 \200 \200\224occupational, family and 1 Gunn J (2000) Personality disorder: a clinical suggestion. In Tyrer P (ed.), Personality disorders: diagnosis, management and cause, pp. 44 \200\22350. Oxford: Butterworth Heineman n. 13_Semple_Chap13.indd 505 12/7/2012 3:43:12 PM CHAPTER 13 Personality disorders 506 Management of personality disorder 1: general aspects It is generally felt that PD is resis tant to speci \201 c psychiatric treatment. However, there is no good evidence to either r efute or support this state- ment. Patients often present at a time of crisis and/or when t hey develop a comorbid axis I disorder. Although some may wish to, psychiatrists cannot avo id having to manage patients with PD. Principles of successful management plans1 A successful management plan in PD is tailored t o the individual \200\231s needs andjj explicitly states jointly agreed and realistic goals . The approach to these patients should be consistent and agreed across the services having contact with the patient. Plans should take a long-term view, recognizing that change, if it comes, will only be observable over a long period. Possible management goals Potential management goals include: psychological and practical s upport; monitoring and supervision; intervening in crises; increasing motivation and compli ance; increasing understanding of dif \201 culties; building a thera- peutic relationship; limiting harm; reducing distress; treating comorbid axis I disorders; treating speci \201 c areas (e.g. anger, self-harm, social skills); and giving practical support (e.g. housing , \201 nance, childcare). Managing comorbid axis I disorders It is important to recognize and treat comorbid axis I p athology in patients with PD. Standard treatment approaches should be used, taking into acc ount aspects of the patient \200\231s personality (e.g. impulsivity and an anti- authoritar ian attitude may lead to non-compliance with medication). Understanding and managing the relationship between the patient and staff2 Rejection for tr eatment of patients with PD (even when they present with mental illness) is often due to th e intense negative feelings these patients may engender, and the disruptive and uneasy rela tionships they form with those that try to help them. Just as they do in many of their inte rpersonal relationships, patients with PDs display disordered attachment in their relations hips with staff (whether with individuals or with a service). When dealing with such patien ts this needs to be recognized, acknowledged, and managed. An acceptance of, and tolerance for, these dif \201 culties needs to be combined with continuing commitment to the patient . However, patients, staff, and other agencies need to realize there are no instant solutio ns and that psychiatric services cannot take responsibility for all adverse behaviors. Admission to hospital Patients with PD bene \201 t little from prolonged admissions to con ventional psychiatric units. Admission to such units may be necessary when there is a speci \201 c crisis (usually in the short term) or when the patient presents with an axis I dis order. Longer-term admission for the treatment of PD 13_Semple_Chap13.indd 506 12/7/2012 3:43:12 PM MANAGEMENT OF PD 1: GENERAL ASPECTS 507 could be undertaken in a therapeutic community. Involuntary long-term hospitalization of pa tients with PD primarily to prevent harm to others where there is little prospect of clinic al bene \201 t to the patient is ethically dubious. Managing crises Individuals with PD often present in crisis. This may follow life events, r elationship problems, or occur in the context of the development of comorbid mental illness . In some cases the crisis may follow what appears to the outside observer to be a relative ly minor or non-existent stressor. Where patients repeatedly present in crisis it can be he lpful for the various professionals involved to plan what the response should be in such si tu- ations. A consistent response is important, but there should be suf \201 cient \202 exibility to deal with changes in circumstances. For example, where a patient repeatedly pr esents with self-harm it may be appropriate for out- patient treatment to continue followin g any necessary medical treatment; however, if this patient presents threatening suicide fo llowing the death of a partner, then it may be appropriate to arrange admission to hospital . Other approaches to individuals presenting with threats of self-harm or of violence and t o manipulative patients are covered on b p. 994. 1 Davison SE (2002) Principles of managing patients with personality disorder. Advances in Psychiat Treat 8: 1 \200\2239. 