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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 12 – Old age psychiatry Chapter 12 Old age psychiatry P.470
Psychiatric illness in older people and psychogeriatrics Psychogeriatrics, or old age psychiatry, is a new specialty which has arisen over the last 40 years in response to demographic changes and the growth of geriatric medicine. It was inspired by the ‘social psychiatry’ movement and growing emphasis on the care and welfare of vulnerable sectors of the population. Psychiatric illnesses in older people include:

  • Pre-existing psychiatric disorders in the ageing patient
  • New disorders related to the specific stresses and circumstances of old age (e.g. bereavement, infirmity, dependence, sensory deficits, isolation)
  • Disorders due to the changing physiology of the ageing brain, as well as psychiatric complications of neurological and systemic illnesses

Psychiatric problems often coexist with physical problems, and treatment strategies need to take account of this (as well as the different pharmacokinetics of the older patient). Furthermore, the elderly are more likely to manifest physical symptoms of psychiatric disorder than younger adults. Cognitive assessment and physical examination are always essential parts of psychiatric management of the older person. Dementia is generally the main focus of interest in psychogeriatrics, but the discipline also concerns itself with depressive illness, paranoid states, and other late-onset problems. Since older people are often dependent on others, consideration of the role and the needs of carers are important aspects of holistic care. Psychiatric care of the elderly interfaces with multiple services, both state and independent (e.g. social services, housing and welfare services, the legal system, charity organisations, and religious institutions). The demographics of old age In developed countries such as the UK, the elderly population has been increasing steadily over the last century. For example, in the UK the percentage of the population older than 65 yrs was 5% in 1900, is 15% in 2003, and is projected to be 24% in 20341. This trend is largely attributed to the decline in infant mortality, control of infectious diseases, and improvement in sanitation, living standards, and nutrition as well as a declining birth rate. The implications of increasing elderly people in society are many, including a drop in the proportion of the working population, an increase in overall disability and health needs, and a corresponding increase in the need for both health and social services. In terms of psychiatric disorders, it is well known that certain disorders increase in frequency with advancing age. For example, 5% of people older than 65 yrs suffer from moderate to severe dementia and the prevalence increases to over 30% of those over 85 yrs2. The prevalence of other disorders in people >65 yrs is approximately: 1.1% for schizophrenia; 1.4% for bipolar disorder; and 12.5% for neurosis and personality disorder3. Other research has shown a particularly high prevalence of mental disorder among numbers of elderly people in sheltered accommodation (~30% in old age homes have cognitive impairment) and in hospital (30–50% patients >65 yrs in general hospital wards have psychiatric disorder)4. Finally, it is P.471
regrettably the case that psychiatric disorders are commonly either undiagnosed or misdiagnosed at primary care level. Having said this, research has demonstrated a marked improvement over the last decade in both diagnosis and management at this level. The role of the old age psychiatrist5

  • Advocate Together with various pressure groups, the old age psychiatrist (OAP) is an active proponent of the interests of the elderly, whether it comes to sourcing funding or providing education to the public in an effort to dispel the stigma attached to ageing.
  • Teacher The OAP is well placed to provide education in both medical and non-medical contexts. Medical and nursing students, across-discipline specialists and trainees, school pupils, community forum and service organisers may all benefit from the expertise of the OAP.
  • Health educationalist/promoter Holistic care of the elderly includes both health education and preventative intervention.
  • Student Psychogeriatrics is a major arena of new research, while the changing demography of ageing requires the OAP to make academic forays into other disciplines such as sociology, history, and human geography.
  • Innovator The relative infancy of the discipline means that individuals working in this area have had the opportunity to be creative and innovative in developing appropriate services.
  • Team player The multidisciplinary nature of old age psychiatry means that the OAP engages with professionals and lay people both in the community and in institutions.
  • ‘Missionary’ The concept and practice of psychogeriatrics originated in the UK and was spread to North America, Australia, and the rest of Europe by a core of zealots. A number of international organisations have formed and the global challenges for the 21st Century include expanding the discipline within developing countries as well as finding new strategies for caring for the growing numbers of elderly people within the first world.

References 1 Butler R and Brayne C (1998) Epidemiology In: Seminars in Old Age Psychiatry Eds: Butler R and Pitt B. Gaskell, London. 2 Jorm AF, Korten AE, Henderson AS (1987) The prevalence of dementia: a quantitative integration of the literature. Acta Psychiatrica Scandinavia 76, 465–79. 3 Kay DW, Beamish P, Roth M (1964) Old age mental disorders in Newcastle upon Tyne. I. A study of prevalence. British Journal of Psychiatry 110, 146–58. 4 Mayou RA and Hawton KE (1986) Psychiatric disorder in the general hospital. British Journal of Psychiatry 149, 172–90. 5 Jolley D (1999) The importance of being an old age psychiatrist. In: Everything you need to know about old age psychiatry… Ed. R Howard. Wrightson Biomedical Publishing Ltd. P.472
Normal ageing1 Neurobiology of ageing

