Review: Somatization in the elderly

Somatization is a common medical problem encountered at all levels of medical care. It is strongly associated with use of services and may be difficult to treat. Somatization in the elderly has been traditionally seen as a masked presentation of depression. Population studies have shown no consistent increase in somatization among the elderly, and the elderly may down-play physical symptoms. Among the elderly depressed, somatization is common and may be commoner if physical illness is also present. Psychological distress is usually acknowledged, not masked, in the elderly depressed. Neuroticism, as well as psychiatric illness, may be an important aetiological factor for somatization in the elderly. Treatment strategies must attend to underlying psychiatric disorders, but there is a need for studies of treatment of the phenomenon in the elderly.     

Complexity in late-life depression: impact of confounding factors on diagnosis,treatment, and outcomes

Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.     

Evaluation and treatment of paranoid syndromes in the elderly: a review

Paranoid symptoms in the elderly patient may be a manifestation of medical, neurologic, psychiatric, or medication-induced illness. Because of the potential for multiple interacting factors between underlying organicity and psychiatric illness precise assessment of the etiology of the patient's psychotic behavior may be difficult. This article reviews the medical and neurologic illnesses often associated with paranoia in the elderly as well as the psychiatric differential diagnosis. Psychotic depression, late-onset schizophrenia, and delusional/paranoid disorders are examined, as are their treatments. Revisions in the nosology of late-onset psychosis as they are affected by revisions in DSM-III-R are also discussed.     

ECT in the medically ill elderly: a case report

Electroconvulsive therapy (ECT) is well recognized as an effective treatment for depression. However, it is not often used among the elderly due to increased co-morbid medical problems and fear of complications. We present here the case of an 88-year-old man with a history of depression and co-morbid medical illness. This patient was successfully treated with ECT. With the population of individuals above the age of 65 expected to double in the next 40 years, the use of ECT to treat major depression and other psychiatric conditions among the elderly will likely increase.     

Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale.

Reliable quantitative ratings of chronic medical illness burden have proved to be difficult in geropsychiatric practice and research. Thus, the purpose of the study was to demonstrate the feasibility and reliability of a modified version of the Cumulative Illness Rating Scale (CIRS; Linn et al., 1968) in providing quantitative ratings of chronic illness burden. The modified CIRS was operationalized with a manual of guidelines geared toward the geriatric patient and for clarity was designated the CIRS(G). A total of 141 elderly outpatient subjects (two medical clinic groups of 20 each, 45 recurrent depressed subjects, 21 spousally bereaved subjects, and 35 healthy controls) received comprehensive physical examinations, reviews of symptoms, and laboratory testing. These data were then used by nurse practitioners, physician's assistants, and geriatric psychiatrists to compute CIRS(G) ratings of chronic illness burden. As hypothesized, analysis of variance demonstrated significant differences among groups with respect to total medical illness burden, which was highest among medical clinic patients and lowest in control subjects. Good interrater reliability (i.e., intraclass correlations of 0.78 and 0.88 in a subsample of 10 outpatients and a separate group of 10 inpatients, respectively) was achieved for CIRS(G) total scores. Among medical clinic patients, a significant correlation was found, as expected, between CIRS(G) chronic illness burden and capability as quantified by the Older Americans Activities of Daily Living Scale; and between CIRS(G) scores and physicians' global estimates of medical burden. Finally, with repeated measures of illness burden approximately 1 year from symptom baseline, significant rises were detected, as expected. The current data suggest that the CIRS(G) can be successfully applied in medically and psychiatrically impaired elderly subjects, with good interrater reliability and face validity (credibility).     

