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Geriatric Psychiatry:
An Introductory Overview
Carl I. Cohen M.D.
Distinguished Service Professor &
Director
Division of Geriatric Psychiatry
email: [email protected]
Case of Ms Jones


Ms Jones is a 76-year-old African American woman
who presents with a history of not seeing her
friends, loss of interest in sewing and gardening,
and some forgetfulness. She has some difficulty
hearing and also complains of arthritic pain. She
has hypertension, hyperlipidemia, and type 2
diabetes. She takes medications for these
conditions.
Several of her friends died in recent years, and her
daughter has moved to New Jersey. She has always
been a very independent woman, but now feels
more helpless.

On examination she is found to memory
deficits and mild difficulties in executive
functioning. She meets 3 of 9 DSM IVTR
depression criteria. Laboratory tests and
physical examination are within normal
limits, except for a BP of 155/95 and
elevated cholesterol.

She was initially treated for depression with
medication and psychotherapy. She showed
some improvements in mood and cognitive
functioning initially. However, she never
completely remitted, and three years later
she showed evidence of early dementia, with
impairments in cognition and daily
functioning.
Principles of Geriatric Psychiatry
1. Older adults are the most heterogeneous group in
the population.
2. The demographics of aging are shifting.
3. Assessment is different in older age.
4. Disorders may present differently.
5. Treatment may be different.
6. The course of disorders may be different.
7. Aging is characterized by both longstanding
conditions and late-onset conditions that may
become chronic.
8. Nearly all older adults with psychiatric disorders will
have comorbid conditions, although not all comorbity
is alike.
9. There is continuity in personality.
10. Psychiatric illness must be understood within a
social and biological context.
11. The prevalence of psychiatric disorders in older
adults and mental disorders are best viewed on a
continuum.
12. It is essential to view the treatment goals for older
adults with mental illness in the context of a life
course trajectory.
13. Disorders overlap with respect to neuropathology
and symptoms.
14. Mental illness in older age is complex.
Question 1

Older adults are extremely heterogeneous and
have little in common with each other?

Answer: False
1. Older adults are the most
heterogeneous group in the
population.
Older
persons differ dramatically in their physical and
mental health, functional abilities, social networks, political
and religious beliefs, and so forth.
Although
we often categorize aged persons based on
chronological age –e.g., the census bureau defines “older
adults” as aged 55 to 64, and elderly as 65 and over—there
are marked differences in biological aging.
This
is especially true among persons with chronic
schizophrenia who may have health problems more
characteristic of persons who are 10 or 15 years older.

Although older adults are heterogeneous they do
share some common life experiences that may have
psychosocial ramifications (so called “cohort
effects”).

However, with the increasing number of older
persons reaching very old age, the number of
cohorts within the aging population has grown.
Persons born before 1930 came of age during the Great
Depression and World War II, whereas those born after
the war came of age during more prosperous times and
included the cultural and social turmoil of the 1960s.
The oldest African Americans grew up during periods of marked
racial segregation and discrimination, whereas “young-old” African
Americans came of age during the period of the civil rights and
black power movements
Clinical Implications

Mental and physical health care to older adults
should not be determined solely by chronological
age because of the marked diversity within this age
group.

However, living through similar historical periods
can provide a common background context for
older adults of the same age.
Question 2: The 1 percent

Which group is part of the 1%: The percentage of
persons aged 90 and over or persons in gangs?

Answer: Persons aged 90+; however, persons in
gangs (currently 1%) are one of the fastest growing
segments of society (40% in past 3 years)
2. The demographics of aging are
shifting.



The baby boomers (people born between 1946 to
1964) will first turn 65 beginning 2011.
The older population is projected to nearly double
from 38 million (12.6 %) in 2008 to 72 million (20%)
in 2030.
Persons over aged 85 and over are the most rapidly
growing segment of our population and their
numbers will double over the first quarter of the
century and more than quadruple over the first half
the century (to over 19 million persons).


