Psychiatry of old age 32

Ajit Shah Shaloo Jain

CHAPTER CONTENTS Psychiatry of old age services . . . . . . . . . . . . . . . . 495

Sources and mode of referrals . . . . . . . . . . . . . . 495
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Site and nature of initial assessment . . . . . . . . . . 495
Demography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487 Outpatient clinics . . . . . . . . . . . . . . . . . . . . . . . . . 496
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487 Day hospitals . . . . . . . . . . . . . . . . . . . . . . . . . 496
Dementia . . . ............... . . . . . . . . . . 487 Inpatient care . . . . . . . . . . . . . . . . . . . . . . . . . 496
Depression . ............... . . . . . . . . . . 488 Role of the general practitioner . . . . . . . . . . . . . 496
Neurosis . . . ............... . . . . . . . . . . 488 Liaison service . . . . . . . . . . . . . . . . . . . . . . . . 496
Schizophrenia and late paraphrenia . . . . . . . . . . 488 Mental health legislation and elderly patients . . . . . . 496
Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Non-cognitive features . . . . . . . . . . . . . . . . . . . 488 Introduction
Alzheimer disease . . . . . . . . . . . . . . . . . . . . . . 489
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489 The psychiatry of old age, including demography, epidemiology,
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489 individual disorders and their management, suicide and
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
attempted suicide and the principles of service delivery, are
Vascular dementia . . . . . . . . . . . . . . . . . . . . . . 489 described in this chapter.
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489 Demography
Dementia with Lewy bodies . . . . . . . . . . . . . . . 489
Other dementias . . . . . . . . . . . . . . . . . . . . . . . 490
Population projections worldwide predict an increase in the
The management of dementias . . . . . . . . . . . . . 490
elderly population over the next few decades. In the UK, there is
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
General treatment . . . . . . . . . . . . . . . . . . . . . . . . 491 a particular increase in the ‘old old’ (80 years) compared with
the ‘young old’ (65–80 years). The prevalence of dementia doubles
Pharmacological treatments . . . . . . . . . . . . . . . 491
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
every 5.1 years after the age of 60. Thus, the absolute number of
dementia cases will increase. Although the prevalence of depression
Clinical features . . . . . . . . . . . . . . . . . . . . . . . 492
is not age-related, the absolute number of cases will also increase.
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Management . . . . . . . . . . . . . . . . . . . . . . . . . 492
Mania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 Epidemiology
Late paraphrenia . . . . . . . . . . . . . . . . . . . . . . . . . 493
Squalor syndrome . . . . . . . . . . . . . . . . . . . . . . . . 493
Suicide and attempted suicide . . . . . . . . . . . . . . . . 494 Dementia
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 The prevalence of dementia in the UK is up to 5.6% in those
Correlates of suicide . . . . . . . . . . . . . . . . . . . . . . . 494 over the age of 65 years (Copeland et al 1987). There is broad
Medical contact . . . . . . . . . . . . . . . . . . . . . . . . . . 494 agreement on the prevalence rates of severe dementia, but not
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 of mild dementia. The prevalence of Alzheimer disease,
Suicide notes . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 vascular dementia and mixed dementia are 46%, 20% and
Attempted suicide . . . . . . . . . . . . . . . . . . . . . . 495 10%, respectively in those over 65 years, and 75%, 20% and

ã 2012 Elsevier Ltd.

 PART TWO Clinical psychiatry
5%, respectively in those over 75 years with dementia. Alzhei-
mer disease is more common in men and vascular dementia is
more common in women.
The prevalence of dementia in nursing and residential home
populations is 35–50% for mild/moderate dementia and around
30% for severe dementia. The prevalence of dementia among
acutely ill and continuing care geriatric inpatients is 35–61%
and up to 90%, respectively.
Depression
The reported prevalence of depression in the elderly ranges
from 11% to 16%. There is evidence that prevalence of depres-
sion increases with age in women (Copeland et al 1987). The
prevalence of depression in residential and nursing home popu-
lations is about 35%. The prevalence of depression in acutely ill
and continuing care geriatric inpatients of up to 50% and 38%,
respectively has been reported.
Neurosis
The Liverpool study reported a prevalence of 2.4% for all
neuroses (Copeland et al 1987). The Guy’s/Age Concern survey
reported prevalence of 3.7% for generalized anxiety and 10% for
phobias (7.8% agoraphobias, 1.3% social phobias and 2.1% spe-
cific phobias) (Lindesay et al 1989). However, many of these
individuals also had co-morbid depression and thus, the preva-
lence of pure neurosis is likely to be lower. Personality disorder
has not been systematically studied in the elderly.
Schizophrenia and late paraphrenia
In the Liverpool study, the prevalence of these disorders was
0.1% (Copeland et al 1987).
Dementia
Definition
The ICD-10 defines dementia as follows: dementia is a syn-
drome due to disease of the brain, usually of chronic or progres-
sive nature, in which there is impairment of multiple higher
cortical functions, including memory, thinking, orientation,
calculation, learning capacity, language and judgement.
Consciousness is not clouded. The cognitive impairments are
commonly accompanied, and occasionally preceded, by deteri-
oration in emotional control, social behaviour or motivation.
This syndrome occurs in Alzheimer disease, in cerebrovascular
disease, and in other conditions primarily or secondarily affect-
ing the brain.
Thus, dementia implies global intellectual deterioration.
Moreover, functional impairment is a necessary prerequisite
for the diagnosis of dementia (see Ch. 27 and Box 32.1).
488
Box 32.1
Diagnostic guidelines for ICD-10 diagnosis
of dementia in Alzheimer disease
The following features are essential for a definite diagnosis:
• Presence of dementia as described above
• Insidious onset with slow deterioration. While the onset usually
seems difficult to pin-point in time, realization by others that the
defects exist may come suddenly. An apparent plateau may occur
in progression
• Absence of clinical evidence, or findings from special
investigations to suggest that the mental state may be due to
other systemic or brain disease which can induce a dementia
(e.g. hypothyroidism, hypercalcemia, vitamin B12 deficiency,
niacin deficiency, neurosyphilis, normal pressure hydrocephalus,
or subdural)
• Absence of a sudden, apoplectic onset, or of neurological signs of
focal damage such as hemiparesis, sensory loss, visual field
defects, and incoordination occurring early in the illness (although
these phenomena may be superimposed later).
Non-cognitive features
In addition to cognitive impairment, dementia encompasses
several non-cognitive domains, including disorders of behav-
iour, personality, mood, thought content and perception
and functional disability. These are nowadays referred to
as behavioural and psychological signs and symptoms of
dementia (BPSD).
Behaviour disturbances including agitation, aggression, wan-
dering, pacing, restlessness, sleeplessness and sexual disinhibi-
tion are not uncommon and occur in over 50% of patients
during the course of dementia (Burns et al 1990a). Personality
changes, including emergence of new personality features or
an exaggeration of pre-morbid personality traits, are common
in dementia (Jacomb & Jorm 1996). Personality in this con-
text includes the ability to express and experience emotions,
however inappropriate.
The prevalence of depressive symptoms and depressive
illness in Alzheimer disease are 0–87% (median 41%) and
0–86% (median 19%), respectively (Wragg & Jeste 1989).
The prevalence of depressive symptoms and syndrome
is generally greater in vascular dementia than Alzheimer
disease.
Auditory, visual and olfactory hallucinations have been
described (Burns et al 1990b). A former classification of delu-
sions (simple persecutory, complex persecutory, grandiose and
those associated with specific neurological deficits) has been
modified into delusions of theft, delusions of suspicion and
systematized delusions (Burns et al 1990c). Four types of mis-
identification syndromes have been described (Burns et al
1990b): people in the house, misidentification of mirror im-
age, misidentification of television and misidentification of
people. The prevalence of delusions, hallucinations and misi-
dentification syndromes in Alzheimer and vascular dementia
varies: 20–50%, 17–36% and 11–34%, respectively (Burns
et al 1990b,c).

