Review Article
Obsessive-Compulsive Disorder in Older Adults:
A Comprehensive Literature Review
We reviewed English-language articles concern-
ing obsessive-compulsive disorder (OCD) in older
adults. PubMed was searched using key words
that included obsessive-compulsive disorder, geri-
atric, elderly, aging, and older. Of the 644 articles
identified, we included 78 that were relevant to
the topic. Articles that were excluded as irrele-
vant included studies that were not focused on
OCD in older adults, animal studies, and older
Downloaded from http://journals.lww.com/practicalpsychiatry by BhDMf5ePHKbH4TTImqenVIhz0dzqyKWS/Onek2o5H0e9E9z+CvPjlqb1N01se2wpYqAeS4odujY= on 06/08/2020
case reports if we identified similar more recent
case reports. The literature contains very little
information about the epidemiology, diagnosis,
psychopathology, and treatment of OCD in older
adults. Even though the diagnostic criteria for
OCD are the same for older and younger adults,
different manifestations and progression in older
patients have been reported. While the domains
and severity of symptoms of OCD do not change
with age, pathologic doubt may worsen. The
Yale-Brown Obsessive Compulsive Scale is used
for diagnosing and evaluating illness severity,
and the Obsessive-Compulsive Inventory-Revised
is another valuable tool for use in older adults.
Psychotherapy, specifically exposure and respo-
nse prevention, is the first-line treatment for OCD
because of minimal adverse effects and reported
benefit. Although the US Food and Drug Admin-
istration has not approved any medications
specifically for OCD in older adults, pharmaco-
therapy is a consideration if psychotherapy is not
successful. Selective serotonin reuptake inhib-
itors have the fewest side effects, while the
cardiovascular and anticholinergic side effects
of tricyclic antidepressants are especially worri-
some in older adults. OCD in older adults has
received little attention, and further studies are
needed.
(Journal of Psychiatric Practice 2020;26;175–184)
KEY WORDS: obsessive-compulsive disorder (OCD),
obsessions, compulsions, older adults, geriatric, psycho-
therapy, psychopharmacology
Although obsessive-compulsive disorder (OCD) has
been studied extensively in most age groups,1 there is
little research on the neuropsychology, epidemiology, or
Journal of Psychiatric Practice Vol. 26, No. 3
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ALI NAJAFIAN JAZI, MD
ALI A. ASGHAR-ALI, MD
clinical manifestation of OCD in the geriatric popu-
lation.2–4 The lifetime prevalence of OCD has been
reported to be between 1.5% and 3.5%.3,5 It has been
reported that the prevalence of OCD decreases with
age, with a prevalence between 0% and 0.8% in people
over 60 years of age.3,6 However, in 2017, Cath et al7
reported an overall prevalence of 5.7% for provisional
diagnoses of OCD based on self-report, with younger
and older individuals ( > 65 y of age) having higher
prevalence rates than individuals in middle age.
Most available knowledge on late-onset OCD comes
from case studies.8 Onset of OCD after 50 years of age
is rare; and, if it occurs, requires consideration of
general medical causes.9 However, case reports have
described the onset of OCD in individuals older than
65 years of age after a stressful life situation in the
absence of brain injuries.10,11
Significant stressors, including health problems or
losses, may occur in late life, which can broadly influ-
ence adjustment and affect the occurrence of late-life
emotional disorders.12 There are studies suggesting an
association between OCD and quality of life.13 Social
functioning is more affected in older adults with OCD
than in those with anxiety disorders. OCD is associated
with disabilities in older people, particularly in rela-
tionships with others such as spouses or life partners
with whom they often have conflicts or whom they may
involve in their OCD symptoms, such as rituals.5
NAJAFIAN JAZI: Department of Psychiatry and Biobehavioral
Sciences, Geffen School of Medicine at University of California
Los Angeles, Los Angeles, CA; ASGHAR-ALI: Baylor College of
Medicine, Michael E. DeBakey Veterans Affairs Medical Center,
and South Central Mental Illness Research, Education and
Clinical Center, Houston, TX
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Please send correspondence to: Ali A. Asghar-Ali, MD,
(MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX
77030 (e-mail: asgharal@bcm.edu).
This work involved the use of facilities and resources of the
Houston VA HSR&D Center for Innovations in Quality, Effective-
ness, and Safety (CIN13-413) and was supported in part by the VA
South Central Mental Illness Research, Education and Clinical
Center. The views expressed reflect those of the authors and not
necessarily those of the Department of Veterans Affairs, the US
government, or Baylor College of Medicine.
The authors declare no conflicts of interest.
DOI: 10.1097/PRA.0000000000000463
May 2020 175
 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS

