Geriatric Psychiatry Research Paper

The importance of geriatric psychiatry expanded greatly in the latter decades of the twentieth century, mainly because of the unprecedented change in the world’s population: many more people are living into old age, and even more are becoming very old. For example, according to predictions published by the United Nations (1998), by 2050, the world’s population aged 60 and over will be 74 percent larger than the number of people under 15 years of age. The population aged 80 years and older will rise from 61 million in 1995 to 1,055 million in 2150, a 17-fold increase. And it is in less developed countries where the most dramatic increases will occur. The social, economic, and public health consequences for many countries are profound. This is because the very elderly tend to have poor physical health, a greatly increased risk of dementia, and a degree of personal disablement that makes them dependent on others. The prevention and effective treatment of age-related disease has become a compelling need.

The agenda of geriatric psychiatry falls into three categories: how it is practiced; the main disorders treated; and the research questions or gaps in knowledge that are currently the most important. Jeste et al. (1999) have set out the response that is needed to this forthcoming crisis. It is generally acknowledged that, to be effective, the practice of geriatric psychiatry requires close collaboration with other professionals, particularly nurses, social workers, clinical psychologists, family physicians, and specialists. This is because of the nature of the disorders being encountered, the behavior of the elderly person in poor health, and the simultaneous presence of both medical and psychiatric problems that so commonly occurs. Much of the practice of geriatric psychiatry is in the community and in primary care, not in specialist settings or hospitals.

2. Mental Disorders In Later Life

2.1 The Dementias

The most common group of disorders in geriatric psychiatry is the dementias. In these, changes have taken place in the structure and function of the brain, particularly areas concerned with memory, information processing, and social behavior. ‘Dementia’ originally meant ‘out of one’s mind,’ from the Latin de (out of) and mens (the mind). Early in the nineteenth century, Esquirol (1845) gave a succinct definition of dementia as ‘a cerebral affection … characterised by a weakening of the sensibility, understanding, and will’ (cited by Caine et al. 1995). In describing with such words how the condition can be recognized, Esquirol drew attention not only to the cognitive features of the disorder, with impairment of memory and thinking in day-to-day life, but also to its other manifestations such as apathy, deterioration in social behavior, occasional aggressiveness, delusional ideas, and hallucinations. These show how widespread the changes are in the brain. Following extensive consultations with experts in some 40 countries, the World Health Organization ([WHO] 1992) has described dementia as:

a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement. Consciousness is not clouded. Impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. This syndrome occurs in Alzheimer’s disease, in cerebrovascular disease, and in other conditions primarily or secondarily affecting the brain.

In Alzheimer’s disease, an abnormal protein called β-amyloid accumulates in the brain, particularly in the hippocampus. In vascular dementia, areas of the brain become damaged by having their blood supply interrupted, as happens in stroke. Other causes of dementia are Lewy body disease, Pick’s disease, Huntington’s disease, Creutzfeldt-Jakob disease, and AIDS.

2.1.1 Prevalence. There are published reports on the prevalence of dementia in diverse areas of the world including North America, Europe, Scandinavia, Russia, Japan, China, Singapore, India, Africa, and Australasia. An integrative analysis of 47 surveys across 17 countries has suggested approximate rates under one percent for dementia from any cause in persons aged 60 to 69 years, rising to about 39 percent in persons 90 to 95 years old (Jorm et al. 1987). The prevalence doubles with every five years of age within that range. Throughout the world, many more people than in the past are living to an age when the prevalence of dementia greatly increases, so that the absolute number of persons with dementia is now expanding rapidly. In some countries, the proportion with a dementia is increasing much faster than the growth of the elderly population. This is because of the greater increase in the very old, in whom the prevalence of dementia is highest.

2.1.2 Secular Change. It is often asked if there is more dementia now than some decades ago. Because there are larger numbers of the elderly now, and more of the very elderly in particular, there has inevitably been a large increase in the number of persons suffering from a dementia. Furthermore, having developed a dementia, an elderly person is now likely to survive longer. This is at least partly attributable to the ‘failure of success.’ Even with no change in incidence, longer duration of illness leads to an increased prevalence. Studies in Sweden and across Western Europe have found no change in the age-specific incidence of Alzheimer’s disease, but it is intuitively plausible that vascular dementia may be decreasing in many countries in parallel with a general decrease in vascular disease.