2 Adshead G (1998) Psychiatric staff as attachment \201 gu res. Understanding management problems in psychiatric services in the light of attachment t heory. Br J Psychiat 172: 64 \200\2239. 13_Semple_Chap13.indd 507 12/7/2012 3:43:12 PM CHAPTER 13 Personality disorders 508 Management of personality disorder 2: speci \201 c treatments1,2 Medication3 The main indi cation for medication in patients with PD is the development of comorbid mental illness. Th ere is no good evidence that medication has any effect on PD itself. The positive \201 nd ings from studies have been short-term, and probably due to the effects of medication on co morbid disorders rather than on the PD itself. Bearing this in mind, the following have bee n suggested: \200 Antipsychotics borderline) and cluster A (particularly schizotypal and perhaps paranoid) disorders. Antidepressants harming patients (particularly borderline), an d in cluster C (particularly avoidant and obsessive \200\223compulsive) disorders. Anticonv ulsants and lithium affective instability or impulsivity. may be of some bene \201 t in cluster B (particularly may be of bene \201 t in impulsive, depressed, or self- have been suggested where there is Therapeutic community A therapeutic community is a consciously designed social environment and program within a residential or day unit, in which the social and group process is harn essed with therapeutic intent. It is an intense form of psychosocial treatment in which eve ry aspect of the environment is part of the treatment setting, in which interpersonal behav ior can be challenged and modi \201 ed. The main principles are democratization, permissiv eness, communalism, and reality confrontation. There are various interactions between patie nts and staff both individually and in groups, particularly in the daily community groups, which contribute towards achieving these principles. There is some evidence that such treat ment is effective with some patients with PDs. Dialectical behavioral therapy (DBT) (b p. 8 56) Combination of individual and group therapy lasting at least 12mths. In stage 1, indivi dual therapy focuses on a detailed cognitive \200\223behavioral approach to self-harm and o ther \200\230therapy interfering \200\231 behaviors. Internal and external antecedents are explored, and alternative problem-solving strategies are developed. Group therapy focuses on tolerance of distress, emotional regulation and interpersonal skills. \200\230Mindfulne ss training \200\231 based on Eastern meditation techniques is a key part of this. In stage 2, patients are helped to process previous trauma, but only when stage 1 skills are develo ped. In stage 3, the focus is on developing self-esteem and realistic future goals. Another aspect of DBT is that patients may contact therapists by telephone between sessions to hel p them apply skills when dif \201 culties arise. There is evidence that DBT may be an effe ctive therapy for out- patients with borderline PD. 13_Semple_Chap13.indd 508 12/7/2012 3:43:12 PM MANAGEMENT OF PD 2: SPECIFIC TREATMENTS 509 Cognitive analytic therapy (b p. 858) May be appropriate for some patients with borderline PD. Aims to iden- tify different \200\230self-states \200\231 and associated \200\230reci procal role procedures \200\231 (pat- terns of relationships learned in early childhood). P atients are helped to observe and change thinking and behavior related to these self-states . Countertransference helps provide useful information about \200\230reciprocal role relat ionships \200\231 either through identi \201 cation with the patient or reacting to their projections. The aim is for patients to be able to recognize their various \200\230self-st ates \200\231 and to be aware of them without dissociating. Psychodynamic therapy (b p. 840 ) Classic Freudian or Jungian psychoanalysis is of no proven bene \201 t for patients with PD, and is probably contraindicated in patients with severe PDs. However, psychodynamic co ncepts are extremely useful in under- standing personality disordered patients and the reac tions they provoke in others, including ourselves. Modi \201 ed psychodynamic approaches f or patients with borderline and narcissistic PDs have been developed. Cognitive behavioral therapy (b p. 850) Schema-focused therapy concentrates on identifying and modifying early m aladaptive schemas and related behaviors. Patients are educated about schemas and led to ex pect that they will be dif \201 cult to change (for example, patients will distort new inf ormation to \201 t in with their existing schemas). \200\230Empathic confrontation \200 \231 is used to help patients to repeatedly and persistently challenge their