The psychiatry of old age is of growing importance, because the proportion of elderly people in the UK population is increasing. ìOld ageî services as opposed to ìgeneral adultî services may take patients over the age of 65, or 70 depending on local arrangements. In some districts, patients with long-term mental health problems from adult life are kept on by general psychiatry, with elderly psychiatry taking cases which present after 65 or other agreed cutoff.

Psychiatric illness becomes more common with advancing age. This is because elderly people have a high prevalence of cerebral and systemic diseases which can cause organic brain syndromes, and because they are often subject to emotional stresses and loss.

These include the deaths of spouse, siblings and friends; loss of occupation, company and income following retirement; deterioration in bodily functions; the prospect of further ageing and death; and sometimes, both within private households and institutions, mistreatment by those with the responsibility for care (ìelder abuseî).

FREQUENCY Community surveys show the following approximate prevalence figures for psychiatric illness in people over the age of 65:

Depression 15%
Anxiety and phobias 15%
Dementia 10%

Prevalence rises sharply after about the age of 75.

CLINICAL SYNDROMES Depression is the most common psychiatric disorder in old people, and first admission rates for depression are highest in the 50ñ70 age group. Mixed anxiety-depressive states frequently present in primary care with psychiatric symptoms, insomnia, physical problems or social difficulties (ìfailure to copeî).

Most depressive episodes recover in the short term, but long-term prognosis is worse than for younger patients. At least 70% develop further episodes.

Suicide rates rise with age, and suicide in elderly people is often associated with clinical depression as well as with social isolation.

Depression in old people may be associated with cognitive impairment and therefore be difficult to distinguish from early dementia. A careful history, mental state examination, and a brain scan often help to make the distinction, but the two disorders may co-exist.

Antidepressant drugs are effective but low doses should initially be used because unwanted effects, for example postural hypotension with tricyclics, are more severe than in younger adults. If successful, antidepressants should be continued for 1ñ2 years in old people, perhaps even for life, because of the high likelihood of relapse.

ECT is readily considered in the elderly, as it acts more quickly than medication and, apart from transient mental confusion, often has fewer unwanted effects. ECT may be lifesaving in a severely depressed patient who is dehydrated due to refusal to eat and drink.

Mania: although first admission rates for mania show a slight increase with age, it remains an unusual presentation. It is important to exclude physical causes such as a brain tumour, cerebrovascular disease, or medication such as steroids, especially if a careful search (old casenotes, interviewing relatives) fails to reveal any previous history. Patients with longstanding bipolar illness tend to suffer less mania and more depression if they survive into old age. Transient depressive symptoms occur during most manic illnesses in the elderly. Physical illness or injuries often result from self-neglect and over-activity, so inpatient treatment is desirable.

Schizophrenia and Paranoid Disorders: a small proportion of psychotic illnesses (probably less than 10%) start after the age of 65. This is usually the paranoid form with good preservation of general personality. (The term paraphrenia may be used). It is important to check for sensory impairment, which may be contributing to the problem through increasing the patientís isolation and re-inforcning any paranoid tendency. Social activity, for example through a day centre or residential home, may be helpful if the patient will accept it. Antipsychotic drugs are used but results are sometimes disappointing.

Case Example

A widower aged 73 had lived an increasingly isolated life since retirement. His GP was called to see him as an emergency by the police, to whom he had made frequent 999 calls alleging that his neighbours were trying to murder him with gas. Apart from his obvious delusions, he was otherwise in good health. He did not believe that he was in any way unwell. He was compulsorily admitted, after a domiciliary visit from the duty psychiatrist, to a psychiatric ward under the Mental Health Act 1983. He was unwilling to take oral medication, but his symptoms partially resolved with a small dose of a depot antipsychotic injection. Although he was able to be discharged, he remained isolated and generally suspicious, and his community psychiatric nurse (CPN) frequently had difficulty in persuading him to have his injection.

Neurotic disorders: reactions to bereavement or other stressors may produce brief adjustment disorders in the elderly, just as in younger people, however it is unusual for a prolonged neurotic condition to become established in an elderly person who has previously been free of such symptoms. Such a first presentation in an elderly person should raise suspicion of organic disorder or depressive illness.

