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Functional Disorders
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Depression
This is the most common psychiatric disorder found in old people (if milder cases are counted) and the second commonest single underlying cause for all GP consultations for people over 70. The majority of depressive syndromes are of mild to moderate severity. About one fifth of cases are severe and carry the risk of suicide - especially in men, in those which fail to remit within 6 months of onset and in those who feel physically ill (hypochondriacal) especially if they have the delusional belief that they suffer from cancer. Depression in old age may be precipitated by adverse life circumstances: bereavement; loss of health; threat of bereavement or loss of health in a key figure. As with younger patients, those who suffer from depression may have vulnerable personalities (i.e. they may be anxious and obsessional by nature) or they may have no close confidantes (i.e. they may be socially isolated). More recently evidence has emerged suggesting that depression occurring for the first time in later life may be associated with subtle brain abnormalities, such as an increase in white matter lesions (detected on neuroimaging), which may reflect hidden or undetected cerebrovascular disease.
Depressive illness in old people shows a wide range of clinical presentations. The typical picture of low mood, anhedonia and vegetative disturbance of sleep and appetite seen in younger people may predominate. Some patients become apathetic, withdrawn and appear to lose their cognitive abilities (this is called depressive "pseudodementia" as cognitive impairment may be so marked as to mimic organic dementia). Others may present with a picture of severe agitation and restlessness, accompanied by delusions of ill health or poverty, e.g. that they are dying of a brain tumour, that their bowels have stopped working and are rotting inside them, or that they are unable to pay for their hospital treatments.
The clinical approach with mild cases of depression is unlikely to involve the Old Age Psychiatry Service, since they will be treated by the Primary Health Care Team. Support and counselling may be supplemented by the use of antidepressants. More severe or persistent cases are likely to be referred for specialist assessment and treatment. The majority of cases respond as well to treatment as younger patients - perhaps even better! Poor outcome is often the consequence of inadequate treatment. The older tricyclic antidepressants are often not well tolerated, postural hypotension, urinary and gastrointestinal side effects being prominent.
Dosage should be titrated to the maximum tolerated, starting doses generally being 1/3 - 1/2 of those for younger patients. Newer antidepressants such as SSRIs have a particular place in the treatment of the elderly. Delusional depressions require the addition of neuroleptics - for unresponsive or severe depressions ECT is a safe and effective treatment. Lithium carbonate has a valuable place in prophylaxis of recurrent episodes and is also effective in potentiating or augmenting the antidepressant actions of tricyclics.
Many elderly depressed patients have previous or current physical illness. Not only must this be taken into account during treatment (e.g. tricyclic antidepressants are usually avoided in a patient with ischaemic heart disease and, in patients with a high risk of bleeding, SSRIs should be used with caution), but also physical illness must be treated in its own right to maximise the patient's chances of recovering from the depression.
Anxiety Disorders
Anxiety disorders do occur in old people, about half of it persisting from early life and half coming on for the first time in response to the stresses of ageing. A common precipitant stress is that of failing physical health, e.g. developing an acute phobic state after a fall from a bus, leading to a fracture and a period of reduced mobility.
Behavioural methods of treatment may be effective. Diffuse anxiety and loss of confidence, even if precipitated by an adverse event, may indicate an atypical form of depression. Such patients respond better to antidepressant, rather than anxiolytic, drugs.
Paranoid States
It appears to be a normal feature of ageing that individuals become rather more inflexible in their attitudes and fearful of adverse influence by the outside world. Elderly people are often not only physically and financially disadvantaged, but they enjoy relatively low social status and are often the victims of attack or deception. It is, therefore, perhaps not surprising that persecutory ideas (which we tend to lump together as paranoid symptoms) often emerge. The main conditions in which paranoid persecutory symptoms occur are as follows:
Late onset schizophrenia/delusional disorder
This was formerly known as paraphrenia. The typical subject is an elderly spinster, with sensory impairments (deafness or visual impairment), living alone and isolated. Her self-care skills are good and she is apparently normal apart from the possession of a complex delusional system in which she believes she is the victim of a conspiracy (usually to defraud her). She hears third person auditory hallucinations, may smell odours, which she interprets as poison gas pumped into her room and misinterprets chance occurrences as having special significance. This psychotic illness, similar to schizophrenia in younger life, responds to antipsychotic drugs if the patient can be persuaded to take them. The delusions, however, seldom completely disappear but instead become "encapsulated": the patient is no longer bothered by them although he or she never gains full insight into their delusional nature. A depot injection given by a Community Psychiatric Nurse is often a useful vehicle which improves compliance with medication and provides regular contact with the patient.
Acute confusional state/delirium
Paranoid symptoms are common during delirium, the patient misinterpreting events because of his/her altered level of consciousness. The management of these symptoms has already been described - neuroleptic medication may help to reduce agitation and behavioural disturbances.
Paranoid Reactions to Forgetfulness
These usually occur in independent old people who explain their experience of forgetting where things have been placed by accusing others of stealing them. Objects stolen are usually everyday ones, e.g. cups, teapots, pension book, money or glasses. Stolen objects often are returned or reappear in the usual place. The most likely cause of forgetfulness and paranoid misinterpretation is, of course, a dementing process. Neuroleptic medication is seldom of benefit in these circumstances.
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