core beliefs a bout themselves and others. Issues related to interpersonal schemas may arise in the therap eutic rela- tionship and be used as \200\230data \200\231 for dealing with these schemas. There are other models used in cognitive behavioral therapy to treat PD, but all have in co mmon: the goal-directed problem-solving approach; the teaching of speci \201 c skills; a l onger timescale than the relatively brief length of therapy for most other disorders; empha sis on developing, main- taining, and utilizing the therapeutic relationship; a focus on un derlying core beliefs (schemas) regarding self and others; and, a longer-term his- torical perspective in therapy as opposed to the here-and-now focus with many other disorders. 1 Davidson K and Tyrer P (2000) Psychosocial treatment in personality disorder. In Tyrer P (ed.), Personality disorders: diagnosis, management and cause, pp. 90 \200\223100. Oxford, Butterworth Heinemann. 2 Deary I and Power M (1998) Normal and abnormal personality. In Joh nstone EC, Freeman CPL and Zeally AK (eds), Companion to psychiatric studies, 6th edn, pp. 565 \200\22396. Edinburgh: Churchill Livingstone. 3 Tyrer P (2000) Drug treatment of person ality disorder. In Tyrer P (ed.), Personality disorders: diagnosis, management and cause, p p. 126 \200\22332. Oxford: Butterworth Heinemann. 13_Semple_Chap13.indd 509 12/7/2012 3:43:12 PM CHAPTER 13 Personality disorders 510 Outcome of personality disorder1 Morbidity and mortality High rates of accidents, suicide, and violent death, particularly where clus- ter B features are prominent. As mentioned alre ady, there are high rates of other mental disorders. Outcome of other disorders in patients with personality disorder The outcome of mental illn ess and physical illness is worse in patients with PDs. Persistence of personality disorder Some contend that PD is by de \201 nition lifelong and therefore has a poor prognosis, but the evidence for this is far from conclusive. Comparison between different age groups Personality disorder is less prevalent in older adu lts than younger adults, particularly for cluster B disorders. In terms of \200\230normal \200\231 personality, compared with young adults the elderly are more likely to be cautious and rigid, and less likely to be impulsive and aggressive. However, cross- sectional studi es looking at different age groups at one point in time tell us little about the developmen t of personality in individuals over time. Follow-up of individuals over time Antisocial/dissocial Children presenting to child servic es with antisocial behavior are 5 \200\2237 times as likely to develop antisocial PD as tho se pre- senting with other problems. May show some improvement in antisocial behavior by \201 fth decade. However, may just change with time from \200\230overt \200\231 criminal b ehavior to more \200\230covert \200\231 antisocial behavior such as domestic violence and child abuse. There is contradictory evidence as to whether \200\230burnout \200\231 or \200\230maturation \200\231 in later life really does occur. Borderline A third to a half of patients ful \201 lling the criteria for border- line PD d o not have PD at all when followed up after 10 \200\22320yrs. About a third continue to hav e borderline PD and others have other predominat- ing PDs. Poor prognostic indicators are s evere repeated self-harm and \200\230comorbid \200\231 antisocial personality; a good prog nostic indicator may be an initial presentation with comorbid affective disorder. Schizotypal Generally have poorer prognosis than borderline patients. About 50% may develop schizophrenia. Obsessional May worsen with age. More likely to develop depression than OCD. Clusters There is some evidence that cluster A traits worsen with age, cluster B traits imp rove, and cluster C traits remain unchanged. 1 Tyrer P and Seivewright H (2000) Outcome of personality disorder. In Tyrer P (ed.), Perso nality disorders: diagnosis, management and cause, pp. 105 \200\22325 Oxford: Butterworth H einemann. 