The older population is also growing more
diverse.
In 2000, 16% of population were nonwhites (Blacks, Hispanics, Asians, Native
Americans) or 5.8 million persons. In 2050,
36% of population will be non- white or
29.5 million persons.
Thus, there will be a 5-fold increase in the number of
minority elders over the first half of the 21st century.
Clinical Implications

Mental health providers can expect to be
working with increasingly older and more
diverse populations

They must possess appropriate clinical skills
and cultural knowledge if they are to deliver
competent care.
Question 3

Emergency rooms are an ideal place to examine
older adults?

Answer: False
3. Assessment is different in older age
The assessment of older adults must take into
account communication difficulties in vision and
hearing, physical handicaps, and cognitive
difficulties.
Clinical Implications



Clinicians should generally assess cognitive and
physical dysfunction on the initial examination
Continue to closely monitor for the effects of
treatment on the patient’s mental & physical
functioning.
Another key difference from younger persons is the
likelihood that caregivers, both formal and
informal, will be more involved in providing
information and treatment.
Question 4

Depressive symptoms in later life are similar to
those in younger persons

False
4. Disorders may present differently
Like physical disorders, the clinical presentations of
psychiatric disorders may differ in older persons.
Examples:
 Depression may present with fewer signs of
sadness and with more symptoms of social
withdrawal, somatic concerns, motor disturbances,
and apathy. Sometimes described as:“Depression
without sadness” or a “depletion syndrome”
manifested by withdrawal, apathy, and lack of vigor.

Also may see more executive dysfunction, which
may be due to vascular depression (see figure re:
vascular depression).
Major Depression
Similar across lifespan but there may be some
differences. Among older adults:
•Psychomotor disturbances more prominent (either
agitation or retardation),
•Higher levels of melancholia(symptoms of noninteractiveness, psychological motor retardation or
agitation, weight loss)
•Tendency to talk more about bodily symptoms
•Loss of interest is more common
•Social withdrawal is more common
•Irritability is more common
•Somatization (emotional issues expressed through
bodily complaints)is more common
Vascular depression (depression due to vascular lesions):
more common in late-onset disease.
Evidence that cerebrovascular disease seemingly plays a
role in depression beginning in late life.
Vascular lesions include periventricular hyperintensity,
deep matter hyperintensity, and subcortical gray matter
hyperintensity. Disruption of prefrontal systems may be
responsible.

Symptoms include greater levels of apathy,
psychomotor retardation and disability,

and

less agitation,psychoses, family history of
psychiatric illness, guilt, and insight versus
other older depressed persons.
Vascular Depression Hypothesis
(Krishnan & McDonald, 1995;Sneed & Cuslng-Reimlieb, 2011)
Risk Factors
•Age
•Hypertension
•Hyperlipidemia
•Smoking
•Diabetes
Artherosclerosis
Deep white matter lesions ( vulnerability to late onset depression)
Negative life events
Poor social support
Vascular depression with
executive dysfunction
Disorders may present differently (cont.)

Late-onset schizophrenia—onset after
age 40 or 45(about 15-20% of all
schizophrenia)--tends to occur
disproportionately more in women, to have
more persecutory delusions, fewer negative
symptoms, and formal thought disorders
(see chart comparing early and late
disorders)
Characteristics
Early-Onset
Schizophrenia
Late-Onset
Schizophrenia
Persecutory
delusions
+
+++
Visual
hallucinations
+
++
Olfactory
hallucinations
+
++
Tactile
hallucinations
+
++
Thought disorder
+++
+
Affective blunting
+++
+
+
++
Sensory
impairment
Male –female
ratio
Medication
dosage
Male slightly
higher
high
Women much
higher
low
Summary of
differences between
early and late onset
schizophrenia
Clinical Implications

Clinicians must be vigilant for more atypical
symptoms in older adults.
Question 5

All drug metabolism is appreciably affected by
aging

False
5. Treatment may be different
With increased age:
 There are declines in the absorption rate of
medications, although amount of
medication absorbed does not change
 Distribution of drugs as a result of an
increase in adipose tissue relative to lean
body mass
 Diminished metabolism in the liver
 Declines in renal clearance
Clinical Implications




Dosages of medications may need to be lower than
in younger persons, and considerations of side
effects and drug interactions become more
relevant.
Must be cautious in prescribing drugs that are apt
to affect the Cytochrome P450 metabolic pathways
in the liver (Phase I hepatic metabolism), and if
used, their potential interactions with other
medications should be reviewed.
Some pathways such as CYP1A2 and CYP3A4 are
most affected by aging.
It is best to use drugs that do not undergo Phase I
hepatic metabolism, but only Phase II hepatic
metabolism (conjugation), since this process is not
affected by aging.

