PART
XVII Geriatric Psychiatry
71  Geriatric Psychiatry
M. Cornelia Cremens, MD, MPH
KEY POINTS
• Depression in the elderly carries a very high risk of
suicide.
• Symptoms of alcoholism and substance abuse are
often confused with those of medical illness.
• The differential diagnosis of dementia is broad and
the behavior problems challenging to treat.
• Delirium increases the prevalence and severity of
disability, the length of hospital stay, and rates of
morbidity and mortality.
• Caregivers of the elderly are at risk for depression,
anxiety, and burnout.
OVERVIEW
The population older than 65 years has increased dramatically
over the past several years; this trend reflects improved health,
nutrition, and access to medical care. This remarkable length-
ening of the average life span in the US, from 47 years in 1900
to more than 75 years at present, will continue to increase
along with improvements in medicine and the health con-
sciousness of the baby boomers.1 Equally noteworthy has been
the increase in the number of those over the age of 85 years.
Older adults continue to learn and to contribute to society,
despite the physiological changes associated with aging and
the ever-threatening health and cognitive problems they face.
Ongoing intellectual, social, and physical activity is important
for the maintenance of mental health at all stages of life.
Stressful life events (e.g., declining health; loss of independ-
ence; and the loss of a spouse or partner, family member, or
friend) typically become more common with advancing age.
However, major depression, anxiety disorders, memory loss,
and unrelenting bereavement are not a part of normal aging;
they should be treated when diagnosed. A host of effective
interventions exist for most psychiatric disorders experienced
by older adults and for many of the mental health problems
associated with aging.
The prevalence of medical and psychiatric illness increases
with advancing age in part due to stressful life events, the
burden of co-morbid illness, and the various combinations of
a bevy of medications used.2
The reduction in hepatic, renal, and gastric function associ-
ated with aging impairs the elder’s ability to absorb and to
metabolize drugs; aging also influences the enzymes that
degrade these medications (Table 71-1).1
Disability due to mental illness in elderly individuals will
increasingly become a major public health problem in the
very near future. The elderly are more susceptible to disease
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and are more vulnerable to the side effects of prescribed drugs
and other substances (be they illicit or over-the-counter sub-
stances).3 Approximately 40% to 60% of hospitalized medical
and surgical patients are over the age of 65 years; moreover,
they are at greater risk for functional decline while hospital-
ized than are younger individuals.4 Adequately treating older
adults who have psychiatric disorders provides benefits for
their overall health by improving their interest and ability to
care for themselves and to follow their primary care provider’s
directions and advice with regard to health promotion and
medication compliance. Older individuals can also benefit
from advances in psychotherapy, medications, and other treat-
ment interventions for mental disorders, when these interven-
tions are modified for age and health status.
Barriers to access of appropriate mental health services
have arisen in the organization and financing of services for
the elderly. Unfortunately, numerous problems exist in the
structure of Medicare, Medicaid, nursing homes, and managed
care. Primary care practitioners are the critical link in identify-
ing and addressing mental disorders in older adults. Oppor-
tunities to improve mental health and general medical
outcomes are missed when mental illness is under-recognized
and under-treated in primary care settings.
General themes in geriatric psychiatry include the follow-
ing: the differentiation of symptoms of normal aging from the
symptoms of illness in later life; the modifiability of illness in
later life; the modifiability of normal aging to improve func-
tion; the capacity to change; and distinguishing differences in
the manifestations of early-onset and late-onset psychiatric
disorders.
