In Review

Psychiatric Disorders in the Elderly

Ingmar Skoog, MD, PhD1

Recent research has shown that depression, anxiety disorders, and psychosis are more
common than previously supposed in elderly populations without dementia. It is unclear
whether the frequency of these disorders increases or decreases with age. Clinical
expression of psychiatric disorders in old age may be different from that seen in younger age
groups, with less and often milder symptoms. Concurrently, comorbidity between different
psychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitive
function is often decreased in people with depression, anxiety disorders, and psychosis,
but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders
in the elderly are often related to cerebral neurodegeneration and cerebrovascular disease,
although psychosocial risk factors are also important. Psychiatric disorders, common among
the elderly, have consequences that include social deprivation, poor quality of life, cognitive
decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal
mortality.

Can J Psychiatry. 2011;56(7):387–397.

Key Words: depression, anxiety, psychosis, elderly, epidemiologic methods,

prevalence, risk factors, comorbidity

M ost research on mental disorders have been concerned

with dementia and to some extent with depression.
Other mental disorders, such as anxiety disorders and
psychotic disorders, have received less attention. This
review will discuss the frequency of mental disorders in the
elderly, and its relation to age. Aspects of mental disorders
in the elderly without dementia, such as clinical expression
and comorbidity, cognitive function and dementia, cerebral
neurodegeneration and cerebrovascular disease, and risk
factors and consequences, will also be discussed.
Frequency of Mental Disorders in the Elderly
The prevalence of mental disorders is high among the
elderly,1–4 with a prevalence of almost 20% in people
without dementia aged 65 years and older.2 While most
people in epidemiologic studies are below age 90 years,
it was recently reported that almost one-third of people
without dementia aged 95 years fulfilled criteria for a
psychiatric disorder: 17% had depression, 9% anxiety, and
7% a psychotic disorder.5
Most studies on the epidemiology of mental disorders in
the elderly without dementia have been concerned with
depression. Cross-sectional studies report prevalence
figures of around 5% to 10% for depression,3,6–12 and 1%
to 5% for major depression.2,3,13 These figures may be even
higher in the developing world.14 This makes depression
more common than dementia in people aged 65 years and
older. The prevalence of depressive symptoms are even more
common than the clinical diagnoses. Such subsyndromal
forms of depression are nevertheless associated with adverse
outcomes, such as stroke, disability, and mortality.15–18
Anxiety disorders include GAD, agoraphobia, panic
anxiety disorder, OCD, social phobia, and specific phobias.
Recent research suggests that anxiety disorders may be
as common, if not more common, as depression1,2,4 in the
elderly. Among recent studies, prevalences between 6%
and 12% have been reported in people aged 65 years and
older.2–4 The prevalence was 10.5% in people aged 85 years7
and 4% in those aged 95 years.5
The prevalence of GAD ranges between 1% to 10%.2,3,19–22
In people aged 85 years, the prevalence was 6%,7 and in
those aged 95 years, 2%.5 Few studies have examined
the prevalence of OCD among the elderly. Studies on
populations aged 65 years and older have reported
prevalences ranging from 0.2% to 1.5%.2,22–25 In people
aged 85 years, the prevalence of OCD was 3.2%7 and
in those aged 95 years, 0.3%.5 Specific phobia is often
considered the most common among the anxiety disorders.
Prevalence estimates vary from 2% to 12% in populations
aged 65 years and older.2,3,21,22,26–29
Using DSM-IV criteria, the prevalence of social phobia
was 1.3% among people aged 55 years and older,30 1.8%