  • The weight and volume of the brain decreases by 5% between ages 30 and 70 yrs, by 10% by the age of 80, and by 20% by the age of 90. There is a proportionate increase in ventricular size and size of the subarachnoid space.
  • MRI shows ↓cortical grey matter with little change to white matter.
  • CBF in frontal and temporal lobes and thalamus decreases with age.
  • There is some nerve cell loss in the cortex, hippocampus, substantia nigra, and purkinje cells of the cerebellum. There may also be reduction in dendritic processes. The cytoplasm of nerve cells accumulates a pigment, (lipofuscin), while there are also changes in the components of the cytoskeleton.
  • Tau protein (links neurofilaments and microtubules) can accumulate to form neuro-fibrillary tangles (NFTs) in some nerve cells. In normal ageing NFTs are usually confined to cells of the hippocampus and entorhinal cortex.
  • Senile plaques (extra-cellular amyloid and neuritic processes) are found in the normal ageing brain in the neocortex, amygdala, hippocampus, and entorhinal cortex.
  • Lewy bodies (intra-cellular inclusions) occur normally and are confined to the substantia nigra and the locus coeruleus.
  • Hirano bodies (rod-shaped actin) occur in new hippocampal pyramidal cells.
  • Amyloid deposits (β-amyloid and A4 amyloid) may be widespread in superficial cortical and leptomeningeal vessels as well as patchy within the cortex.

Psychology of ageing

  • Cognitive assessment is often complicated by physical illness or sensory deficits.
  • IQ peaks at 25 yrs, plateaus until 60–70, and then declines.
  • Performance IQ drops faster than verbal IQ, which may be due to reduced processing speed or to the fact that verbal IQ depends largely on familiar ‘crystallised’ information while performance IQ involves novel, fluid information.
  • Problem solving deteriorates due to declining abstract ability and increasing difficulty applying information to another situation.
  • Short-term memory (STM) does not alter with age. However, working memory (WM) shows a gradual decrease in capacity and this is worse with ↑complexity of task and ↑memory load.
  • Long-term memory (LTM) declines, except for remote events of personal significance which may be recalled with great clarity.
  • There is a characteristic pattern of psychomotor slowing and impairment in the manipulation of new information.
  • Tests of well-rehearsed skills such as verbal comprehension show little or no decline.

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Social problems of old age With the breakdown of traditions and family structures in many societies, increasing numbers of elderly live alone or in homes for the aged. Losses include: loss of status, loss of independence, and loss of spouse/partner. Most elderly have limited income and are unemployed. Increase in medical problems compounds the dependency and care needs. The elderly face variable degrees of isolation, marginalisation, and stigmatisation. References 1 Gelder M, Gath D, Mayou R, Cowen P (1996) Oxford Textbook of Psychiatry, 3rd Edition, Oxford University Press, Oxford. P.474
Multidisciplinary assessment Elderly people suffering from mental health problems often have a range of psychological, physical, and social needs. This implies that individual assessment, management, and follow-up requires collaboration between health, social, and voluntary organisations and family carers. Assessment of the older patient with mental illness includes the following:

  • Full history from the patient, family, and carers
  • Full physical and neurological examination
  • MSE, including full cognitive assessment
  • Functional assessment (evaluation of ability to perform functions of everyday living)
  • Social assessment (accommodation; need for care; financial and legal issues; social activities)
  • Assessment of carers’ needs

The best place for performing an assessment is in the patient’s home. A domiciliary visit has the advantage of being more convenient and relaxing for the patient and it provides the health carer with an opportunity to assess living conditions, social activities, and medications kept in the house. In addition, family members, neighbours, and carers may be available for interviewing. A follow-up visit to the day hospital may be required in order to perform physical examination and medical investigations. Sometimes brief admission is indicated, especially if the elderly person has pressing physical or psychiatric needs or if support is unavailable (or desperately needs respite). Obviously a full assessment may involve doctors, nurses, occupational therapists, psychologists, social workers, voluntary workers, legal professionals, and others involved with the elderly. In obtaining a thorough history it is important to allow the patient to tell their own story. One needs to enquire about the presenting problem and how it has evolved, whether it is a new or longstanding problem, and whether the individual has a personal or family history of mental problems. In addition, enquire about losses, social history, and social circumstances (housing, income, social activities, etc), medical problems and medications, alcohol history, and presence or absence of family support and carers. It is particularly important to assess activities of daily living such as level of independence, ability to cook, shop, pay accounts, maintain the home, and cope with bathing, toilet, laundry, etc. MSE needs to include an assessment of sight and hearing as well as determining the presence or absence of anxiety or mood symptoms, suicidality, abnormal beliefs or perceptions, and cognitive impairment. Cognitive assessment must include: orientation; memory; concentration and attention; language, praxis, and simple calculation; intelligence; insight; and judgement. An MMSE will incorporate these elements (see p. 66). There is a wide range of rating scales for assessing mental state, cognitive performance, activities of daily living, and carer burden—see Burns et al1 (2002) for an overview. P.475
Key questions for carers include:2