An understanding of geriatric mental health relies in part
on an appreciation of neurochemistry. Neurochemistry of the
aging human brain is closely related to an irreversible loss of
function and a decline in global abilities. Fortunately, our
brain has remarkable plasticity; it allows for the well-designed
compensation for neuronal loss and functional decline that is
linked with an age-related loss in neurons, dendrites, enzymes,
and neurotransmitters.5 Enzymes and neurotransmitters in the
brain change as we age: e.g., monoamine oxidase increases
and acetylcholine and dopamine decrease.6
MENTAL HEALTH DISORDERS COMMON IN  
LATE LIFE
Late-life Depression
Depression in late life lowers life expectancy. Depression and
cognitive impairment affect approximately 25% of the elderly.1
New research confirms that the risk for post-stroke depression
increases especially in the “old-old” (i.e., those over 85 years
of age).7 Depression in the elderly is not more common
according to Epidemiological Catchment Area (ECA) data;
however, making the diagnosis is more difficult. A higher rate
763
764 PART XVII  Geriatric Psychiatry

of depression exists in older women as compared to older depressed patients have co-morbid anxiety and 40% of anxious
men; among those with a history of depression there is a 50% patients have co-morbid depression.10
chance of a second episode (either a recurrence or a relapse).8 Neurological disorders also complicate the diagnosis of
Use of medications for medical problems often generates depression. The risk for depression in the post-stroke period
adverse effects and complicates the diagnosis of depression; is high, with 25% to 50% developing depression within 2
moreover, medical illness may mimic depression and depres- years of the event.7 Alzheimer’s disease (AD) carries an
sion may mimic medical illness. Depression (as occurs with increased risk of depression; approximately 20%–30% (either
stroke, fractured hip, arthritis, and cardiac illness) is common before or at the time of diagnosis) are diagnosed with depres-
in disabled elderly. Depression is also associated with both sion. Delusions are also prominent in depression associated
acute and chronic medical illnesses and late-onset depression with dementia.11 Recent research confirms the association of
is closely associated with physical illness.9 Of note, undiag- depression with the increased risk of developing late-onset
nosed medical illness can manifest as depression. Grief and AD.12 Fifty percent of patients with Parkinson’s disease develop
loss may also contribute to depression. As many as 60% of depression or have a history of depression with anxiety, dys-
thymia, or frontal lobe dysfunction.13 Degeneration of the
sub-cortical nuclei (especially the raphe nuclei) is related to
TABLE 71-1  Metabolic Changes Associated with Aging the development of depression in Parkinson’s disease.
Function Impact Domain
Assessment of depression can be challenging. The Geriatric
Depressions Scale (Table 71-2)14 is a helpful tool in this regard,
Hepatic Decreased Blood flow and often the information provided by the caregiver is crucial
function Affects first-pass effect as elders may not be forthcoming with their symptoms.15
Decreased Enzyme activity
Demethylation
However the PHQ-9 used in the primary care office is simpler
Hydroxylation to complete and therefore more readily used.15 The criteria for
Absorption Decreased Blood flow diagnosing depression in the elderly are the same as they are
Acidity in the general population.
Motility Treatment of late-life depression is challenging in part
Gastrointestinal surface area because there is a decline in one’s biological ability to metabo-
Renal Decreased Blood flow lize drugs and to bind proteins (because of reduced receptor
excretion Can lead to lithium toxicity sensitivity), as well as an increased sensitivity to drug side
Glomerular filtration rate
effects. In an effort to reduce adverse consequences of medica-
Hydroxymetabolites affected
Tubular excretion tions, drugs with the fewest side effects should be started (and
Benzodiazepine clearance slowed be used in small doses); in addition, monotherapy should be
Distribution Increased Volume of distribution attempted16,17 (Tables 71-3 and 71-4). In more refractory cases
Especially for lipophilic drugs or with psychotic symptoms, electroconvulsive therapy (ECT)
Increased Fat stores should be considered early in treatment and as an adjunct
Decreased Water content for one or more drugs.18 Individual psychotherapy or group
Decreased Muscle mass therapy complements somatic treatments and often leads to a
Decreased Cardiac output and perfusion to organs
swift recovery. Interpersonal therapy and cognitive-behavioral
Protein- Decreased Albumin levels (except alpha1-
binding glycoprotein)
therapy (CBT) are both suited to this population as they are
more focused and interactive treatments.19

TABLE 71-2  PHQ-9

Nine Symptom Checklist
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not At All Several Days More Than Half the Days Nearly Every Day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself—or that you are a failure or 0 1 2 3
have let yourself or your family down
7. Trouble concentrating on things, such as reading the 0 1 2 3
newspaper or watching television
8. Moving or speaking so slowly that other people could have 0 1 2 3
noticed? Or the opposite—being so fidgety or restless that
you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting 0 1 2 3
yourself in some way
(For office coding: Total Score _____ = ___ + ___ + ___ )
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with
other people?
Not difficult at all Somewhat Very difficult Extremely difficult
difficult
From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). The PHQ was developed by Drs. Robert L.
Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at rls8@columbia.edu. PRIME-MD® is a
trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved, and Kroeke K, Spitzer RL. The PHQ-9: A new depression diagnostic and
severity measure, Psychiatric Annals 32(9):1–7, 2002.