The Canadian Journal of Psychiatry, Vol 56, No 7, July 2011 W 387

In Review
for those aged 65 years and older,31 and 1.9% for those
aged 70 years and older.32 The criteria for social phobia,
according to DSM-IV, require: A) fearing social situations,
B) experiencing the fear as unreasonable or excessive,
C) avoiding feared social situations or enduring them with
intense anxiety or distress, and D) that this causes social
consequences. Using these criteria in an elderly population,
Karlsson et al32 found a 1-month prevalence of social
phobia of 1.9%. However, an additional 1.6% fulfilled
DSM-IV-TR Criteria A, C, and D, but not Criterion B; that
is, they did not find their fear unreasonable. Thus 3.5% had
social phobia that caused social consequences. DSM-IV
criteria thus exclude a large group of elderly with social
phobia.
The term paraphrenia was previously used to describe
psychotic syndromes in the elderly. Currently used
terms are late-onset schizophrenia or late-life psychosis,
encompassing visual and auditory hallucinations and
delusions arising in late life.33 Psychotic symptoms and
disorders, such as schizophrenia, are supposed to be rare
in the elderly without dementia. Population studies report
that the prevalence of self-reported psychotic symptoms in
the elderly without dementia range from 1.7% to 4.2%.2,34–36
However, there may be underreporting because the elderly
are reluctant to report psychotic symptoms. Using several
sources of information (including self-reports, close
informants, and patient records), it was recently reported
that 10% of the elderly without dementia aged 85 years37
and 8% of those aged 95 years38 had psychotic symptoms.
The prevalence was substantially lower (1%) among people
without dementia aged 70 years using the same methods.39
Prevalence is affected not only by the occurrence of new
cases, but also by the duration of the disorder and by its
mortality. Incidence is therefore a better measure of risk.
However, studies on incidence of mental disorders in old
age are rare and rates vary considerably. The incidence of
depression vary from 2 to 140 per 1000 person-years.16,40–44
In the Epidemiologic Catchment Area Program study,40
the incidence of phobic disorder in people aged 65 years
and older was 27 per 1000 person-years for males and 55
for females, and the incidence of OCD was 10 per 1000
person-years in females. The incidence of social phobia was
17 per 1000 person-years after age 70 years.45 Regarding
Abbreviations
CT computed tomography
DSM Diagnostic and Statistical Manual of Mental Disorders
GAD generalized anxiety disorder
ICD International Classification of Diseases
MRI magnetic resonance imaging
OCD obsessive–compulsive disorder
WML white matter lesion
388
the incidence of psychotic symptoms in the elderly, 9%
of people without dementia followed from age 70 to 90
years developed a first-onset psychotic symptom during the
follow-up.46 Others have reported a cumulative incidence
of 5% for psychotic symptoms during 3.6 years of follow-
up in the cognitively intact elderly.34 The incidence for
schizophrenia was 0.03 per 1000 person-years and for
delusional disorder 0.16 per 1000 person-years for people
aged 65 years and older.47 The incidence of first-onset
psychotic symptoms was 5.3 per 1000 person-years for
people aged between 70 and 90 years.46 Another population
study48 estimated the incidence of visual hallucinations to
25 per 1000 person-years for people aged 70 to 79 years,
and 40 per 1000 person-years for people aged 80 years and
older.
What Is the Relation Between Age and
Frequency of Mental Disorders?
The prevalence of many factors associated with mental
disorders increases with age, including loss of close
relatives, social network, previous status in society,
sensory functions, functional ability, and health.11,49 The
presence of different organic factors, such as brain atrophy,
cerebrovascular disease, underactivity of serotonergic
transmission, hypersecretion of cortisol, and low levels
of testosterone, also increases.50–52 Old age may also have
positive dimensions, with freedom of time, less stressors of
work, and less competition. When the previously mentioned
negative factors are controlled for, age has not been shown
to emerge as a risk factor for depression, even in studies that
otherwise report an age-related increase.8,53
Several cross-sectional studies, both in the past and more
recently, suggest that the prevalence of depressive disorders
is highest in people aged 50 to 65 years, and decreases
thereafter.1,4,11–13,54–58 However, studies on representative
samples aged 65 years and older are heavily weighted
toward the age strata of 65 to 75 years, and the group aged
75 years and older is therefore concealed in these types of
studies.11 This is important as it seems that the prevalence
of depression may increase in people aged 75 years and
older,5,8,27,53,57,59,60 and that the prevalence is higher in those
aged 95 years and older than in those aged 90 to 94 years.61
However, a decrease in prevalence in people aged 85 years
and older was also reported in some studies.60,62,63 Thus
depression may have its highest prevalence in people during
the 10 years before retirement age (65 years) and its lowest
prevalence in those aged between 65 and 75 years, with an
increase again after age 75 years.11 Even if the prevalence of
depression does not increase in the elderly, the prevalence
of depressive symptoms are constantly reported to increase
with age.56,64,65 This may reflect that elderly people with
depression may exhibit less symptoms than younger people
with depresson.66 The incidence of depression has been
reported to increase43 or be unaffected by age.44
The prevalence of anxiety disorders is also reported to
decrease with age.20,28,55,57,58,67 However, the pattern differs
among the anxiety disorders.67 Panic disorder is considered
W La Revue canadienne de psychiatrie, vol 56, no 7, juillet 2011