Hyponatraemia in elderly psychiatric patients treated with Selective Serotonin Reuptake Inhibitors and venlafaxine: a retrospective controlled study in an inpatient unit

OBJECTIVE: To determine the prevalence of hyponatraemia associated with selective serotonin reuptake inhibitor (SSRI) and venlafaxine use in elderly patients compared to that in elderly patients not prescribed these drugs, while controlling for age, sex, depression status and illnesses or prescribed medications also associated with hyponatraemia. Design and setting Retrospective controlled analysis in a 36-bed inpatient unit for elderly psychiatric patients in Melbourne. PATIENTS: Inpatients (199) with a mean age of 74.2 years of whom 74 were prescribed an SSRI or venlafaxine. RESULTS: Patients on SSRIs or venlafaxine were 5.6 times as likely as patients not so treated to have hyponatraemia. Thirty-nine percent of patients on an SSRI or venlafaxine had hyponatraemia compared with 10% of controls. Ten of the 14 patients on venlafaxine were hyponatraemic. Controlling for thiazide status did not reduce the odds of these patients having hyponatraemia and taking an SSRI or venlafaxine was still strongly associated with hyponatraemia after also controlling for age, sex, and depression status, consumption of other drugs potentially causative of hyponatraemia and medical illness severity (Odds Ratio (OR) 3.5, p = 0.008). CONCLUSIONS: SSRI and venlafaxine use is strongly associated with the presence of hyponatraemia in a population of elderly psychiatric inpatients and the association is not due to confounding by age, sex, depression status, medical illness severity or consumption of other drugs. Elderly patients on SSRIs or venlfaxine should have sodium levels checked before and after commencement of antidepressant treatment.     

Profile of psychiatric disorders and life events in medically ill elderly: experiences from geriatric clinic in Northern India

BACKGROUND: Morbidity among elderly people has an important influence on their psychological well-being. Evaluation of the morbidity profile and its determinants, which have implications for management of medical problems of elderly people, are scarce in developing countries. Even the physicians' detection rate of mental distress in elderly populations is low in medical outpatient clinics. This could be due to the large caseloads and also, importantly, underestimation of psychological concerns of the elderly. The objective of this study was to study the psychiatric co-morbidity and life events among elderly medical outpatients. METHODS: One hundred medically ill elderly (>60 years) patients attending the Geriatric Clinic at Bikaner (North India) constituted the study population. The physical diagnosis was made by a physician based on reported illness, clinical examination and medical records. Psychiatric diagnosis was made by detailed clinical psychiatric interview using ICD-10 guidelines. Life events were assessed by the Indian adaptation of Presumptive Stressful Life Events Scale. RESULTS: Hypertension was the most commonly reported physical diagnosis (50%), other specific medical illnesses were osteoarthritis (15%), diabetes (13%) and constipation (8%). The study found 18% subjects had depression and 11% had other mental disorders. Patients with mental disorders had suffered more recent stressful life events. Among life events, conflicts in family (16%); unemployment of self or children (9%) was reported by elderly psychiatric patients. Other reported life events in psychiatric diagnosed elderly were conflict in family (7%), illness of self (6%) or family members (5%) and death of family members (5%) or close relatives (4%). CONCLUSION: Mental disorders are common among medically ill elderly patients, but they are poorly recognized and treated. Assessment of the psychiatric morbidity will help in strengthening psycho-geriatric services and thus, improve the quality of life of the elderly.     

Comorbidity of depression with other medical diseases in the elderly.

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.     

Elderly suicide in Alberta: difference by gender.

OBJECTIVE: To determine differences by gender among elderly persons who commit suicide on demographic characteristics, place of suicide, suicide method, previous suicide behaviour, and precipitant stressor. METHOD: This study included completed suicides of individuals aged 55 years and over during 1984-1995 in Alberta (n = 920). Information was abstracted from suicide records of medical examiners. RESULTS: Relative to elderly female suicides, elderly males who commit suicide characteristically use guns to commit suicide (43.8%), are single (12.5%), live in rural areas (46.7%), and have a lower frequency of previous suicide attempts (16.5%). Physical illness and financial difficulty as precipitant stressors of suicide are significantly more frequent among males (40.3% and 8.7% respectively) than females (29.9% and 1.8% respectively). Mental illness as a precipitant stressor is more common among females, 35.8% for women and 15.3% for men. CONCLUSIONS: Lethal methods of suicide and physical illness and financial difficulty as precipitant stressors of suicide are more common among elderly males than females who commit suicide.     

