Introduction

Obsessive–compulsive disorder (OCD) has been a hidden disease. It was thought to be uncommon, largely untreatable when it occurred, and was thought to be treated mostly in specialty units. It was believed possible to be helped when depression was associated with OCD in that treatment of depression was often associated with remission of the OCD. In recent years, epidemiological studies have suggested a general population prevalence of about 2 % for OCD. Previous data had relied on numbers of patients attending specialist facilities, while ignoring morbidity in the general community. Furthermore, new and more effective psychological and physical treatments have resulted in renewed interest in diagnosing and treating this disabling disorder.

Almost nothing has been written about OCD in the elderly. This is despite the fact that it would be expected that approximately 2 % of the elderly would be affected by OCD and that it is both disabling and potentially treatable. The failure to diagnose OCD in the elderly may reflect the general way in which this is a hidden disorder. Many patients are embarrassed and reluctant to talk about the problem, or reveal it, even to people close to them. Elderly sufferers may lead relatively restricted lives without their OCD being challenged and made manifest by the need to cope with a job and raise a family. As the disabilities would have waxed and waned over the course of their lives, there may also have been an assumption on the patient's part, as well as that of their attending doctors, that any symptoms are simply ‘the way that person is’, or assumed to be a personality trait, rather than reflecting a disorder which is eminently treatable.

Introduction

Epidemiological studies can give information on the distribution of the various mood disorders (in time and place), and alert us to factors that appear to influence that distribution. Certain situations and changes may predispose individuals to develop depression or elevation of mood, precipitate it, prolong its course or alleviate it. Such knowledge may allow us to take a preventative approach, or may help in planning our clinical interventions.

Awareness of the prevalence and incidence of mood disorders is important when planning health services, but we need also to know how effective our various health services are. What do the outcome studies show? Of those who might benefit from our interventions, what proportion are referred to appropriate services?

In this chapter, attention will be given to the prevalence of depressive and bipolar disorders among elderly people in the community and in institutional settings. The importance of physical disorders in relation to depression in old age will be stressed, with particular mention of Parkinson's Disease, cerebrovascular disorders and organic brain disease.

More detailed discussion of depression in residential and primary care settings will be found in Chapters 10 and 11. The relationship between rates of suicide and depression will be reviewed in Chapter 14.

Perhaps the most important question to ask (before attempting to identify depressive disorders in the community, hospital or elsewhere) is this: if we find it, what can we do about it? Is it worth knowing? As will be shown, the prevalence of depressive symptoms and syndromes in old age is high, especially among the physically ill.

The development of noninvasive computerized brain imaging techniques and their application to functional psychiatric disorders such as depression and schizophrenia represents one of the most important research advances in psychiatry over the past two decades. This chapter reviews the results of reported brain imaging studies of depression, schizophrenia and schizophrenia-like illnesses in the elderly.

X-ray computer tomography studies

In cranial Computed Tomography (CT), an X-ray source is moved around the head in the transverse plane, and detectors directly opposite the source record the quantity of radiation that has passed through the head. From a large series of such readings, a two-dimensional image made up of scanned squares, or pixels, is built up and represents a transverse slice of the head 5–10 mm thick. Most CT scanners produce an image of 256 × 256 pixels. CT scanning is cheap, widely available, involves a scanning time of only around 10 minutes and is generally well tolerated by subjects. There have been a large number of studies of CT in depression in both young, elderly and mixed age populations of patients. Despite varying methodology, both in terms of patient and control selection and method of measurement of anatomical structures (hand tracing, mechanical planimetry or computerized quantification), the results are in general agreement.

Depression

In an early CT study of elderly depressed patients, Jacoby & Levy (1980) examined the scans of 41 patients diagnosed with the Geriatric Mental State Schedule (GMS) (Copeland et al. 1976) and 50 healthy age-matched controls.

This book originates in Australia, but it is of international significance. Deriving from a World Psychiatric Association meeting hosted in Melbourne, this is no mere text of conference proceedings; Edmond Chiu and David Ames have used the theme of that conference as the basis for a carefully planned series of commissioned contributions to a well-structured book.