In this study, we sought to examine what is known more recent, similar case reports were already included
about the epidemiology, psychopathology, diagnosis, in our review, articles in which the focus of the study
comorbidities, and treatment options of OCD in older was not OCD in older adults, non–English-language
adults. studies, and nonhuman animal studies.

METHODS
We searched PubMed for any English article the
title or abstract of which contained the term obsessive
compulsive disorder as well as one of the following
terms: geriatric, elder (every word with elder as a prefix),
old, older, older adult(s), aging.
Given the general dearth of literature, we did not
limit the timeframe for the articles or the type of study.
The most recent publication date included in our search
result was February 2018. We reviewed all abstracts
that were found and included meta-analyses, system-
atic reviews, review articles, clinical trials, cohort stud-
ies, case-control studies, cross-sectional studies, case
reports and series, and any other article identified in
PubMed in which OCD in older adults had been dis-
cussed. The only articles excluded were case reports if
RESULTS
Our electronic search strategy identified 644 abstracts.
Of these, 501 articles did not focus on OCD in older
adults (eg, they focused on children or younger adults,
illnesses other than OCD, or topics unrelated to OCD
such as “life satisfaction”); 5 articles were older case
reports with newer, similar case reports available; 56
articles were not in English; and 4 articles described
nonhuman animal studies. After we excluded these
articles, 78 studies remained and were included in the
review (Fig. 1).
Epidemiology
In a 1997 review, which studied the epidemiology of
late-life mental health conditions between 1970 and

FIGURE 1. Schematic Illustration of the Study Selection Criteria

Identification

1. Records identified through

database searching
(N = 644)

Records excluded
Screening

(n = 501) because they did

Records screened not focus on OCD in older
(n = 644) adults
Eligibility

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 143) (n = 65)

Older case reports with

newer similar case reports
Included

Studies included in available–5

qualitative synthesis Not in English–56
(n = 78) Animal studies–4

Flow diagram based on the PRISMA method of reporting presented in Moher et al.14 For more information, see http://www.
prisma-statement.org. OCD indicates obsessive-compulsive disorder.