2.1.3 Age-Related Cognitive Decline. There is no doubt that nearly all people undergo a deterioration in memory and a slowing of mental processes in very late life; and some experience these changes earlier than others for reasons that are not yet well understood. Various terms have emerged to describe such states. The term ‘benign senescent forgetfulness’ was introduced by Kral to describe one group of such states. Although it was not well defined by him, the term has persisted because it fulfills a need and has no sinister connotations. Other concepts have since been introduced. A useful review of this important issue has been provided by Ritchie and Touchon (2000).

2.1.4 Risk Factors For Alzheimer’s Disease. As reviewed by Jorm (2000) and Henderson and Jorm (2000), four risk factors can now be regarded as confirmed for Alzheimer’s disease: age, a family history of dementia; having the Apolipoprotein E ε4 genotype; and having Down’s syndrome. There are then a number of risk factors where the evidence is at present not fully established: a firstdegree relative with Down’s syndrome, advanced maternal age, a head injury earlier in life, a previous depressive episode, hypothyroidism, and a longstanding history of physical inactivity. Aluminum has been considered, whether ingested in drinking water or the diet, or absorbed from antiperspirants. From all the evidence available, it remains unproven that aluminum from drinking water or any other source plays a role in causing Alzheimer’s disease (Doll 1993).

2.1.5 Possible Protective Factors. Some factors may confer protection against dementia, or even specifically against Alzheimer’s disease. For the latter, four have so far been proposed, each having been identified through epidemiological research: education, anti-inflammatory drugs, estrogen replacement therapy, and statins. Each of these points the way to the possibility of prevention. It is well established in medicine that prevention can precede an understanding of etiology.

2.1.6 Education. A recurrent finding in field surveys is that rates for dementia and cognitive impairment are higher in elderly persons who have had little education. One interpretation is that education may delay the point at which a developing dementia becomes clinically manifest. A recent longitudinal study of American nuns (Snowdon et al. 1996) suggests that intelligence or education, which are inextricably linked, may actually protect against the neuropathological processes in Alzheimer’s disease. If such a protective effect does apply, the implications for public health could be appreciable because education has become much more widely available to young persons during the twentieth century.

2.1.7 Geographic And Ethnic Comparisons. Alzheimer’s disease and vascular dementia may occur at different rates in different parts of the world and in different ethnic groups. But it is not easy to be certain what factors are responsible. There may be different patterns of mortality for dementia cases under different living conditions, different genetic vulnerabilities, or different environmental exposures. A finding of potential significance comes from a comparison of prevalence rates for dementia and specifically for Alzheimer’s disease in elderly Nigerian Africans and African Americans in Indianapolis by Hendrie et al. (1995). The two groups have much of their heredity in common, but very different lifestyles. The prevalence was only 2.3 percent and 1.4 percent for dementia and Alzheimer’s disease respectively in the Nigerians, but 8.2 percent and 6.2 percent in the combined community and nursing home sample of African Americans in Indianapolis. This demonstration of significant differences in rates in two different communities having similar ethnic origins again points to the possibility that some unknown environmental factors promote the neuropathological processes in Alzheimer’s disease. The Cree Indians in Canada have also been found to have a lower prevalence of Alzheimer’s disease than White Canadians (Hendrie et al. 1993).

In India, Ganguli et al. (1996) and Chandra et al. (1998) undertook a methodologically sophisticated survey of 5,126 individuals aged 55 years and over in Ballabgarh, Northern India. Using the same criteria to define a case, they found a prevalence of only 1.1 percent in persons aged 65 and over for Alzheimer’s disease, much lower than in industrialized countries. Neither gender nor literacy were associated with prevalence, but this rose with age for both Alzheimer’s disease and all dementias. Their conclusion was that the low prevalence compared to Western estimates could be due to shorter survival of cases, but it is also possible that the incidence is lower, speculatively attributable to differences in the underlying distribution of risk and protective factors.