Alzheimer disease
Definition
The essential features for an ICD-10 diagnosis of dementia of
Alzheimer type are listed in Box 32.1. ICD-10 further classifies
this dementia into four sub-groups: dementia in Alzheimer dis-
ease with: (i) early onset, (ii) late-onset, (iii) atypical or mixed
and (iv) unspecified. The DSM-IV definition of Alzheimer
disease is similar.
Pathology
Pathological changes include widening of sulci, narrowing of gyri
and ventricular enlargement consistent with brain atrophy. His-
tological changes include senile plaques, neurofibrillary tangles,
granulovacuolar degeneration and amyloid deposition in blood
vessel walls in cortical and subcortical grey matter. Amyloid
has been identified as the main ingredient of senile plaques.
The severity of cognitive impairment and neurotransmitter
changes are associated with the number of senile plaques
(see Ch. 27).
Aetiology
First-degree relatives of Alzheimer disease sufferers have a
three-fold higher risk of developing the disorder, although most
cases are sporadic. Three specific pathogenic loci and several
risk-associated loci have been identified using linkage studies
of family pedigrees. Autosomal dominant pattern of inheritance
is observed in some families with early-onset disease. Patients
with Down syndrome, with trisomy 21 and variants, have a
higher risk of developing Alzheimer disease. Mutations in the
amyloid precursor protein (APP) gene located on chromosome
21 have been identified as a cause of early-onset Alzheimer dis-
ease. APP is a transmembrane glycoprotein and its derivative,
b-amyloid peptide, is found in amyloid plaques. APP gene
mutations can cause the three secretase enzymes involved in
the cellular processing of APP to produce more b-amyloid.
Mutations on presenilin-1 gene, located on chromosome 14,
account for some early-onset familial Alzheimer disease.
A homologous gene, presenilin-2, on chromosome 1 has a sim-
ilar effect. The precise function of the presenilin genes is
unclear, but they may be involved in the transport and proces-
sing of APP within the nerve cell (see Ch. 3).
Apolipoprotein is found both in plaques and tangles. More-
over, Alzheimer disease is associated with apolipoprotein E genes
(ApoE) located on chromosome 19 (Saunders et al 1993).
ApoE exists in three forms in the following order of frequency:
E3, E4 and E2. The various permutations individuals can have
are E3E3, E3E2, E3E4, E4E4, E4E2 and E2E2. Having one E4 allele
increases the risk of having Alzheimer disease four-fold and hav-
ing two E4 alleles increases the risk 16-fold. Presence of E4 alleles
can reduce the age of onset. However, about 40% of Alzheimer
disease patients do not possess an E4 allele, so its presence is
not necessary or sufficient for the development of Alzheimer
disease. Other risk modifying genes of possible importance in-
clude a1-antichymotrypsin gene and possible candidate genes
on chromosome 12 (see Ch. 3).
Psychiatry of old age CHAPTER 32
Other risk factors include age, infections, autoimmune con-
ditions, head injury, hypertension and hypotension, aluminium,
previous history of depression, advanced maternal age at birth
and thyroid disease. Diagnosis of rheumatoid arthritis, long
term prescription of non-steroidal anti-inflammatory drugs, ste-
roids and oestrogens are reported to be protective against the
development of Alzheimer disease.
Vascular dementia
Definition
The ICD diagnosis of vascular dementia assumes the general
definition of dementia described earlier. ICD-10 vascular
dementia is divided into several categories including acute on-
set, multi-infarct, subcortical vascular dementia, mixed cortical
and subcortical dementia, other vascular dementia and unspeci-
fied. The DSM-IV criteria are similar. The probability of the
diagnosis is increased by abrupt onset (possible index vascular
event), stepwise decline (possible recurrent vascular events),
presence of associated arteriosclerosis, focal neurological signs
and symptoms, patchy cognitive deficits, relative preservation
of personality, nocturnal confusion, hypertension and evidence
of cardiovascular disease.
Pathology
In vascular dementia there may be gross or localized brain
changes with atrophy and ventricular dilatation. There may be
evidence of ischaemia and infarction in brain tissue, and arterio-
sclerosis in the major blood vessels. There are no characteristic
neurochemical changes (see Ch. 27).
Aetiology
Risk factors for the development of vascular dementia include
male sex, increasing age, oriental culture, hypertension, heart dis-
ease, strokes, diabetes, cigarette smoking and hyperlipidaemia.
Dementia with Lewy bodies
This dementia, also called cortical Lewy body disease and Lewy
body dementia, is characterized by Lewy bodies in the cerebral
cortex and the substantia nigra (see Ch. 27). It is also associated
with reduction in acetylcholine transferase in the neocortex and
reduced dopamine in the caudate nucleus. Variable prevalence
of 6–15%, depending on sample types, has been reported.
Clinical features include fluctuating cognition with pro-
nounced variations in attention and alertness, recurring visual
hallucinations, which are typically well formed and detailed,
spontaneous motor features of parkinsonism and neuroleptic
sensitivity (Consensus Guidelines for the Clinical Diagnosis
of Dementia with Lewy Bodies, DLB 1996). Repeated falls,
transient disturbance of consciousness, systematized delusions
and hallucinations in other modalities also occur. Mortality is
increased in patients treated with neuroleptics. Severity of cog-
nitive impairment is associated with the density of cortical
Lewy bodies.
489
 PART TWO Clinical psychiatry

