Only arthritis is a more common cause of disability among adults age 65 and older than dementia, a generally progressive and irreversible impairment of the intellect, the prevalence of which increases with age. About 5 percent of persons in the United States older than age 65 have severe dementia, and 15 percent have mild dementia. Of persons older than age 80, about 20 percent have severe dementia. Known risk factors for dementia are age, family history, and female sex.
In contrast to mental retardation, the intellectual impairment of dementia develops over timeâ€”that is, previously achieved mental functions are lost gradually. The characteristic changes of dementia involve cognition, memory, language, and visuospatial functions, but behavioral disturbances are common as well and include agitation, restlessness, wandering, rage, violence, shouting, social and sexual disinhibition, impulsiveness, sleep disturbances, and delusions. Delusions and hallucinations occur during the course of the dementias in nearly 75 percent of patients.
Cognition is impaired by many conditions, including brain injuries, cerebral tumors, acquired immune deficiency syndrome (AIDS), alcohol, medications, infections, chronic pulmonary diseases, and inflammatory diseases. Although dementias associated with advanced age typically are caused by primary degenerative central nervous system (CNS) disease and vascular disease, many factors contribute to cognitive impairment; in older persons, mixed causes of dementia are common. Cognitive disorders including dementia and delirium are covered in Chapter 10.
About 10 to 15 percent of all patients who exhibit symptoms of dementia have potentially treatable conditions. The treatable conditions include systemic disorders, such as heart disease, renal disease, and congestive heart failure; endocrine disorders, such as hypothyroidism; vitamin deficiency; medication misuse; and primary mental disorders, most notably depressive disorders.
Depending on the site of the cerebral lesion, dementias are classified as cortical and subcortical. A subcortical dementia occurs in Huntington’s disease, Parkinson’s disease, normal pressure hydrocephalus, vascular dementia, and Wilson’s disease. The subcortical dementias are associated with movement disorders, gait apraxia, psychomotor retardation, apathy, and akinetic mutism, which can be confused with catatonia. Table 56-4 lists some potentially reversible conditions that may resemble dementia. The cortical dementias occur in dementias of the Alzheimer’s type, Creutzfeldt-Jakob disease (CJD), and Pick’s disease, which frequently manifest aphasia, agnosia, and apraxia. In clinical practice, the two types of dementias overlap and, in most cases, an accurate diagnosis can be made only by autopsy. Human prion diseases result from coding mutations in the prion protein gene (PRNP) and may be inherited, acquired, or sporadic. They include familial CJD, Gerstmann-StrÃ¤ussler-Scheinker syndrome, and fatal familial insomnia. These are inherited as autosomal-dominant mutations. The acquired diseases include kuru and iatrogenic CJD. Kuru was an epidemic prion disease of the Fore people of Papua, New Guinea, caused by cannibalistic funeral rituals, which peaked in incidence in the 1950s. Iatrogenic disease is rare and is caused, for example, by the use of contaminated dura mater and corneal grafts and treatment with human cadaveric pituitary-derived growth hormone and gonadotropin. Sporadic CJD accounts for 85 percent of the human prion diseases and occurs worldwide, with a uniform distribution and an incidence of about 1 in 1 million per annum, with a mean age at onset of 65 years. It is exceedingly rare in individuals under 30 years of age. (Additional information on dementia and prion disease is contained in Chapter 10, Section 10.3.)
Depressive symptoms are present in about 15 percent of all older adult community residents and nursing home patients. Age itself is not a risk factor for the development of depression, but being widowed and having a chronic medical illness are associated with vulnerability to depressive disorders. Late-onset depression is characterized by high rates of recurrence.
The common signs and symptoms of depressive disorders include reduced energy and concentration, sleep problems (especially early morning awakening and multiple awakenings), decreased appetite, weight loss, and somatic complaints. The presenting symptoms may be different in older depressed patients from those seen in younger adults because of an increased emphasis on somatic complaints in older persons. Older persons are particularly vulnerable to major depressive episodes with melancholic features, characterized by depression, hypochondriasis, low self-esteem, feelings of worthlessness, and self-accusatory trends (especially about sex and sinfulness) with paranoid and suicidal ideation. A geriatric depression scale is shown in Table 56-5.