Cumulative Illness and Neuropsychological Decline in Hospitalized Geriatric Patients

A substantial portion of elderly patients admitted for inpatient rehabilitation treatment evidence cognitive dysfunction. Frequently, such patients also present with considerable medical comorbidity, that is, multiple concurrent illnesses. Identifying the potential role of cumulative illness in the etiology of cognitive decline in this group of frail elderly is limited by a lack of empirical information as little is known about this relationship. The goal of the present research was thus to investigate the relationship between cumulative illness and cognitive dysfunction while controlling for age and neurological and psychiatric symptomatology as these are previously known to affect cognitive function. Results indicate that cumulative illness predicts neuropsychological decline beyond the effects attributable to advanced age, mood, neurological pathology and psychiatric impairments. Even mild illness, if cumulative across several physical systems, can be predictive of cognitive deficits in this frail population. Of 11 organ systems studied, impairment of the vascular system was associated with the most diffuse profile of declined neuropsychological performance. Performances on measures of reasoning and judgment showed the strongest associations with cumulative illness. Implications of findings for neuropsychological diagnosis and prognosis are reviewed.     

Cumulative illness and neuropsychological decline in hospitalized geriatric patients

A substantial portion of elderly patients admitted for inpatient rehabilitation treatment evidence cognitive dysfunction. Frequently, such patients also present with considerable medical comorbidity, that is, multiple concurrent illnesses. Identifying the potential role of cumulative illness in the etiology of cognitive decline in this group of frail elderly is limited by a lack of empirical information as little is known about this relationship. The goal of the present research was thus to investigate the relationship between cumulative illness and cognitive dysfunction while controlling for age and neurological and psychiatric symptomatology as these are previously known to affect cognitive function. Results indicate that cumulative illness predicts neuropsychological decline beyond the effects attributable to advanced age, mood, neurological pathology and psychiatric impairments. Even mild illness, if cumulative across several physical systems, can be predictive of cognitive deficits in this frail population. Of 11 organ systems studied, impairment of the vascular system was associated with the most diffuse profile of declined neuropsychological performance. Performances on measures of reasoning and judgment showed the strongest associations with cumulative illness. Implications of findings for neuropsychological diagnosis and prognosis are reviewed.     

Electroconvulsive therapy for the elderly: a review

Treatment of psychiatric disorders among the elderly is complicated by such factors as high incidence of medical illness and changes in drug metabolism; electroconvulsive therapy (ECT) is considered a reasonable treatment alternative for the elderly for several psychiatric syndromes. The authors review indications, complications, and precautions related to ECT for older patients. The primary indication is major depression; about 80 percent of elderly patients respond favorably. ECT appears less effective for depression secondary to dementia or somatization disorder. Although ECT is relatively safe for the elderly, up to one-third may experience a complication that interferes with treatment. Careful pre-ECT medical evaluation is essential, with special attention to cardiovascular factors and to concurrent medications.     

Psychosomatic tendency for suicide among the elderly in Mie Prefecture, Japan

Background: The aim of the present study is to show the causative factors of suicide among the elderly (over 65) in Mie Prefecture, Japan, and to discuss the prevention of the suicidal influences in elderly patients. Methods: We investigated all inquest records during the 14‐year period 1989–2002 in cooperation with the First Department of Criminal Investigation of Mie Prefectural Police Headquarters. From all cases classified as suicides, we extracted data on age, sex and background, and we focused on suicide in the elderly group. Results: During the test period, there were 5048 suicides (3276 male and 1772 female suicides) of which 1513 (691 male and 822 female) were in the elderly group. The rate of suicide in the elderly group was approximately 30% of the total in all age groups. The rate of female suicides in the elderly group was approximately 46.3%. The major causative factors of suicide among the elderly were ‘suffering from physical illness’, and ‘psychiatric disorders’. ‘Physical diseases’ were not negligible backgrounds in middle and elderly groups. Among physical diseases, the number of malignant neoplasm was clearly less than the other diseases. Notably, ‘cardiovascular disease’ and ‘orthopedic disorders’ were most frequent causative factors of suicide other than malignant neoplasm. Conclusion: It is consequently concluded that improvements in the system of home nursing and health care should be involved in the suicidal prevention of the elderly who ‘suffer from physical illness’. The patients who ‘suffer from physical illness’ should be given physical and mental support. In order to prevent suicide, not only psychiatrists but also general practitioners as well as medical staff and general public should be provided with education regarding depression among ‘psychiatric disorders’.     