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 Geriatric Psychiatry 765

TABLE 71-3  Medications for Depression in the Elderly

71
Drugs Dose Range Comments
TRICYCLIC ANTIDEPRESSANTS
Nortriptyline 10–150 mg/day Reliable blood levels, minimal orthostasis
Desipramine 10–250 mg/day Mildly anticholinergic
MONOAMINE OXIDASE INHIBITORS
Tranylcypromine 10–30 mg/day Orthostasis (possibly delayed), pedal edema, weakly anticholinergic, requires dietary restrictions
STIMULANTS
Dextroamphetamine 2.5–40 mg/day Agitation, mild tachycardia
Methylphenidate 2.5–60 mg/day
Modafanil 50–200 mg/day
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Fluoxetine 5–60 mg/day Akathisia, headache, agitation, gastrointestinal complaints, diarrhea/constipation
Sertraline 25–200 mg/day
Paroxetine 5–40 mg/day
Fluvoxamine 25–300 mg/day
Citalopram 10–40 mg/day
Escitalopram 2.5–20 mg/day
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
Venlafaxine 25–300 mg/day Increase in systolic blood pressure, confusion, light-headedness
Nefazodone 50–600 mg/day Pedal edema, rash, hepatotoxicity (rare)
Duloxetine 20–60 mg/day Diarrhea, dizziness
ALPHA2-ANTAGONIST/SELECTIVE SEROTONIN
Mirtazapine 15–45 mg/day Sedation, weight gain
ATYPICAL ANTIDEPRESSANTS
Trazodone 25–250 mg/day Sedation, orthostasis, incontinence, hallucinations, priapism
50–600 mg/day Pedal edema, rash
Bupropion 75–450 mg/day Seizures, less mania/cycling, headache, nausea

TABLE 71-4  Medications for Psychotic Symptoms in the Elderly

Drug Dose Range Sedation Ach Potency EPS/Comments
ATYPICAL ANTIPSYCHOTICS
Clozapine 12.5–100 mg High High Very low
Check WBC count weekly; excessive drooling, hypotension
Risperidone 0.25–3 mg Low Low Low
More EPS than initially reported
Olanzapine 2.5–10.0 mg Moderate Moderate Low
Quetiapine 12.5–200 mg High Low Low
Ziprasidone 20–80 mg BID Moderate Low Low
Aripiprazole 15–30 mg Low Low Moderate
Ach, Anticholinergic; EPS, extrapyramidal symptoms; WBC, white blood cell.

men and 35% of women who committed suicide in that age

Late-life Depression and Suicide
Depression with psychotic features is linked with a higher risk
of suicide. The rate of suicide in those greater than 65 years is
double that of the rate for the US population in general, and
those with the highest suicide rates of any age group are those
aged 65 years and older.20 In 2011, suicide ranked as the 10th
leading cause of death among those aged 65; this group rep-
resented 12.5% of the population, but it accounted for 15.7%
of all suicides. Suicide disproportionately affects the elderly;
the suicide rate among those 65 to 69 years old was 13.1 per
100,000 (N.B.: all of the following rates are per 100,000 popu-
lation), and the rates increased as age increased (i.e., it was
15.2 among those between 70 and 74, it was 17.6 among
those between 75 and 79, it was 22.9 between those 80 and
84, and it was 21.0 between persons 85 or older). Firearms
(71%), overdose (11%), and suffocation (11%) were the three
most common methods of suicide used by persons aged 65
years or older. Firearms are the most common method of
suicide by both males and females, accounting for 78% of
group and cohort.21
Risk factors for suicide among the elderly differ from those
among the young. In addition to a higher prevalence of
depression, older persons are more socially isolated and they
more frequently use highly lethal methods. They also make
fewer attempts per completed suicide, have a higher male-to-
female ratio than other groups, have frequently visited a
health care provider before their suicide, and have more physi-
cal illnesses. Approximately 20% of elderly (i.e., over 65 years)
persons who commit suicide have visited a physician within
24 hours of their death, 41% visited within 1 week of their
suicide, and 75% were seen by a physician within 1 month of
their suicide. Of every 100,000 people aged 65 and older, 14.3
died by suicide in 2004. This figure is higher than the national
average of 10.9 suicides per 100,000 people in the general
population. Caucasian men aged 85 or older had an even
higher rate, with 17.8 suicide deaths per 100,000. Suicide rates
among the elderly are highest for those who are divorced or
widowed. Among men aged 75 years and older, the rate for

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766 PART XVII  Geriatric Psychiatry
divorced men was 3.4 times that for married men, and for
widowed men it was 2.6 times that for married men. In the
same age group, the suicide rate for divorced women was 2.8
times that of married women, and for widowed women it was
1.9 times the rate among married women. Several factors
(including growth in the size of that population; health status;
availability of, and access to, services; and attitudes about
aging and suicide) relative to those over 65 years will play a
role in future suicide rates among the elderly.