very rare among the elderly.2,27,55 The reports on GAD
are inconsistent. Some report that the frequency of GAD
increases with age, at least until age 55 years, or remains
stable.20,68,69 Others suggest that the highest frequency
of GAD occurs in people aged around 40 years,70,71 and
declines thereafter.70,72 OCD is believed to be less common
among the elderly than among younger people.23 OCD
generally has its onset in people aged around 20 years, but
it has been suggested that a second peak of onset occurs
in late life.73 Beekman et al22 reported a peak prevalence
of OCD among women aged from 65 to 74 years (2.7%),
compared with women aged 55 to 64 years (0.3%) or 75
to 85 years (0.8%). The prevalence of specific phobia26,74,75
and phobic fears76 are reported to decrease with age, with
some exceptions.21,77 New onset seems to be rare in late
life,78 and more than 80% of people aged 70 years reported
onset before they were aged 21 years.29 Also the prevalence
of social phobia may be lower among the elderly, compared
with younger age groups.30,74,79–81 Social phobia also has an
early age of onset, developing in most cases during the mid-
teens, with decreasing frequency thereafter.30,31,82
It has been suggested that age increases risk for psychotic
symptoms in the elderly.83 It seems that the prevalence is
considerably higher among people aged between 8537 and
95 years,38 than in younger age groups.39
Several factors may influence whether the frequency
of mental disorders increases with age. Comorbidity,
dementia, and clinical manifestations will be discussed in
the following sections of this review.
Comorbidity
Little is known about comorbid psychiatric disorders
among the elderly, although recent studies indicate that
comorbidity between depression and anxiety disorders, as
well as between different anxiety disorders, is very high also
in old age,1,2,4,29,32,75,78,84–89 with reported comorbidity of 50%
to 90%. This comorbidity was already noted by Kay et al,90
who found that most affective disorders in the elderly were
an admixture of depressive and anxiety symptoms. Lindesay
et al27 reported that 91% of the elderly with general anxiety
in the population also had depression, and Blanchard et al42
reported that 95% of those with depression had symptoms
of anxiety. This comorbidity seems to be high for all types
of anxiety disorders. The very high comorbidity between
GAD and depression91 has led to a discussion as to whether
GAD should be included among the mood disorders in the
upcoming DSM-5. This discussion has been concerned
with younger age groups, and it is unclear whether it is
applicable also to the elderly.
There is also a high comorbidity between different anxiety
disorders, such as social phobia, panic disorder, agoraphobia,
GAD, and OCD.32,84,85 This emphasizes the close relation
between psychiatric disorders, and the difficulty of making
diagnostic demarcations. Psychiatric comorbidity is also
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Psychiatric Disorders in the Elderly
related to greater subjective impairment and disability, and
more limitations in activities of daily living.32,84
Enforcement of exclusion criteria has been suggested to
explain the lower prevalence of anxiety disorders, especially
GAD, among the elderly, as more comorbid disorders occur
with age.20 Thus the large disparities in the prevalence
between different studies partly depend on how exclusion
criteria regarding presence of other psychiatric disorders,
especially depression, are applied. One important aspect
when evaluating frequency of psychiatric disorders is thus
whether a hierarchical approach to diagnosis has been made
(as in DSM-IV and ICD-10 criteria). In such a hierarchy,
most anxiety disorders cannot be diagnosed in the presence
of concurrent depressive illness, as a main diagnosis
of depression is given when the diagnostic threshold
for depression is reached irrespective of the severity of
anxiety symptoms.28 This has an immense influence on
the frequency of anxiety disorders in the population. If
comorbidity between depression and anxiety is higher
in the elderly, this might explain some of the decrease in
frequency of anxiety disorders with age.
Comorbidity between mental disorders may have several
explanations. It may reflect shared vulnerability or common
pathological pathways. Another possibility is that people
with anxiety disorders have an increased risk to develop
a depressive disorder, thus shifting their diagnosis from
anxiety to depression with increasing age. However, there
also seems to be a shift in the opposite direction with
increasing age.
Clinical Manifestations
Manifestations of mental disorders may be different in the
elderly, compared with younger age groups, and there may
be difficulties in separating symptoms of mental disorders
from those occurring in normal aging. For example, there is
an overlap in symptoms of depression and those occurring
in physical disorders and in normal aging (for example, loss
of appetite, tiredness, and sleep disturbances). This may
lead not only to overdiagnosis59 but also to underdiagnosis
if depressive symptoms are thought to be due to physical
disorders or normal aging.6,7,42,57,92,93
Depression may also have different manifestations in the
elderly.6,64,93 For example, elderly people may present with a
smaller number of symptoms66 or one dominating symptom.
Depressed elderly people may also more often show
aggressiveness, cognitive difficulties, and loss of interest
and apathy, and less often symptoms of depressed mood.66
However, it has to be emphasized that the symptoms of
depression most often are similar in the old and in the young.94
Depression is reported to have a poor rate of recovery in
the elderly, although it is unclear whether the recovery rate
is worse than for younger depressed people,95,96 and about
one-third of depressed elderly people still have depression
