Psychiatry - Old age psychiatry

Question 1

Is there anything different about psychiatric diseases in the elderly compared to other demographics?

Answer 1

Older people may suffer from the same functional psychiatric disorders as younger adults (e.g. mood, anxiety and psychotic disorders) and the presentation and management of these are essentially the same as earlier in life.

Older people continue to manifest personality disorders.
The degree of disability caused by impulsive and antisocial traits decreases with age.
Other traits may cause particular difficulty in negotiating the challenges of being old.

Question 2

What is the epidemiology of depression in old age?

Answer 2

Increased age is NOT linked with higher rates of depression, which affects around 13% of older people. Depression is more common in those with physical illness or dementia.

Question 3

Are older people with depression likely to be treated the same as a younger patient?

Answer 3

No. Older people with depression are less likely to receive treatment with antidepressants or talking therapy, even though they frequently consult their GP. This is partly because of the unjustified idea that depression is an inevitable part of ageing and also because of differences in clinical presentation.

Older people are also less likely to report low mood compared to younger people. They may present as needing help but with resenting complaints other than low mood. They are also less likely to present with suicidal ideation despite being at higher risk of completed suicide.

Question 4

How do elderly patients present with depression?

Answer 4

Compared to younger patients, elderly patients with depression are more likely to present with:

• disturbed sleep (but increased sleep duration occurs in normal ageing)
• multiple physical problems for which no cause can be found
• motor disturbance
• motor disturbance (retardation and/or agitation)
• dependency having previously be independent

Question 5

What is the aetiology of late onset depression?

Answer 5

Genetic factors are significant, although family history is less often positive than in younger depressed patients.

People who become depressed for the first time later in life are more likely to have brain imaging abnormalities and poor treatment response. This suggests that late onset depression may, in some cases, reflect the onset of neurodegenerative changes.

• dementia is a risk factor for developing depression
• vascular risk factors increases risk of depression (20%)

Being in a residential or nursing home patient doubles the risk of depression in older age.
Losses such as bereavement, deteriorating physical health or financial insecurity may lead to depression. Social isolation also plays a role.

Question 6

Outline the management of depression in the elderly

Answer 6

Treating depression in older people should involve:

• talking therapies
• ECT for severe depression, especially if refusing fluids or food
• medication
• reduce social isolation - e.g. day centres
• reduce sensory isolation - e.g. glasses, hearing aids

Question 7

What antidepressants are useful in elderly patients?

Answer 7

Antidepressants with a relative lack of contraindications and favourable side effect profiles, including SSRIs , venlafaxine, and mirtazapine.

TCAs are effective but usually avoided because of the higher risk of clinically important side effects, particularly postural hypotension and resultant falls.

Lithium augmentation is effective in older people with refractory depression.

Antidepressants are NOT effective in dementia.

Question 8

When should you consider switching antidepressants in an older patient with depression?

Answer 8

Adherence to antidepressant treatment may be difficult to achieve in older people, particularly since it takes longer (up to eight weeks) to take effect. However, if there is little or no response to adequate antidepressant at four weeks, a switch to an antidepressant of a different class should be considered.

Question 9

What is the prognosis for depression in old age?

Answer 9

Depression doubles the mortality rate in older people. Factors explaining this include:

• medical morbidity - related to hypercortisolaemia in chronic depression, decreased exercise, non-adherence to medication and self neglect
• increased risk of suicide, especially in older depressed men

The prognosis is improved by early intervention, because longer duration of depressive episode predicts poor outcome. There is a high risk of chronicity (about 50% if untreated) and of relapse. Secondary prevention (continuing antidepressant therapy to prevent a response) is highly effective.

Question 10

What anxiety disorders affect elderly patients?

Answer 10

General anxiety is often co-existent with (and responsive to the same treatment approaches as) depression.

New episodes of phobic disorder, particularly agoraphobia, are often precipitated by traumatic events (e.g. falls).

Question 11

How common is mania in old age?

Answer 11

Mania accounts for about 20% of all psychiatric admissions for affective disorder in older people. Most have a past history of depression.

In about 20% of cases, new onset mania in older age is precipitated by acute physical illness such as stroke. A tenth of new onset cases of mania occur in the over 60s.

Question 12

How do patients with late onset mania present?

Answer 12

Overt elation is less often present than in mania in earlier life, although the patient generally has grandiose ideation. The clinical picture more usually consists of irritability, lability of mood and perplexity, much like that of delirium but distinguishable by clear consciousness.

Question 13

How should mania be treated in the elderly?

Answer 13

Antipsychotics are effective in acute treatment and some (e.g. olanzapine) are affective at preventing relapse. But atypical antipsychotics must be used with caution n people with dementia r vascular risk factors because of the increased risk of stroke.

Lithium may be used both acutely and in prophylaxis, although as many as 25% of older people (particularly those with Parkinson’s disease or dementia) develop neurotoxicity. Both therapeutic and toxic effects of lithium may occur at lower blood levels in old age so close monitoring is needed.

Prognosis with treatment is good, although recurrence occurs in up to 50% by 10 years.

Question 14

How do elderly patients with psychosis present?

Answer 14

Old people with psychosis may have illnesses that have continued from earlier in life or be presenting with a first episode. Symptoms are as for younger adults.

There is a second peak in schizophrenia over the age of 60.

Question 15

What is defined as late onset schizophrenia?

Answer 15

The ICD-10 and DSM-5 do not distinguish between illnesses with onset in early and later life, but in general:

• late onset schizophrenia = onset age 40 to 60
• very late onset schizophrenia = onset age 60+

Question 16

What is the aetiology of late onset schizophrenia?

Answer 16

Aetiological factors include:

• a genetic component (with excess family history of psychiatric illness and particularly schizophrenia)
• sensory deprivation (particularly deafness)
• social isolation - people who have had few relationships often become isolated with retirement or immobility or occasionally loss of a partner in older age
• brain imaging abnormalities in schizophrenia as in younger people
• organic brain disease and underlying physical illness

Question 17

How should late onset schizophrenia be managed?

Answer 17

Treatment is often difficult because of lack of insight, but response to antipsychotics, combined if possible with social reintegration, is usually good. As older people are at particular risk of tardive dyskinesia, atypical antipsychotics are recommended. Relapse is frequent if antipsychotics are withdrawn.