13_Semple_Chap13.indd 510 12/7/2012 3:43:12 PM 511 Chapter 14 Old age psychiatry Psychiatric illness in older people and psychogeriatrics 512 Normal ageing 514 Multidiscipl inary assessment 516 Speci \201 c aspects of psychiatric illnesses in the elderly 1: overv iew and neuroses 518 Speci \201 c aspects of psychiatric illnesses in the elderly 2: mood disorders 520 Speci \201 c aspects of psychiatric illnesses in the elderly 3: psychoses 522 Other mental health problems in the elderly 524 Issues of elder abuse 526 Psychopharmacolog y in the elderly 528 Services for the elderly 530 The end of life, living wills, and withdr awal of active treatment 532 14_Semple_Chap14.indd 511 12/7/2012 3:43:47 PM CHAPTER 14 Old age psychiatry 512 Psychiatric illness in older people and psychogeriatrics Psychogeriatrics, or old age psych iatry, is a comparatively new specialty which has developed over the last 50yrs in response to demographic changes and the growth of geriatric medicine. It was inspired by the \200 \230social psychiatry \200\231 movement and growing emphasis on the care and welfare of vul nerable sectors of the population. Psychiatric illnesses in older people include: \200 \200 Pre-existing psychiatric disorders in the ageing patient. New disorders related to the spec i \201 c stresses and circumstances of old age (e.g. bereavement, in \201 rmity, dependen ce, sensory de \201 cits, isolation). Disorders due to the changing physiology of the agei ng 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 pharma- cokinetics of the older patient). F urthermore, the elderly are more likely to manifest physical symptoms of psychiatric disord er 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 o f interest in psychogeriatrics, but the discipline also con- cerns itself with depressive i llness, paranoid states, and other late-onset problems. Since older people are often dependent on others, consideration of the role and the needs o f 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 welf are services, the legal system, charity organizations, and religious institutions). The demographics of old age In developed countries such as the UK, the elderly population h as been increasing steadily over the last century. For example, in the UK the per- centage of the population older than 65yrs was 5% in 1900, 15% in 2003, and is projected to be 24% in 2034.1 This trend is largely attributed to the decline in infant mortality, control of i nfectious 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 man y, including a drop in the proportion of the working population, an increase in overall dis ability and health needs, and a corresponding increase in the need for both health and soci al services. In terms of psychiatric disorders, it is well known that certain disorders increase in freq uency with advancing age. For example, 5% of people older than 65yrs suffer from moderate t o severe dementia and the prevalence increases to over 30% of those over 85yrs.2 The preval ence of other dis- orders in people >65yrs is approximately: 1.1% for schizophrenia; 1.4% f or bipolar disorder; and 12.5% for neurosis and personality disorder.3 Other research has shown a particularly high prevalence of mental dis- order among elderly people in sheltered accommodation. Of the 80 000 persons in the UK who die in care homes an nually, up to two thirds have 14_Semple_Chap14.indd 512 12/7/2012 3:43:47 PM PSYCHIATRIC ILLNESS IN OLDER PEOPLE AND PSYCHOGERIATRICS 513 some form of dementia. Up to two thirds of patients >65yrs in general hospital wards have p sychiatric disorder; of these, 20% may suffer from delirium, 31% from dementia and 29% from depression at any one time.4 Finally, it is regrettably also the case that psychiatric dis orders are com- monly either undiagnosed or misdiagnosed at primary care level. Having said this, research has demonstrated a marked improvement over the last decade in both diagnosi s and management at this level. The role of the old age psychiatrist5 \200 Advocate psychiatrist is an active proponent of the interests of the elderly, whether it co mes to sourcing funding or providing education to the public in an effort to dispel the sti gma attached to ageing. Teacher An old age psychiatrist 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 organizers may all ben e \201 t from their expertise. Health educationalist/promoter both health education and pr eventative intervention. Student changing demography of ageing requires the old age psychia trist to make academic forays into other disciplines such as sociology, history, and human geography. Innovator working in this area have had the opportunity to be creative and innov ative in developing appropriate services. Team player The multidisciplinary nature of old a ge psychiatry means that the old age psychiatrist engages with professionals and lay people both in the community and in institutions. \200\230Missionary \200\231 in the UK and was spread to North America, Australia, and the rest of Europe by a core of zealots. A number o f international organizations have formed and the global challenges for the twenty- \201 r st century include expanding the discipline within developing countries as well as \201 n ding new strategies for caring for the growing numbers of elderly people within the \201 rst world. Together with various pressure groups, the old age Holistic care of the elderly includes Psychogeriatrics is a major arena of new research, while the The relative infancy of the discipline means that individuals The concept and practice of psychogeriatrics originated 1 Butler R and Brayne C (1998) Epidemiology. In Butler R and Pitt B (eds), Seminars in old age psychiatry, pp. 16 \200\22327. London: Gaskell. 