Because of changes in the distribution of drugs in
the body, the fat soluble drugs, which includes
many of the drugs used in psychiatry, tend to
remain in the body longer and may cause toxicity.

Conversely, water soluble drugs such as lithium
need to be used cautiously because of the
diminution of total body water with age.

Finally, some psychotropic drugs remain active
(e.g. lithium, gabapentin, rivastigmine) until they
are cleared by the kidney, and doses may need to
be adjusted in older adults.
Question 6

Prognosis for depression in later life is no worse
than younger persons

False
6. The course of disorders may be different
In schizophrenia



There is a diminution in positive symptoms with age.
Levels of co-occurring depression may remain the same
or increase.
Mild cognitive problems that present earlier in life may
worsen due to normal effects of the aging process.Thus,
older persons may be at the level of a mild dementia.
In depression:
 More subtypes (e.g. vascular depression;
and depression with cognitive
deficits/dementia also known as
“pseudomentia”) that may be more resistant
to treatment.

There is some evidence that older persons
with major depression may be more prone to
relapse and relapse sooner than their
younger counterparts.
Clinical Implications


In treating persons with schizophrenia need
to be aware of changes in symptoms that
occur with aging, and to adjust treatment
accordingly.
In treating older adults with depression, it is
important to determine the subtype of
depression, because prognosis varies
considerably depending on the etiology of
the depression.
7. Aging is characterized by both longstanding
conditions and late-onset conditions that may
become chronic.


Depression in older adults is often chronic, and
more than half of persons with clinical depression
in later life remain syndromally depressed and an
additional 30% have some residual symptoms
(subsyndromal or subthreshold depression).
Even under the most ideal treatment conditions
(e.g., medication and psychotherapy), about onethird of older persons with new –onset depression
relapse on 2-year follow-up (Reynolds et al, 2006).
Two-thirds relapse without medications.

The line between reversible and irreversible
illness may become less distinct.
Examples:

Late-onset depression may be a prodromal
symptom of dementia. It is estimated that twofifths of late-onset depression with some cognitive
problems (so called “pseudodementia”) may
eventually progress to a true dementia, despite
there having been an initial resolution of
depression.

Persons with vascular depression are more prone
to dementia.
Clinical Implications



Although treatment can help reduce recurrence and
levels of symptoms, the complex interaction of
psychiatric and physical conditions may make full
recovery less likely.
Treatment of late-onset depression may benefit
(i.e., reduced likelihood of dementia) from a
combination of an SSRI and cholinesterase inhibitor
such as donepezil (Aricept), although depression
recurrence may be higher.
While the ultimate goal for all patients may be the
remission of symptoms, sometimes treatment goals
will have to be adjusted, and like some chronic
physical disorders, persons may have to live with a
modest level of symptoms.
Question 7

Comorbid illnesses are important determinants
of outcome in older adults

True
8. Nearly all older adults with psychiatric
disorders will have comorbid conditions,
although not all comorbity is alike

Some comorbid conditions can contribute
substantially to disability and functional decline
(e.g., severe osteoarthritis, severe heart disease,
neurocognitive disorders), whereas other
conditions have minimal effects on functioning
(e.g., controlled hypertension or
hypercholesterolemia).

There is a reciprocal interaction between
depression and many physical disorders.
Depression may result in higher occurrence
of certain physical illnesses, and physical
disorders may increase levels of depression
e.g. mortality rates are higher among postmyocardial infarct patients with depression

Depression and anxiety often co-occur, and
having more anxiety symptoms (e.g. half of
persons with depression have anxiety), is a poor
prognostic indicator in depression.