  • Relationship to the patient
  • Amount of care provided
  • Degree of stress they are under
  • What help they would accept
  • Understanding and knowledge of the patient’s illness
  • What expectations they have from services
  • Their awareness of support or voluntary organisations

References 1 Burns A, Lawlor B, Craig S (2002) Rating scales in old age psychiatry. BJP 180, 161–7. 2 Butler R and Pitt B (1998) Assessment. In: Seminars in Old Age Psychiatry Ed. R Butler and B Pitt. Gaskell. P.476
Specific aspects of psychiatric illnesses in the elderly (1)—overview and neuroses Overview The range of psychiatric illnesses in the elderly is very similar to that in younger people. However, the individual factors that contribute to aetiology, clinical presentation, and management strategy differ due to the specific biopsychosocial conditions of old age. In order to grasp a full understanding of elderly psychopathology it is necessary to appreciate the physiological, psychological, and socio-cultural factors unique to this age group. Disorders in the elderly may present with some ‘classic’ symptoms (common to adult psychopathology), but very often their clinical manifestation varies significantly due to the unique conditions of old age. The following pages focus on the ‘unique’ features of psychiatric illnesses in the elderly. Neuroses Prevalence Depression and anxiety are more prevalent than dementia in old age. There is no decline in their prevalence with advancing age, but of concern is the fact that there is a reduction in referrals to psychiatry. This may be due to increased acceptance of symptoms by the elderly or due to deficiencies in detection by health professionals. The estimated prevalence of neurotic disorders is 1–10% with a female predominance and roughly equal frequency of ‘old’ and ‘new’ cases. Clinical features Non-specific anxiety and depressive symptoms predominate and hypochondriacal symptoms are often prominent. Obsessional, phobic, dissociative, and conversion disorders are less common. Factors such as physical ill health, immobility, and lack of social support may give rise to fear and a lack of confidence about going out of the home—this has been termed ‘space phobia’. Aetiology Multiple factors may contribute to new neurotic symptoms in the elderly. Among these, major life events, physical illness, feelings of loneliness, impaired self-care, and ‘insecure’ personality style are most common. Differential diagnosis Physical illness; acute or chronic organic brain disease; affective disorders. Management

  • The mainstay of treatment is to identify and manage aetiological factors. This obviously very often calls for social interventions and thus a multidisciplinary approach is essential.
  • Counselling may be difficult especially where older people have had limited exposure to psychological methods.
  • Antidepressants may be indicated for severe and disabling symptoms and are certainly preferable to benzodiazepines.

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Specific aspects of psychiatric illnesses in the elderly (2)—mood disorders1 Epidemiology Less than 10% of new cases of mood disorder occur in old age and very few are bipolar. Episodes occur more frequently and last longer. Studies suggest that mood disorders in the elderly have a worse prognosis and there may be a tendency towards chronicity. Gender differences in prevalence also diminish with advancing age. Prevalence of clinically significant depression is 10% for those >65 yrs, with 2–3% being severe. Rates of depression differ depending on setting: 0.5–1.5% in the community; 5–10% of clinical outpatients; 10–15% of clinical inpatients; 15–30% of those in residential and nursing homes. Mania accounts for 5–10% of mood disorders in the elderly. Aetiology Positive family history becomes less relevant in older-onset mood disorder. Physical illnesses are associated in 60–75% of cases. Major life events are common, as is the lack of a confiding and supportive relationship. Older patients are less likely to complain as losses are ‘expected’. Neuroimaging yields conflicting results and brain changes noted may relate to the normal ageing process. The strongest imaging evidence for brain changes is for mania in men. Clinical features Depression There are no clear distinctions between the clinical presentation of depression in the elderly and that in younger people. However, some symptoms are often more striking:

  • Severe psychomotor retardation or agitation occurs in up to 30% of depressed elderly patients.
  • A degree of cognitive impairment has been detected in 70% (esp. with effortful tasks).
  • Depressive delusions regarding poverty, physical illness, or nihilistic in nature, are common (e.g. Cotard’s syndrome, p. 85).
  • Paranoia is also common, while derogatory and obscene auditory hallucinations may occur.
  • Classic symptoms may not even be evident and the patient may instead present with somatic, anxiety, or hypochondriacal complaints. A high index of suspicion is required when older patients present with these symptoms, especially abnormal illness behaviour.

‘Pseudodementia’ A minority of retarded depressed elderly present with ‘pseudodementia’ (i.e. marked difficulties with concentration and memory), but careful testing excludes dementia. Features suggestive of pseudodementia: previous history of depression; depressed mood; biological symptoms; ‘islands of normality’; exaggerated symptoms; response to antidepressant medication. Mania presents a similar clinical picture as in younger patients; however, it is more often followed immediately by a depressive episode in older patients. P.479
Hypomania may occur but there is usually a history of BAD. First episode of mania or hypomania in an elderly person requires careful screening for cerebral (or systemic) pathology (e.g. stroke or hyperthyroidism). Differential diagnosis Dementia—difficult to distinguish and can occur together, if in doubt best to treat; Paranoid disorder—depressive paranoia and delusions may be difficult to distinguish from psychoses; Stroke—especially after left frontal CVA or 2° to the lability, reactive stress, organic apathy, ↓motivation, or drug side-effects associated with stroke; Parkinson’s disease—drug side-effects in treating PD may suggest depressive illness; other physical disorders e.g. infection, hypothyroidism, tumours, alcohol, drug side-effects. NB Full physical investigation is vital. Management