176 May 2020 Journal of Psychiatric Practice Vol. 26, No. 3

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
1996, OCD was reported as one of the most anxiety-
provoking conditions in late life.15 In 2017, Dell’Osso
et al3 reported the results of a study of the prevalence,
sociodemographics, and clinical manifestations of OCD
in the geriatric population in an international sample.
This study found that ∼5% of individuals receiving
care at OCD specialty clinics were 60 years of age or
older and that most of them had experienced symp-
toms for decades. It also found that people with OCD
who were over 65 years of age had a significantly later
age at onset (29.4 ± 15.1 vs. 18.7 ± 9.2 y, P < 0.001),
more frequent adult-onset (75% vs. 41.1%, P < 0.001),
and less frequent use of cognitive-behavioral therapy
(CBT) (20.8% vs. 41.8%, P < 0.05) compared with peo-
ple younger than 65 years.3 A British group in 2013
reported that the 1-month prevalence of obsessive
symptoms, compulsive symptoms, and OCD were
4.7%, 2.3%, and 0.4%, respectively, in adults between
60 and 79 years of age, compared with 5.9%, 3.2%, and
0.8% in younger participants.2 In this study, the focus
of the analysis was obsessive and compulsive symp-
toms rather than OCD itself. Among the people with
symptoms, 67.8% reported obsessive symptoms as
being distressing; and 70.2% reported compulsive
symptoms as being distressing and associated with
worse mental health-related quality of life.2
Data on the gender difference in OCD in older adults
vary. Some studies report no significant difference
between the prevalence of OCD in older men and
women.2,5 However, 1 study found a higher percentage
of geriatric women than men with OCD (63.1% vs.
52.1%, P < 0.05).3 whereas another study noted a higher
prevalence of OCD in geriatric men than women.5
Clinical Manifestation and Diagnosis
Older adults more frequently experience somatic
symptoms, religiosity, and moral scrupulosity than
younger adults.4 In a 40-year follow-up of individuals
with OCD,16 83% improved, even without effective
pharmacological treatment, and 48% recovered (20%
completely recovered, and 28% showed partial recov-
ery). However, the results of this study also suggested
that recovery, even at a young age, does not exclude
very late relapses.16 This study also found that the
content of symptoms changed in two thirds of individ-
uals. Another study, however, found no change in the
focus of OCD symptoms in an 18-month follow-up using
the Obsessive-Compulsive Inventory-Revised (OCI-R).1
Journal of Psychiatric Practice Vol. 26, No. 3
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
The severity of obsessive-compulsive symptoms
appears to remain stable across age, except for patho-
logic doubt, which increases after age 60.7 Lower verbal
IQ estimates and lower verbal fluency scores in older
adults have been found to be associated with OCD2 and
might contribute to the increased severity of pathologic
doubt.7
There is no clear definition for late-onset OCD,8 and
onset in late life is quite rare.2 Late-onset OCD is
defined variably, with onset described as between 30
and 50 years of age.8 A systematic review of late-onset
OCD showed individuals with onset on or after age
30 years displayed significantly shorter durations
of illness before treatment; milder obsessions; and less
frequent contamination, religious, or somatic obses-
sions. Comorbidity, insight, depressive symptoms,
quality of life, and social functioning did not differ
between earlier and later onset groups (onset before vs.
after 30 y of age).8,17 An older review reported that
OCD can occur as a primary disorder for the first time
in older women, whereas in men it either persists from
younger years or arises in the context of another psy-
chiatric or medical disorder.18
OCD’s protean symptomology results in individuals
being misdiagnosed with many other conditions.19
Underlying structural brain damage, such as caused by
infections, degenerative disorders, brain injury, or cer-
ebrovascular lesions, needs to be strongly considered in
new-onset OCD that occurs in someone over 50 years of
age.20 Frontal lobe syndrome, impulsivity, and dop-
amine dysregulation syndrome can all be considered as
differential diagnoses in individuals with compulsive
behaviors.21 Punding, a stereotypical behavior charac-
terized by an intense fascination with repetitive han-
dling and examining of mechanical devices or arranging
common objects, is seen in persons with parkinsonism
and can be mistakenly diagnosed as OCD.22
The most frequently used measure to assess OCD is
the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
The Y-BOCS includes a 10-item clinician-rated scale
assessing both the presence and severity of obsessions
and compulsions in the previous week, with 5 items
addressing obsessions and 5 items addressing compul-
sions. In addition, the Y-BOCS symptom checklist
assesses the severity of 54 symptoms in terms of time
spent, interference, distress, resistance, and control.23
Another scale used to assess OCD is the OCI-R, a self-