at 1 to 3 years of follow-up.41,97 In contrast, social phobia
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seems to have a good prognosis in the elderly, with 50%
being free of social fear at 5-year follow-up.45
Also anxiety disorders may have different manifestations
among the elderly, with fewer symptoms, less somatic
and autonomic symptoms, and less avoidance, and more
agitation, irritability, talkativity, and tension,20 and with
more somatization.98 However, most anxiety disorders have
similar symptoms in the old and in the young.99
Compared with early onset psychosis, people with late-onset
psychosis have better preserved personality, less affective
blunting, less formal thought disorder, more insight, and
less excess of focal structural brain abnormalities and
cognitive dysfunction, compared with age-matched control
subjects.33,100 Also late-life psychosis may show less
symptoms, and one symptom may dominate the picture.
Finally, criteria for mental disorders are often validated
in younger age groups, and their use in the elderly has
therefore been questioned.66,101
Dementia and Cognitive Decline
The prevalence of dementia and milder forms of cognitive
decline increases with age. Therefore, dementia and
cognitive symptoms need to be considered in all studies
of the elderly, especially in those aged 80 years and older.
It is obvious that people with dementia may underreport
symptoms and other factors owing to memory problems.
It is therefore surprising that studies concerned with the
elderly sometimes do not even assess dementia, which may
be one reason for the reported decline with age of self-
reported psychiatric disorders.
Further, most criteria, including DSM-IV, exclude organic
causes of psychiatric disorders (for example, dementia).
This means that with increasing age, a large proportion of
the total population will be removed from the population at
risk for depression and anxiety disorders, giving lower total
prevalence of depression in higher ages. Indeed, it has been
reported that the apparent decline with age for depression
and anxiety disorders disappear if people with dementia are
exluded.5,63
Cognitive symptoms are one of the core symptoms for
depression in DSM-IV. It is therefore not surprising that
many studies report that people with manifest depression
exhibit signs of cognitive decline.56,59,102–105 This decline
is generally mild62,106 and of frontal-subcortical type,103–106
and does not fulfil criteria for dementia. The cognitive
manifestations of depression are probably more accentuated
among the elderly, and may be more common in those with
their first episode in old age than in those with episodes
earlier in life.107 Anxiety disorders in the elderly,89 including
social phobia32 and GAD,99 are related to worse cognitive
performance. In addition, psychotic symptoms108 have
been related to worse cognitive performance. Thus people
without dementia aged 85 years with psychotic symptoms
390
or paranoid ideation performed worse on verbal ability,
problem solving, and spatial ability.108
Depression109–111 has repeatedly been suggested to be a
prodrome or risk factor for dementia. Prospective population
studies are contradictory, with several studies reporting that
depression increases risk for dementia,103,112–114 while others
found no associations41,115–118 A meta-analyses including
22 studies suggested that depression increased the risk
for later development of dementia.111 However, this meta-
analysis included a mixture of population-based studies
and studies from memory clinics, which made it difficult
to evaluate whether depression increases risk for dementia
in cognitively intact people from the general population.
Anxiety119 and psychotic symptoms37 may also increase risk
for subsequent dementia.
Psychotic symptoms, hallucinations, delusions, and
paranoid ideation in a population aged 85 years were each
related to an increased incidence of dementia during a 3-year
follow-up, but only one-third of those with these symptoms
developed dementia.37 In people who were followed from
age 70 to 90 years, only 45% of those who developed
first-onset psychotic symptoms developed dementia.46 The
mean interval between first onset of psychotic symptoms
and development of dementia was 5 years. Already Post120
reported that only 15% of elderly patients with persecutory
states in a psychogeriatric hospital developed dementia at
follow-up, and Holden121 reported that 35% of patients with
late paraphrenia had dementia within 3 years of diagnosis.
Thus psychotic symptoms are risk factors or prodromes
for dementia, but still only a minority of those developing
psychotic symptoms in old age will develop dementia.
Factors Associated With Mental Disorders in
the Elderly
Most studies on risk factors for mental disorders are
concerned with depression. As in all common disorders,
depression in late life results from multiple factors.11,122,123
However, it is not always easy to judge what is a cause and
what is a consequence of the mental disorder, and in many
instances associations are in both directions.
Among associations most constantly reported for depression,
many are related to aging, including female sex, adverse life
events,8,124,125 physical health,8,122,126–129 disability,8,122,126,129–131
institutionalization,54,132,133 medical drugs,134 decreased
social network and support,8,122,135–137 and cerebral organic
factors,52 such as brain atrophy and cerebrovascular
disease.138 In addition, previous psychiatric history,8,122,139
family history of depression,8 low education,8,60 personality
factors,8,140,141 smoking,135 and alcohol consumption142 have
been associated with depression in the elderly. Even when
health factors are present, psychosocial factors often play a
mediating role.137
Risk factors for anxiety disorders include female
sex, physical disorders,1,22 being unmarried,1,22 lower