  • Antidepressants TCAs are not absolutely contraindicated in the elderly, but care must be exercised in prescribing. ECG and BP monitoring is important due to postural drops as well as other cardiac problems. Also suicide risk may exclude TCAs. First-line is probably SSRIs due to ↓ side-effects and relative safety in OD. Others include: trazodone; SNRIs such as venlafaxine; and, occasionally, moclobemide (delayed hypotension a problem). General rules include: low starting dose; gradual increases; prolonged trial periods (2–3 months); long maintenance periods (up to 2 years); beware of suicide risk; consider lithium augmentation.
  • ECT First-line treatment for severe illness and specifically where there is marked agitation, life-threatening stupor, suicidality, or contra-indications, failure, or excessive side-effects of drugs. ECT is generally safe and effective. Dementia is not a contraindication. Post-ECT confusion may be a problem, in which case treatments should be given at longer intervals. Following ECT, antidepressant medication should be given for a longer maintenance period than in younger patients. ECT may also be used for maintenance therapy.
  • Psychological treatments Therapies include: CBT for depression; supportive psychotherapy; bereavement counselling.
  • Treatment of mania Age-appropriate doses of neuroleptics may be used, in particular haloperidol or atypicals such as risperidone. Lithium is first-line in prophylaxis but lower dosages are indicated (levels: 0.4–0.7 mmol/L) and regular thyroid and renal checks are essential. Also note that levels may easily change in the presence of infection, dehydration, and use of other medications (e.g. diuretics).

Prognosis Generally prognosis is good, especially: onset <70 yrs short illness; good previous adjustment; absent physical illness; good previous recovery. Poor outcome is associated with: severity of initial illness; psychotic symptoms; physical illness; poor medication compliance; severe life events during follow-up period. References 1 Gelder M, Gath D, Mayou R, Cowen P (1996) Oxford Textbook of Psychiatry, 3rd Edition, Oxford University Press, Oxford. P.480
Specific aspects of psychiatric illnesses in the elderly (3)—psychoses Psychotic illness in the elderly may be classified as follows:

  • ‘Old psychosis’—the ‘graduate’ population
  • ‘New psychosis’—late-life schizophrenia or late paraphrenia
  • Other conditions with paranoid and/or hallucinatory symptoms

‘Old psychosis’ With the advent of antipsychotic drugs in the 1950s, there followed a progressive decrease in the numbers of long-stay patients with schizophrenia in institutions. Thus more and more ageing patients with chronic schizophrenia moved into the community, and in countries such as the UK and USA, many of these patients are increasingly referred to psychogeriatric services. ‘New psychosis’ Paraphrenia—a term coined by Emil Kraepelin in 1909; described a psychotic illness characterised by delusions and hallucinations, without changes in affect, form of thought, or personality. Late paraphrenia—described by Roth and Morrisey in 1952; they noted that this type of illness was the most common form of psychosis in old age (defined as >60 yrs). NB Some controversy remains as to whether late paraphrenia represents schizophrenia of late onset or whether it is a distinct entity (most evidence supports the former). Epidemiology Relatively rare condition; population studies estimate <1% prevalence. Approximately 10% of admissions to psychiatric wards for the elderly will have the condition. One study showed that when ICD-10 criteria were used, 60% cases were classified as paranoid schizophrenia, 30% as delusional disorder, and 10% as schizo-affective disorder1. Gender distribution is estimated at 4–9:1 female: male predominance. (NB Schizophrenia has a later onset in women.) Aetiology

  • Genetics The risk of schizophrenia in 1st degree relatives is 3.4% in late paraphrenics, compared with 5.8% in young schizophrenics, and less than 1% in the general population2.
  • Premorbid personality of people with late paraphrenia is characterised by poor adjustment and it is estimated that nearly 45% show lifelong paranoid and/or schizoid traits.
  • Sensory impairments such as deafness, of onset in middle life, increases risk of late paraphrenia.
  • Social isolation and major life events may also be contributory factors.
  • Organic factors Structural imaging demonstrates mild ventricular enlargement; cerebrovascular pathology is a common comorbid finding.

Clinical features Persecutory delusions are the most common symptom of late paraphrenia (roughly 90% of patients) and tend to relate to commonplace themes (such as neighbours spying). Other common delusions P.481
include: referential, misidentification, hypochondriacal, and religious. Auditory hallucinations occur in approximately 75%, while visual (13%), somatic/tactile (12%), and olfactory (4%) hallucinations are not uncommon3. Schneiderian 1st rank symptoms are common (46%), while negative symptoms, thought disorder, and catatonia are extremely uncommon. 10–20% may present with delusions only. Treatment

  • Relieve isolation and sensory deficits
  • Establish rapport and develop a therapeutic alliance (often difficult!)
  • Exclude cognitive or medical disorders
  • Hospital admission is often required
  • Low-dose atypical antipsychotics preferred as elderly are very sensitive to side-effects.