Other dementias
A number of other dementias occur in old age, including those
due to alcohol, fronto-temporal dementias, normal pressure
hydrocephalus, neurosyphilis, and those due to vitamin defi-
ciencies (see Ch. 27).
The management of dementias
The government has made dementia a national priority and
recently published the National Dementia Strategy for England
(DoH 2009). It aims to ensure that significant improvements
are made to dementia services across three key areas: improved
awareness, earlier diagnosis and intervention, and a higher qual-
ity of care. The strategy lists 17 key objectives which are
outlined in Box 32.2.
delirium, the severity of self-neglect due to dementia and sen-
sory impairment. This should facilitate distinction between de-
mentia, delirium superimposed on dementia, delirium alone
and other mental illness. Table 32.1 illustrates some of the dis-
tinguishing features between delirium and dementia (see
Ch. 27).
In general, the findings of the history and examination will
guide as to which special investigations are needed (listed in
Box 32.3) in order to further identify reversible causes of
dementias and super-added delirium and identify the severity
of self-neglect. MRI and CT scans may allow identification of
other structural pathologies like tumours and help in the differ-
ential diagnosis of dementias. They can help identify ischaemic
Table 32.1 Distinction between dementia and delirium

Dementia Delirium
Diagnosis Onset Insidious Acute
A detailed history from the patient and informants, mental and
Decline Relatively slow Rapid
physical state examination, and special investigations are re-
quired for accurate diagnosis. The history should also address Level of Alert Clouding of consciousness
any sensory impairment and loss of function. A detailed cogni- consciousness
tive assessment will allow accurate identification of the precise Sensory No Hypersensitivity (e.g. perceptions
cognitive deficits and their functional consequences. This can be hypersensitivity hyperacusis)
further supplemented by formal neuropsychometric assess-
ment by a clinical psychologist, particularly when there are Visual Less common More common
doubts about diagnosis. Physical examination will allow identi- hallucinations
fication of the aetiology of dementia and any associated Stability of Fairly stable Fluctuating
mental state

Box 32.2
National Dementia Strategy: Key objectives
1. Raise awareness of dementia and encourage people to seek help Box 32.3
2. Good quality early diagnosis, support and treatment for people
with dementia and their carers, explained in a sensitive way Special investigations in mental illness in the elderly
3. Good quality information for people with dementia and
their carers Commonly indicated
4. Easy access to care, support and advice after diagnosis • FBC
5. Develop structured peer support and learning networks • ESR
6. Improve community personal support services for people living • U&Es
at home • Calcium
7. Implement the new deal for carers
• TFT
8. Improve the quality of care for people with dementia in
general hospitals • LFT
9. Improve intermediate care for people with dementia • Glucose
10. Consider how housing support, housing-related services, • B12
technology and telecare can help support people with dementia • Folate
and their carers • Lipid profile
11. Improve the quality of care for people with dementia in • Syphilis serology
care homes
• MSU
12. Improve end of life care for people with dementia
13. An informed and effective workforce for people with dementia • Chest X-ray
14. A joint commissioning strategy for dementia • CT brain
15. Improve assessment and regulation of health and care services • ECG
and of how systems are working
16. Provide a clear picture of research about the causes and
Sometimes indicated
possible future treatments of dementia • EEG
17. Effective national and regional support for local services to help • Lumbar puncture
them develop and carry out the Strategy. • MRI scan.