One of the more significant health challenges
involve persons with some combination of chronic
pain , dementia, depression, anxiety, bereavement,
multiple losses, social isolation and poor nutrition.
Clinical Implications


There is some evidence that treating
depression can improve health outcomes
and that improving physical health can
improve depression and anxiety.
Unfortunately, the ability to successfully
treat depression is less robust in older
persons with concomitant physical
disorders.
Question 8

There are considerable changes in personality
over time

False
9. There is continuity in personality

Each older person is a product of the lifelong
effects of physiological, environmental, and
psychological factors.

With respect to psychological factors, although
some changes occur across a lifespan, various
personality traits (e.g., coping , sense of control,
self-esteem, interpersonal skills) tend to be fairly
stable over time, and they will affect how one
deals with late-life stressors.
Clinical Implications


On the positive side, continuity means that most
older persons have been able to successfully use
various coping strategies to manage their stressors
over the life course.
Therapists must help to gird up these formerly
successful coping mechanisms, and in turn,
improve the sense of self-esteem.

However, with increasing age and disability,
formerly successful strategies may not be
working and therapy must address some of
the physical, cognitive, and social losses that
occur in later life.
10. Psychiatric illness must be understood within a
social and biological context

The importance of material and emotional resources as well
as physiological conditions (co-occurring illness,
medications) must be considered.

It is said that aging is a bit like gambling:
“The longer you go on, the more likely you are to lose.”
Thus, older adults have to confront and deal with various
losses, perhaps best summarized by the 4D’s of Aging:
disability, dependency, desertion (e.g., loss of close
relationships as people move away or dying), and death
(e.g., one’s own mortality and the death of others).
Clinical Implications


For some adults who are physically healthy
and have strong social resources, a useful
strategy might be to encourage activities
and engagement following losses of kin or
friends or in the context of life stressors.
On the other hand, for persons with more
disabilities and fewer resources,
encouraging too much engagement may be
unrealistic and further exacerbate their
feelings of worthlessness and depression.
11. The prevalence of psychiatric disorders in older
adults and mental disorders are best viewed on a
continuum
Official psychiatric disorders may not accurately reflect
psychiatric distress in the aging community because:
 Older adults may present atypically,
 Co-morbid physical and cognitive disorders may make
fulfillment of the diagnostic criteria more difficult,
 Older adults with psychiatric disturbances may cluster
in certain settings so that they may not be adequately
sampled (e.g., natural occurring retirement
communities, assisted living facilities, and nursing
homes).
 Thus, we may need to view illness on a continuum and
looking at subsyndromal or subthreshold disorders
with respect to depression, anxiety disorders,
psychoses, and neurocognitive disorders.
Prevalence of Depression

The National Comorbidity Survey-Replication
(NCS-R) allowed for the most comprehensive
examination of psychiatric disorders among older
adults in the United States. The 12-month
prevalence of depressive mood disorders for
persons aged 55+ was 4.9%. There was a steady
decline in prevalence across each decade, with the
highest rates in the 55 to 64 year old group (7.6%)
and the lowest rates in the 85 and over
group(2.4%).
Age pattern
55
75
85
Prevalence of Anxiety

The 12 -month prevalence for anxiety
disorders in older adults was 11.6%.
However, in this case, while the youngest
group (age 55-64) had the highest
levels(16.6%), the 75-84 year old age group
had lower rates(6.0%) than the oldest age
(85+) group (8.1%)
55
Age pattern
85
75
Age differences

By comparison, in the national sample, across all
age categories (age 18+) the
12 –month prevalence for any mood disorder or
anxiety disorder was 9.5 % and 18.1%, respectively
(Note the much higher rates in younger than the
older groups). In all age groups, major depression
was the most common mood disorder and specific
phobia were the most common anxiety disorder.