Depression and frequent attendance in elderly primary care patients

OBJECTIVE: The aim of this study is to investigate the association between depression and frequent attendance in elderly primary care patients. Moreover, we compare the prevalence and clinical characteristics of frequent attenders (FAs) in the elderly and the nonelderly patients. METHODS: This nationwide, cross-sectional, two-phase epidemiological study involved 191 primary care physicians (PCPs) and 1896 patients aged 14 and over. We consider FAs those subjects attending PCP practice more than once a month in the last 6 months. Screening for psychiatric disorders was conducted by using the General Health Questionnaire-12. Subsequently, probable cases were assessed by the PCPs with the WHO ICD-10 Checklist for Depression. RESULTS: Prevalence value of frequent attendance was 22.4% in the elderly. Depression was associated with frequent attendance in the elderly even after controlling for physical illness and unexplained somatic complaints. The risk for being an FA was more than twofold in the elderly than in the nonelderly (cOR=2.58; 95% confidence interval, 1.97-3.37). Considering subjects without medical illness, depression increased the risk of being an FA fivefold among the elderly and threefold among the nonelderly. CONCLUSION: Frequent attendance in primary care is associated with depressive disorder in the elderly. Depression seems to play a more important role in determining frequent attendance in the elderly patients in respect to the nonelderly.     

Suicidal attempts by prescription drug overdose in the elderly: a study of 44 cases

A series of 44 consecutive elderly, admitted to a busy general hospital following deliberate self-poisoning, is reviewed for associated medical and psychosocial factors. In all but 3 cases the act involved an overdose of drugs prescribed for the treatment of a chronic medical and/or psychiatric disorder. Women outnumbered men by 2.7 to 1. There was high proportion of chronic psychiatric (80%, mostly depressive) and medical (60%) conditions. Chronic stress from the physical illness, social isolation, or tacit family conflict were common and seemed instrumental in the self-poisoning act. Most attempts were carried out around the weekend and during winter. One man succumbed to complications of the overdose but the rest of the patients recovered. Psychosocial (especially depressive) and medical vulnerability, plus availability of prescribed drugs, were the most important determinants of suicidal behavior among these elderly attempters.     

Intérêt d'une approche multidisciplinaire en psycho-oncologie des personnes âgées

Old age is not an illness. However the incidence of cancer increases with age. The care of elderly persons with cancer has its own “technical” specificities that will lead to decide whether to apply or not, to adjust or not, cancer treatments in the most individual way possible. This implies a global and pluri-disciplinary approach of the elderly cancer patient. Among the actors of care, psycho-oncologists will have to explore the vast and little-known world of the behaviour of elderly cancer patients, their repercussions on the illness and the results of the treatments on the quality of life of the patients. That is what the “onco-more or less psychologist” expects from the “psycho-more or less oncologist”…     

Personality disorder in the elderly

Psychiatrists tend not to ascribe personality disorder to elderly patients who present with psychiatric or medical illness, perhaps because of the difficulty of defining personality disorder in older persons or because of the belief that it does not exist among the elderly. Based on a review of the literature, the author concludes that personality and personality disorder are most reliably described in behavioral terms and that normal aging can change preexisting behaviors and produce new behaviors. However, personality remains relatively stable as people age, and healthy personality traits are as durable as pathological personality traits. Finally, he concludes that the elderly are not immune from personality disorder but that age-related behavioral changes may mask the presence of the disorder. Therefore, diagnostic guidelines for personality disorder should include age-associated criteria.