Other conditions with paranoid or hallucinatory symptoms These include the following conditions:

  • Secondary paranoid states—due to organic disorders or substances (see p. 130)
  • Delirium (see pp. 734, 735)
  • Dementia (see pp. 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145)
  • Affective disorders (see pp. 478, 479)
  • Schizoaffective disorder (see p. 228)

Hallucinations of sensory deprivation In the elderly, complex visual hallucinations can occur as a non-specific phenomenon, secondary to visual impairment—this is sometimes referred to as Charles Bonnet syndrome. These hallucinations may be well-formed and contain animals, people, or scenes. There may be partial or complete insight. Differential diagnosis includes: DLB (pp. 140, 141), acute confusional state (pp. 734, 735). Reassurance may be adequate, but in some cases a small dose of antipsychotic medication may reduce distressing symptoms. References 1 Howard R, Castle D, Wessely S, Murray R (1993) A comparative study of 470 cases of early-onset and late-onset schizophrenia. BJP 163, 352–7. 2 Kay DWK and Roth M (1961) Environmental and hereditary factors in the schizophrenias of old age (late paraphrenia) and their bearing on the general problem of causation in schizophrenia. Journal of Mental Science 107, 649–686. 3 Almeida O (1998) Late paraphrenia. In: Seminars in Old Age Psychiatry, eds. Butler R and Pitt B, Gaskell. P.482
Other mental health problems in the elderly Alcohol problems With decreasing tolerance for alcohol in advancing age, there is a corresponding increase in risk of intoxication and adverse effects. Males predominate, although there is an increase in prevalence of alcohol problems in women in their 8th and 9th decades. Risk factors for late onset of alcohol problems include: women; higher socioeconomic class; physical ill-health; precipitating life events; neurotic personality; psychiatric illness. Korsakoff psychosis is an important sequel in ‘old cases’—see p. 530 Principles of management

  • Prognosis is good if alcohol problems commence secondary to practical problems.
  • Encourage and facilitate involvement in non-drinking social activities.
  • In extreme cases consider need for supervision of finances.
  • Orientate towards reducing physical problems.
  • Moving to residential care may reduce social isolation.

Drug abuse Generally, illicit substance abuse is not a significant problem in the elderly. However, misuse of prescription drugs such as benzodiazepines, opiates, and analgesics frequently becomes a problem in this age group. Dependence on these medications may result from careless prescription of long-term treatments for common problems of ageing such as insomnia and arthritis. With the best of intentions, doctors sometimes believe that it is ‘cruel’ to withdraw patients from these medications, especially if the patient has been using the drug for years and is advanced in age. However, it is important to consider whether withdrawal may actually enhance quality of life by diminishing chronic side-effects such as depression. Sexual problems Factors influencing the sexual life of younger adults are relevant to older people too (e.g. social stresses, illness, and side-effects of medications). In addition, the elderly may experience added problems related to the specific physiological changes that accompany ageing. Dementia sufferers may become sexually demanding as part of the disinhibition that frequently characterises this disorder. Health carers may fail to detect sexual problems experienced by older people as a sexual history is commonly overlooked. This may result from incorrect assumptions that carers often make regarding sexuality in this age group. The client too may assume that his or her sexual dysfunction is a ‘normal’ aspect of ageing. Some practical remedies are: hormone replacement therapy; vaginal lubricants and topical oestrogen; and, of course, Viagra. Personality problems Personality traits often become more prominent and rigid in old age; in particular traits such as cautiousness, introversion, and obsessionality. P.483
Paranoid traits may intensify, especially in situations where there is increasing social isolation. In some cases increasing paranoia may be mistaken for a paranoid psychotic state such as delusional disorder. Psychopathy is said to ‘burn-out’ with advancing age and criminal behaviour is rare in the elderly (approximately 1% of male offenders are >60 yrs). Roughly 5–10% of older people exhibit features of personality disorder and these individuals often come to the attention of health services when they are residents in homes for the elderly. Since personality disorder is by definition lifelong, any significant change in personality needs explanation. Both organic and functional brain disorders may manifest as ‘a change in personality’. Personality problems are often the cause of Diogenes syndrome—also called senile squalor syndrome—in which eccentric and reclusive individuals become increasingly isolated and neglect themselves, living in filthy, poor conditions. They are often oblivious to their condition and resistant to help, necessitating intervention. Suicide Old age is a risk factor for suicide and it is estimated that approximately 20% of all suicides are of the elderly. There is a male predominance of 2:1 in this age group, as suicide rates tend to increase with age in men and decrease with age in women. The rate of elderly suicides declined markedly during the 1960s due to the detoxification of the mains gas supply. Predictive factors for suicide in the elderly:

  • Increasing age
  • Male
  • Physical illness (35–85% cases)
  • Social isolation
  • Widowed or separated
  • Alcohol abuse
  • Depressive illness, current or past (80% cases)
  • Recent contact with psychiatric services