Subsyndromal Depression and Anxiety
If non-DSM criteria are used, rates of clinical or
“syndromal” depression (based on meeting symptom
prevalence and severity criteria) is about 12%(range 816%) and may be as high as 24% for subsyndromal
(“subthreshold” ) depression. Thus, about one-third
of older adults may meet criteria for syndromal or
subsyndromal depression.
Clinical depression is about 25% in medically ill.
Likewise, syndromal and subsyndromal anxiety may be
found in slightly over 15% of the older population
These findings are important because
subyndromal depressive and anxiety
disorders have been found to be associated
with higher rates of functional impairment,
disability, medical illness, and mortality.
Prevalence of Psychoses



Prevalence rates of psychoses are especially
difficult to determine because of the clustering of
persons with psychoses in more supported
environments or perhaps their unwillingness to
consent to interviews.
The Epidemiologic Catchment Area study found
only 0.3% of persons aged 65 and over had a
lifetime history of schizophrenia .
The National Comorbidity Study (NCS)-R has not
provided age data on non-affective psychoses,
although the general population was found to have
a 1.5% lifetime prevalence.

If one views psychoses on a continuum,
NCS-R data indicated that lifetime
prevalence of psychotic symptoms in the
older adults in the general population is
11%, or over 7 times the lifetime prevalence
of the formal diagnostic category for
psychotic illness.
Prevalence of Dementia and Mild
Cognitive Impairment


The prevalence rates of dementia have been
found to range from 5 to 10%.
The prevalence rate is about 1% at age 65,
but there is a doubling of prevalence rates
every 5 years until age 90, when the rates
may continue to increase but more slowly.
“MA9” ----Mnemonic for Neurocognitive Disorders
(formerly known as dementia & mild cognitive disorder)
Based on concern of pt/informant of significant
cognitive decline and one or more of the following:
Memory & learning impairment
Attention impaired(sustained, selective, divided)
Aphasia (expression, naming, understanding)
Agnosia/Apraxia/Art & visuospatial tasks
Appropriate social cognition impaired
(emotional recognition, empathy)
Abstraction and other executive functioning impaired
(planning, decisions, flexibility) --- PLUS--Absence of delirium
Ability to function is impaired
Causes of Dementia (and most defining
features)
1. Alzheimer’s disease 60-70% (insidious onset;
memory deficits early; consistency in loss of various cognitive
functions)
2. Vascular 10-30% (sudden onset,stepwise; less
consistency (“patchy”) in cognitive deficits)
3. Mixed (AD + Vascular) 10%
4. Lewy Body 10-25% (central feature: dementia & 2
of 3 core sx: parkinson sx; fluctuating cognition with
variations in attention and alertness; visual
hallucinations; also suggestive: neuroleptic sensitivity;
REM sleep behavior; also milder cognitive deficits; falls;
visuospatial deficits;
5. Depression 5-15% (‘pseudodementia’).
6. Frontotemporal 5-10% : executive or language
(semantic/primary progressive aphasia) prominent early;
memory less impaired early in disorder.
Three types of cellular inclusions:
a. Tar-DNA binding protein of 43kDa (TDP-43) --most
common
b. Tau
c. Fused in sarcoma (FUS) protein
Both Tau and TDP are associated with diverse pathologic
subtypes including CBD, Pick’s, PNP ALS,PD types and
semantic dementia
7. Other 10-20% e.g. Parkinson’s disease
(movement disorder early--1-yr before dementia)
Mild Neurocognitive Disorder
(Mild Cognitive Disorder)

As with other disorders, a subsyndromal
category, “Mild Cognitive Impairment,” has
been identified that consists of various objective
cognitive deficits (same categories as major
cognitive disorder), usually in memory, but
daily functioning remains largely intact and
self/observer identified decline is “mild”. It is
estimated that about 10% of persons aged 70 to
79 have MCI, and this rate is about 20% in the
80 to 89 year old category .
Clinical Implications