report scale that has been reported to be both reliable
and valid in detecting OCD in older people. The OCI-R
has only 18 items and covers 6 subscales, including
May 2020 177
 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
washing, checking, ordering, obsessing, hoarding, and
mental neutralizing. Rather than being a diagnostic
tool, it is a screening tool that can be completed in a
short time.1,24
Biopsychopathology
In 1998, Beekman et al25 studied anxiety disorders,
including OCD using the criteria in the Diagnostic
& Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) and reported that neither ageing
nor age-related changes were very important in the
etiology of anxiety disorders. However, more spe-
cifically, they found that, in older individuals,
stress-related risk factors such as partner loss,
chronic physical illness, and poor subjective health
were strongly associated with OCD.
According to available studies, the underlying
mechanism of OCD in geriatric and other age groups
seems to be similar; however, difficulty in identifying a
unique mechanism in older adults may be due to a lack
of studies in geriatrics.12 Many studies have inves-
tigated the role of anatomic structures, including the
involvement of basal ganglia-thalamocortical circuits,
in the development of OCD.26–29 In a 2007 case
report,30 the occurrence of OCD secondary to brain-
stem and pons infarction was presented. In that case,
brain magnetic resonance imaging showed only pon-
tine infarction; but a single-photon emission computed
tomographic scan of the brain showed decreased
regional cerebral blood flow in the temporal lobes and
other cerebral cortical areas. This phenomenon is
termed diaschisis, and temporal lobe diaschisis was
associated with OCD in this patient. In another study,
the use of single-photon emission computed tomog-
raphy in a 71-year-old individual showed an associa-
tion between acute onset of OCD and decreased
regional cerebral blood flow in the right basal ganglia
and temporal areas and higher activity in the right
orbitofrontal area.31
Prouvost et al12 evaluated the possible relation-
ship between cognitive dysfunction and the devel-
opment of obsessive symptoms in late life. They
tested their hypothesis that older adults’ concerns
about changes in cognitive functioning and related
vigilance about their cognitive abilities [ie, cognitive
self-cognition (CSC)] were correlated with OCD
symptoms and might influence reactivity to aspects
of cognition, including their reactions to common
178 May 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
negative intrusive thoughts. CSC is defined as an
excessive awareness of, and attention to, thought
experiences, which can differentiate individuals
with OCD from persons with a generalized anxiety
disorder.12,32 Prouvost et al12 also reported that
lower cognitive scores predicted an increase in CSC,
which is associated with OCD.
In 2014, Frydman et al33 proposed that OCD with
onset after 40 years of age is more likely in women
with at least 10 years’ history of subclinical obses-
sive-compulsive symptoms, those with comorbid
posttraumatic stress disorder after age 40 years,
and individuals with a history of recent pregnancy
in self or significant others.
In a case series involving over 1000 individuals
with OCD, only 5 had an age of onset at 50 years or
older; and, among those, 4 had brain lesions in the
frontal lobe and caudate nuclei.34 Compulsive whis-
tling has been reported in people with frontal lobe
lesions following cardiac arrest.21 The reactivation of
OCD symptoms following cerebrovascular incidents
in prefrontosubcortical circuits after decades of being
asymptomatic has also been reported.35 It was also
reported that a 69-year-old individual with glioma-
tosis cerebri with lesions of the caudate nuclei and
frontal lobe possibly developed late-onset OCD.20
Acute onset of OCD was also reported in a 62-year-
old woman with no psychiatric history in association
with left cerebellar lesions secondary to an arachnoid
cyst in the left posterior fossa.9
A family study of a woman with both OCD and
Alzheimer disease (AD) involving 15 family mem-
bers showed a strong association between AD and
OCD in multiple generations, which might support a
similar underlying mechanism involving glutamatergic
dysfunction.36 However, age of onset of OCD has not
been associated with memory impairment in adults.
Although this finding is not conclusive, aging might not
influence memory impairment in patients with OCD.37
There are also other reports about the role of the glu-
taminergic system in the pathophysiology of OCD.36,38
Comorbid Conditions
It has been reported that the pattern of comorbid
conditions is similar in older and younger adults with
OCD.2 Dell’Osso et al3 reported no significant associa-
tion between age and comorbid psychiatric conditions
in older adults with OCD. In an international,
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 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
multicenter, cross-sectional study in 1994, the inves-
tigators studied the prevalence of comorbid conditions