Cognitive impairment in depressed geriatric patients is referred to as the dementia syndrome of depression (pseudodementia), which can be confused easily with true dementia. In true dementia, intellectual performance usually is global, and impairment is consistently poor; in pseudodementia, deficits in attention and concentration are variable. Compared with patients who have true dementia, patients with pseudodementia are less likely to have language impairment and to confabulate; when uncertain, they are more likely to say â€œI don’t knowâ€; and their memory difficulties are more limited to free recall than to recognition on cued recall tests. Pseudodementia occurs in about 15 percent of depressed older patients, and 25 to 50 percent of patients with dementia are depressed. Depression and bipolar disorder are covered in Section 15.1.
Schizophrenia usually begins in late adolescence or young adulthood and persists throughout life. Although first episodes diagnosed after age 65 are rare, a late-onset type beginning after age 45 has been described. Women are more likely to have a late onset of schizophrenia than men. Another difference between early-onset and late-onset schizophrenia is the greater prevalence of paranoid schizophrenia in the late-onset type. About 20 percent of persons with schizophrenia show no active symptoms by age 65; 80 percent show varying degrees of impairment. Psychopathology becomes less marked as patients age.
The residual type of schizophrenia occurs in about 30 percent of persons with schizophrenia. Its signs and symptoms include emotional blunting, social withdrawal, eccentric behavior, and illogical thinking. Delusions and hallucinations are uncommon. Because most persons with residual schizophrenia cannot care for themselves, long-term hospitalization is required.
Older persons with schizophrenic symptoms respond well to antipsychotic drugs. Medication must be administered judiciously, and lower-than-usual dosages often are effective for older adults. Schizophrenia is covered in Chapter 13.
The age of onset of delusional disorder usually is between ages 40 and 55, but it can occur at any time during the geriatric period. Delusions can take many forms; the most common are persecutoryâ€”patients believe that they are being spied on, followed, poisoned, or harassed in some way. Persons with delusional disorder may become violent toward their supposed persecutors. Some persons lock themselves in their rooms and live reclusive lives. Somatic delusions, in which persons believe they have a fatal illness, also can occur in older persons. In one study of persons older than 65 years of age, pervasive persecutory ideation was present in 4 percent of persons sampled.
Among those who are vulnerable, delusional disorder can occur under physical or psychological stress and can be precipitated by the death of a spouse, loss of a job, retirement, social isolation, adverse financial circumstances, debilitating medical illness or surgery, visual impairment, and deafness. Delusions also can accompany other disordersâ€”such as dementia of the Alzheimer’s type, alcohol use disorders, schizophrenia, depressive disorders, and bipolar I disorderâ€”which need to be ruled out. Delusional syndromes also can result from prescribed medications or be early signs of a brain tumor. The prognosis is fair to good in most cases; best results are achieved through a combination of psychotherapy and pharmacotherapy.
A late-onset delusional disorder called paraphrenia is characterized by persecutory delusions. It develops over several years and is not associated with dementia. Some workers believe that the disorder is a variant of schizophrenia that first becomes manifest after age 60. Patients with a family history of schizophrenia show an increased rate of paraphrenia. Delusional disorders are covered in Section 14.3.
The anxiety disorders include panic disorder, phobias, obsessive-compulsive disorder (OCD), generalized anxiety disorder, acute stress disorder, and posttraumatic stress disorder (PTSD). Anxiety disorders begin in early or middle adulthood, but some appear for the first time after age 60. An initial onset of panic disorder in older persons is rare, but can occur. The ECA study determined that the 1-month prevalence of anxiety disorders in persons age 65 and older is 5.5 percent. By far the most common disorders
are phobias (4 to 8 percent). The rate for panic disorder is 1 percent.
The signs and symptoms of phobia in older adults are less severe than those that occur in younger persons, but the effects are equally, if not more, debilitating for older patients. Existential theories help explain anxiety when no specifically identifiable stimulus exists for a chronically anxious feeling. Older persons must come to grips with death. The person may deal with the thought of death with a sense of despair and anxiety, rather than with equanimity and Erikson’s â€œsense of integrity.â€ The fragility of the autonomic nervous system in older persons may account for the development of anxiety after a major stressor. Because of concurrent physical disability, older persons react more severely to PTSD than younger persons.