490
 Psychiatry of old age CHAPTER 32

changes and areas of infarction in vascular dementia and charac- Pharmacological treatments
teristic radiological features of normal pressure hydrocephalus.
Functional MRI scanning, positive emission tomography (PET) Acetylcholine deficit is common in Alzheimer disease. Drugs
and SPEC scanning are not normally used in routine clinical designed to inactivate the acetylcholinesterase enzyme, which
practice, but may be needed. breaks down acetylcholine in the synaptic cleft, have been advo-
cated to improve cognition. Three drugs in this group, donepezil
(Gauthier et al 2002), galantamine (Tariot et al 2000) and
General treatment rivastigmine (Rosler et al 1998) are available in the UK and
have modest efficacy for improving cognitive impairment in
A simple explanation of the diagnosis, management plan and
mild to moderately severe Alzheimer disease (see Ch. 39).
possible sequelae should be given to the patient and the profes-
There is increasing evidence that these drugs also improve be-
sional or family carer. Box 32.4 illustrates some of the specific
haviour and psychotic symptoms of dementia (BPSD) and func-
issues that should be addressed during such explanations. Pro-
tion. Furthermore, rivastigmine has been shown to improve
fessional carers and relatives often require considerable support
cognitive impairment and BPSD including apathy, anxiety, de-
to understand and cope with the behaviour disturbance. Both
lusions and hallucinations in dementia with Lewy bodies
groups of carers may also require opportunities to ventilate
(McKeith et al 2000).
their feelings. Relatives may be able to join support groups such
In the UK, the amended National Institute of Clinical
as the Alzheimer Disease Society in the UK, which provide
Excellence (NICE) guidelines (see: www.nice.org.uk) recom-
information and peer group support.
mend that only those with a diagnosis of moderate Alzheimer
Almost all drugs can cause delirium and many exacerbate the
disease and a Mini Mental State Examination score of 10–20
cognitive impairment of dementia. Thus, indications for their
should be prescribed these drugs, usually in secondary
continued use should be reviewed. Any potentially reversible
care. Where MMSE is not an appropriate tool to be used
or partially reversible causes of dementia, hypothyroidism or
(e.g. in presence of learning disability, or other disabilities,
neurosyphilis for example, should be treated. Common causes
communication/linguistic difficulties), other appropriate
of delirium and behaviour disturbance such as pain, constipa-
methods should be used. Another drug called memantine,
tion, urinary tract infection and chest infection should be rigor-
which works by reducing overstimulation of the N-methyl-
ously sought and treated, and advice from specialist geriatric
D-aspartate (NMDA) receptor by glutamate (memantine is
medicine services should be sought when appropriate. Optical,
NMDA antagonist) improves cognition and also produces
ophthalmology or audiology opinion should be sought when sen-
global improvement (Reisberg et al 2003). However, even
sory impairment is identified because their correction may
though it is licensed, it is not recommended for clinical
improve cognitive deficits.
use in UK.
Early identification and intervention may avoid a full-blown
The efficacy of other psychotropic drugs in the treatment of
crisis. Both professional and non-professional carers could be
BPSD is unclear and probably modest. Research in this area is
advised to use some simple calming strategies. Disturbed
open to criticism because of poor methodology and it has been
patients should be approached from the front, gently and
argued that psychotropics simply sedate the patient rather than
calmly. Communication should be clear and unambiguous. Judi-
modify target behaviour (Shah & Thomas 2006). The Commit-
cious use of touch and non-threatening postures may also be of
tee on Safety of Medicines has advised against using risperidone
value (see Ch. 34).
and olanzapine in dementia because they both increase the risk
of strokes and for olanzapine mortality is also increased. Because
of altered pharmacokinetics and pharmacodynamics in the el-
Box 32.4 derly, small doses should be used with careful observations
for side-effects.
Specific areas of information shared with carers
Short-acting benzodiazepines or clomethiazole may be
• Diagnosis of dementia and its implications
helpful in the management of acute disturbance in patients
• Behaviour problems in dementia
with dementia. However, tolerance, dependence and other
• Possible causes of the behaviour problem
side-effects mandate that they should be used briefly and
• How the problems are going to be managed
avoided if at all possible. Carbamazepine and sodium val-
• Results of any special investigations
proate may have efficacy in the treatment of aggressive
• Role of medication, if any
behaviour.
• Need for day-care
Antidepressants have proven efficacy for the treatment
• Need for respite-care
of depression in dementia. Ideally one of the newer antidepres-
• Need, if appropriate, for admission into hospital
sants from the selective serotonin uptake inhibitor (SSRI)
• Need to refer to psychogeriatric services
group or other newer antidepressants should be used because
• What resources may be available to carers
they have fewer anticholinergic side-effects. The SSRI citalo-
• Need for placement into a residential facility
pram has been shown to decrease agitation in double-blind
• Management of financial resources (power of attorney or Court of
Protection), health and social welfare studies and other drugs acting on the serotonin system
• Ability to drive a car. have anecdotally been reported to reduce aggressive behaviour
in dementia.