Suicide occurs early (often during the first 6 months) in the
illness, but it can occur at any time, often in combination with
other mental disorders. More than 90% of older people who
commit suicide have the following risk factors: depression or
other mental disorders; a substance abuse disorder or a family
history of such; stressful life events, in combination with other
risk factors, such as depression; a prior suicide attempt or
family history of an attempt; family violence (including physi-
cal or sexual abuse); firearms in the home (the method used
in more than half of suicides); incarceration; or exposure to
the suicidal behavior of others, such as family members, peers,
or media figures.22 The rate of completed suicide is greater in
this population than in any other age group; older adults
account for 25% of all suicides. Older white males make up
the highest-risk group, and rates are increasing. Isolation
increases the risk for suicide, and alcoholism or substance
abuse is a contributing factor to successful suicides in all pop-
ulations, including older adults. Aggressive treatment with
antidepressants is indicated for these individuals, and inpa-
tient treatment is the safest venue for care.
Most of the antidepressants are equally effective for depres-
sion; however, drugs with anticholinergic effects and undue
sedation should be avoided to reduce complications (such as
falls, confusion, and poor compliance). However, matching
the symptoms with the side effects is useful for a patient with
significant weight loss and insomnia; a sedating medication
that increases appetite may be beneficial. ECT early in the
course of major depressive disorder (MDD) should be consid-
ered strongly as appropriate care of this high-risk population.
Alcoholism
Alcoholism, often overlooked in many patients, may go unno-
ticed in older adults despite a lifelong pattern of daily drinking;
even if the elderly drink only small amounts, they may experi-
ence a significant and life-threatening withdrawal. Co-morbid
illness (both psychiatric and medical) confounds accurate Psychosis (manifest by hallucinations, delusions, disorganized
diagnosis of both the alcoholism and the medical or surgical
diagnosis. Symptoms of problem-drinking include insomnia,
memory loss, confusion, anxiety, and depression, as well as
somatic complaints that may mimic medical illness, further
delaying accurate diagnosis. Older adults who drink alcohol
are at greater risk due to the fact that often they take more
prescribed medications that can interact adversely with alcohol.
The prevalence of alcoholism in the ECA study was 1.5%
to 3.7%. Although cross-sectional studies suggested that the
percentage of alcoholism declines after age 60, longitudinal
studies propose a stable pattern of lifelong alcohol abuse.23
Women drink less than men at all ages, but older widowed
women are at risk for increasing their intake. Studies note that
the prevalence of alcohol problems in women is on the rise.
Older adults with alcohol dependence also have a high preva-
lence of co-morbid nicotine dependence. Alcohol dependence
can lead to liver damage, cancer, immune system disorders,
and brain damage.
Depression is more common in those with alcoholism, as
is grief, anxiety, psychosis, and dementia. Suicide risk is greater
in elderly alcoholics; therefore, obtaining a comprehensive
history from family, friends, and caretakers is essential.
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Hospitalization is typically required for detoxification of the
older patient.24 Newer medications (such as naltrexone and
acamprosate) and the familiar disulfiram (Antabuse) can be
beneficial, but disulfiram may generate problematic side
effects in older adults.25
Anxiety
Recently, anxiety (generally associated with normal aging and
with medical, financial, and health-related hardships) has
been increasingly recognized in the elderly. However, since
anxiety is not a direct consequence of normal aging, the symp-
toms of anxiety should not be ignored. Among the most
common categories of anxiety are simple phobias and general-
ized anxiety; if left untreated these conditions may lead to
serious depression.26 Anxiety may co-exist with many other
psychiatric diagnoses (such as depression, bipolar disorder,
alcoholism, and dementia). Diagnostic challenges often arise
when anxiety (e.g., worry, fear, apprehension, concern, and
foreboding), as well as somatic complaints (such as tachycar-
dia, sweating, abdominal distress, dizziness, and vertigo)
develop in the context of a medical illness (e.g., diabetes with
hypoglycemia, hyperthyroidism, or cardiac disease with
hypoxia) as it can be manifest by similar symptoms.26 Worries,
fears, and concerns are often related to finances, dependency
issues, loneliness, and memory loss. Manifestations of medical
illness can mimic psychiatric symptoms; certain substances or
medications (e.g., caffeine, stimulants, ephedrine, and bron-
chodilators) produce anxiety-like symptoms. Withdrawal from
a prescribed or an illicit drug can precipitate severe anxiety and
panic; life-threatening withdrawal can result from sudden
abstinence from alcohol, benzodiazepines, or barbiturates.
Fortunately, anxiety can be effectively managed in the
elderly by use of medications, therapy, or a combination of
the two.26 Among the anxiolytics, benzodiazepines are the
most frequently prescribed class of agents (especially by
primary care physicians) for the elderly; however, significant
side effects (such as confusion, falls, over-sedation, and para-
doxical agitation) can arise.27 Complications of long-term use
include daytime somnolence, confusion, cognitive impair-
ment, an unsteady stance or gait, paradoxical agitation,
memory disturbance, depression, and respiratory depression.