Psychiatric symptoms among older adults are
common and may cause dysfunction, even when
they do not meet DSM IV criteria.
Perhaps even more so than in any other age
category, it is important to not overly rely on
strict diagnostic criteria and to focus on the
clinical symptoms that are causing distress.
DSM Disorders in age 65+
(in order of frequency)
12 -month
prevalence
Anxiety Disorders
(phobic disorders,gen anx, panic)
6%-12% female>male
Dementia
5-10%
female>male
Major depression
1-2%
female>male
Dysthymic disorder
2%
female>male
Alcohol abuse /dependence
1%
male>female
Schizophrenia
0.3 -0.5% male=female
Bipolar
0.3%
male=female
Any DSM disorder
12%
female>male
12. It is essential to view the treatment goals
for older adults with mental illness in the
context of a life course trajectory.
It is now recognized that the outcome for certain
symptoms of schizophrenia in later life are
more favorable than previously believed:
 One-half of persons attain clinical remission
(cross-sectional data) as defined as having mild
or no symptoms in positive and negative
symptoms,
 Nearly half may attain social recovery.
Depression outcome


Older persons with depression do less well than
previously believed, with roughly half continuing
to have clinical depression on follow-up, and
perhaps another 30% may have appreciable
residual symptoms.
Thus, only one-fifth may be in full remission on
long-term follow-up. However, with more
aggressive and creative treatment strategies,
outcome can be improved.
Outcome Across Lifespan

For persons with severe mental illness, the
ideal life trajectory can be viewed as a process
moving from diminishing psychopathology
and impaired functioning to normalization to
positive health and well-being.
Psychopathology  Community
IntegrationSuccessful Aging



The initial part of this trajectory may be
conceptualized as “recovery,” whereas the latter
part may be conceptualized as “successful aging.”
Successful aging can be viewed as a state
involving the absence of disability accompanied by
high physical, cognitive, and social functioning. It
is a state that older adults may aspire towards, but
often do not achieve.
Even among the general aging population, only
one-fifth attain “successful aging.” However,
among persons with schizophrenia, only about 1 in
50 persons attain this status.
Clinical Implications

We now recognize that for many persons
with schizophrenia, middle and older age is
associated with better outcomes than
previously believed, and that as some of the
more severe symptoms relent, and certain
social pressures diminish (e.g. need to have
full-time work or marry), it may be an
optimal time to make strides toward greater
recovery.

For older persons with depression, complete
and permanent recovery is difficult, and the
clinician needs to recognize that depression
in later life is often a chronic disorder that
requires more patience and clinical efforts
than previously believed. In some instances
depression may be a prodrome of dementia
or neurological disorders (e.g. Parkinson’s
disease)
13. Disorders overlap with respect to
neuropathology and symptoms

We now recognize that many of the dementia
disorders share neuropathology
Overlap among Various Dementias
•Pure AD and VaD may be rare.
Pure PD
Pure AD
•AD is multifactorial.
•Similar risk factors: cholesterol,
APOE4, DM, HTN.
•Vascular pathology may
contribute to cholinergic
abnormalities in both
disorders(cholinesterase
inhibitors may help with both).
Pure LBD
Pure
VaD
Vascular
Dementia
All have cholinergic deficits in cortex
AD (often with
EPS)(40 -65%),
PDD(75%),
LBD(60-90%)
Psychotic
depression
Many disorders
share symptoms
Schizophrenia
with depression
depression
psychosis
Schizophrenia
with cognitive
deficits
PDD, LBD,
AD, VaD
with
psychotic sx
med conditions
& drugs
Depression with
dementia
(“pseudodementia”)
Vascular depression
with mild cognitive
impairment (MCI)
MCI with depression
dementia
Dementia with
depression
PD with depression
movement
disorders
Schizophrenia with
movement disorders
PDD, LBD, PD+ with
cognitive deficits
PDD, LBD, AD
with movement sx
Examples:
1. Prevalence of Neuropsychiatric Symptoms (i.e.,
Psychiatric and Behavioral Problems) in AD
Psychoses:
Hallucinations:24%
about half
Delusions:50%
Mood disturbances(depression,tearfulness):29%
About one-quarter
2. Hallucinations in PD, DLB, PDD



¼ Parkinson’s Disease
½ Dementia Lewy Body
¾ Parkinson’s Disease Dementia
Note: In PD and PDD medications may
contribute to psychotic sx
3. Depression and Parkinson’s
Disease