The early years of psychogeriatrics were dominated, rightly and inevitably, by the ‘Everest of dementia’. It is evidence of the maturity and confidence of this branch of psychiatry (now an official subspecialty in the United Kingdom) that it here steps back from its concern with the insistent burden of the organic psychosyndromes, and focuses on the hugely important functional disorders of old age. Dementia in its most obvious manifestations obtrudes itself in a way which is hard (though too often still not impossible) to ignore; the sometimes more personal misery of functional mental disorders is too easy to overlook, or to confront inadequately amid the pressure of the needs of sufferers from the organic disorders and those who look after them.

Yet there were times when it was to functional illness that most of the attention of those working in the field of old age mental disorder was being given; prognosis here is generally better, the course often (not always) shorter, and the gratifications of successful treatment more direct.

Introduction

This chapter begins with the definitions of family therapy, gives an overview of the complex historical developments of the family therapy field, discusses the meager literature on the applications of family therapy to the elderly and ends with suggestions as to how the practitioner can apply family therapy concepts in their daily work. The chapter reflects the thinking of the two authors, who have been collaborating over the last three years in a project introducing family therapy into a geriatric psychiatry service.

The term family therapy can be used to describe interventions that can be added to other treatments within the framework of the biomedical model or the term can be used to describe an alternative model of helping people with problems. Family therapy as alternative model is also called the system or systemic model and it assumes that, to understand and help the older person with symptoms and signs of a functional psychiatric disorder, the clinician should have an understanding of the way symptoms and signs in an individual can be influenced by, and in turn influence interactions, behaviors and beliefs in other people, particularly in the family.

To clarify this distinction, it is useful to make the assumption that communications made by people can be understood in different ways.

Biomedical model

A clinician using the biomedical model, listening to an account given by an older person or one of their relatives would be listening for evidence and watching for behavior that helps them to decide what is wrong with the person.

Why treatment of depression in the elderly is different

Age is associated with differences in response to, and side-effects from, treatment. Pharmacokinetics alter with age (see Chapter 25), rates of pharmacologic sideeffects increase (see Chapter 25), issues of concern for psychotherapy are qualitatively distinct (see Chapters 27, 28, 29) and the outcome of electroconvulsive therapy (ECT) (see Chapter 26), even allowing for diagnosis, may be better in late life (Benbow, 1991).

Secondly, treatment differs in old age because of diagnostic variations. Depression in the elderly may appear phenomenologically similar to that in younger patients but have a different etiology. The reverse may hold too; a depression of putatively similar etiology is more likely to be psychotic and to be associated with psychomotor agitation in an older than in a younger person. Even within the elderly depressive population, there is heterogeneity. Depression with first onset in late life (late-onset depression) is more likely to have an organic basis than depression with first onset early in life and recurrence or persistence into later years (early-onset depression), which is more likely to be associated with a family history of affective disorder (Brodaty et al., 1991). Further, patients with depression of organic etiology or depression and concurrent physical morbidity are likely to have a poorer outcome.

Thirdly, the general health of the older depressed patient must also be considered in setting realistic goals for therapy. Elderly patients with depression are far more likely than younger ones to suffer from medical problems which may be a cause of or concomitant with their depression (Rothblum et al., 1982).

Introduction

With the introduction of modern drug treatment methods in psychiatry, the custodial mental hospitals opened their doors in the late 1950s. The ability to control disturbed behavior and discharge patients back into the community led to the realization of rehabilitation possibilities; the emergence of programs aimed at restoring the psychiatrically disabled person to full functioning and reintegration into home and community. This period coincided with the development of health care professions additional to medical and nursing. Social work, occupational therapy, physiotherapy and psychology evolved and emerged into distinct and autonomous health care disciplines. Music therapy, psychodrama and recreational therapy followed them to achieve health care profession status.

Recognising that the effective operation of a psychiatric treatment program requires the active participation and cooperation of members of these health care disciplines, psychiatrists gradually included them in treatment teams. The rise of the community psychiatry movement in the 1960s and 1970s gave further impetus to the concept and practice of multidisciplinary teams. Now, the concept of team work in psychiatry has evolved to such a degree, that multidisciplinary team work has become axiomatic in psychiatric care.

Definition

The word ‘multidisciplinary’ is not easily found in textbooks of psychiatry published in the 1970s and 1980s. There are few references to multidisciplinary team work in standard psychiatric texts.

The term is not found in the major medical dictionaries. In the 1990 Third Edition of Mosby's Medical Nursing and Allied Health Dictionary, ‘Multidisciplinary health care team’ is defined as ‘a group of health care workers who are members of different disciplines, each one providing specific services to the patient’.