Psychosis
speech, and disorganized or catatonic behavior) in the elderly
has multiple etiologies (e.g., delirium, dementia, depression,
mania, and schizophrenia). Not only is morbidity high with
a diagnosis of delirium but also about 30% of those with
delirium will die within 1 year of their illness.28,29 (see Chapter
18). The differential diagnosis of psychosis in the elderly
includes the following: various types of dementias (e.g., AD,
Lewy body dementia, vascular dementia, frontal lobe demen-
tia [Pick’s disease], and Parkinson’s disease), all of which can
have psychotic symptoms at any point during the illness;
delirium; delusional disorders; bipolar disorder; schizoaffec-
tive disorder; schizophrenia (either early-onset or late-onset);
and major depression with psychotic features. Psychosis in
dementia is common, and it can be episodic or persistent and
can appear early or late during the disease.30 Symptoms of
psychosis (e.g., delusions, hallucinations, misconceptions,
and misperceptions) are distressing to family members and to
caregivers; they can be dangerous if the individual becomes
frightened or energized by them. Alcoholism and substance
abuse should also be considered as a possible etiology of
psychosis.25 The Charles Bonnet syndrome, with visual hal-
lucinations beginning after a sudden loss of vision (as in

BOX 71-1  Activities of Daily Living (ADLs)
Feeding or eating
Bathing
Toileting
Dressing
Continence
Hygiene
Mobility or transferring
BOX 71-2  Instrumental Activities of Daily Living (IADLs)
Housework, light
Telephoning
Cooking and meal preparation
Grocery shopping
Using transportation
Managing medication
Managing finances
macular degeneration), may be confused with a primary psy-
chotic condition. Most individuals know that the hallucina-
tions are not real, and they can adjust to them; however, when
dementia or an anxiety disorder confounds the symptom, this
may be problematic.31
Dementia
Many complaints of memory loss reflect the course of normal
aging or the effects of a treatable condition (such as depression
or delirium). Dementia is not usually diagnosed until its mod-
erate to severe stages, as symptoms and a subtle decline in
function (Boxes 71-1 and 71-2) develop over time.
The prevalence of dementia and cognitive impairment is
higher in women than in men. While higher rates of AD are
reported in women, higher rates of vascular dementia are
reported in men.32 AD typically affects 5%–8% of those over
65 years, 15%–20% of those over 75 years, and 25%–50%
over 85 years; its course is that of a steady decline over approxi-
mately 8–10 years.
Genetics of dementia are discussed in greater detail in
Chapter 63; however, the ApoE-2 allele decreases the risk for
AD (as it may have a protective effect), while patients with
either sporadic or familial AD have a higher frequency of the
ApoE-4 allele than in the general population.1
The mechanisms by which these genetic markers confer
increased risk are not completely determined. Neurobiological
changes associated with normal aging include lower cortical
acetylcholine levels, neuron and synaptic loss, decreased den-
dritic span, and decreased size and density of neurons (espe-
cially in the nucleus basalis of Meynert) and likely play a role
in AD. AD is most accurately diagnosed by post-mortem
examination of the brain (revealing a loss of neurons in the
basal forebrain and cortical cholinergic areas, in addition to
the depletion of choline acetyltransferase, the enzyme respon-
sible for acetylcholine synthesis). The degree of this central
cholinergic deficit is correlated with the severity of dementia;
this has led to the “cholinergic hypothesis” of cognitive deficits
in AD.33 This hypothesis has led, in turn, to promising clinical
interventions (Table 71-5). Acetylcholine is probably not the
only neurotransmitter involved in AD, and numerous medica-
tion trials are underway.34
Vascular dementia, the second most common cause of
dementia, develops as a result of multiple ischemic events or
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Geriatric Psychiatry 767
TABLE 71-5  Medications for Alzheimer’s Disease and Other
Dementias 71
Donepezil 5–23 mg every day
Rivastigmine 1.5–6 mg twice a day
Galantamine 4–12 mg twice a day
Memantine 5–10 mg twice a day
Nausea, diarrhea, abdominal cramps, bradycardia, and fatigue may
develop.
strokes. Approximately 8% of patients develop vascular
dementia after a stroke. Vascular dementia is generally mani-
fest by an abrupt, stuttering, often stepwise, gradual decline;
it commonly co-exists with AD.
Mixed dementia is a combination of AD and vascular
dementia; it is common, and stroke can unmask an underly-
ing AD.
In frontal lobe dementia, cognitive impairment may not be
as noticeable as are the behavioral and personality changes.