2 Jorm AF, Korten AE, and Henderson AS (1987) The prevalence of dementia: a quantitative integration of the literature. Acta Psych iat Scand 76: 465 \200\22379. 3 Kay DW, Beamish P, and Roth M (1964) Old age mental disorde rs in Newcastle upon Tyne. I. A study of prevalence. Br J Psychiat 110: 146 \200\22358. 4 W ho Cares Wins (2005) RCPsych. M http://www.rcpsych.ac.uk/PDF/WhoCaresWins.pdf 5 Jolley D (1 999) The importance of being an old age psychiatrist. In Howard R (ed), Everything you need to know about old age psychiatry, pp. 107 \200\22319. Peters \201 eld: Wrightson Biomedic al Publishing Ltd. 14_Semple_Chap14.indd 513 12/7/2012 3:43:47 PM CHAPTER 14 Old age psychiatry 514 Normal ageing1 Neurobiology of ageing \200 The weight of the brain decreases by 5% between ages 30 and 70yrs, by 10% by the age of 80, and by 20% by the age of 90. There is a proportionate increase in ventricular size and siz e of the subarachnoid space. MRI shows changes affecting gray and white matter, reduction i n volume prominent in the hippocampus, association cortices, and cerebellum. CBF There is s ome nerve cell loss in the cortex, hippocampus, substantia nigra, and Purkinje cells of the cerebellum, but less than was thought previously and reductions in dendrites and synapses are thought to be more important. The cytoplasm of nerve cells accumulates a pigment (lipof uscin), while there are also changes in the components of the cytoskeleton. Tau protein to form neuro \201 brillary tangles (NFTs) in some nerve cells. In normal ageing NFTs are usu ally con \201 ned to cells of the hippocampus and entorhinal cortex. Senile plaques are fo und in the normal ageing brain in the neocortex, amygdala, hippocampus, and entorhinal cort ex. Lewy bodies to the substantia nigra and the locus coeruleus. Hirano bodies ( -amyloid and A4 amyloid) may be widespread in Amyloid deposits super \201 cial cortical and leptome ningeal vessels as well as patchy within the cortex. \200 in frontal and temporal lobes and thalamus decreases with age. (links neuro \201 laments and microtubules) can accumulate (extra-cellular amyloid and neuritic processes) (intracellular inclusions) occur normally and are con \201 ned \200 occur in new hippocampal pyramidal cells. Psychology of ageing \200 Cognitive assessment sensory de \201 cits. is often complicated by physical illness or IQ \200 \200 peaks at 25yrs, plateaus until 60 \200\22370, and then declines. Performance IQ reduced processing speed or to the fact that verbal IQ depends largely on fa miliar \200\230crystallized \200\231 information while performance IQ involves novel, \202 uid information. Problem-solving increasing dif \201 culty applying information to an other situation. Short-term/working memory (WM) capacity and this is worse with complexity of task and memory load. Long-term memory (LTM) personal signi \201 cance which may be rec alled with great clarity. There is a characteristic pattern of psychomotor slowing and impa irment in the manipulation of new information. Tests of well-rehearsed skills such as littl e or no decline. drops faster than verbal IQ, which may be due to deteriorates due to declining abstract ability and shows a gradual decrease in declines, except for remote events of verbal comprehension show 14_Semple_Chap14.indd 514 12/7/2012 3:43:48 PM NORMAL AGEING 515 Social problems of old age With the breakdown of traditional family structures in many soci eties, increasing numbers of elderly live alone or in homes for the aged. Losses include: l oss 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 n eeds. The elderly face variable degrees of isolation, marginalization, and stigmatization. 1 Bittles AH (2009) The biology of ageing. In Gelder M, Andreasen N, Lopez-Igor J, and Gedd es J (eds), New Oxford Textbook of Psychiatry, pp. 15 007 \200\223110. New York: Oxford Uni versity Press. 