Parasuicide Parasuicide is relatively uncommon with older people, accounting for only 5% of cases. Gender distribution is roughly equal. An apparent parasuicide in this age group is much more likely to be a failed suicide and thus all parasuicides should be taken very seriously. It is important to exclude depression and also personality disorder as 90% have a depressive illness. Also 60% are physically ill; 50% have been previously admitted to a psychiatric hospital; and 8% go on to complete a suicide within 3 years of a parasuicide. P.484
Issues of elder abuse1,2 In recent decades the unfortunate problem of elder abuse has become increasingly recognised. It is often overlooked and requires an integrated response from multiple disciplines and agencies, including health and social services, the criminal justice system, and government. The need for a unified multidisciplinary approach cannot be emphasised enough as a fragmented response is fraught with problems, as some countries have learned from bad experience. Types of elder abuse Elder abuse is an all-inclusive term representing all types of mistreatment or abusive behaviour towards older adults. This mistreatment can be an act of commission (abuse) or omission (neglect), intentional or unintentional, and of one or more types:

  • Physical, sexual verbal, or psychological abuse
  • Physical or psychological neglect
  • Financial exploitation

The abuse or neglect results in unnecessary suffering, injury, pain, or loss and leads to a violation of human rights and a decrease in the quality of life. Epidemiology of elder abuse Occurs in both domestic and institutional settings:

  • Domestic setting Approximately 4–6% of elderly people report incidents of abuse or neglect in domestic settings. The most common forms of abuse are verbal abuse and financial exploitation by family members and physical abuse by spouses. Gender distribution (of victims) is equal and economic status and age are unrelated to risk of abuse. Importantly, elder abuse is underreported—450 000 older adults in domestic settings were abused, neglected, or exploited in the USA during 1996, of which only 70 000 were self-reported.
  • Institutional settings No data exists for the extent of abuse within institutional settings. However, one survey of nursing home staff in a US state disclosed that 36% of staff had witnessed at least one incident of physical abuse in the preceding year, while 10% admitted having committed at least one act of physical abuse themselves.

Explaining elder abuse The main risk factors for elder abuse are: dependency and social isolation of the victim; carer has mental or substance misuse problems; absence of a suitable guardian. Factors vary according to the type of abuse; for example, dependency is a risk factor for financial or emotional abuse, but not necessarily for physical abuse. Also the causes of spouse abuse may differ from the causes of abuse by adult offspring. An integrative response to elder abuse Prevention is the best approach and a number of measures have proved effective: training and support of carers; reducing isolation of elders; respite care; CPN visits; etc. Responding to abuse effectively requires a multidisciplinary approach and a P.485
proactive system of assessment of suspicious cases (a number of assessment instruments have been developed3,4). References 1 Payne BK (2002) An integrated understanding of elder abuse and neglect. Journal of Criminal Justice 30, 535–47. 2 Wolf RS (1999) Suspected abuse in an elderly patient. Am Fam Physician. 59, 1319–20. 3 Fulmer T (2003) Elder abuse and neglect assessment. Journal of Gerontological Nursing 29, 8–9. 4 Reis M (1998) Validation of the indicators of abuse (IOA) screen. Gerontologist. 38, 471–80. P.486
Psychopharmacology in the elderly1,2 Pharmacokinetics The physiological changes associated with ageing mean that the older patient’s system ‘handles’ drugs quite differently from that of a younger individual.

  • Absorption generally remains the same, although there are reductions in gastric pH and mesenteric blood flow.
  • Distribution of drugs is altered however: reduced body mass, body water, and plasma proteins, together with increased body fat causes increased levels of free drug and longer half-lives (especially of psychotropics).
  • Drug metabolism is reduced due to decreased blood flow to the liver and loss of efficiency of liver microsomes.
  • Excretion is reduced with the drop in renal clearance that accompanies old age. Thus drug effects are generally prolonged and cumulative and the risk of toxicity is high.

Pharmacodynamics Technology such as PET is enlightening our understanding of the direct effects of drugs in the CNS. Specific differences in these effects in the elderly include:

  • Dopaminergic system—there are less DA cells in the basal ganglia; thus there is increased sensitivity to the EPSEs of neuroleptics (not dystonias).
  • Cholinergic system—there is a normal reduction in cholinergic receptors with advancing age (and a gross reduction in DAT).
  • Noradrenergic system—NA levels decrease with age, which may cause this age group to become increasingly vulnerable to mood disorders.
  • Narcotics and sedative hypnotics—there is increased sensitivity to sedatives in the elderly due to a reduction in the number of available receptors.

The implications of these changes are that elderly patients are more sensitive to almost all drugs used in psychiatry. P.487
General principles of prescribing include:

  • Start with a very low dose.
  • Increases should be made slowly.
  • Maximum efficacy is often achieved at significantly lower doses than in younger adults.
  • Beware of dangerous side-effects such as postural hypotension and arrhythmias.
  • The elderly are particularly sensitive to EPSEs and anti-cholinergic side-effects.
  • Beware of drug interactions due to common problem of polypharmacy in the elderly.
  • Atypical neuroleptics are generally better tolerated than conventionals.
  • SSRIs, SNRIs, and NARIs are generally safer than TCAs; while MAOIs and lithium may be useful in resistant depression.
  • Monitor lithium therapy closely as levels can fluctuate easily and long-term effects on thyroid and renal function are not infrequent.
  • Always consider suicide risk as old age is a risk factor for suicide.