In this condition, there is a loss of personal or social aware-
ness, a lack of insight, indifference, inappropriate and stereo­
typed behaviors, aggression, distraction, a loss of inhibitions,
apathy, or extroverted behavior.
Early or spontaneous parkinsonism, recurrent visual hal-
lucinations, sensitivity to antipsychotics, fluctuating cogni-
tion, falls or syncope, and a transient loss of consciousness
characterize Lewy body dementia.
Mild cognitive impairment (MCI), formerly designated as
age-associated memory impairment (or benign senescent for-
getfulness) or age-related cognitive decline, is characterized by
both subjective and objective cognitive impairment in the
absence of dementia. Between 10% and 12% of persons with
MCI develop AD; others remain with a stable impairment or
a minimal decline, or die from other causes.35 MCI sub-
classifications include an amnestic form (characterized by iso-
lated memory impairments) and one with multiple cognitive
deficits and another with a single deficit.36
Behavioral and Psychological Symptoms of Dementia
More than 80% of patients with dementia exhibit a variety of
psychological symptoms; a majority have delusions, as well as
hallucinations, paranoia, anxiety, apathy, and misidentifica-
tion syndromes. Behavioral symptoms include wandering,
aggression, hostility, insomnia, inappropriate eating, and
abnormal sexual behaviors.37 The caregiver burden increases
with behavioral and psychological symptoms of dementia
(BPSD), and the aggressive, hostile, and accusatory behaviors
and psychotic symptoms often result in institutionalization.
Caregivers are at risk for medical and psychiatric illness due
to the stress associated with caring for such individuals. There-
fore, providing treatment regimens or algorithms has the
potential to improve the quality of life for both the patient
and the caregiver. First-line treatment has involved non-
pharmacological strategies that use environmental and behav-
ioral interventions (such as regularly scheduled routines for
meals, sleep, and bathing). Pharmacological interventions
(that are not symptom-driven) are less well established.
Limited studies have shown the benefit of antipsychotics, but
there are significant side effects from their use; these include
a neurological risk of stroke, a cardiovascular risk for meta-
bolic syndrome, and a propensity for anticholinergic symp-
toms.38 Psychotic symptoms in the elderly are best treated with
antipsychotics, while the atypical agents are of benefit due to
the binding affinity to both dopamine and serotonin. Agi-
tated, hostile, and aggressive behaviors may respond to anti­
psychotics, anticonvulsants, or antidepressants. Patients with
768 PART XVII  Geriatric Psychiatry
dementia may develop paradoxical agitation when given ben-
zodiazepines, and they should be administered with caution.
Cholinesterase inhibitors have been used for treatment of
BPSD since cholinergic deficiency also appears to be involved
in the development of BPSD, as well as AD.39
Schizophrenia
Although schizophrenia usually arises before the age of 30
years, late-onset schizophrenia is not rare. More than 20% of
cases are diagnosed after age 40, and at least 0.1–0.5% of the
population over 65 years has a diagnosis of schizophrenia that
started late in life, with a prognosis that may be made worse
by delay and avoidance of treatment.40 Aggressive treatment of
symptoms and supportive care for patients with this diagnosis
is imperative.
Approximately 85% of these individuals (mostly women)
live in the community. Schizophrenia remains plastic into
later life, with more negative symptoms than positive symp-
toms. Numerous confounding factors (including cognitive
decline, dementia, depression, medical co-morbidity, and use
of medications for medical conditions) occur with aging. Most
of the older individuals with schizophrenia have been destabilizing and cause emergence of otherwise controlled
disabled for most of their life. The side effects from typical
antipsychotics, such as tardive dyskinesia or extrapyramidal
symptoms, may adversely affect independent living. Lowering
the dose of these medications or switching to an atypical
antipsychotic may be reasonable, noting the recent evidence
that atypical agents are linked with an increased risk of stroke.38
Caregiving and community support for these individuals is
the key to maintaining health and stability.
Bipolar Disorder
Bipolar disorder (BPD) may be seen for the first time in late
life, and it is not uncommon in older adults; its prevalence is
0.1%–0.4%. For the majority of elderly patients the illness
begins in middle-age or late-life and often has co-morbid
neurological insults. The patients with co-morbid neurologi-
cal diseases are more apt to have a significantly later age of
onset and a family history of affective illness. Snowdon41
reported that 25% of patients had mania after age 50, had a
history of neurological disease before the onset of the mania,
and had significantly lower genetic (familial) risk factors. A
number of biological risk factors have been identified for BPD
in the elderly, including genetic factors and medical illnesses,
particularly vascular diseases.