14_Semple_Chap14.indd 515 12/7/2012 3:43:48 PM CHAPTER 14 Old age psychiatry 516 Multidisciplinary assessment Elderly people suffering from mental health problems often hav e a range of psychological, physical, and social needs. This implies that individual assess ment, management, and follow-up requires collaboration between health, social, and voluntar y organizations and family carers. Assessment of the older patient with mental illness incl udes the following: \200 \200 \200 \200 Full history from the patient, family, and carers. Full physical and neurological examinati on. MSE, including full cognitive assessment. Functional assessment (evaluation of ability to perform functions of everyday living). Social assessment (accommodation; need for care; \201 nancial and legal issues; social activities). Assessment of carers \200\231 needs. The best place for performing an assessment is in the patient \200\231s home. A domiciliary visit has the advantage of being more convenient and relaxing for the patient and it provi des the health carer with an opportunity to assess living conditions, social activities, an d medications kept in the house. In addition, family members, neighbors, and carers may be available for interviewing. Historically, day hospital may then be involved in more com- pl ex cases, but these now tend to be replaced by intensive home assess- ment and treatment te ams that can also lead to admission being avoided in some cases. Sometimes brief admission is indicated, especially if the elderly person has pressing physical or psychiatric needs o r 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 stor y. One needs to enquire about the presenting problem and how it has evolved, whether it is a new or long-standing problem, and whether the individual has a personal or family history of mental problems. In addition, enquire about losses, social history, and social circumst ances (housing, income, social activities, etc.), medical problems and medications, alcohol history, and presence or absence of family support and carers. It is particularly importan t 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, thoughts of suicide, abnormal beliefs or perceptio ns, and cognitive impair- ment. Cognitive assessment must include: orientation; memory; con cen- tration and attention; language, praxis, and simple calculation; intelligence; insight ; and judgment. An MMSE will incorporate these elements (see b p. 70). There is a wide rang e of rating scales for assessing mental state, cognitive performance, activities of daily l iving, and carer burden \200\224see Burns et al.1 (2002) for an overview. 14_Semple_Chap14.indd 516 12/7/2012 3:43:48 PM MULTIDISCIPLINARY ASSESSMENT 517 Key questions for carers include:2 \200 \200 \200 \200 \200 \200 \200 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 \200\231s illness. What expectations they have from services. Their awareness of support or voluntary organization s. 1 Burns A, Lawlor B, and Craig S (2002) Rating scales in old age psychiatry. Br J Psychiat 180: 161 \200\2237. 2 Butler R and Pitt B (1998) Assessment. In Butler R and Pitt B (eds), Seminars in old age psychiatry, pp. 1 \200\22316. London: Gaskell. 14_Semple_Chap14.indd 517 12/7/2012 3:43:48 PM CHAPTER 14 Old age psychiatry 518 Speci \201 c aspects of psychiatric illnesses in the elderly 1: overview and neuroses Over view The range of psychiatric illnesses in the elderly is very similar to that in younger p eople. However, the individual factors that contribute to aeti- ology, clinical presentatio n, and management strategy differ due to the speci \201 c biopsychosocial conditions of ol d age. In order to grasp a full understanding of elderly psychopathology it is necessary to appreciate the physiological, psychological, and sociocultural factors unique to this age group. Disorders in the elderly may present with some \200\230classic \200\231 symp- toms (common to adult psychopathology), but very often their clinical manifestation varies signi \201 cantly due to the unique conditions of old age. The following pages focus on the \200\230unique \200\231 features of psychiatric illnesses in the elderly. Neuroses Prevalence Depression and anxiety are common in old age. There is no decline in their preva lence 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 t o de \201 ciencies in detection by health professionals. The estimated prevalence of neuro tic disorders is 1 \200\22310% with a female predominance and roughly equal fre- quency of \200\230old \200\231 and \200\230new \200\231 cases. Clinical features Non-speci \201 c anxiety and depressive symptoms predominate and hypochondriacal symptoms are often prominen t. Obsessional, phobic, dissociative, and conversion disorders are less com- mon. Factors s uch as physical ill health, immobility, and lack of social sup- port may give rise to fear and a lack of con \201 dence about going out of the home \200\224this has been termed \200\230space phobia \200\231. Etiology Multiple factors may contribute to new neurotic sym ptoms in the elderly. Among