1 Mohamed Hatta Shaharom Forensic Psychiatrist & Founding Dean Faculty of Medicine Cyberjaya University College of Medical Sciences Malaysia 28 th FIMA

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Mohamed Hatta Shaharom Forensic Psychiatrist & Founding Dean

Faculty of MedicineCyberjaya University College of Medical Sciences

Malaysia

28th FIMA Council MeetingIndonesian Islamic Medical Association Scientific Convention

YARSI UniversityJakarta

September 2011 / Shawwal 1432

Mental Health of the Elderly

الرحيم الرحمن الله بسم�ي� ب و�ع�ر� �ع�ج�م�ي� أ ه �ات آي ف ص�ل�ت� �و�ال� ل وا �ق�ال ل �ا �ع�ج�م�ي أ آن ا ق ر� �اه �ن ع�ل ج� �و� و�ل

ف�اء و�ش� ه د ى وا آم�ن �ذ�ين� �ل ل ه و� و�ق�ر1 ق ل� �ه�م� آذ�ان ف�ي ون� ؤ�م�ن ي ال� �ذ�ين� و�الع�م ى �ه�م� �ي ع�ل و�ه و�

�ع�يد (٤٤) ب �ان9 م�ك م�ن �اد�و�ن� ن ي �ك� �ئ و�ل أ

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Had We sent this as a Qur’an (in the language) other than Arabic,

they would have said: "Why are not its verses explained in detail?

What! (a Book) not in Arabic and (a Messenger) an Arab?" Say: "It is a Guide and a Healing to those who believe;

and for those who believe not, there is a deafness in their ears, and it is blindness in their (eyes);

They are (as it were) being called from a place far distant!"

Fussilat (Explained in Detail) 41:44

Muqaddimah

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The Elderly (Mental Health & Illness)

1. Mental health, medicine and sociology

2. Psychiatric disorders and management

3. Islamic care of the elderly.

Pencegahan Lebih Baik Daripada Rawatan

Prevention is Better Than Cure

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1Mental Health, Medicine and

Sociology

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� وا آم�ن �ذ�ين� الmه� الل �ر� �ذ�ك ب ه م وب ق ل oن� �ط�م�ئ و�ت

ل وب ال�ق ئ�ن� ت�ط�م� الل�ه� ب�ذ�ك�ر� ال�أ�

"Those who believe, and whose hearts find tranquillity in

the remembrance of Allah; for in the remembrance of Allah do

hearts find tranquillity.

Ar-Ra‘d (The Thunder) 13:28

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Experiencing Old Age

i. Retirementii. Dependence and

independence in old age

Alan Clarke, 2001. The Sociology of Healthcare. London: Prentice Hall. Pp155-179.

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Sociology and Older People

i. Disengagement theoryii. Structured dependency theoryiii. Theory of the third ageiv. Cultures of ageing

Paul Higgs, 2008. Later life, health and society. In Graham Scambler (ed).Sociology as Applied to Medicine. Edinburgh: Saunders. Pp 176-189.

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Fact 1Many gerontologists aresubstituting age 85 for age 65as the new chronologicaldefinition of old age.

James McKenzie, Robert Pinger, Jerome Kotecki, 2008. An Introduction toCommunity Health. Boston: Jones and Bartlett. Pp 236-237.

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Fact 2There are more differences among elders than any other segment of the U.S. population.


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Fact 3Elders are the least likely to belonely of any age group; and those who live alone are likely to be in close contact.


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Fact 4It is only in the last half of the twentieth century that a large portion of the U.S. population lived to be 65 years old.

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Fact 4 (cont)If people did live to be old, they were not treated any better than they are today.


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Fact 5Senility is the result of disease and only affects about 5% of elders living in non-institutional setting.


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Fact 6Though elders do gain certain advantage when they retire and when their children leave home, they still face a number of concerns.


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Fact 7Most older people do have at least one chronic health problem, but the majority of elders live active lifestyles.


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Fact 8 Sexual interest does not diminish with age, but there is an alteration in sexual response.