2.1.8 Anti-Inflammatory Drugs. An inverse association was noticed between rheumatoid arthritis and Alzheimer’s disease, suggesting that persons who have taken aspirin, steroids, or nonsteroidal antiinflammatory drugs (NSAIDs) over long periods may have a lower risk of dementia, or have slower cognitive decline in late life. The most recent information is that anti-inflammatory drugs probably do prevent or attenuate the symptoms of Alzheimer’s disease (Breitner 1996). But it is premature for physicians to prescribe anti-inflammatory drugs for Alzheimer’s disease until the size of their effect is established in a randomized controlled trial and the findings are balanced with their risks.

2.1.9 Estrogen Replacement Therapy. Case-control studies have provided pointers to the possible protection against Alzheimer’s disease afforded to women who take estrogen. But since they also tend to be better educated and to differ in other life-style factors, this finding could be misleading. Again, only randomized controlled trials will establish whether a protective effect exists.

2.1.10 Risk Factors For Ascular Dementia. The assumption is that risk factors are similar to those for stroke. These are age, male gender, a family history of stroke or dementia, hypertension, diabetes mellitus, transient ischemic attacks, elevated cholesterol or lipids, cigarette smoking, heavy alcohol use, oral contraceptives, physical inactivity, obesity, and ethnicity.

2.1.11 Treatment Of Dementia. The treatment of dementia presently consists of minimizing the deleterious effects of other conditions and of optimizing the person’s day-to-day social environment. For Alzheimer’s disease, medications have been developed that attempt to correct the deficiency in the neurotransmitter acetylcholine, but none has yet been found to bring about unequivocal and lasting benefit. Intense research is being conducted to find other drugs that enhance cognition. The possibility is emerging that people could be immunized against Alzheimer’s disease in earlier adulthood to prevent the deposition of the harmful β-amyloid protein in the brain (St George-Hyslop and Westaway 1999). Meanwhile, remarkable progress has been made by clinical psychologists in developing nonpharmacological methods for treating dementia, including the reduction of severely difficult behavior such as wandering, incontinence, and screaming (Bird in press).

2.2 Delirium

Delirium, a term introduced by Celsus 2,000 years ago, is derived from the Latin de (from, away) and lira (a track or furrow). It is characterized by incoherence of thought and speech, together with perplexity, in a setting of clouded consciousness that fluctuates in severity. Despite its long-established place in nosology, delirium must number among the most underdiagnosed conditions in medicine. Delirium occurs most commonly at the extremes of life. Its highest incidence is in the elderly, in whom it may indicate the presence of systemic or cerebral disease, or drug toxicity.

2.3 Depression

The elderly might be expected to have higher rates of depressive disorders than younger adults because of their personal and social circumstances. But here a puzzle emerges. Although a high prevalence is usually found in nursing homes, the consistent finding is that the elderly in the community have on average less depression than younger adults (Henderson 1994; Henderson et al. 1998). Some think these findings may be attributable to an error in ascertainment. This could be through inappropriately discounting symptoms that may also be due to physical illness or to age itself, such as tiredness, feeling slowed up, or sleep difficulties. Alternatively, a cohort effect has been proposed, in which people who are now elderly may have been protected against depression; or younger adults may have higher rates through being exposed to factors that older adults have been spared.

There is then a further intriguing possibility that is at first counterintuitive: that aging actually protects against depression, and indeed against a range of other mental disorders. It has been suggested that exposure to adverse experience over a lifetime may induce an increased resistance to depression and anxiety through psychological immunization.

2.3.1 Causes Of Depression In The Elderly. When elderly persons have a depressive disorder, one may reasonably ask if it is a recurrence or if it has developed for the first time. Several studies have noted that severe life events precede the onset of depression in at least half of all patients; conversely, depressive disorder may emerge in elderly persons with relatively untrammeled lives. Risk factors for depression in late life are a past history of such a disorder, physical illness or chronic pain, recent adverse experiences, and the absence of a confiding relationship. Contrary to expectation, elderly persons who live alone have not been found to be at risk for depressive disorder. A consistent finding in community surveys is that the complaint of loneliness is associated more with depression than with actual social isolation.