education,1,22 adverse life events,26,143 disability,144 and
personality factors.89 Risk factors for anxiety disorders in
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late life are thus similar to those of depression.145 However,
some authors stress that risk factors for depression and
anxiety disorders are not similar,143 and risk factors for late-
life depression tend to be more biological than those for
late-life anxiety disorders.145 One reason may be that there
are very few studies examining biological factors in late-
life anxiety disorders.
Factors related to late-life psychosis include female sex,
previous schizoid and paranoid personality traits, being
divorced, living alone, lower education, poor social network
and isolation, low social functioning, sensory impairments,
especially deafness, vascular disease, and more dependence
in community care.100 Psychosis and psychotic symptoms
in elderly populations have been associated with somatic
disorders, for example, hypothyroidism, cerebral tumours,
and cardiovascular and cerebrovascular disease.100 Further,
drugs, such as anticholinergics, antiparkinson, steroids
and beta-blockers, as well as alcohol and benzodiazepine
withdrawal, may produce psychotic symptoms in the
elderly.
Structural Brain Disorders
Structural brain changes become more common with
increasing age,146 and have been associated with mental
disorders in old age by several investigators. Late-life
depression, especially major depression, has been associated
with ventricular enlargement,147–151 changes in the caudate
nuclei,147,152 and the putamen,152 and with atrophy in the
frontal, temporal, and parietal lobes.150–158 However, most
studies on the association between brain atrophy and
depression in the elderly have been cross-sectional and
performed in clinical samples. One longitudinal population-
based study157 reported an association between temporal
lobe atrophy on CT at baseline and development of major
depression during a 5-year follow-up. Another longitudinal
population-based study158 reported a cross-sectional
association between temporal and parietal lobe atrophy
assessed with MRI at baseline and concurrent depressive
symptoms, but no association with depression occurring
during follow-up. A third longitudinal study159 in elderly
without dementia examined the association between mean
depressive symptom scores over time and change in brain
atrophy on MRI during 9 years. Cross-sectional associations
between temporal and frontal lobe atrophy and depressive
symptoms, and a longitudinal association between volume
decline in frontal white matter and depressive symptom
score over time were reported.159
The cellular mechanisms that underlie the association
between brain atrophy and depression in the elderly remain
largely unknown. Postmortem studies have reported
on cellular alterations such as neuronal death, neuronal
shrinkage, decrease in dendritic and glial density, and cell
death in the frontal cortex and hippocampus in the elderly
with major depression.160–161
Anxiety disorders have been related to brain changes in
younger age groups.162 In relation to anxiety disorders in
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Psychiatric Disorders in the Elderly
the elderly, worries in GAD were associated to decreased
volume in the prefrontal cortex.163
Subtle brain changes, such as degenerative or vascular
changes, have also been hypothesized to enhance
vulnerability to psychotic symptoms in the elderly,83,164 but
reports are disparate. Some studies report a higher ventricle-
to-brain ratio, larger third ventricle volume, and volume
reductions of the left temporal lobe or superior temporal
gyrus. In a study165 on people aged 85 years, basal ganglia
calcifications, but no other brain changes, were associated
with increased frequency of psychotic symptoms.
Cerebrovascular Disease
Cerebrovascular diseases such as stroke166 and ischemic
WMLs146 become more common with increasing age.
The concept of vascular depression167 suggests that
cerebrovascular diseases, such as stroke and WMLs, are
especially important for the etiology of depression in old
age. However, the symptoms of depression may not differ
between depressed stroke patients and patients without
stroke.168
Depression is common after stroke.169–173 A systematic
review169,170 found a pooled estimate of 33% for depression
after stroke. In the study by Linden et al,173 stroke was
related to an odds ratio for depression of 3.2 in women and
4.0 in men 1.5 years after the index stroke. Depression is
important to detect in stroke patients, as it is associated with
worse outcome.174–176 Depressed stroke patients have more
cognitive impairments,172 more days in hospital,177 and use
more care than those who are nondepressed.178
The association between stroke and depression may also
go in the opposite direction, as several studies15,179,180 report
that depression increases the risk for first-incidence stroke.
Reasons include that depression is associated with increased
platelet activation181 and increased insulin resistance.182
Another explanation may be that late-life depression is
related to silent cerebrovascular diseases, such as ischemic
WMLs, which may increase incidence of stroke.
WMLs are very common in the elderly,146,183 and most
likely reflect ischemic demyelination.184 The cause of
WMLs is probably that longstanding hypertension causes
lipohyalinosis and thickening of the vessel walls with
narrowing of the lumen of the small perforating arteries
and arterioles that nourish the deep white matter. In living
people, WMLs can be detected on brain imaging.
Cross-sectional studies, often from patient samples,
consistently show associations between WMLs and
depression,152,155,156,158,185,186 although not all studies support
this association.153,187 The results from longitudinal