References 1 Baldwin R and Burns A (1998) Pharmacological treatments. Seminars in Old Age Psychiatry Eds. Butler R and Pitt B, Gaskell. 2 Gareri P, Falconi U, De Fazio P, De Sarro G (2000) Conventional and new antidepressant drugs in the elderly. Progress in Neurobiology 61, 353–96. P.488
Services for the elderly1,2 Services for the elderly are organised differently according to government policies and availability of resources. In principle though, the ideal service should plan to:

  • Maintain the elderly person at home for as long as possible
  • Respond quickly to medical and social problems as they arise
  • Ensure coordination of the work of those providing continuing care
  • Support relatives and others who care for the elderly at home
  • Promote liaison between medical and social and voluntary services

Primary care services At the primary care level GPs, health visitors, community nurses, and health workers will deal with most of the problems of elderly people. Acute and long-term hospital services Elderly patients often require admission for acute assessment and treatment, respite care, or long-term care. Services may be situated within general medical wards for the elderly or within specialised old age psychiatry units. The advantage of acute services being located in general hospitals rather than in psychiatric hospitals is that a range of associated specialist services (such as old age medicine, neurology, and radiology) is often more readily available. Day and outpatient care Ideally a service should have outpatient facilities for the assessment, treatment, and follow-up of mobile elderly patients with mental health problems. Sometimes these clinics offer a specialist service such as the ‘memory clinic’. Day-care services may take the form of a general or psychiatric day hospital, and local authorities often provide day centres and social clubs for functional and social support. Community psychiatric nurses (CPNs) CPNs provide a vital link between primary care and specialist services. They often perform assessments on patients after receiving a referral from a GP. They also monitor treatment in collaboration with GPs and the psychiatric services. In addition, they take part in the organisation of home support for the demented elderly. Informal carers These are the unpaid relatives, neighbours, or friends who care for the elderly person at home. Demographic changes and the move to community care have increased the burden on carers. Informal carers are twice as likely to be women. Carers often suffer considerable stress, especially where the patient is suffering from advanced dementia. Relieving carer burden is a challenge for any service. Active involvement of medical and social personnel, as well as provision of education and respite, are important aspects of carer support. Domiciliary services These include; home helps; meals at home; laundry and shopping services; emergency call systems. In some countries such as the UK, local authorities provide these services; however, in many others these services are either privately engaged, obtained from voluntary organizations, or are unavailable. Residential and nursing care In most countries the local authorities take responsibility for providing old people’s homes and other sheltered accommodation. These range in standard from large crowded institutions to small independent units and, ideally, they need to balance individual P.489
privacy with involvement in outside activities. In many communities private homes are available, but financial constraints put these out of the reach of the majority of older people. In planning residential care for the elderly, authorities need to provide for a wider range of accommodation: a small supported unit with 2 or 3 people may be ideal for the still independent and mobile individual; while larger homes with nursing support are required for those who are more dependent, with a number of physical and/or psychiatric needs. References 1 Wertheimer J (1997) Psychiatry of the elderly: a consensus statement. International Journal of Geriatric Psychiatry 12, 432–5. 2 Gelder M, Gath D, Mayou R, Cowen P (1996) Oxford Textbook of Psychiatry, 3rd Edition, Oxford University Press, Oxford. P.490
Capacity, powers of attorney, and guardianship1 Civil law governs the management of individuals and their affairs in cases where he/she becomes incapable of managing for themselves. These issues are most relevant to the psychotically ill, the learning disabled, and the elderly. Decisions regarding treatment of the individual as well as his/her capacity to enter into contracts are dealt with under civil law. (See general discussion on p. 822). Different countries vary in respect of specific details and provisions within their legal systems, but there are a number of general principles which are discussed below. Capacity refers to the individual’s ability to make a clear and informed decision regarding a specific contract (e.g. a financial transaction; marriage and divorce; making a will; decision about treatment). It is important to recognise that an individual may have capacity to make a specific decision (e.g. get married) regardless of his/her general competence (e.g. may be learning disabled). Testamentary capacity is the ability to make a valid will, and the test for this capacity is whether the individual was of ‘sound disposing mind’ at the time of making the will. Psychiatrists may be asked to report on testamentary capacity and are sometimes required to report on whether the testator was subjected to undue influence. It is important to see the testator alone, although factual accuracy should be checked with others (e.g. family members, carers, etc.). There are 4 legal criteria for determining testamentary capacity:

  • Testator must understand what a will is and what its consequences are.
  • Testator must understand the nature and extent of his/her property (though not in detail).
  • Testator must know the names of close relatives and beneficiaries and be able to assess their claims to his/her property.
  • Testator must not be acting on delusional ideas or be in such an emotional state that might distort feelings or judgements relevant to making the will.