Where depression develops in elderly persons for the first time in their lives, a recent finding is that the brain often shows selective atrophy on neuroimaging.

2.3.2 Treatment. Depression in older persons is highly responsive to psychotherapy and antidepressant medication that is highly effective, nonaddictive, and usually well-tolerated. Often, the main problem lies in having the depression recognized in the first place, instead of its being ascribed by patient, family, and doctor to the inevitable experience of old age.

2.4 Suicide

In most countries, elderly men consistently have higher rates for suicide than other age-groups. Factors associated with death by suicide in the elderly include depressive disorder, disabling physical illness, chronic pain, and social isolation.

2.5 Anxiety Disorders

Anxiety disorders in late life have been overlooked even more than depression as a significant cause of morbidity. In an integrative review of eight community-based surveys of persons aged 60 years and over, anxiety disorders were found to have a lower prevalence than in younger adults. The explanation is unknown. Co-occurrence of depression with generalized anxiety disorder or phobias was a frequent pattern, the depression usually being inappropriately treated with a benzodiazepine. Anxiety symptoms may also occur in the early stages of dementia and in association with depressive disorders. There is little information on the prevalence of post-traumatic stress disorder in the elderly, risk factors for it or its natural history.

2.6 Schizophrenia

It is recognized that schizophrenia can begin in later life. The term paraphrenia has been used for this condition. A number of distinguishing features may be present, as reviewed by Henderson and Kay (1997): a higher ratio of women, a better occupational history, and a higher frequency of marriage than in younger patients, with the occurrence of sensory loss being more common in those with onset at a more advanced aged. Psychotic symptoms are appreciably more common than formal diagnostic categories. Impaired hearing and vision have both been found to be associated with psychotic symptoms. Social isolation is a further associated factor, but it is unknown if this is a premorbid characteristic, a causal factor, or a consequence. There is consistent evidence that paranoid or delusional symptoms are more frequent in persons who also have cognitive impairment.

3. Services For The Elderly

The extent to which the elderly with mental disorders receive services is itself an issue amenable to systematic examination. The notion of filters proposed by Goldberg and Huxley (1992) is very useful. The first filter determines which persons with mental disorders reach a physician, whether they initiate the consultation themselves or whether it is initiated by their families or the physician. The second filter determines whether the physician recognizes that significant mental disturbance is present. This may happen in only about half the consultations. The third filter determines referral to specialist services. Although family physicians recognize early dementia quite efficiently, they may often need further training in the diagnosis of depressive disorders in elderly persons. This is because symptoms of tiredness, poor appetite, insomnia, and apathy may be mistakenly ascribed to old age. The benefits of correct diagnosis for both the patient and the community are self-evident.

4. Disability

From a public health perspective, information about the elderly and the services they require has to include an assessment of disability. This is because it is impairment of functioning in daily life rather than symptoms or diagnoses that brings about the need for services. Dementia is second only to arthritis as a cause of disability in the elderly. Less is known about the impairment of functioning caused by depressive disorders and depressive symptoms but, since they often occur with physical disease, their interactive effect is considerable. One community-based study conducted by an experienced geriatrician found that neuropsychiatric disorders of cognition, behavior, and mood, together with Parkinson-related disorders of gait, are major predictors of disability in late life.

5. Research In Geriatric Psychiatry

There has been an enormous expansion of research activity in recent decades. Much of it is directed at the following questions:

(a) What determines the course of cognitive decline in old age?

(b) Are there factors in the environment that contribute to dementia?

(c) Can dementia be prevented?

(d) Can drug treatments for dementia be found?

(e) What are the applications of the new neuroimaging techniques to diagnosis and treatment?

(f ) What improvements are needed in primary health care for older persons; and how can these be brought about?

(g) What interventions will promote quality of life in the elderly?

The needs of tomorrow’s communities, together with the rapid advances taking place in neuroscience, will ensure an exciting future for geriatric psychiatry. Its practitioners will need, as never before, to be highly trained but interpersonally skilled physicians.

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