population-based studies are conflicting. Three prospective
MRI studies188–190 and 1 CT study157 reported that WMLs
increased the risk of subsequent depression, while 2 MRI
studies could not confirm these findings.158,191 Part of the
relation between white matter changes and depression may
be mediated by loss of functional ability.192 WMLs in elderly
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depressed patients may influence outcome of depression,
such as time to relapse193 and response to antidepressant
therapy.194 Depression may also influence the development
of WMLs. One recent study195 reported that depression at
baseline was associated with faster progression of WMLs
during follow-up. Ischemic WMLs have also been reported
in late-onset paranoid psychosis,196 while little is known
about the impact of WMLs on anxiety disorders in the
elderly.
Sex
Women live longer than men, and at the age of 95 years,
the female-to-male ratio is 4:1.5 Female sex is the most
consistent risk factor for depression and some anxiety
disorders. The female preponderance of depression is most
accentuated in middle life,55,57 and the sex difference may
diminish with increasing age.197 Some studies1,5,7,41,102 are
in line with this opinion. However, depression is generally
reported to be more common in women, also among the
elderly.2,4,8,12,27,63,90
The prevalence of most anxiety disorders is higher in
women than in men.1,4,27,28,67 However, there is a different
pattern among the anxiety disorders. GAD is more common
in women than in men in most studies in the elderly.2,3,20
Similarly as in depression, some authors suggest that the
ratio of women to men for GAD decreases with age.20 Most
studies report that OCD is more common among women
than among men. This sex difference is suggested to be
even more pronounced among the elderly.22,88 However, a
recent Canadian study25 reported that elderly people with
OCD were more likely to be men, compared with those
having another anxiety disorder or a mood disorder. Fear
of social situations,32 and phobic fears and simple phobia
are generally more common in women than in men,29,198
especially fears of animals and the natural environment.
This may have several explanations.29 First, some fears (for
example, spiders and heights) may be innate in humans.199
As part of gender socialization, boys may be, to a greater
extent than girls, encouraged to expose themselves and
habituate toward these stimuli.29 Second, fears may
develop more often in girls owing to gender differences in
role modelling or in information regarding the danger of
different exposures.
Many clinical studies report that late-onset schizophrenia
is more common among women, with female-to-male
ratios ranging from 1.9:1.0 to 22.5:1.0.33 Cross-sectional
population studies on psychotic disorders in the elderly
report disparate results, with female-to-male ratios ranging
from 0.7:1.0 to 1.5:1.0.90,200 Among people aged 8537 and
95 years, there were no sex differences.38
Consequences of Mental Disorders
Mental disorders are thus very common and have
consistently been reported to have a poor outcome in the
elderly. Among the consequences of depression are social
deprivation,201 loneliness,8 poor quality of life,14,201,202
392
disability,14,131,201,202 increased use of health and home care
services,42,203 decline in cognition,102,104,105 increased risk for
physical disorders (for example, stroke),15,204 chronicity,14,97
suicide,205 and an increased nonsuicidal mortality.206
Among the consequences of anxiety disorders are an
increased mortality rate, increased risk for ischemic
heart disease and stroke, and an increased suicide risk.
Social phobia is associated with lower social and mental
functioning, and reduced quality of life in the elderly.32,82
Among the consequences of psychotic symptoms are
disability in daily life, dependence on community care,
cognitive dysfunction, increased risk for dementia, and
increased mortality.100 Studies on attempted207–210 and
completed suicides205,211 in old age have reported a stronger
association with depression, with less alcoholism and fewer
personality disorders, than in younger age groups. Psychotic
disorders and anxiety disorders are also associated with an
increased risk of suicide in the elderly.205 Suicidal attempts
in the elderly are often characterized by a greater degree of
lethal intent.208,211 Although it is often suggested that suicide
in the elderly primarily is a question of undiagnosed,
untreated depression, it was reported that two-thirds of
elderly people who died by suicide in Gothenburg, Sweden,
had a history of treatment for affective illness and 48% had
had such treatment 6 months before their suicide.212 These
findings emphasize that once diagnosed, depression in the
elderly must be managed with persistence.
It is constantly reported that depressed elderly people have
an increased risk of dying, compared with the general
population.41,204,206,213–216 The association between anxiety
disorders and mortality is more complex, with a U-shaped
curve,215 while hallucinations and paranoid ideations were
related to increased mortality in women aged 85 years.37
Acknowledgements
Dr Skoog has received honoraria as a speaker for Esai,
Janssen Cilag, General Electric, Shire, Pfizer, and Novartis.
The Canadian Psychiatric Association proudly supports the
In Review series by providing an honorarium to the authors.
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Manuscript received August 2010, revised, and accepted November 2010.
1
Professor in Social Psychiatry and Epidemiology, Institute of
Neuroscience and Physiology, Section for Psychiatry Section, Unit of
Neuropsychiatric Epidemiology, University of Gothenburg, Gothenburg,
Sweden.
Address for correspondence: Dr I Skoog, Neuropsychiatric
Epidemiology, Neuropsykiatri SU/Mölndal, Wallinsgatan 6,
431 41 Mölndal, Sweden; Ingmar.Skoog@neuro.gu.se