in people with OCD from all age groups and found that
49.7% of the individuals had a comorbid anxiety dis-
order and that 28.77% had comorbid depression.39 A
Brazilian group found that 92% of 1001 individuals
with OCD from all age groups had at least 1 comorbid
condition.13 They reported on 3 illnesses that presented
before OCD: separation anxiety disorder, attention-
deficit/hyperactivity disorder (ADHD), and tic disorders.
Those who first presented with a separation anxiety
disorder were more likely to develop posttraumatic
stress disorder later in life. People who first had ADHD
had higher frequencies of substance use disorders later
in life. Finally, people who first presented with tic dis-
orders had higher frequencies of obsessive compulsive
spectrum disorders (trichotillomania, skin picking, and
body dysmorphic disorder) later in life.13 Although
hoarding behaviors may be seen in people with OCD, in
an inpatient sample of 100 geriatric patients, hoarding
behaviors were seen in 5 patients, 4 of whom had
schizophrenia and dementia, while the fifth had bipolar
disorder and dementia.40 Obsessional illness and, in
particular, its relationship with brain mechanisms and
cognitive disorders, are not fully understood. Relative
impairment in executive function in older adults with
OCD has been reported, and this finding may support
more close workup for cognitive impairment in older
adults with OCD.2 In another study, nocturnal
walking was significantly associated with OCD in
individuals of all ages.41 An association between
OCD and movement disorders has also been
reported in different age groups.26
Although rare, OCD, especially in older people,
can contribute to serious health conditions, such as
scurvy, severe self-starvation, or death due to
restricted intake.42,43 As noted earlier, chronic OCD
may also contribute to cognitive impairment in older
individuals.2 Few reports exist concerning OCD as a
prodromal condition. However, in a case report, a
64-year-old woman with chronic OCD was sub-
sequently diagnosed with progressive supranuclear
palsy, leading the authors to conclude that a complex
group of neurodegenerative disorders may mas-
querade for many years as refractory psychiatric
disorders.44 In another case report, a 57-year-old
woman with new-onset OCD who was followed for
7 years developed AD at 64 years of age.8
Many older adults with psychiatric conditions,
including OCD, experience pain. Pain in younger and
Journal of Psychiatric Practice Vol. 26, No. 3
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
older adults differs in clinical and theoretical ways.45
Pain, traditionally linked with old age, was reported by
22% of nursing home residents (293,827 total resi-
dents) in a 2009 study that used data from the results
of the 2004 National Nursing Home Survey.46 In this
study, 18.3% of the residents with OCD reported pain;
and its intensity was higher in those individuals than
in residents with other neuropsychiatric disorders.
However, as the authors mentioned, their scale was
not validated, which might have a complicated inter-
pretation of their results.46
Treatment
Although remission of OCD in patients who have
never received treatment has been reported, OCD is
more often a chronic condition that rarely improves
without treatment.13 On the basis of a large pop-
ulation survey, Grenier et al5 reported that only
10% of older adults with OCD had sought treat-
ment. Little is known about the best treatment for
older patients with OCD.12
Psychotherapy
CBT, in the form of exposure and response prevention
(ERP), has been reported to be the most effective
treatment for OCD and to be equally effective in older
and younger adults.47 However, psychotherapy for
OCD in older people has received little attention.48
Although CBT for OCD has not been adequately
evaluated in older adults, there are case reports of its
successful use. For example, the successful use of CBT
in an older patient with 7 decades of OCD and symp-
toms of excessive reassurance-seeking was described in
2017.49 However, there are limitations in using CBT in
older adults, such as not being able to use it with
people with moderate-to-severe intellectual disabilities
and/or severe physical impairment and issues related
to availability/affordability.3
Several case reports of successful use of ERP in
older patients with OCD have appeared. In a 1997
case report, in vivo ERP with a 78-year-old woman
with acute late onset of progressive OCD reduced the
Y-BOCS score from 35 to 11 after 8 hours of treat-
ment in the individual’s home and this improvement
was maintained at 2-month follow-up.50 In another
case, an 80-year-old man with a 60-year history of
moderate OCD received fourteen 50-minute ERP
sessions, which resulted in a 65% reduction in his
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 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
Y-BOCS score from 20 to 7 and a 45% reduction in his
OCI-R score from 38 to 21 at 7-month follow-up.51 In
another study, an 80-year-old man responded to 3