Obsessions and compulsions may appear for the first time in older adults, although older adults with OCD usually had demonstrated evidence of the disorder (e.g., being orderly, perfectionistic, punctual, and parsimonious) when they were younger. When symptomatic, patients become excessive in their desire for orderliness, rituals, and sameness. They may become generally inflexible and rigid and have compulsions to check things again and again. OCD (in contrast to obsessive-compulsive personality disorder) is characterized by ego-dystonic rituals and obsessions and may begin late in life. Anxiety disorders are covered in Chapter 16.
Somatoform disorders, characterized by physical symptoms resembling medical diseases, are relevant to geriatric psychiatry because somatic complaints are common among older adults. More than 80 percent of persons over 65 years of age have at least one chronic diseaseâ€”usually arthritis or cardiovascular problems. After age 75, 20 percent have diabetes and an average of four diagnosable chronic illnesses that require medical attention.
Hypochondriasis is common in persons over 60 years of age, although the peak incidence is in those 40 to 50 years of age. The disorder usually is chronic, and the prognosis guarded. Repeated physical examinations help reassure patients that they do not have a fatal illness, but invasive and high-risk diagnostic procedures should be avoided unless medically indicated.
Telling patients that their symptoms are imaginary is counterproductive and usually engenders resentment. Clinicians should acknowledge that the complaint is real, that the pain is really there and perceived as such by the patient, and that a psychological or pharmacological approach to the problem is indicated.
Alcohol and Other Substance Use Disorder
Older adults with alcohol dependence usually give a history of excessive drinking that began in young or middle adulthood. They usually are medically ill, primarily with liver disease, and are either divorced, widowed, or are men who never married. Many have arrest records and are numbered among homeless persons. A large number have chronic dementing illness, such as Wernicke’s encephalopathy and Korsakoff’s syndrome. Of nursing home patients, 20 percent have alcohol dependence.
Over all, alcohol and other substance use disorders account for 10 percent of all emotional problems in older persons, and dependence on such substances as hypnotics, anxiolytics, and narcotics is more common in old age than is generally recognized. Substance-seeking behavior characterized by crime, manipulativeness, and antisocial behavior is rarer in older than in younger adults. Older patients may abuse anxiolytics to allay chronic anxiety or to ensure sleep. The maintenance of chronically ill cancer patients with narcotics prescribed by a physician produces dependence, but the need to provide pain relief takes precedence over the possibility of narcotic dependence and is entirely justified.
The clinical presentation of older patients with alcohol and other substance use disorders varies and includes confusion, poor personal hygiene, depression, malnutrition, and the effects of exposure and falls. The sudden onset of delirium in older persons hospitalized for medical illness is most often caused by alcohol withdrawal. Alcohol abuse also should be considered in older adults with chronic gastrointestinal problems.
Older persons may misuse over-the-counter substances, including nicotine and caffeine. Over-the-counter analgesics are used by 35 percent of older persons and 30 percent use laxatives. Unexplained gastrointestinal, psychological, and metabolic problems should alert clinicians to over-the-counter substance abuse.
Advanced age is the single most important factor associated with the increased prevalence of sleep disorders. Sleep-related phenomena reported more frequently by older than by younger adults are sleeping problems, daytime sleepiness, daytime napping, and the use of hypnotic drugs. Clinically, older persons experience higher rates of breathing-related sleep disorder and medication-induced movement disorders than younger adults.
In addition to altered regulatory and physiological systems, the causes of sleep disturbances in older persons include primary sleep disorders, other mental disorders, general medical disorders, and social and environmental factors. Among the primary sleep disorders, dyssomnias are the most frequent, especially primary insomnia, nocturnal myoclonus, restless legs syndrome, and sleep apnea. Of the parasomnias, rapid eye movement (REM) sleep behavior disorder occurs almost exclusively among elderly men. The conditions that commonly interfere with sleep in older adults also include pain, nocturia, dyspnea, and heartburn. The lack of a daily structure and of social or vocational responsibilities contributes to poor sleep.
