Other conditions common in old age

If dementia did not exist, there probably would not be a separate speciality of Old Age Psychiatry. However, there are several reasons why having a separate speciality is also an advantage when it comes to the assessment and management of other mental health problems. First, there are differences in the way functional mental illnesses present in elderly people, as will be described below. Second, it can sometimes be difficult to differentiate between the mental illnesses found most frequently among elderly people, and old age psychiatrists become skilled in making this differential diagnosis (Fig. 1). Third, prescribing psychotropic medication for elderly people is particularly challenging (Fig. 2), especially as there is a high rate of medical problems among elderly people with mental illness. Finally, social problems are an important cause of mental health problems in all age groups. The social needs of elderly patients are usually different to their younger counterparts and so are more likely to be met by teams with expertise in this area.

Fig. 1 Differential diagnosis of functional illness in the elderly.

Fig. 2 Problems associated with prescribing psychotropic medication in the elderly.

Depressive disorders

It used to be thought that the prevalence of depressive disorders increased with age. However, more recent research has found the prevalence of depressive episodes to be 3–5% in people over 65 years, with a further 10% suffering from depressive symptoms which are not severe enough for a diagnosis of depressive episode to be made. These rates are similar or even slightly lower than rates in younger people. Many elderly people with depression are suffering a recurrence of a depressive disorder that started earlier in their lives and the risk of becoming depressed for the first time actually decreases from 60 years onwards. Women are affected more often than men, as is the case for all age groups. There are some differences in aetiology compared with younger patients, as described in Figure 3.

Fig. 3 Aetiology of depression in the elderly.

Presentation

Clinical presentation of depression in the elderly is much the same as in younger people with a few differences. Older people are less likely to complain of low mood, perhaps because discussion of emotions is a relatively recent fashion. As a result, the diagnosis often has to be based on other symptoms of depression such as loss of interest and enjoyment of life and disturbed sleep and appetite. Symptoms such as psychomotor retardation or agitation, paranoid beliefs, nihilistic delusions and hypochondriacal worries probably occur more often than in younger people, although this is controversial. Depression often has an impact on concentration and attention, which in turn can impair memory. Some patients will present with prominent cognitive impairment as a consequence of depression. This is sometimes referred to as ‘pseudodementia’. Anxiety disorders usually begin earlier in life and so an underlying depressive episode should be suspected if anxiety symptoms develop for the first time in an elderly person.

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