these, major life events, physical illness, feelings of lonelin ess, impaired self-care, and \200\230insecure \200\231 personality style are most common. Differential diagnosis Physical illness; acute or chronic organic brain disease; affective disorders. Management \200 The mainstay of treatment is to identify and manage aetiological factors. This obviously ve ry often calls for social interventions and thus a multidisciplinary approach is essential. Counseling may be dif \201 cult especially where older people have had limited exposure t o psychological methods but there is increasing evidence for the ef \201 cacy of CBT in th e elderly. Antidepressants may be indicated for severe and disabling symptoms and are certa inly preferable to BDZs. 14_Semple_Chap14.indd 518 12/7/2012 3:43:48 PM This page intentionally left blank CHAPTER 14 Old age psychiatry 520 Speci \201 c aspects of psychiatric illnesses in the elderly 2: mood disorders Epidemiolog y Less than 10% of new cases of mood disorder occur in old age. Episodes occur more frequen tly and last longer. Studies suggest that mood disorders in the elderly have a worse progno sis and there may be a tendency towards chronicity. Gender differences in prevalence also d iminish with advancing age. Prevalence of clinically signi \201 cant depression is 10% for those >65yrs, with 2 \200\2233% being severe. Rates of depression differ depending on sett ing: 0.5 \200\2231.5% in the community; 5 \200\22310% of clinical out- patients; 10 \200 \22315% of clinical inpatients with up to 30% of inpatients suffering from at least mild de pression; 15 \200\22330% of those in residential and nursing homes. Mania accounts for 5 \200\22310% of mood disorders in the elderly. Etiology Positive family history becomes less relevant in older-onset mood disorder. Physical illnesses are associated in 60 \200\22375% of cases. Major life events are common, as is the lack of a con \201 ding and supportive rela- tionship. Older patients are less likely to complain as losses are \200\230expected \200\231. Neuroimaging yields con \202 icting results and brain changes noted may relate t o the normal ageing process. The strongest imaging evidence for brain changes is for mania in men. Clinical features There are no clear distinctions between the clinical presentation of depr ession in the elderly and that in younger people. However, some symptoms are often more str iking: \200 Severe psychomotor retardation or agitation occurs in up to 30% of depressed elderly patien ts. 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 comm on (e.g. Cotard \200\231s syndrome, b p. 89). Paranoia is also common, while derogatory and obscene auditory hallucinations may occur. Classic symptoms may not even be evident and th e 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 behavior. Pseudodementia A minority of retarded depressed elderly present with \200\230pseudodementi a \200\231 (i.e. marked dif \201 culties with concentration and memory). Features suggesti ve of pseudodementia include: previous his- tory of depression; depressed mood; biological symptoms; \200\230islands of nor- mality \200\231; exaggerated symptoms; poor effort on te sting, frequent comments such as \200\230I can \200\231t be bothered \200\231, \200\230it \200\231s too dif \201 cult \200\231 to relatively easy tasks; response to antidepressant medication. For some this may herald/uncover the onset of a dementia syndrome and there is a proven association between depressive pseudodementia and later diagnosis of dementia. 14_Semple_Chap14.indd 520 12/7/2012 3:43:48 PM PSYCHIATRIC ILLNESSES IN THE ELDERLY 2: MOOD DISORDERS 521 Mania or hypomania present a similar clinical picture as in younger patients; however, they are more often followed by a depressive episode in older patients. There is usually a hist ory of bipolar affective disorder. A \201 rst episode of mania in an elderly person requi res careful screening for cerebral or systemic pathology (e.g. stroke or hyperthyroidism). Differential diagnosis Dementia \200\224dif \201 cult to distinguish and can occur togethe r, if in doubt best to treat; paranoid disorder \200\224depressive paranoia and delusions m ay be dif \201 cult to distinguish from psychoses; stroke \200\224especially after left fr ontal CVA or s to the lability, reactive stress, organic apathy, d motivation, or drug side -effects associated with stroke; Parkinson \200\231s disease \200\224drug side-effects in t reating may suggest depressive illness; other physical disorders e.g. infection, hypothyroi dism, tumors, alcohol, drug side-effects. Note: full physical investigation is vital. Management \200 Antidepressants