Howard Fenster and Lynn Stothers, and valvular heart disease by Drs. Ernane Reis and Mercè Roqué.

Enjoy this issue.

Stephen Holzapfel, MD, CCFP, FCFP, Medical Director, Sexual Medicine Counselling Unit,
Sunnybrook and Women's College Health Sciences Centre;
Associate Professor, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

Sexual function and self-perception is integral to our sense of self and well-being. Yet we live in a society that desexualizes older people, especially women. Aging women experience changes in their sexuality that are often associated with negative effects on mood. Can we help women who are distressed by these changes?

Mood and Sexuality Changes Associated with Menopause
Most women make the transition through menopause with few long-term negative effects on their sexuality. Two-thirds of women in relationships are still sexually active in their 60s, with a gradual decline to about 25% of couples in their 80s. While many are comfortable with these changes, some are distressed by the loss of physical intimacy. The absence of a partner due to death, divorce or partner illness curtails women's sexual lives more often than do their own medical issues. Aging men face increasing erectile dysfunction, with one in seven men experiencing complete impotence by age 70.¹ Given that North American women marry men who are on average four years older than themselves, and that men die six years sooner, most women face up to a decade of widowhood.

Laumann et al.

Prognosis for Elderly Patients is as Favourable as for Younger Ones

Barry Goldlist, MD, FRCPC, FACP

Mental health issues in the elderly have long been rendered more confounding by the high prevalence of dementia. In the past, health care practitioners have tended to ascribe all mental health problems to 'senility'. Since it was felt that nothing could be done for these patients, little diagnostic acumen was 'wasted on these hopeless patients'. As we can see from this issue of Geriatrics and Aging, mental health problems in the elderly are both numerous and varied. Caring for these patients is not a hopeless waste of energy; it does, however, require considerable knowledge and skill. In many cases the prognosis for elderly patients is as favourable as for younger patients. Again, extensive knowledge of age-related pharmacokinetics is often required.

Even the management of dementia is no longer considered hopeless. Previous issues of Geriatrics & Aging have highlighted some of the advances in the diagnosis and management of dementia, particularly in Alzheimer's disease. Measures to prevent stroke in elderly patients, such as the wider use of antihypertensives, the use of anticoagulants in atrial fibrillation, and aspirin use for transient ischemic attacks, will also decrease the prevalence of dementia. However, there is currently a huge problem, one that will only become worse over the next few years. I am referring to the mental health problems that are so prevalent among nursing home patients.

Mental health problems in nursing homes often present as unacceptable behaviours. These span the gamut from verbal aggression, to sexual assault and physical abuse. Wandering, pacing, and repetitive vocalizations are also difficult for the staff in nursing homes (or anywhere else!) to cope with. Withdrawal from activities and 'failure to thrive' can often represent a treatable depression, as well as dementia. Nursing home patients often have multiple medical problems and even obtaining a history can be quite challenging. Because of these factors, the psychiatric diagnosis and subsequent management of nursing home patients often requires a very high degree of clinical expertise, and yet it is precisely this group of patients that is tremendously disadvantaged in terms of having access to expert psychiatric care. Previous attempts to upgrade nursing homes' capabilities to manage these patients have only been partially successful. These efforts have ignored the requirements for upgrading the skills (and perhaps the salaries) of the primary care givers, and have not constructed patterns of care that will allow easy access to specialist help. In many areas of the country, specialized psychiatric services of any type are non-existent, let alone available to the frail elderly.

If we assume that the manpower issues are not going to be solved soon (or never if no initiatives are taken), what else can be done? Perhaps sessional fees for psychiatrists could be awarded to nursing homes. A great deal of psychiatric intervention in these settings involves education and support for staff, and multidisciplinary team meetings to plan comprehensive strategies for individual patients. These services are currently poorly funded, if at all. Similarly, specialist nurses and occupational therapists could be tremendously helpful, but are not currently financially feasible for nursing homes.

As well as type and expertise, the number of staff required is a problem. Family members always complain about the extent to which the staff in nursing homes are stretched. The same is true in acute hospitals, but they are not functioning as 'homes'. It would certainly be a grim existence, if in your last residence, nobody had the time to sit and talk to you for a few moments.

Many of these concerns could be tested in clinical trials, but they are difficult studies to perform and there is no great interest. Studies are available for specific medical conditions such as depression, but these trials are relatively scarce in nursing homes, and often do not address the multiplicity of issues that exist.

One of the key issues that has only recently been looked at closely, is the nature of nursing home design. No large institution can ever be truly 'home-like', but current design stresses that breaking a large institution into smaller home-like modules can be useful. For patients who wander or pace, a secure environment with ample space for physical activity can result in a dramatic decline in psychoactive drug use.

My personal activity as a member of the Chief Coroner of Ontario's Long Term Care and Review Committee has emphasized to me the difficulties that health care providers face in nursing homes. Over the past few years, the committee has reviewed cases in which an aggressive act by a resident has resulted in the death of another resident. These tragedies are becoming more frequent as nursing homes accept more and more patients with dementia and behavioural problems. Although there is no easy solution to this problem, I am not convinced that we, as a society, are even seriously trying to address this problem. Incredibly, even as the difficulty of caring for nursing home residents increases, some jurisdictions are decreasing the payments to the physicians who provide primary care for these patients. The inordinate amounts of time that conscientious physicians spend with staff in planning care for these patients are often not remunerated at all, but this topic probably warrants an editorial of it own! The recent settlement for physicians in Ontario might address some of these issues in that province which is discussed in another article in this issue.