As a result of the decreased length of their daily sleepâ€“wake cycle, older persons without daily routines, especially patients in nursing homes, may experience an advanced sleep phase, in which they go to sleep early and awaken during the night.
Even modest amounts of alcohol can interfere with the quality of sleep and can cause sleep fragmentation and early morning awakening. Alcohol can also precipitate or aggravate obstructive sleep apnea. Many older persons use alcohol, hypnotics, and other CNS depressants to help them fall asleep, but data show that these persons experience more early morning awakening than trouble falling asleep. When prescribing sedative-hypnotic drugs for older persons, clinicians must monitor the patients for unwanted cognitive, behavioral, and psychomotor effects, including memory impairment (anterograde amnesia), residual sedation, rebound insomnia, daytime withdrawal, and unsteady gait.
Changes in sleep structure among persons over 65 years of age involve both REM sleep and non-rapid eye movement (NREM) sleep. The REM changes include the redistribution of REM sleep throughout the night, more REM episodes, shorter REM episodes, and less total REM sleep. The NREM changes include the decreased amplitude of delta waves, a lower percentage of stages 3 and 4 sleep, and a higher percentage of stages 1 and 2 sleep. In addition, older persons experience increased awakening after sleep onset.
Much of the observed deterioration in the quality of sleep in older persons is caused by the altered timing and consolidation of sleep. For example, with advanced age, persons have a lower amplitude of circadian rhythms, a 12-hour sleep-propensity rhythm, and shorter circadian cycles.
Elderly persons have a higher risk for suicide than any other population. The suicide rate for white men over the age of 65 is five times higher than that of the general population. One third of elderly persons report loneliness as the principal reason for considering suicide. Approximately 10 percent of elderly individuals with suicidal ideation report financial problems, poor medical health, or depression as reasons for suicidal thoughts. Suicide victims differ demographically from individuals who attempt suicide. About 60 percent of those who commit suicide are men; 75 percent of those who attempt suicide are women. Suicide victims, as a rule, use guns or hang themselves, whereas 70 percent of suicide attempters take a drug overdose, and 20 percent cut or slash themselves. Psychological autopsy studies suggest that most elderly persons who commit suicide have had a psychiatric disorder, most commonly depression. Psychiatric disorders of suicide victims, however, often do not receive medical or psychiatric attention. More elderly suicide victims are widowed and fewer are single, separated, or divorced than is true of younger adults. Violent methods of suicide are more common in the elderly, and alcohol use and psychiatric histories appear to be less frequent. The most common precipitants of suicide in older individuals are physical illness and loss, whereas problems with employment, finances, and family relationships are more frequent precipitants in younger adults. Most elderly persons who commit suicide communicate their suicidal thoughts to family or friends before the act of suicide.
Older patients with major medical illnesses or a recent loss should be evaluated for depressive symptomatology and suicidal ideation or plans. Thoughts and fantasies about the meaning of suicide and life after death may reveal information that the patient cannot share directly. There should be no reluctance to question patients about suicide, because no evidence indicates that such questions increase the likelihood of suicidal behavior.
Other Conditions of Old Age
Feelings of vertigo or dizziness, a common complaint of older adults, cause many older adults to become inactive because they fear falling. The causes of vertigo vary and include anemia, hypotension, cardiac arrhythmia, cerebrovascular disease, basilar artery insufficiency, middle ear disease, acoustic neuroma, and MÃ©niÃ¨re’s disease. Most cases of vertigo have a strong psychological component, and clinicians should ascertain any secondary gain from the symptom. The overuse of anxiolytics can cause dizziness and daytime somnolence. Treatment with meclizine (Antivert), 25 to 100 mg daily, has been successful in many patients with vertigo.
The sudden loss of consciousness associated with syncope results from a reduction of cerebral blood flow and brain hypoxia. A thorough medical workup is required to rule out the various causes listed in Table 56-6.
About 30 percent of persons over age 65 have significant hearing loss (presbycusis). After age 75, that figure rises to 50 percent. Causes vary. Clinicians should be sensitive to hearing loss in patients who complain they can hear but cannot understand what is being said or who ask that questions be repeated. Most elderly persons with hearing loss can be treated with hearing aids.