Dementia, delirium and other organic brain syndromes are considered in more detail here.

Case Example

A woman of 83 had been diagnosed as suffering from moderate to severe dementia of Alzheimerís type, but was able to remain at home because of the devoted care of her 62-year-old daughter. Her behaviour became much more agitated and confused over a period of two days, alternating with periods of drowsiness; her urine had become foul-smelling over this time. The GP and CPN diagnosed acute-on-chronic confusion due to urinary tract infection, and continued to look after the patient at home, for her daughter wished to avoid hospital admission. With antibiotics, a change of catheter and some sedation with small doses of chlorpromazine, the patientís condition returned to normal over a few days. Her daughter nevertheless appeared exhausted, and regular respite care admissions were arranged to ease her burden.

Alcohol and Drugs: alcohol misuse may become a problem in old age, but is often concealed. Depression, loneliness and boredom, perhaps following the death of a spouse, are common precipitants. Drug misuse usually involves prescribed drugs, such as benzodiazepines, which often cause ataxia and cognitive impairment in this age group. If an elderly person with unrecognised alcohol or drug dependence develops an intercurrent illness and/or is admitted to hospital, withdrawal symptoms may ensue.


ASSESSMENT Although it is important to reach a psychiatric and/or medical diagnosis, identification of the practical problems facing the patient may be the most urgent requirement. Often the point at issue is whether he or she is able to cope at home. This may hinge on something as mundane as, for example, whether a neighbour who does the shopping is prepared to continue doing so.

An assessment in the patientís home surroundings is more meaningful than one carried out in hospital, and an interview with an informant is highly desirable especially if there is any question of cognitive impairment. The timespan of the illness can be crucial in making a diagnosis; an acute confusional state will usually come on over hours or days, a mental illness such as depression over weeks, and a dementia over months or years.

Psychiatric history and mental state are recorded in the usual way. Particular emphasis should be placed on medical factors and social circumstances, and it is essential to test cognitive function. Physical examination may well reveal undiagnosed pathology, which needs attention.

Standardised instruments for interviewing elderly patients include the CAMDEX (Cambridge Examination for Mental Disorders of the Elderly) and GMSS (Geriatric Mental State Schedule). Short questionnaires for assessing cognitive function include the Mini Mental State Examination.

SPECIFIC TREATMENTS

Psychotropic drugs should be used in small starting doses because metabolism and excretion are slow. Both therapeutic effects and unwanted effects may be found with low doses. Medical conditions necessitating caution in drug use may be present, and interactions with other medication may occur.

Forgetfulness and other factors may lead to poor compliance, so single-drug therapy in once-daily dosage is desirable.

The prescriber should become familiar with a small number of preparations and their unwanted effects, make a special effort to gain the trust of the patient, and pay great attention to explanation and detail. For example, someone with severe arthritis of the hands may not be able to take tablets which are dispensed in a ìblister packî; and a change in colour of tablet, or from tablet to capsule, may be worrying for an elderly person.

Antidepressants: either tricyclics or SSRIs may be used. Tricyclics are cheaper, have predictable unwanted effects, and can be started at very low doses. Some authorities recommend drugs of secondary tricyclic structure, such as nortriptyline, because anticholinergic and hypotensive effects are less than with tertiary tricyclics such as amitriptyline.

The major advantage of the SSRIs is their lack of toxicity in overdosage. However, they frequently cause worsening in anxiety and gastrointestinal upset, though it is not possible to predict which patients will be affected.

Lithium is used in prophylaxis of depression and mania.

Sedatives for use in psychosis or agitation include:

• promazine, an effective sedative but weak antipsychotic
• haloperidol, often effective in doses as low as 1 mg, but having marked Parkinsonian side-effects
  

"Atypicalî antipsychotics, such as olanzepine and risperidone, have, since the last edition of this book, come and gone for use in the elderly. (This stands as a further warning to enthusiastic prescribers of new drugs). They rapidly became popular on introduction, because of a perceived reduction in extra-pyramidal side effects. However, it has now become clear that olanzepine and risperidone are associated with an increased risk of stroke in elderly patients with dementia, and the CSM has advised that risperidone and olanzepine should not be used for treating behavioural symptoms of dementia.