Résumé : Troubles psychiatriques chez les personnes âgées

La recherche récente indique que la dépression, les troubles anxieux, et la psychose sont plus communs
qu’on ne l’avait supposé auparavant chez les populations âgées sans démence. On ne sait pas avec
certitude si la fréquence de ces troubles s’accroît ou décroît avec l’âge. L’expression clinique des troubles
psychiatriques en âge avancé peut être différente de celle qu’on observe dans des groupes moins âgés, les
symptômes étant moins nombreux et souvent moins florides. Parallèlement, la comorbidité entre différents
troubles psychiatriques est immense, ainsi que la comorbidité avec les troubles somatiques. La fonction
cognitive est souvent diminuée chez les personnes souffrant de dépression, de troubles anxieux, et de
psychose, mas il reste à déterminer si ces troubles sont des facteurs de risque de démence. Les troubles
psychiatriques chez les personnes âgées sont souvent liés à la neurodégénérescence cérébrale et à la
maladie cérébrovasculaire, bien que les facteurs de risque psychosociaux soient également importants.
Les troubles psychiatriques, répandus chez les personnes âgées, ont des conséquences, notamment la
défavorisation sociale, une mauvaise qualité de vie, le déclin cognitif, l’incapacité, le risque accru de troubles
somatiques, le suicide, et la mortalité non suicidaire accrue.

The Canadian Journal of Psychiatry, Vol 56, No 7, July 2011 W 397