491
 PART TWO Clinical psychiatry

Depression everyone with depression has experienced adverse life events

Clinical features
The clinical features of depression in the elderly are essentially
similar to those in younger individuals. Agitation, retardation,
hypochondriasis, cognitive impairment and delusions of physical
ill-health, persecution, poverty, self-blame, worthlessness and
guilt are common; nihilistic delusions may occasionally occur.
Hallucinations are unusual, but when they occur they are usually
second person auditory hallucinations with a derogatory content
(and are mood congruent). Cognitive impairment in depression
may be mistaken for dementia, a phenomenon referred to as
depressive pseudodementia. This can be discriminated from
dementia by the clarity of onset, relatively rapid onset, its dura-
tion and speed of cognitive decline, the manner in which the
patient answers the questions, presence or absence of higher
cortical deficits and/or other depressive symptoms (Table 32.2).
Aetiology
The aetiology of depression can be divided into predisposing
factors, precipitating factors and perpetuating factors. Predis-
posing factors can be classified into genetic factors, physical
health, personality and social support. Up to 30% of late-onset
depressions have a family history. Physical illness and its treat-
ment may predispose to depression in up to 50% of medically ill
elderly inpatients. Occult malignancies may present with
depression and drugs like corticosteroids can produce depres-
sive side-effects. Late-onset depression may be associated with
anxiety-prone, avoidant and dependent personality. The associ-
ation between depression and the presence of a confidante or an
intimate relationship are unclear, with some studies supporting
and others refuting such a relationship.
Precipitating factors include independent adverse life events,
which are important in precipitating depression and are fre-
quent in the preceding year. Bereavement is an important life
event associated with depression in the elderly. However, not
Table 32.2 Significant clinical differences between depressive
pseudodementia and dementia
Pseudodementia Dementia
Onset Acute Insidious
Course Rapid Insidious
Duration Relatively brief Permanent
Main complaint Impaired memory No complaints
Cognitive questioning Cannot respond or does Incorrect response
not know answer
Higher cortical Intact Impaired
functioning
Mood congruent Common Uncommon
delusions
and not everyone experiencing such events becomes depressed.
Thus, other factors must operate. Personality traits, including
an inability to form close relationships, a tendency to be
helpless and hopeless, an inability to tolerate change and loss
of control, and feelings of loneliness, despair and dependence
on others may be vulnerability factors predisposing to depres-
sion. Both precipitating and predisposing factors may also act
as perpetuating factors.
Management
An accurate diagnosis is essential in the treatment of depression
and this can be achieved by satisfactory history from the
patient and a collateral source, mental state examination and
a thorough physical examination. This process will also allow ex-
clusion of differential diagnoses. Box 32.2 summarizes the
most significant differences between dementia and depressive
pseudodementia. Physical examination and selected special inves-
tigations from the list in Box 32.3 will allow identification of self-
neglect (e.g. dehydration or anaemia) and other physical illnesses
(e.g. hypothyroidism or hypercalcaemia mimicking depression).
Treatment plans should be tailored to individual patients
with regard to the severity of the depression and its aetiol-
ogy. Treatment should be directed at predisposing factors,
precipitating factors and perpetuating factors on the social,
psychological and biological axis. NICE (see: www.nice.org.
uk) recommends the stepped care model aiming to match
patient needs to the most appropriate services. Where possi-
ble, rectification or adjustment of correctable factors should
be effected. Treatment should be divided into three phases:
acute, aimed at remission of the index episode; continuation,
aimed at preventing relapse of the index episode after treat-
ment; and maintenance, aimed at prevention of new epi-
sodes. First-line pharmacological treatment should be with
newer antidepressants (selective serotonin reuptake inhibi-
tors and related drugs, selective noradrenaline (norepineph-
rine) reuptake inhibitors and reversible monoamine oxidase
inhibitors), which are as potent as older antidepressants
but have fewer side-effects (see Ch. 39). In the elderly,
due to altered pharmacokinetics and sensitivity, it is wise
to start at small doses and increase doses slowly with close
monitoring for side-effects. Efficacy may begin at 3 weeks
but may not be observed for up to 10 weeks in some patients.
After recovery antidepressant medication should continue for
a longer period than in younger patients. The multicentre
study from the Old Age Depression Research Interest
Group (1993) suggests a minimum maintenance period of
2 years, although a study did not show efficacy for sertraline
in relapse prevention over a 2-year follow-up period (Wilson
et al 2003).
Should an antidepressant appear ineffective, the adequacy
of dosage, compliance and treatment duration, improvement
of perpetuating factors and the accuracy of the diagnosis
should be examined before changing medication. If all these
factors are satisfactory, consideration should be given to
changing the antidepressant to one from another chemical
group. There are no hard and fast rules with regard to which