Symptoms of mania or hypomania manifest differently in
older patients, with more symptoms of anger or irritability
and at times aggressive behavior, delusions, and paranoia; in
addition, less grandiosity and euphoria occur, episodes of
mania are longer, and cycling may be more rapid. Treatment
response is inconsistent, although lithium, anticonvulsants
(e.g., divalproex sodium, carbamazepine, and lamotrigine),
atypical antipsychotics (e.g., olanzapine, quetiapine, and ris­
peridone), and antidepressants have all been beneficial in the
treatment of elderly patients with BPD. In the differential
diagnosis of secondary mania, consideration needs to given to
co-morbid illnesses. Many patients with dementia or delirium
can manifest with a picture of mania secondary to their
illness.42 Although the treatment of the symptoms is similar
in both cases, an accurate diagnosis is important.
Personality Disorders
Usually personality disorders in older adults have been life-
long and well articulated by family members. These disorders
are distinguished from a change in personality resulting from
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an illness, dementia, delirium, depression, a disaster, or a cata-
strophic event. Neurological disorders (such as stroke, brain
injury, trauma, frontal lobe syndrome, seizures, or Parkinson’s
disease) are examples of conditions that may precipitate a
change in personality. In the differential diagnosis, although
the patient may be paranoid, avoidant, or threatening, the
change in personality may be related to the underlying medical
or neurological disorder and not classified as a personality
disorder but a change in personality due to the specific
diagnosis. Major depression is commonly co-morbid with
aging, ranging from 10% to 70%, most often associated with
obsessive-compulsive personality disorder. Co-morbid depres-
sion and panic are also noted in older patients with somato-
form disorder, specifically with hypochondriasis. The pattern
of lifelong distress, social dysfunction, and exacerbation of
prior symptoms or traits constitutes the diagnosis of a person-
ality disorder. The popular thought that modification of symp-
toms or traits and possibly adaptation may occur through
prior psychotherapy, aging, or life experiences is not evidence-
based in the literature. Professionals working with older adults
have noted that older adults are more vulnerable to illness,
losses, and possibly forced dependency. These changes can be
personality symptoms. Engaging patients and caregivers in
communication to allay fears and engender trust and under-
standing, although not an easy task in those with cluster B
personalities, is the entrée to stabilization. Medications may
be of benefit but their efficacy may be limited without con-
comitant therapy.
DISASTERS
Senior citizens comprise a sturdy, reliable generation, who has
proven over the years to have the ability to survive myriad
disasters (e.g., the Great Depression, world wars, threats of
nuclear holocaust, terrorist attacks, and hurricanes); yet they
remain proud, tough, and resilient. Older adults are a genera-
tion of survivors.43 However, when a disaster strikes they often
feel terrified, alone, and vulnerable. Older adults often need
the most assistance but can mistakenly be overlooked during
relief efforts. Feelings of helplessness can frighten elderly indi-
viduals; this places them at greater risk for both physical and
mental health illnesses. It is important for older adults recov-
ering from the after-effects of a disaster to talk about their
feelings, to share their experiences with others, and to recog-
nize that they are not alone. Symptoms of post-traumatic
stress disorder (PTSD) can be re-ignited by war experiences or
by recollections of childhood trauma. They should be encour-
aged to become involved in the disaster recovery process and
to help others; this can be beneficial to their own recovery.
Seeking assistance is a step toward recovery, and older adults
should be encouraged to ask for any type of help needed (such
as financial, emotional, and medical).44
CAREGIVER STRESS AND BURDEN
The health and well-being of the caregivers, family members,
or employees of the patient need to be considered during the
evaluation, because they are at risk for depression.45 Caring for
the caregiver is as important as caring for the patient. The
inordinate stress and burden can place the caregiver at risk for
medical and psychiatric crisis. Caregivers can become depressed
or have symptoms of depression related to burnout (i.e.,
fatigue, loss of social contacts, lack of interest in work, inabil-
ity to perform at work, weight gain or loss, feeling helpless,
and using alcohol or other substances). Burnout may not
present during the most stressful times in caring but emerges
months later, somewhat similar to PTSD.

ELDER ABUSE
Each year thousands of elderly, who are often frail and vulner-
able, are abused, neglected, or exploited by family members,
caregivers, friends, and others, on whom they depend to assist
them with basic needs.46 Elder abuse may be subtle and be as
simple as not providing medications, or being avoided. Family
and caregivers may not intend to harm or exploit the patient
but often are overwhelmed and overextended. Hotlines are
available in every state (www.elderabusecenter.org) for helpful
information, guidance, or reporting.
Access a list of MCQs for this chapter at https://expertconsult
.inkling.com
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MULTIPLE CHOICE QUESTIONS
Select the appropriate answer.