An estimated 10 percent of persons above 65 years of age are abused. Elder abuse is defined by the American Medical Association as â€œan act or omission which results in harm or threatened harm to the health or welfare of an elderly person.â€ Mistreatment includes abuse and neglectâ€”physically, psychologically, financially, and materially. Sexual abuse does occur. Acts of omission include withholding food, medicine, clothing, and other necessities.
Family conflicts and other problems often underlie elder abuse. The victims tend to be very old and frail. They often live with their assailants, who may be financially dependent on the victims. Both the victim and the perpetrator tend to deny or minimize the presence of abuse. Interventions include providing legal services, housing, and medical, psychiatric, and social services.
Demographic data suggest that 51 percent of women and 14 percent of men over the age of 65 will be widowed at least once. Spousal loss is
among the most stressful of all life experiences. As a group, older adults appear to have a more favorable outcome than expected following the death of a spouse. Depressive symptoms peak within the first few months after a death, but decline significantly within a year. A relationship exists between spousal loss and subsequent mortality. Elderly survivors of spouses who committed suicide are especially vulnerable, as are those with psychiatric illness.
Psychopharmacological Treatment of Geriatric Disorders
Certain guidelines should be followed regarding the use of all drugs in older adults. A pretreatment medical evaluation is essential, including an electrocardiogram (ECG). It is especially useful to have the patient or a family member bring in all currently used medications, because multiple drug use could be contributing to the symptoms.
Most psychotropic drugs should be given in equally divided doses three or four times over a 24-hour period. Older patients may not be able to tolerate a sudden rise in drug blood level resulting from one large daily dose. Any changes in blood pressure and pulse rate and other side effects should be watched. For patients with insomnia, however, giving the major portion of an antipsychotic or antidepressant at bedtime takes advantage of its sedating and soporific effects. Liquid preparations are useful for older patients who cannot, or will not, swallow tablets. Clinicians should frequently reassess all patients to determine the need for maintenance medication, changes in dosage, and development of adverse effects. If a patient is taking psychotropic drugs at the time of the evaluation, the clinician should discontinue these medications, if possible, and, after a washout period, reevaluate the patient during a drug-free baseline state.
Adults over 65 years of age use the greatest number of medications of any age group; 25 percent of all prescriptions are written for them. Adverse drug reactions caused by medications result in the hospitalization of nearly 250,000 persons in the United States each year. Psychotropic drugs are among the most commonly prescribed, along with cardiovascular and diuretic medications; 40 percent of all hypnotics dispensed in the United States each year are to those older than 75 years of age, and 70 percent of older persons use over-the-counter medications, compared with only 10 percent of young adults. (Chapter 36 presents a comprehensive survey of the psychopharmacological agents.)
The major goals of the pharmacological treatment of older persons are to improve the quality of life, maintain persons in the community, and delay or avoid their placement in nursing homes. Individualization of dosage is the basic tenet of geriatric psychopharmacology.
Alterations in drug dosages are required because of the physiological changes that occur as persons age. Renal disease is associated with decreased renal clearance of drugs; liver disease results in a decreased ability to metabolize drugs; cardiovascular disease and reduced cardiac output can affect both renal and hepatic drug clearance; and gastrointestinal disease and decreased gastric acid secretion influence drug absorption. As a person ages, the ratio of lean to fat body mass also changes. With normal aging, lean body mass decreases and body fat increases. Changes in the ratio of lean to fat body mass that accompany aging affect the distribution of drugs. Many lipid-soluble psychotropic drugs are distributed more widely in fat than in lean tissue, so a drug’s action can be unexpectedly prolonged in older persons. Similarly, changes in end-organ or receptor-site sensitivity must be taken into account. In older persons, the increased risk of orthostatic hypotension from psychotropic drugs is related to reduced functioning of blood pressure-regulating mechanisms.
As a general rule, the lowest possible dose should be used to achieve the desired therapeutic response. Clinicians must know the pharmacodynamics, pharmacokinetics, and biotransformation of each drug prescribed and the effects of the interaction of the drug with other drugs that a patient is taking.