weeks of ERP after failing to respond to selective
serotonin reuptake inhibitors (SSRIs).52 Techniques
such as ERP may be preferred in older individuals in
whom side effects of psychopharmacologic treatments
are a greater concern than in younger patients.51 Some
modifications in the ERP (eg, motivational enhance-
ment) may be needed on a case-by-case basis.48,51
Other types of psychotherapy have also been
shown to be effective in older patients with OCD.
For instance, brief dynamic psychotherapy was
reported to be successful in a 57-year-old man with
late-onset OCD who was reluctant to take medi-
cations and successfully responded to 9 sessions
based on David Malan’s model.53 There are also
reports of successful treatment of OCD in older
people with simultaneous use of behavioral therapy
and antidepressants such as clomipramine, imipr-
amine, and sertraline.54–56
Psychopharmacological Treatment
Currently no pharmacological agents have US Food
and Drug Administration approval specifically for
treating OCD in older adults, although a number of
agents have been approved for the treatment of
OCD in the general adult population. Options for
treatment-resistant OCD in older people have also
not been well studied.57 However, based on available
evidence, psychopharmacological treatment may be
considered, even if the older adult has had OCD for
decades.16 The general principle for medication
intervention in geriatric patients is slow titration
(eg, beginning at one half or even one fourth of the
usual starting dose of antidepressants). In addition,
regular follow-ups and reassurance are necessary.58
Pharmacological interventions in older adults are
usually complicated by issues such as polypharmacy
and comorbidity.57 Because SSRIs have fewer side
effects (eg, anticholinergic effects, hypotension), they
are considered the first-line treatment for OCD in
older patients.3 Fluvoxamine was examined in a
small, open-label trial in older people. After 12 weeks
of treatment, 8 of 12 subjects achieved a 50%
reduction in symptoms; and 7 of 12 showed very
much improvement.59 In contrast to findings con-
cerning depressive and anxiety disorders, no studies
support the use of paroxetine in older adults with
OCD. However, in 1 case study, daily use of paroxetine
180 May 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
40 mg was helpful in managing sexually compulsive
behavior in an older adult with frontotemporal
dementia.60 There are also reports of response to
serotonin and norepinephrine reuptake inhibitors such
as venlafaxine for the treatment of comorbid major
depressive disorder and OCD.61
Tricyclic antidepressants, especially clomipr-
amine, have been used to treat OCD. Although
these agents appear to be promising for the treat-
ment of younger adults with OCD, the serious car-
diac side effects of the tricyclic antidepressants are
a limiting factor in their use in the geriatric pop-
ulation. Tricyclic antidepressants can cause slow
cardiac conduction, arrhythmias, and orthostatic
hypotension.4,62–65 In addition, dropout rates from
treatment with paroxetine (9%) are significantly
less than those with clomipramine (17%).66 Anti-
cholinergic side effects and, consequently, delirium
also need to be considered in older patients.67
Clinicians may need to pay special attention when
using medications with anticholinergic side effects
to treat individuals with cognitive impairment.4 It
has been suggested that 70 years of age is a rea-
sonable threshold to delineate an older group at
risk for significant adverse effects from tricyclic
antidepressants.4
Case studies have also reported on augmentation
techniques in the treatment of OCD in older patients.
For example, augmenting mirtazapine with bupropion
was successful in treating compulsive buying behavior
in a 60-year-old woman.68 Augmentation of clomipr-
amine with the glutamatergic agent lamotrigine was
also reported to be successful in a 59-year-old woman
with treatment-resistant OCD.69 Although side effects
of second-generation antipsychotics are common,70
their off-label use to augment SSRIs in the treatment
of OCD has also been tested.71 Risperidone has been
associated with a 3.9-fold greater likelihood of “res-
ponding,” defined as a 25% to 35% improvement on the
Y-BOCS compared with placebo.70 In 1 case report,
fluoxetine was successfully augmented with olanza-
pine in a 77-year-old woman with chronic but acutely
exacerbated OCD.43
Although the occurrence of comorbid movement
disorders, such as Parkinson disease (PD), with OCD,
has been recognized for the past century, the treat-
ment of OCD in these individuals is still complicated.
Common therapeutic strategies for OCD such as
SSRIs can aggravate motor symptoms by stimulating
5-HT2 receptors and inhibiting dopamine release in
Journal of Psychiatric Practice Vol. 26, No. 3
 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
the basal ganglia. In contrast, the use of levodopa in
PD may trigger compulsive and impulsive behaviors.
In a case series published in 2008, promising results
were reported with clomipramine in treating late-
