|Disorders in the Elderly|
|Depression: Older people may present with the classical depressive symptoms seen in younger patients, but there are some special features in older age groups that may prevent its recognition:
The elderly are less likely to admit to depressive symptoms spontaneously.
The elderly depressed patient may present with persistent pain or other physical complaints
Depression in old age may present with behavioural disturbance, especially in association with dementia.
Apparent cognitive impairment or mental slowing, so-called "pseudodementia", may be an indication of a primary depressive illness.
In the setting of physical disability or illness, depression may be less easily recognised because of overlapping symptoms.
Dementia: People with dementia (loss of cognitive and intellectual ability caused by cerebral disease) frequently present to their primary care doctors with psychiatric symptoms. Common presentations in the doctor's surgery that may indicate dementia are acute confusion (delirium superimposed on dementia), listlessness, inactivity and loss of interest (superimposed depression), and medical instability or injury (which may indicate poor compliance with treatment regimens). The cognitive impairment of dementia modifies the clinical presentation of other mental disorders so that it can be difficult to tease out specific target symptoms.For example, depression may be masked by cognitive slowing. It is wise to suspect depression in a patient with vascular dementia who becomes irritable or aggressive.
Forty per cent of people with dementia will develop psychotic symptoms during some phase of their illness.
Dementia sufferers are more likely to develop delirium.
Delirium: The elderly, and particularly those with pre-existing dementia, are particularly vulnerable in the setting of acute physical illness and polypharmacy. Suspicions should be raised when there is a sudden onset or increase in confusion or when there is a fluctuation in a person's mental state, especially when there is worsening at night.
Paranoid disorders: Schizophrenia and delusional disorders in old age can be longstanding or of recent onset. An annual incidence of about 17-23 per 100 000 has been reported in community surveys. Isolated elderly people may be psychotic for some time before they come to the attention of medical services. Initial referral may be via police or other community agencies. A typical presentation may involve an elderly person repeatedly asking police or doctor to intervene because they are being harassed in some way.
Anxiety: It is unusual for primary anxiety disorders to develop for the first time in old age. If they develop, general practitioners should be alert to the possibility of underlying depression or occult physical illness such as cardiac or thyroid disease. Like dementia and post-traumatic stress, longstanding but unrecognised anxiety may be revealed by the death of a spouse or the sudden discontinuation of prescribed or non-prescribed medication
The value of the home assessment: A quick appraisal of how a person is managing at home will provide a rich source of information about such issues as hygiene, nutrition, neglected injuries, hoarding or misunderstanding of prescribed medication, or alcohol abuse. For example, a previously highly functioning individual may let standards slip during a depressive episode, or a paranoid person may have barricades at windows and doors, important features that will not be evident at a surgery-based consultation.
Confusion, aggression and tearfulness: These are common symptomatic presentations in the elderly, for which there may be many possible causes. The major causes of confusion are dementia (onset months-years), depression (onset days-months) and delirium (onset hours-weeks). Other causes are physical illness and side effects of medications.
Collateral history: It is essential to obtain a reliable collateral history of the presenting complaint. A cognitively impaired person will not be able to give essential information, and a deluded or depressed person may not give an accurate account of events. If available, the doctor should seek substantiation of the history from a close relative or friend.
Medical history: A thorough, well substantiated medical history, including recent changes in somatic symptoms and/or treatments, is fundamental when performing psychiatric evaluation of the elderly. For example, a history of thyroid disorder would be important when assessing someone with anxiety; occult carcinoma may present with paranoia and hallucinations. Alterations in medication regimens may account for changes in mental state (e.g., an anticholinergic drug prescribed for urinary incontinence is a prime suspect in the onset of delirium, or the discontinuation of a benzodiazepine may cause withdrawal agitation).
Physical examination: Patients with dementia are particularly at risk of undiagnosed physical illness, such as infections or fractures, as they may be unable to identify somatic symptoms accurately. Acute confusion in a patient with dementia may indicate, at one extreme, a minor problem such as constipation or, at the other extreme, a major problem such as unrecognised hip fracture. Patients receiving neuroleptic drugs are at risk of postural hypotension and falls.
Investigation: Judicious and well targeted tests should be performed according to the physical and mental status findings. Marginally abnormal pathology results may indicate delirium in patients whose cognitive function is already compromised. Major depression occurring for the first time in later life may signal occult disease, such as carcinoma of the lung, and investigations, such as plain x-ray of chest, should be performed to exclude this. Urinary tract infections may be relatively asymptomatic and a simple dip test will indicate the need for further investigation.