Q1 True or False. The risk for depression in the post-stroke
period is lower than the risk for depression in
Alzheimer’s disease.
○ True
○ False
Q2 True or False. The rate of suicide in the elderly is higher
than that of adolescents.
○ True
○ False
Q3 Which of the following MOST closely approximates the
prevalence of the elderly population that has a problem
with alcoholism?
○ 1%
○ 10%
○ 15%
○ 25%
○ 50%
Q4 Which of the following MOST closely approximates the
prevalence of Alzheimer’s disease in those over age 85?
○ <2%
○ 5% to 8%
○ 15% to 20%
○ 25% to 50%
○ >50%
MULTIPLE CHOICE ANSWERS
Q1 The answer is: False.
The risk for depression in the post-stroke period is high, with
25% to 50% developing depression within 2 years of the
event. Alzheimer’s disease (AD) carries an increased risk of
depression; approximately 20% to 30% (either before or at
time of diagnosis) are diagnosed with depression; delusions
are also prominent in depression associated with dementia.
Recent research confirms the association of depression with
the increased risk of developing late-onset AD.
Fifty percent of patients with Parkinson’s disease develop
depression or have a history of depression with anxiety, dys-
thymia, or frontal lobe dysfunction.
Q2 The answer is: True.
The rate of suicide in those greater than 65 is nearly double
that of the rate for the U.S. population in general, and the
group with the highest suicide rate of any age-group is those
age 65 years and older. In 1998, suicide ranked as the sixteenth
leading cause of death among those age 65; this group repre-
sented 13% of the population, but it accounted for 19% of all
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Geriatric Psychiatry 769.e1
suicides. Suicide disproportionately affects the elderly; the
suicide rate among those age 65 to 69 was 13.1 per 100,000 71
(all of the following rates are per 100,000 population), the
rates increased as age increased (i.e., it was 15.2 among those
age 70 to 74; it was 17.6 among those age 75 to 79; it was
22.9 among those age 80 to 84; and it was 21.0 among persons
age 85 or older). Firearms (71%), overdose (11%), and suf-
focation (11%) were the three most common methods of
suicide used by persons age 65 years or older. Firearms are the
most common method of suicide by both Men and women,
accounting for 78% of male and 35% of female suicides in
that age-group and cohort.
Risk factors for suicide among the elderly differ from those
among the young. In addition to a higher prevalence of
depression, older persons are more socially isolated and they
more frequently use highly lethal methods. They also make
fewer attempts per completed suicide, have a higher male-to-
female ratio than other groups, have frequently visited a
health care provider before their suicide, and have more physi-
cal illnesses. Approximately 20% of elderly (i.e., over 65 years)
persons who commit suicide have visited a physician within
24 hours of their death, 41% visited within 1 week of their
suicide, and 75% were seen by a physician within 1 month of
their suicide. Of every 100,000 people ages 65 and older, 14.3
died by suicide in 2004. This figure is higher than the national
average of 10.9 suicides per 100,000 people in the general
population. Caucasian men age 85 or older had an even
higher rate, with 17.8 suicide deaths per 100,000. Suicide rates
among the elderly are highest for those who are divorced or
widowed. Among men age 75 years and older, the rate for
divorced men was 3.4 times that of married men and for
widowed men it was 2.6 times that for married men. In the
same age-group, the suicide rate for divorced women was 2.8
times that of married women and for widowed women it was
1.9 times the rate among married women. Several factors
(including growth in the size of that population; health status;
availability of, and access to, services; and attitudes about
aging and suicide) relative to those over 65 years will play a
role in future suicide rates among the elderly.
Q3 The answer is: 1%.
Symptoms of problem-drinking include insomnia, memory
loss, confusion, anxiety, and depression, as well as somatic
complaints that may mimic medical illness, further delaying
accurate diagnosis.
Roughly 1% of the elderly population has a problem with
alcoholism; the prevalence of alcoholism in the Epidemiologi-
cal Catchment Area (ECA) study was 1.5% to 3.7%. Although
cross-sectional studies have suggested that the percentage of
alcoholism declines after age 60, longitudinal studies propose
a stable pattern of lifelong alcohol abuse.
Women drink less than men at all ages, but older widowed
women are at risk for increasing their intake. Studies note that
the prevalence of alcohol problems in women is on the rise.
Older adults with alcohol dependence also have a high preva-
lence of co-morbid nicotine dependence.
Q4 The answer is: 25% to 50%.
Alzheimer’s disease typically affects 1% of 60-year-olds, 5% to
8% of those over 65 years, 15% to 20% of those over 75 years,
and 25% to 50% of those over 85 years; its course is that of a
steady decline over approximately 8 to 10 years.