elderly, but care must be exercised in prescribing. ECG and BP monitoring i s important due to postural drops as well as other cardiac problems. First-line is probably SSRIs due to dside-effects and relative safety in OD. Others include: SNRIs such as venlaf axine; and, occasionally, moclobemide (delayed hypotension a problem). General rules includ e: low starting dose; gradual increases; longer maintenance periods (up to 2yrs); beware of suicide risk; consider lithium augmentation. Caution needs to be observed when considering changing/reducing/stopping long-term antidepressants in this group as this not uncommonly may precipitate a relapse even in persons who have been stable for years. ECT where there i s marked agitation, life-threatening stupor, suicidality, or contraindications, failure, or excessive side-effects of drugs. ECT is generally safe and effective. Dementia is not a co ntraindication. Post- ECT confusion may be a problem, in which case treatments should be gi ven at longer intervals. Psychological treatments supportive psychotherapy; bereavement cou nseling. Age-appropriate doses of antipsychotics may be Treatment of mania used, in particu lar haloperidol and risperidone. Lithium is \201 rst-line in prophylaxis but lower dosage s are indicated (levels: 0.4 \200\2230.8 mmol/L) and regular thyroid and renal checks (at l east three monthly) are essential. Also note that levels may easily change in the presence of infection, dehydration, and use of other medications (e.g. diuretics). Levels should be taken at 10 \200\22314hrs after last lithium dose. Following increase in lithium dose, 5 \200\2237 days should be allowed for serum levels to stabilize. TCAs are not absolutely contraindicated in the (b p. 284) First-line treatment for severe illness and speci \201 cally Therapies include: CBT for depression; Prognosis Generally prognosis is good, especially: onset <70yrs; short illness; good previo us adjustment; absent physical illness; good previous recovery. Poor outcome is associated with: severity of initial illness; psy- chotic symptoms; physical illness; poor medication compliance; severe life events during follow-up period. 14_Semple_Chap14.indd 521 12/7/2012 3:43:48 PM CHAPTER 14 Old age psychiatry 522 Speci \201 c aspects of psychiatric illnesses in the elderly 3: psychoses Psychotic illnes s in the elderly may be classi \201 ed as follows: \200 \200 \200 \200\230Old psychosis \200\231 \200\224the \200\230graduate \200\231 population. \200 \230New psychosis \200\231 \200\224late-life schizophrenia or late paraphrenia. Other condi tions with paranoid and/or hallucinatory symptoms (Box 14.1) Old psychosis With the advent of antipsychotic drugs in the 1950s, there followed a progres sive decrease in the numbers of long-stay patients with schizo- phrenia in institutions. Th us more and more ageing patients with chronic schizophrenia moved into the community, and i n countries such as the UK and USA, many of these patients are increasingly referred to psy chogeri- atric services. Caution needs to be observed when considering changing/ redu cing/ stopping long-term antipsychotic in this group as this not uncom- monly may precipitate a r elapse even in persons who have been stable for years. It is advisable that the patient hav e a psychiatric review and opinion in this regard. New psychosis Paraphrenia \200\224a term coined by Emil Kraepelin in 1909; described a psyc hotic illness characterized by delusions and hallucinations, with- out changes in affect (a lthough there may be reactive anxiety), form of thought, or personality. Late paraphrenia \200\224described by Roth and Morrisey in 1952; they noted that this type of illness was the most common form of psychosis in old age (de \201 ned as >60yrs). Epidemiology \200\224relatively rare condition; population studies estimate <1% prevalence. Approximately 10% of admissions to psychiatric wards for the elderly will have the conditi on. One study showed that when ICD-10 cri- teria were used, 60% of cases were classi \201 ed as paranoid schizophrenia, 30% as delusional disorder, and 10% as schizoaffective disord er.1 Gender distribution is estimated at 4 \200\2239:1 female:male predominance. Etiology \200 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 p opulation.2 Premorbid personality characterized by poor adjustment and it is estimated that nearly 45% show lifelong paranoid and/or schizoid traits. Sensory impairments increases ri sk of late paraphrenia. Social isolation Organic factors enlargement; cerebrovascular patho logy is a common comorbid \201 nding. of people with late paraphrenia is such as deafness, of onset in middle life, \200 