onset OCD in patients with comorbid PD who did not
respond to, or could not tolerate, SSRIs.26
Other Treatment Options
A few studies, mainly case reports, have discussed
the use of alternative treatments for OCD in older
people.
Deep brain stimulation (DBS). One case
report described a 58-year-old man with PD whose
comorbid OCD and mood symptoms improved fol-
lowing the addition of bilateral ventral capsule/
ventral striatum DBS to subthalamic nuclei DBS.72
Another report presented the case of a 60-year-old
man with chronic OCD who responded to DBS
implanted next to the nucleus accumbens.73
Transcranial magnetic stimulation (TMS).
The use of repetitive TMS has not been well studied
in geriatric patients. However, a study that
reviewed findings concerning the use of TMS in a
variety of neuropsychiatric disorders found that
TMS appeared to be ineffective in treating OCD.74
Electroconvulsive therapy (ECT). A case study
reported improvement in compulsive behaviors
following intensive ECT treatment in a 67-year-
old man with polyembolokoilamania (insertion of
foreign objects in body orifices), depression, and
frontotemporal dementia.75 The compulsive symp-
toms were independent of the individual’s sexual
behavior and failed to respond to antiestrogen
agents. Another publication reported the case
of an 81-year-old woman without medical pro-
blems or psychiatric history who developed treat-
ment-resistant, late-onset OCD after an acute right
macular hemorrhage and loss of vision who
responded to ECT.76
Surgical intervention. Another publication
reported the case of a 74-year-old woman with
chronic OCD whose symptoms abruptly dis-
appeared following a left capsular genu infarction.77
This infarction might have simulated a bilateral
anterior capsulotomy, which is a last-resort treat-
ment for treatment-resistant OCD. Finally, a case
series published in 2002 compared resolution of
OCD symptoms following radiofrequency capsu-
lotomy in an 18- and a 64-year-old patient, both of
whom had chronic treatment-refractory OCD. The
Journal of Psychiatric Practice Vol. 26, No. 3
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
older patient improved gradually over 24 months
(Y-BOCS score decreased from 30 to 8), whereas the
younger patient improved shortly after the surgery
(Y-BOCS score decreased to 0).78
DISCUSSION
While OCD has been reported to be less prevalent in
older adults than in younger age groups, these
results might be the consequence of difficulties
including individuals in studies because of age-spe-
cific limitations, such as living in skilled facilities and
having multiple other heath conditions.12 In addi-
tion, the very low prevalence of OCD compared with
other mental health conditions in older adults may
not reflect reality, since this finding might be the
result of other factors such as individuals being lost
to follow-up due to reduced severity of the illness,
deciding to stop treatment due to lack of efficacy, or
the predominance of comorbid medical conditions.3
In older adults, obsessive-compulsive symptoms can
be the result of an interplay of chronic psychi-
atric illnesses and the development of cognitive
disorders.13 This can be further complicated by the
presence of medical illnesses that can compromise an
older adult’s mental state and impair the ability to
reliably identify symptoms and make accurate diag-
noses. The absence of a specific psychometric scale
for diagnosing OCD in this age group may also con-
tribute to the lack of adequate investigations1 and
diagnosis in clinical settings. These limitations in the
recognition of OCD, coupled with a limited under-
standing of the biological underpinnings of the con-
dition in older adults, further limit the ability to
diagnosis the disorder. While OCD may be less
common among older patients, the condition results
in significant distress in these individuals. Although
the situation is improving, the exclusion of older
adults in medical research limits the ability of those
caring for older adults to glean recommendations
from existing literature.79 There is a great need for
well-studied interventions in this field. However,
based on the available data, psychotherapy, espe-
cially ERP, is the most favorable option, followed by
the use of SSRIs, which have the fewest side effects
among the pharmaceutical options.
To better describe OCD in older adults, more
research is needed in the manifestation of obses-
sive-compulsive symptoms in older adults with
comorbid psychiatric and mental illnesses. In
May 2020 181
 OBSESSIVE-COMPULSIVE DISORDER IN OLDER ADULTS
addition, greater refinement of the potential neu-
ropsychological contributions to the manifestation
of OCD in older adults is needed to understand how
a person’s aging brain may influence the pre-
sentation of OCD. Finally, once OCD is better
described in older adults, it will be important to
develop more targeted treatment interventions that
are tailored to the needs of older adults, including
adaptations of psychotherapy to different cognitive
levels.
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