Mental state examination: Mental state examination begins from the time the patient walks into the surgery or the doctor walks into the patient's residence. The environment, and the patient's interaction with it, are important pointers to his or her mental health.
Many older people are not used to speaking in psychological terms and may need to be coaxed to explain their feelings. It is sometimes awkward for family physicians to ask questions about memory and orientation when they have known the patient over many years, but it is essential to perform at least a brief cognitive test. This may reveal surprisingly poor cognition once a patient is pressed beyond the social niceties or "well worn tracks".
Neuroleptic agents are not only prescribed for psychotic symptoms in the elderly, but can be effective for agitation and aggression that accompanies dementia. They are least effective for repetitive, non-aggressive behaviours such as wandering, excessive vocalisations and sexual disinhibition. High-potency, low-dose agents (e.g., haloperidol) are usually preferred to low potency, high-dose agents (e.g., thioridazine or chlorpromazine) because of their lesser propensity to cause confusion and postural hypotension. However, haloperidol can cause extrapyramidal symptoms even at low doses and tardive dyskinesia is a risk with long-term use. The new atypical neuroleptic agents (e.g., risperidone and olanzapine) are postulated to minimise these side effects and are likely to be increasingly used as first-line treatments in the elderly.
Antidepressants, unlike neuroleptic agents, are usually prescribed in doses similar to those used with younger patients. However, courses of treatment are likely to be significantly longer or given indefinitely if late-life depressive episodes are recurrent or severe. Given the potential anticholinergic and cardiotoxic effects of tricyclic antidepressants, these agents are now prescribed far less frequently. The expanding range of new antidepressants, with their more selective mode of action, higher degree of tolerance and less lethal side effects, has enabled the pharmacological treatment of depression in old age to be undertaken more assertively.
Anxiolytic agents, particularly benzodiazepines, must be prescribed with caution in the elderly. In this age group central nervous system toxicity (drowsiness, ataxia and confusion) is more likely to occur, especially with longer-acting agents. Short-acting bezodiazepines (e.g., oxazepam, temazepam and lorazepam) are preferable, although rebound symptoms will develop if treatment is prolonged and dosage is not tailored to the half-life of the drug.
Psychological/ behavioural strategies The elderly are less likely to be considered for psychological therapy, whether to enhance benefits gained from pharmacotherapy or as an alternative treatment. However, even when cognitive deficits are present, modified psychotherapeutic strategies can be beneficial. Psychological treatments for elderly patients include:
Cognitive-behavioural strategies as adjunctive treatment in depression.
Supportive/reminiscence therapy for bereavement.
Behavioural strategies and carer support/education for dementia-related problems.
Respite/ residential care Periods of temporary respite care for people with dementia have been shown to lessen carer burden and stress. Unfortunately, the more behaviourally disturbed the elderly person is, the more difficult it becomes to find residential facilities with an appropriate safe physical environment and the necessary nursing expertise. Some aged care and aged psychiatric services dedicate a small number of hospital beds to this function, depending on their resources. It must be remembered that, while removing an elderly confused and demanding patient temporarily from their home may provide relief for their carer, it is not always in the best interests of the patient. Changes in environment have been shown to increase confusion and behavioural disturbance in persons with dementia, even when specialised care is provided. "In home" respite programs provide an alternative that still allows the carer to have some relief, but does not remove the elderly patient from their familiar environment. Expense is usually the main factor restricting this form of care, but local government and community agencies are increasingly becoming involved in providing these needed services.
In the past, longer term psychogeriatric residential care was provided in the large psychiatric asylums, which are now closing. Small, specialised facilities such as the CADE (confused and disturbed elderly) units in New South Wales and psychogeriatric nursing homes in Victoria offer an alternative, more home-like environment for the elderly with persistent behavioural disturbance. As this type of care is resource-intensive, stringent gatekeeping is required to maximise the efficiency of these facilities. There is an expectation that most patients will only require this form of care for a limited time and can then be transferred to generic aged hostels or nursing homes.
As part of the continuum of psychiatric services for the mentally ill of all ages, aged psychiatry is continuing to grow as a major healthcare area and a challenge to government health authorities worldwide. The chronically mentally ill, particularly those who have grown old with schizophrenia, must be acknowledged and provided for. As the politically powerful generation of baby-boomers grows old, perhaps we will see, at last, a more adequate level of attention to the conditions under which the elderly mentally ill live.