Psychotherapy for Geriatric Patients
The standard psychotherapeutic interventionsâ€”such as insight-oriented psychotherapy, supportive psychotherapy, cognitive therapy, group therapy, and family therapyâ€”should be available to geriatric patients. According to Sigmund Freud, persons older than 50 years are not suited for psychoanalysis because their mental processes lack elasticity. In the view of many who followed Freud, however, psychoanalysis is possible after age 50. Advanced age certainly limits plasticity of the personality, but as Otto Fenichel stated, â€œIt does so in varying degrees and at very different ages so that no general rule can be given.â€ Insight-oriented psychotherapy may help remove a specific symptom, even in older persons. It is of most benefit when patients have possibilities for libidinal and narcissistic gratification, but it is contraindicated if it would bring only the insight that life has been a failure and that the patient has no opportunity to make up for it.
Common age-related issues in therapy involve the need to adapt to recurrent and diverse losses (e.g., the deaths of friends and loved ones), the need to assume new roles (e.g., the adjustment to retirement and the disengagement from previously defined roles), and the need to accept mortality. Psychotherapy helps older persons to deal with these issues and the emotional problems surrounding them and to understand their behavior and the effects of their behavior on others. In addition to improving interpersonal relationships, psychotherapy increases self-esteem and self-confidence, decreases feelings of helplessness and anger, and improves the quality of life. As described by Alvin Goldfarb, geriatric psychotherapy has the general aim of assisting older adults to have minimal complaints, to help them make and keep friends of both sexes, and to have sexual relations when they have interest and capacity.
Psychotherapy helps relieve tensions of biological and cultural origins and helps older persons work and play within the limits of their functional status and as determined by their past training, activities, and self-concept in society. In patients with impaired cognition, psychotherapy can produce remarkable gains in both physical and mental symptoms. In one study conducted in an old-age home, 43 percent of the patients receiving psychotherapy showed less urinary incontinence, improved gait, greater mental alertness, improved memory, and better hearing than before psychotherapy.
Therapists must be more active, supportive, and flexible in conducting therapy with older than with younger adults, and they must be prepared to act decisively at the first sign of an incapacity that requires
the active involvement of another physician, such as an internist, or that requires consulting with, or enlisting the aid of, a family member.
Older persons usually seek therapy for a therapist’s unqualified and unlimited support, reassurance, and approval. Patients often expect a therapist to be all powerful, all knowing, and able to effect a magical cure. Most patients eventually recognize that the therapist is human and that they are engaged in a collaborative effort. In some cases, however, the therapist may have to assume the idealized role, especially when the patient is unable or unwilling to test reality effectively. With the help of the therapist, the patient deals with problems that had been avoided previously. As the therapist offers direct encouragement, reassurance, and advice, the patient’s self-confidence increases as conflicts are resolved.
Goldfarb has described a brief, supportive therapy technique for institutionalized, cognitively impaired patients. The therapist promotes patients’ foundering self-esteem, sense of control, and safety by permitting them to develop an apparent special relationship with the therapist, who is perceived as a benevolent and powerful figure. The patients believe they have some control over the benevolent physician. This is accomplished in small, subtle ways. For example, the physician elicits the patient’s preferences for the frequency of sessions, daily timetables, diet, or socializing and then acquiesces to the patient’s wishes, while maintaining a quiet caution about being unduly manipulative. The technique includes weekly, short (15 minutes) visits and gratifying the patient’s realistic requests when possible.
Life Review or Reminiscence Therapy
Robert Butler and others have noted the universal tendency of the aging person to reflect on, and reminisce about, the past. Reminiscence is characterized by the progressive return of memories of past experiences, especially those that were meaningful and conflictual. To varying degrees, elderly patients in therapy reminisce about the past, search for meaning in their lives, and strive for some resolution of past interpersonal and intrapsychic conflicts. Life review therapy systematically enhances this reminiscing process and makes it more conscious and deliberate. The therapist may guide the process by encouraging the patient to write or tape a biography with review of special events and turning points. Techniques include reunions with family and good friends and looking through memorabilia, such as scrapbooks or picture albums. This technique has been reported to resolve old problems, increase tolerance of conflict, relieve guilt and fears, and enhance self-esteem, creativity, generosity, and acceptance of the present.
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