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Fact 8 (cont)Nonetheless, many elder in reasonably good health have active and satisfying sex lives.


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Fact 9Only approximately 4% of those above the age of 65 live in nursing homes, homes for the age, or other group quarters.


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Fact 10Older adults are more likely to be retired, but they are very likely to be productively engaged at home and in the community.


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Mental State Examinationi. Memory impairmentii. Disorientationiii. Needs physical helpiv. Risk in the homev. Risk outsidevi. Apathy

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Mental State Examination(cont)

vii. Poor communicationviii. Repetitivenessix. Uncontrolled

behaviorx. Incontinence xi. Emotional reactions

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Neil Anderson, Alan Jacques, 2004. Old-age psychiatry. In Eve Johnstone, D.

Owens, S. Lawrie, M. Sharpe. C. Freeman. Companion to Psychiatric Studies.

Edinburgh: Churchill Livingstone. Pp 613-660.

Mental State Examination(cont)

xiii. Other reactionsxiv. Mistaken beliefsxv. Decision Makingxvi. Burden on family

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Investigations and Differential diagnoses

i. Physical examinationii. Full blood countiii. ESRiv. Urea and electrolytesv. Liver function tests

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Investigations and Differential diagnoses (cont)

vi. Thyroid function testvii. Calcium and phosphateviii. Midstream urineix. Glucosex. Chest X-ray

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xi. ECGxii. Vitamin B12 and folatexiii. Syphilis serologyxiv. HIV testingxv. Autoantibody screen

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xvi. Copper studiesxvii.Heavy metal screen xviii.Lumbar puncturexix. EEGxx. CT scan

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xxi. MRI scanxxii. SPECT scan




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Neuroimaging in dementiai. Alzheimer’s diseaseii. Vascular dementiaiii. Dementia with Lewy

bodiesiv. Frontotemporal dementia




2Psychiatric Disorders and

Management

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بسم الله الرحمن الرحيم

�ض م ر� م ل وب�ه� ق ف�ي & ضا م�ر� الل�ه اد�ه م ز� ف�

ون� �ذ�ب �ك ي وا �ان ك �م�ا ب �يم1 �ل أ ع�ذ�اب1 �ه م و�ل

In their hearts is a disease; and Allah has increased their disease;

and grievous is the penalty they (incur), because they are false.

Al-Baqarah (The Cow) 2:10

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The Elderly and Mental Illness

1. From 15 to 25 percent of elderly people suffer from significant symptoms of mental disorders

2. Ratio of Moderate organic disorders : Severe organic mental disorders (Ratio of 2 : 1).

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The Elderly and Suicide

The highest suicide rate in America is among those aged 65 and older. In 1985, this age group represented 12 percent of the total U.S. population, but accounted for 20 percent of suicides nationwide.

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The Elderly and Mental Illness

Worldwide, elderly people lead the World Health Organization's list of new cases of mental illness: 236 elderly people per 100,000 suffer from mental illness, compared to 93 per 100,000 for those aged 45 to 64, the next younger group.

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1. Nearly 25% of elderly persons suffer from symptoms of mental illness,

2. Only 4% of the patients in community mental health centers, 2% of the patients seen in private practitioners' offices or hospitals are elderly

3. Less than 1.5% of the direct costs for treating mental illness is spent on older people living in the community.

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Depression (Epidemiology)

1. Most common mental disorder, afflicts up to 5% of people aged 65 and older

2. Can mimic dementia3. About 10% of those diagnosed with dementia

actually suffer from depression that, if treated, is reversible

4. More than one third of all depressed patients seen by doctors will go untreated due to misdiagnosis

5. Lifetime risk for major depression is only 7-12% in men, but a whopping 20-25% in women!

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Depression (and Women’s Indirect

Complaints)

The elderly are also commonly taking many more medications than younger people are; some of these medications:•Anti-inflammatory drugs •Progesterone•Anticancer drugs

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Depression (and Medications of the

Elderly)

Usually women will not complain directly of sadness; symptoms can include, but are not limited to:1. Alzheimer's disease 2. Cancer (including breast and ovarian) 3. Congestive heart failure 4. Parkinson's disease 5. Rheumatoid arthritis 6. Sexual dysfunction7. Diabetes