Hypnotics and ìminorî tranquilizers were overprescribed in the past, creating a large population of elderly long-term users. However, it is possible that the pendulum has swung too far against these drugs; provided they are used judiciously in line with British National Formulary recommendations, they remain a safe and effective treatment for transient neurotic states such as insomnia after a bereavement.

ECT may be used if the patient is fit for anaesthetic, and is often better tolerated than antidepressant drugs, but many patients need long-term drug prophylaxis also.

Psychological treatments: psychotherapy in its briefer forms may be helpful, though not in dementia.. Intensive exploratory work is inappropriate because major changes in personality or attitudes are not likely to be achieved. Individual or group treatment may be focused on adaptation to bereavement or the other losses of old age. Marital therapy may be indicated, because conflicts in a marriage often become more obvious when the partners are brought into continuous contact by retirement or restricted mobility. Special techniques for this age group include reality orientation (RO) and reminiscence therapy.

Practical memory aids (e.g lists) may be of benefit for dementia patients.

ORGANISATION OF SERVICES The vast bulk of psychiatric disorders is coped with by patients themselves, their relatives and carers; some cases are recognised and treated in primary care, but only the minority reach secondary care. General practitioners have sometimes been criticized for not knowing about such problems in patients on their list, but there is evidence that GPs avoid making these diagnoses if they feel, as is often unfortunately the case, that local psychiatric services for the elderly are overstretched.

Multidisciplinary teams in old age psychiatry, as in general adult psychiatry, include doctors, nurses, psychologists, social workers and occupational therapists. They work in liaison with primary health care teams, social services, and gerontology departments.

Many of the problems identified in a comprehensive assessment are social rather than psychiatric, and require practical interventions accordingly. For example, a depressed patient who is living alone in poor accommodation will be unlikely to make a good recovery with antidepressant medication alone. Attending a day centre might combat loneliness and improve nutrition, and a social worker would advise about housing and social security benefits.

Physical problems also need to be addressed. Undiagnosed medical illness, inappropriate medication, and dietary deficiencies are common in this age-group.
Hospital admission is frequently valuable to treat illness or, commonly, to relieve a social crisis. However, hospitalisation should not be undertaken too lightly. Many old people survive in their own homes through a complex network of informal care and company from relatives, friends, church, the voluntary sector and domestic pets, and this network may prove impossible to reassemble following an admission. If the patient does go into hospital, a gradual discharge with increasing periods of home leave is the rule.

Occupational therapy assessment is often important, to see if the patient can manage day-to-day tasks such as cooking, cleaning and shopping.

Inpatient facilities include assessment wards for functional psychiatric illness and for dementia patients. These are separate from the wards for younger adults, but some facilities may be shared with physicians for the elderly.

Respite admissions at regular planned intervals are particularly valued by relatives, and provide patients themselves with care and company, and an opportunity for thorough medical and nursing review.

Day hospital care is often preferable to inpatient admission, and also less costly.

Home care: a ìpackageî of ìcommunity careî can not only support people with continuing difficulties, but can also be used as a treatment, with increased support at times of crisis.

Most care is now provided in the community. However, old age psychiatry remains a ìCinderellaî specialty with many unmet needs; it is clear that the health and social services would be entirely unable to cope were it not for unpaid carers and the voluntary sector.

A major change has been the new responsibility of local authority social services to ìpurchaseî appropriate care for individuals. This care may range from provision of home helps, laundry and meals-on-wheels, to residential accommodation. Such measures can no longer be directly prescribed by health services, so good local day-to-day working relationships with social workers are vital. Integrated teams of health and social services staff are now the norm.

Supported accomodation such as warden-controlled housing can be very helpful in maintaining independent living. Alternatives include nursing or residential homes, almost all privately run now. Long-stay hospital provision for dementia patients is now almost extinct.