492

treatment to adopt after first-line antidepressants fail. It
will be dictated by previous response, patient and carer pref-
erence and psychiatrist’s preference. Choices include a
different SSRI, mirtazapine, moclobemide, reboxetine or
lofepramine. Venlafaxine can be given for more severe de-
pression, taking into account the special considerations as
outlined by NICE.
ECT is well tolerated in the elderly (Benbow 1994). How-
ever, the recent NICE (www.nice.org.uk) guidelines recom-
mend that ECT should only be used to achieve rapid and
short-term improvement of severe symptoms, after an ade-
quate trial of other treatments has proven ineffective or
when the condition is thought to be potentially life threaten-
ing, in individuals with severe depression (catatonia, a pro-
longed, or a severe episode of mania). It controversially
suggests caution in the use of ECT in the elderly. Depressive
delusions, psychomotor retardation, agitation and other bio-
logical symptoms predict a good response (Benbow 1994).
If exacerbation of confusion is an issue, unilateral ECT
may be considered.
Most depressed elderly patients benefit from supportive psy-
chotherapy and some may need more formal counselling.
Cognitive–behavioural therapy and group psychotherapy are
effective, while reminiscence therapy, problem-solving therapy,
family therapy and more in-depth interpersonal psychotherapy
may be of benefit but have not been systematically evaluated.
Psychotherapeutic techniques must take account of factors
associated with old age including memory, sensory deficits
and articulation difficulties.
Over a 12-month follow-up period, between 35% and 68%
of treated depressed patients remain well, between 14% and
29% remain continuously depressed, and between 12% and
19% relapsed (Baldwin & Jolley 1986). Over a 3-year follow-
up period between 22% and 31% achieved lasting recovery, be-
tween 28% and 38% had a further episode with recovery,
between 23% and 32% achieved partial recovery, and between
7% and 17% remained continuously ill (Baldwin & Jolley
1986). Mortality is also increased among depressed elderly
patients.
Mania
The prevalence of mania decreases with increasing age, but
among patients with bipolar illness, mania may not infrequently
present for the first time in old age. Up to 50% of 1st-degree
relatives of such patients have affective disorders and such a
family history is associated with early onset of illness. Two sub-
types of mania have been described in elderly patients:
• Affective disorder with depression in middle age and manic
episodes late in life
• Secondary mania in which the first affective episode is
associated with coarse neurological disorder in an individual
with low genetic loading.
The clinical presentation of mania in old age is similar to that
seen in younger patients.
The pharmacological treatment of mania is essentially sim-
ilar to that in younger patients, but should allow for the age-
Psychiatry of old age CHAPTER 32
related altered pharmacokinetics and prolonged half-life of
various drugs. Neuroleptics are of value in acute mania. Lith-
ium and anticonvulsants, like carbamazepine and sodium
valproate, can be of value in acute mania, but are also used
for prophylaxis.
Late paraphrenia
In ICD-10 and DSM-IV late paraphrenia is subsumed under
paranoid schizophrenia or persistent delusional disorder.
Patients with late paraphrenia present for the first time in old
age with persecutory delusions, auditory and/or visual hallucina-
tions and Schneiderian first rank symptoms. Delusions of
reference, hypochondriasis and grandeur, misidentification syn-
dromes and hallucinations in other modalities may also occur.
Affective symptoms are concurrently present in up to 60% of
cases. Late paraphrenia patients do not show an obvious marked
cognitive decline, but their performance on some cognitive test
batteries is worse than normal ageing.
Late paraphrenia is commoner in women. They have sensory
deficits including auditory and visual impairment. Personality
features of suspiciousness, sensitivity, quarrelsomeness and
unsociability are also associated with this disorder.
There are no controlled trials of neuroleptic usage in late
paraphrenia, but anecdotally neuroleptics are accepted as the
treatment of choice. Correction of sensory deficits may also
help. All this should be coupled with social, psychological and
occupational support.
Squalor syndrome
This syndrome is characterized by extreme self-neglect,
domestic squalor, social withdrawal, apathy, tendency to hoard
rubbish and lack of shame (Snowdon et al 2007). The annual
incidence has been estimated as 0.5/1000 population over the
age of 60 years. Sex ratio is unclear with conflicting reports.
The vast majority of these individuals live alone and many are
known to the community authorities, but they tend to decline
offers of help. Financial hardship may be absent, many own
properties and they come from all social classes. Physical illness
and biochemical and haematological abnormalities commonly
occur in these individuals. Deafness and visual impairment
are common accompaniments.
Normal mental state is observed in up to 50% of cases. The
remainder have the following diagnosis in order of decreasing
frequency: dementia, paraphrenia or chronic schizophrenia,
alcoholism and manic-depressive illness. Their subjectively
measured personality characteristics are domineering, quarrel-
some and independent.
Management should be along the lines of principles de-
scribed for individual disorders earlier and consistent with
general principles of management in old age psychiatry de-
scribed below. Use of various legislations, including the Men-
tal Health Act in the UK, in this syndrome has been described
(Shah 1995).
493
 PART TWO Clinical psychiatry
Suicide and attempted suicide
Suicide