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Depression (Signs & Symptoms)

1. Feelings of worthlessness, hopelessness, helplessness, inappropriate guilt;

2. Prolonged sadness, crying spells; 3. Jumpiness, irritability; 4. Loss of interest in and withdrawal from

formerly enjoyable activities, family, friends, work or sex (anhedonia);

5. Intellectual problems: loss of memory, cannot concentrate, disorientation.

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Depression (presentation in brief)

1. Disturbances in sleep, self-esteem, libido, appetite, interest, energy, concentration, memory, and movement

2. Feelings of guilt 3. Suicidal thoughts, plans, or attempts 4. Physical pain

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Therapies for Depression

Pharmacotherapy (anti-depressants) is fairly successful at improving the quality of life of the elderly patient. Psychotherapy is often used in combination with anti-depressants, which can include drugs in these classes:

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Anti-Depressants (Types)

1. Heterocyclics 2. Selective serotonin reuptake

inhibitors (SSRIs) such as Prozac3. Monoamine oxidase inhibitors

(MAOIs)4. Tricyclics such as imipramine,

desipramine, amitryptyline, and nortriptyline.

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Anti-Depressants (Side-effects)(the elderly is more susceptible to)

•Blurred vision •Dry mouth •Urinary retention •Confusion •Constipation •Drowsiness •Insomnia •Cardiac arrhythmia •Hypotension •Weight fluctuations •Gastrointestinal distress •Sexual dysfunction

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Dementias

1. Characterized by confusion, memory loss, and disorientation

2. Only 15% of older Americans suffer from this condition (of that number, an estimated 60% suffer from Alzheimer's disease, a progressive mental deterioration for which no cause or cure has been found)

3. Alzheimer's being the most prevalent type (degeneration can last from 5 to 20 years).

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Dementias (Causes)

About 40% of all dementias can be caused by complications of chronic high blood pressure, blood vessel disease or a previous stroke. Deterioration is in steps rather than in a steady progression.

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Dementia (Symptoms)

1. Delirium 2. Depressed mood 3. Behavioral disturbances4. Delusions

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Sometimes medications are used to treat symptoms that are secondary to dementia, such as sleep disruption, depression, and aggressive behaviors. These medications are only treating the symptoms that arise out of the underlying dementia, and do not treat the dementia itself.

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Dementia (and Parkinson’s)

Parkinson's disease, which generally begins with involuntary and small tremors or problems with voluntary movements. Dementia may occur when the disease is severe or very advanced.

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Dementia (and Huntington’s)

Huntington's disease, a genetic disorder that begins in middle age and has symptoms of changed personality, mental decline, psychosis and movement disturbance.

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Dementia and Creutzfeldt-Jakob

Creutzfeldt-Jakob disease, thought to be caused by a viral infection leading to rapid and progressive dementia.

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DeliriumElderly patients, and especially women, are extremely sensitive to things such as surgery and anesthesia, drug toxicity, and infections like urinary tract infections (especially in women). The symptoms of delirium are often misdiagnosed as relating to other conditions. Symptoms can be reduced with Haloperidol.

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Delirium (common symptoms)

EEG shows a slowing of activity in the brain

1. Disturbed consciousness 2. Sudden reduced ability to focus,

sustain, or shift attention 3. Sudden onset of misperceptions 4. Impaired judgement 5. Increased or decreased motor

activity

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Psychosis1. Schizophrenia is a group of mental disorders

that involve disturbances of thinking, mood, and behaviour

2. Bipolar disorders involve periods of depression followed by periods of mania (accompanied by grandiosity, lack of sleep, and excessive activity)

3. Elderly patients who are diagnosed with psychosis may also experience delirium or dementia, so these conditions must be treated in addition to the psychosis.

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Schizophrenia

1. Only 3% of patients with schizophrenia experience their first symptoms in their sixties or after

2. The treatment of schizophrenia for elderly patients is largely the same as in other schizophrenic patients

3. Minor differences in treatment are the necessity to treat depression that often results in elderly patients as a result of psychosis.