In Parkinson’s disease about 40-50% have
depression; about 1/3 have anxiety disorder
Depression precedes motor dysfunction in 12 to
37% of PD patients
Clinical Implications

Because symptoms and pathology overlap,
obtaining good histories and conducting
comprehensive evaluations are necessary to
determine the diagnosis.
Obtaining a good history is critical
Psychoses
Cognitive Impairment
Depression
Movement Disorder
Recent Onset
Primary
Mental
Illness:
Depression
(mood
congruent
delusions)
Secondary to
physical illness
or drugs:
Delirium
Psychoses
Depression
Longer duration
Primary Mental
Illness:
Schizophrenia
(bizarre delusions,
auditory
hallucinations
more common,
psychoses
precedes
depression & any
movement sx);
Delusional
disorder
(circumscribed
delusion;
mild
hallucinations,
depressed mood
secondary to
delusions)
Psychiatric sx are
secondary:
Alzheimer’s
disease
(dementia
depression
psychoses
movement
disorders);
Lewy Body
Dementia
( psychoses and
dementia and
movement
disorder within 1
year)
Parkinson’s
Disease
(movement
disorder
psychoses
dementia
Five “Ds” of Psychiatric Disease in
Older Adults
Think of these possibilities and consider
course:
 Delirium: days to weeks
 Drugs: days to months
 Disease: days to months
 Depression: weeks to months
 Dementia: months to years
14. Mental illness in older age is complex

Items 2 through 13 suggest a high degree of
complexity with respect to the interaction of age
and mental illness.

In later life there is a complex interaction between
depression, anxiety, physical illness, cognitive
impairment, personality factors, and life stress.



Although aging is associated with a
multitude of stressful events, older adults
do not develop more psychiatric
disturbances.
For example, the prevalence of major
depression is lower in elderly persons than
young and middle-aged adults .
Many elders have physiological,
psychological, and environmental
resources that modify these processes and
avert unfavorable outcomes.
Clinical Implications


A good clinician must recognize the
biopsychosocial factors influencing the
mental state.
Care of the older adult, each biological,
psychological, and social element is likely to
be more complex than in younger adults
because their longer life has provided more
experiences as well as more chances for
interactions among these elements.
•Importantly, older adults are survivors, having
outlived many of their original age cohorts, and they
have strengths that must be recognized along with any
shortcomings.
Important : Use these questions to study for examination
Test yourself on Alzheimer’s disease(AD) and dementia—
True or False?
1.Memory loss must always be present in dementia
true
2. Depression is found in about ½ of AD patients
false
3. Dementia is occurs about 5-10% of the elderly population
true
4. Mild cognitive impairment includes memory problems and
functional impairment
false
5. Plaques and tangles may be found in AD, PD, and LBD
6. Psedodementia is usually not a prodrome of dementia
7. LBD is characterized by visual hallucinations, EPS, and
cognitive sx
true
false
true
Test yourself on depression and anxiety—true or false?
1. About one-fourth to one-third of community elders have syndromal or subsyndromal
depression
true
2. Among older adults, the highest rates of DSM depressive disorders are found in the
85+ group
false
3. About ¼ of medically ill persons suffer from depression
true
4. Mortality rates are not greater among post MI pts with depression
false
5.Social withdrawal is rare among older depressed pts
6. Vascular depression is associated with apathy
false
true
7. Elders with major depression are more likely to show social withdrawal
true
8. Elders with major depression are more likely to talk about physical symptoms
true
false
9. Anxiety and depression rarely occur together
10. It is best to use drugs that undergo phase 1 and phase 2 metabolism in older adults
false
11. Anxiety disorders are the most common disorders in elderly persons
true
Test yourself on schizophrenia-true or false?
1. About ¾ of schizophrenia begins before age 40
true
2. Compared to early onset cases, persons with late-onset
true
schizophrenia are more likely to have visual
hallucinations, to be more paranoid, and to be women
3. Psychotic symptoms generally do not improve over the
life course of schizophrenic persons
false
Congratulations—you are now an
expert in geriatric psychiatry