A comprehensive review covering issues discussed in this sec-
tion in greater detail is provided elsewhere (Shah & De 1998).
Epidemiology
There are large variations in elderly suicide rates across different
countries. Generally, suicide rates in the elderly for both sexes
are higher than the average rate in the general population. Sui-
cide rates in the elderly for both sexes have declined over recent
years in most countries.
Risk factors attributable to age, period and cohort member-
ship will influence the suicide rate for any given age at a given
time (Skegg & Cox 1991). Thus, individuals born in a particular
cohort will have suicide rates peculiar to that cohort (cohort
effect). Moreover, the individual’s age at any given time within
the cohort will further influence the suicide rate (age effect).
Furthermore, environmental factors related to the period of
study will further influence suicide rates (period effects). The
period effect of the Second World War, detoxification of
domestic gas and restricted barbiturate prescribing on reducing
elderly suicide rates has been well demonstrated.
Correlates of suicide
Suicide rates in most countries are higher among elderly males
than females. Male suicide rates continue to increase with age,
whereas female suicide rates increase until about 60 years and
decline thereafter. Elderly people who kill themselves often live
alone, are lonely and are more likely to be widowed, single or
divorced. Bereavement is an important precipitant and suicide
rates are higher in the first few years after the death of spouse,
particularly in men. Marital and family discord may be further
precipitants.
Between 50% and 90% of elderly suicides have depressive ill-
ness at the time of their death. Severity of depression ranges
from mild to severe and the duration from 6 to 12 months.
A first episode of depression is a particularly vulnerable time
with 20–35% of suicides occurring then. Symptoms of agitation,
anergia, anhedonia, dysphoria, poor concentration, loss of
weight, guilt, somatic preoccupations, hopelessness and insom-
nia are commonly associated with suicide in depressed elderly
individuals.
Alcohol or substance abuse or dependence is present in up to
44% of elderly suicide victims. Alcohol may be the predominant
intoxicating agent, may potentiate other poisonous agents like
barbiturates or may be taken as ‘Dutch courage’ prior to suicide.
A smaller but significant proportion of elderly suicides have
suffered from schizophrenia or paraphrenia with a prevalence of
6–17%. The relationship between elderly suicide and personal-
ity disorder has been less well examined. The prevalence of per-
sonality disorder in elderly suicide victims has been reported at
16% (with an odds ratio of 4) (Harwood et al 2001). Personality
trait accentuation of anankastic and anxious types were associ-
ated with suicide (Harwood et al 2001).
494
Prevalence rates for dementia (prevalence of 4%) and delir-
ium (prevalence of 7% for other organic disorders including de-
lirium) are reported to be higher in elderly suicide victims than
in the control group (Harwood et al 2001). Up to 13% of
elderly suicides may have been judged to have no formal
mental illness.
Physical illness is present in up to 65% of elderly suicides and
is often prolonged, sufficiently severe to cause acute discomfort
or interfere with daily living. Up to 23% of elderly suicides
receive inpatient investigation and treatment for their physical
illness in the preceding year. Pain is a common accompaniment
and present in up to 27% of cases and may be severe and asso-
ciated with definite organic pathology such as ischaemic heart
disease, post-herpetic neuralgia and chronic pain associated
with the musculoskeletal system or hypochondriacal in nature.
It has been speculated that both metastatic and non-metastatic
effects of carcinoma can precipitate mental illness, which in
turn can lead to suicide. A significant number of elderly suicides
have an occult carcinoma; all these suicide victims also had
depression and this concurs with the traditional observation that
neoplasms may present with depression.
Medical contact
Up to 90% of elderly suicide victims are reported to have seen
their general practitioner in the preceding 3 months and up to
50% in the week prior to suicide. Up to 20% had seen a psychi-
atrist in the preceding 6 months and about 50% of elderly
suicide victims have a lifetime history of psychiatric contact.
Most studies report that a relatively small proportion of
elderly suicide victims were being treated with antidepressants
(12–53%), often utilizing subtherapeutic doses, while a signifi-
cant proportion are treated with sedatives or hypnotics.
Methods
With increasing age, violent methods are used more frequently,
particularly by men. Hanging, jumping from a height, drowning
and suffocation are common means of suicide by the elderly in
the UK, Japan, Finland, Singapore, New Zealand and Australia.
In contrast to the USA, Australia, Finland and New Zealand,
shooting is uncommon in the UK, Singapore and Japan due to
tighter firearms regulation. Suicide by inhalation of car exhaust
fumes is increasing in the UK and New Zealand. Self-poisoning
is generally more common in elderly women, but there has
been a reduction in elderly suicides by self-poisoning in both
sexes, largely due to a reduction in barbiturate poisoning.
Suicides due to benzodiazepines and analgesics have increased
in recent years, particularly in women. Analgesics are the com-
monest drugs taken in overdoses. Over 90% of such deaths are
due to aspirin, paracetamol and dextropropoxyphene. Tricyclic
antidepressants are now rarely used.
Suicide notes
Fewer elderly compared to their younger counterparts leave
suicide notes because many are isolated and have no one to write
to, while others have lost the ability to express themselves.