3Islamic Care of the Elderly

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بسم الله الرحمن الرحيم�ك م ج�اءت ق�د� �اس الن oه�ا ي

� أ �ا ي م� �ك ب �ر م�ن م�و�ع�ظ�ة1

د ور الص� ف�ي ا ل0م� اء ف� و�ش��ين� �م ؤ�م�ن �ل ل ح�م�ة1 و�ر� و�ه د ى

O mankind! There has come to you an admonition from your Lord-Sustainer,

and a Healing for all (the diseases) that are in the breasts;

and a Guidance and a Mercy for the Believers.

Yunus 10:57 56

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Psychological

Bio-physical

Spiritual

Social

Holistic Approach

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Human PsychologyCognition &

EmotionHumanPsychologyPsikologi Insan

Basic CharacteristicsSifat Asas

ExcellentCharacteristicsSifat Cemerlang

Cognition (Thinking)Al-‘Aql (Fikiran)

SanityKewarasan

MaturityKematangan

Emotion (Feeling)Al-Qalb (Perasaan)

SincerityKeikhlasan

TranquilityKetenangan

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Pantun Akal

Tunduk padi kerana isiKekal emas tidaklah senangTunjuk budi disanjung tinggi

Akal waras menjadi matang.

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Pantun Kalbu

Fasih lisan biar berbudiBuku Hadis menyuluh

terangKasih Tuhan berperi-peri

Kalbu ikhlas menjadi tenang.

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�ه م� ل ون� �ك ف�ت ر�ض�� األ� ف�ي وا ير �س� ي �م� �ف�ل ل ون� أ ي�ع�ق� �ل وب �ه�اق ب

�ص�ار �ب األ� �ع�م�ى ت ال� �ه�ا �ن ف�إ �ه�ا ب م�ع ون� �س� ي آذ�ان1 و�� أ

الصoد ور ف�ي �ي �ت ال �ق ل وب ال �ع�م�ى ت �ك�ن �و�لDo they not travel through the land,

so that their hearts gain understanding and causing their ears to hear?

Truly it is not their eyes that are blind, but blind have become their hearts which are in

the breasts.

Al-Haj (The Pilgrimage) 22:46

Allah Maha Sombong, Maha Agung

Dari Abu Hurairah r.a., ia berkata: Rasulullah s.a.w. bersabda, “Allah

‘azzawajalla berfirman, “Kesombongan (al-kibriyaa’)

selendang-Ku, dan Keagungan itu sarung-Ku; sesiapa yang melawan-Ku dalam salah satu daripadanya, maka

akan Aku lemparkan ke dalam neraka.””

(Abu Dawud)

Achmad Sunarto & Syamsuddin Noor, S.Ag., 2005. Himpunan Hadits Qudsi. Jakarta: An Nur, hal. 89-90.

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Care and Therapies for the Elderly

1. Pharmacotherapy2. Psychotherapy & Religio-spiritual

therapy3. Social therapy

Pertemuan Dengan AllahDari Aisyah r.a., ia berkata: Rasulullah

s.a.w. bersabda, “Barangsiapa yang kasihkan pertemuan dengan Allah, maka

Allah kasihkan pertemuan dengannya, dan barangsiapa yang bencikan pertemuan

dengan Allah, maka Allah bencikan pertemuan dengannya; sedangkan mati

adalah sebelum pertemuan dengan Allah.”(Muslim)

Achmad Sunarto & Syamsuddin Noor, S.Ag., 2005. Himpunan Hadits Qudsi. Jakarta: An Nur, hal. 83-84.

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Khatimah

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Care of the Elderly

1. Prevention better than cure2. The Islamic approach is a cross

pollination of different modalities (accepted by Islam)

3. The care-giver and care-recipient are beloveds of Allah.

Documents

1 Mohamed Hatta Shaharom Forensic Psychiatrist & Founding Dean Faculty of Medicine Cyberjaya University College of Medical Sciences Malaysia 28 th FIMA