Powers of attorney (POA) In a case where an individual suffers from a fluctuating (e.g. schizophrenia) or deteriorating (e.g. dementia) mental disorder, it is advisable for him/her to appoint a power of attorney during a ‘lucid interval’. This involves the patient and the attorney signing a document with a witness present (a doctor may be an appropriate witness where the patient’s mental state and capacity may be in question). When the patient becomes ill and no longer has capacity, the attorney applies to register the POA with the court (Court of Protection in the UK) and is then able to act on behalf of the patient. This form of POA is sometimes called a ‘durable’ or ‘enduring’ POA. Guardianship Where no provision has been made in advance of the patient losing capacity, a more formal procedure is required involving the courts. This is known as guardianship, receivership (UK), or curatorship. This is most commonly invoked with the elderly. In most cases a relative, close friend, business advisor, or officer of the local authority applies to the court for guardianship. Where the patient is in hospital, the doctor may become involved in either notifying relatives of the patient’s change in P.491
capacity, or making the application him/herself (if relatives are absent or unwilling). A doctor (usually specialist) is required to examine the patient and complete a certificate affirming that the patient is incapable, by reason of mental disorder, of managing and administering his/her affairs. In cases where the patient’s estate is very small, the court may direct one of its officers to take a specific action. However, in most cases, a guardian is appointed by the court to administer the patient’s affairs. The guardian is usually a relative but is sometimes a professional person if there is a conflict of interest. The guardian is required to visit the patient regularly, investigate and manage his/her affairs, and report back to the court regarding decisions made. Guardianship is usually a costly business for the patient and/or his/her family. References 1 Jeffreys P (1998) Law. In: Seminars in Old Age Psychiatry Eds. Butler R and Pitt B, Gaskell. P.492
The end of life, living wills, and withdrawal of active treatment The end of life Managing a patient’s final weeks or days and ensuring that their death is a ‘good death’ is a challenge that has only recently been addressed in our health services and training programmes1. Many health professionals have never received any guidance regarding their involvement in this common and extremely important phase of people’s lives. Contemporary palliative services stress the following components in providing a ‘good death’:

  • A multidisciplinary approach
  • Ability to ‘diagnose dying’
  • Communication with patient and family
  • Provision of adequate physical support (e.g. analgesia, hydration)
  • Minimise unnecessary interventions
  • Establish a non-resuscitation plan
  • Psychological, social, cultural, and spiritual support

Living wills2 A living will is an advance directive (usually written and witnessed) made by an individual regarding their preferences for future treatment during their final illness. Usually the person specifies the degree of irreversible deterioration after which they want no further life-sustaining treatment. They may also give clear instructions refusing certain medical interventions. If a health professional is asked to assist someone in drawing up a living will, the following issues should be considered: the patient should be fully informed about the illness and treatment options; the patient should be mentally competent; the patient should be reflecting his/her own views, free from influence. The health carer is required to abide by the living will, although basic care (i.e. analgesia, catheter, fluids) should be provided in all cases. (The BMA has a code of practice entitled Advance Statements about Medical Treatment). Withdrawal of treatment 3,4 The active or passive involvement of a carer in hastening an individual’s death is highly controversial and morally complex. There are differing degrees of involvement that should be distinguished:

  • Withdrawal of active interventions such as medications, blood transfusion, etc. This is an accepted aspect of palliative care and draws little debate.
  • Withdrawal of life-sustaining treatment such fluids, food, etc. This is equivalent to ‘allowing a patent to die’. Since the current emphasis is on preserving human dignity rather than preserving life, this is morally acceptable for many and should not be considered euthanasia.
  • Active intervention which hastens or precipitates the patient’s death-euthanasia. This is distinguishable from homicide in that the patient has either consented to the assisted death or is unable to (e.g. comatose) and the intervention is regarded as a ‘mercy killing’.

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That time of year thou mayst in me behold When yellow leaves, or none, or few, do hang Upon those boughs which shake against the cold, Bare ruin’d choirs, where late the sweet birds sang. In me thou see’st the twilight of such day As after sunset fadeth in the west; Which by and by black night doth take away, Death’s second self, that seals up all in rest. In me thou see’st the glowing of such fire, That on the ashes of his youth doth lie, As the death-bed whereon it must expire Consum’d with that which it was nourish’d by. This thou perceiv’st, which makes thy love more strong, To love that well which thou must leave ere long. Shakespeare: Sonnet 72 References 1 Ellershaw J and Ward C (2003) Care of the dying patient: the last hours or days of life. BMJ 326, 30–34. 2 Ramsay S (1995) UK doctors get advance-directive guidance. Lancet 345, 913–14. 3 Hermsen MA and ten Have HA (2002) Euthanasia in palliative care journals. Journal of Pain and Symptom Management 23, 517–25. 4 Sharma BR (2003) To legalize physician-assisted suicide or not?—a dilemma. Journal of Clinical Forensic Medicine 10, 185–90.

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