When left, notes are often brief with a self-reproachful content.
In one study, only 43% of the victims left notes.
Attempted suicide
Elderly individuals account for up to 15% of all attempted sui-
cides and most are unmarried, live alone, have relationship or
financial difficulties or unresolved grief. Serious physical illness
and pain are also associated with attempted suicides.
Depression may be present in over 90% of elderly individ-
uals attempting suicide, and in some studies psychotic symp-
toms (including mood congruent depressive delusions), sleep
disturbance and somatization were also common. Alcoholism
and alcohol consumption before attempted suicide are com-
mon, and both lower and higher rates of organic brain syn-
drome have been reported. It has been suggested that many
attempted suicides in late life are serious bids that have failed
due to confusion from physical illness, overmedication and
alcohol misuse.
Drug overdoses are the most common method (up to 90%) of
attempted suicide in elderly patients, the drugs employed in-
clude minor tranquillizers, hypnotics, antidepressants and anal-
gesics. Barbiturate self-poisoning has declined while non-opiate
analgesic poisoning, particularly paracetamol and paracetamol-
containing analgesics, has increased. Self-poisoning is more
common among women while wrist cutting, shooting,
attempted drowning, jumping from heights and attempted as-
phyxiation are favoured by men.
Psychiatry of old age services
The management of individual disorders described above
should be considered in tandem with the general provision of
psychiatric services for elderly individuals. These services, in
the UK, will now have to follow the standards set by the new
National Service Framework for Older People (NSF) (DoH
2001). There are eight specific standards as listed in Box 32.3.
Ideally, the service should cater for a defined geographical
area, and while a useful administrative cut-off age is 65 years,
there must be some flexibility for patients with early onset de-
mentia and graduates (patients who developed mental illness
early in life and have grown old while receiving treatment in
existing services for younger patients). Services should cater
for all mental illnesses in old age, but some services do not
receive graduates. The NSF, in Standards 1 and 7 (Box 32.5),
recommends elimination of any age discrimination in service
delivery for both early-onset dementia sufferers and graduates.
Sources and mode of referrals
Services may accept referrals either from other medical practi-
tioners (closed referral) or from medical and non-medical staff
(open referral). Referrals from general practitioners (GPs) has
several advantages including avoidance of duplication of effort
and substitution of the GP’s role, the filtering of medically ill
patients to geriatric medical services and continuation of
Psychiatry of old age CHAPTER 32
Box 32.5
The National Service Framework for Older People
Standards
Standard 1: Rooting out age discrimination
Standard 2: Person-centred care
Standard 3: Intermediate care
Standard 4: General hospital care
Standard 5: Strokes – the NHS in partnership with agencies will take
action to prevent strokes
Standard 6: Falls – the NHS working in partnership with councils will
take action to prevent falls and their sequelae
Standard 7: Mental health in older people: older people with mental
health problems have access to mental health services, to ensure
effective diagnosis, treatment and support, for them and their carers
Standard 8: Promoting an active healthy life in old age.
management in the community (Shah & Ames 1994). In the
open referral model the GP should be kept fully informed.
Site and nature of initial assessment
The initial assessment of a patient should ideally take place at
the patient’s home (Shah & Ames 1994). Home visits have
no significant disadvantages. The advantages of home assess-
ments include:
• Consultation rate close to 100%
• Direct observation of the home environment
• Avoidance of unnecessary social work and occupational
therapy assessment ordered from the outpatient clinic
• Ready access to the patient’s medication and attention to
polypharmacy, poor compliance, drug interaction,
dependence on benzodiazepines, and hoarding for overdose
• Reduced stigma about attending a psychogeriatric clinic
• Avoiding the irregularities in the timing and availability of the
ambulance for transportation and avoiding the indignity of
lengthy ambulance rides
• Personal cost of a trip to the clinic is avoided by the patient.
Two appropriate members of the multidisciplinary team should
assess the patient. This enables assessment from the perspective
of two disciplines and provides safety from assaults and accusa-
tions. One member should be a doctor to facilitate mental state
and physical examinations. Community psychiatric nurses have
been involved in initial assessment, despite controversy over
their use as filters between GPs and psychiatrists.
Multidisciplinary community meetings, similar to traditional
ward rounds, are used to discuss new cases and their manage-
ment, to facilitate liaison between team members, to cross-refer
cases, to provide mutual support, and to discuss new plans, ideas
and problems. Management should be based on the principle of
case-management where the case-manager not only provides
professional assistance from his/her discipline but also coordi-
nates other management strategies. Standards 2 and 7 of the
new NSF recommends development of close multidisciplinary
working, integration between health and social services,
 PART TWO Clinical psychiatry
development of a single assessment process across different
disciplines and agencies, and agreed protocols between primary
and secondary care for the assessment and management of
dementia and depression.
Patients may require follow-up for further assessment, treat-
ment, rehabilitation, monitoring of side-effects, monitoring of
mental state, support for patient or carers and advocacy
(Shah & Ames 1994). This may be at home, in the outpatient
clinic or at a day-hospital.
Outpatient clinics
Outpatient and specialist memory clinics can complement
home visits with detailed neuropsychometry, and blood and
radiological investigations (Shah & Ames 1994). Such clinics
are being increasingly located in the general hospital because
it allows access to a wide range of facilities. Memory clinics offer
elective, detailed assessment of patients with dementia and
related disorders, but due to the lengthy assessments such
clinics are able to evaluate a relatively small number of patients.
However, through Standard 7 of the NSF, the development of
memory clinics is encouraged.
Day hospitals
Day hospitals are an important component of old age psychiatry
services. They allow assessment, treatment, rehabilitation, long-
term support, development of a social network and support for
carers (Shah & Ames 1994). The UK Royal College of Psychi-
atrists recommend 90 day places for a population of 30 000 over
65-year-olds. Day hospitals cater both for functionally and or-
ganically ill patients, either in separate units or on separate days,
and flexible day hospitals which are open at the weekend
and during the evening are slowly emerging, with obvious
advantages. In rural areas travelling day hospitals have been
developed.
Inpatient care
There are three types of hospital admissions: assessment and/
or treatment, respite and continuing care. The UK Royal
College of Psychiatrists recommends 45 acute beds and 90
continuing care beds for a population of 30 000 over the age
of 65 years.
Factors that may contribute to an inpatient admission include
severity of the illness, severity of the sequelae of the illness, in-
sufficient social and community support at home, need for more
detailed and intensive assessment, and implementation of cer-
tain treatments like ECT. Respite admissions can be in stand-
alone units, acute admissions wards or continuing care wards.
They are usually intended to give carers a break. Some patients
may require long-term (continuing care) admissions. In the UK,
continuing care admissions are regulated by locally agreed cri-
teria (between different agencies) following a department of
health directive.
496
Role of the general practitioner
General practitioners play a vital role in the satisfactory func-
tioning of psychogeriatric services. They see a significant
amount of psychiatric morbidity and have good ability to recog-
nize both depression and dementia, but adopt less good treat-
ment strategies. The latter could be facilitated by the
psychogeriatric service providing support and back-up with liai-
son clinics in general practice involving psychiatrists, commu-
nity psychiatric nurses and social workers. Standard 7 of the
NSF promotes close working between primary care and special-
ist old age psychiatry services through a range of models such as
above and through development of agreed protocols for assess-
ment and management of dementia and depression.
Liaison service
Psychiatry of old age services should provide a liaison service to
departments of geriatric medicine and general hospitals, resi-
dential and nursing homes, social service and voluntary agency
day facilities, voluntary organizations and other local govern-
ment facilities. The liaison service should aim to share knowl-
edge about psychiatry of old age with others and improve the
ability of non-specialist professionals to detect and manage
mental illness. This can be done on a case by case basis (consul-
tation model) and by contributions to their meetings and open
forum seminars (liaison model) or by both models.
Depressed medically ill elderly inpatients experience severe
psychological distress, have more severe physical illnesses, have
physical illnesses that are difficult to treat, are poorly compliant
with treatment, have longer hospital admissions and have a
higher mortality. Moreover, depression is poorly recognized
and treated among geriatric inpatients and more than 80% of
depressed elderly patients have no documented plans for the
management of their depression following discharge. Further-
more, less than half of all elderly medically ill in-patients with
depression are referred to psychiatrists and antidepressants
are used infrequently and at inadequate doses.
The prevalence of mental illness in residential facilities in-
cluding sheltered homes, hostels, residential homes, special ac-
commodation homes and nursing homes is considerable.
Residential facility staff and nursing home staff have limited
psychiatric training, so psychiatric morbidity is often unrecog-
nized in such facilities or, when recognized, poorly treated.
There is considerable need for liaison service development in
this area.
Mental health legislation
and elderly patients
The application of mental health legislation to elderly patients is
essentially the same as its application to younger patients in
most jurisdictions. Thus, in England and Wales, for example,
the various sections of the amended Mental Health Act 2007
apply equally to elderly and young patients. The Mental Capac-
ity Act 2005 (MCA 2005) (Department of Constitutional
Affairs 2005) allows for treatment of incapacitated patients if

this in their best interests. For incapacitated patients who
cannot be detained in hospital under the Mental Health Act,
the Mental Health Act 2007 has introduced Deprivation of
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