Introduction

Why study the biological aspects of psychiatric illness in elderly people? The question leads to three others.

1. (i) Are there features specific to psychiatric illness in elderly patients?

2. (ii) Are the biological features in young patients also present in elderly patients?

3. (iii) Can evidence obtained from such study help determine whether aging itself is a factor in the late onset of psychiatric illness?

Answers to the first two questions might help show whether late onset disorders are materially different from early onset disorders. Some still believe this to be the case with depression (Teicher et al., 1988) and it remains an issue in relation to the para-/schizo-phrenias (Almeida et al., 1992). The last question is perhaps the most interesting but difficult to examine.

In the case of affective disorders, the notion that the process of physical aging acts as a risk factor has long been held (Burton, 1652; Maudsley, 1879; Charcot, 1881). In modern times, Post (1968) eloquently laid out the argument. Given that the genetic contribution was thought to diminish with increasing age of first onset and that there was little evidence to suggest personality weakness was of any importance, he wrote:

Post dismissed the possibility of endocrinological disorder and favored structural changes of the brain, which was reasonable given the state of knowledge at the time.

Introduction

In recent years a great deal has been written about the value of group psychotherapy for older people (Tross & Blum, 1988; Finkel, 1991; Leszcz, 1987, 1991; Lothstein & Zimet, 1988). Few clinics or programs, however, devote extensive resources providing group therapy services to a wide range of older adults. At the Older Adult Program of Northwestern Memorial Hospital, nine diverse group therapy experiences are provided both on-site and in the community at large. Over 80% of this population have diagnoses of functional psychiatric disorders, with depression being the most prevalent. The group therapy modalities include insight-oriented family support, cognitive behavioral, supportive, institutional, activities-oriented, creative, and bereavement groups.

Because there is a shortage of mental health professionals devoted to treating the increasing number of older people with functional disorders, group therapy is a logical and important treatment modality. Besides the obvious economic benefit compared to individual therapy, therapy groups provide nurturance, a sense of sustenance and support that allows older people to enhance their coping mechanisms, to resolve conflicts, and to diminish the disabling symptoms of functional disorders.

Group therapy offers the following special opportunities for older people:

1. To re-establish well-functioning defenses and coping mechanisms via interactions with other group members and to enhance a sense of usefulness in one another.

2. To establish a sense of identity as part of a social entity.

3. To become part of a family unit with a nurturing supportive system that would translate to other environmental situations.

4. […]

Introduction

This chapter deals with the contribution that epidemiology has made to our understanding of the functional psychiatric disorders in the elderly. To start with two terms should be defined. First, what is epidemiology? Descriptions range from the succinct ‘study of disease as a mass phenomenon’ by Greenwood (1934) to seven uses (Morris 1957) to five point definitions (Shepherd 1987). Practically speaking, nowadays, epidemiologists think in terms of four areas: rates of illness, correlates of caseness, risk factors and evaluating treatment and management. These can be addressed with relatively modest budgets and time frames. Other enterprises like longitudinal studies and field trials of new classifications, although fascinating, must be considered expensive and exceptional. Secondly, what does ‘functional’ mean? The Concise Oxford Dictionary (1982) defines functional in the case of mental illness as‘ having no discernable organic cause’. While modern textbooks do not attend to this definition, the Mayer-Gross, Slater and Roth textbook gave it two pages in 1969. There, ‘functional’ is used ‘to denote psychiatric disturbances unassociated with cerebral pathology or identifiable somatic disease’. There was thought to be relatively small overlap between ‘organic’ and ‘functional’. In the section on mental diseases of the aged, in the language of the day, the authors include manic-depressive disorder, chronic schizophrenia, late onset paraphrenia, neuroses and allied disorders and character disorders, including paranoid states.

The utility of epidemiology will be looked at through the perspectives of history, textbooks and recent publications.

Conceptual issues and the classification of affective disorders

The investigation of mania in old age invites a reconsideration of the fundamental nature of affective illness. Studying an elderly cohort offers the opportunity to examine a prolonged longitudinal course of the illness as well as focusing attention on the role of cerebral-organic factors. Recent studies of mania in old age have questioned the legitimacy of separating unipolar from bipolar disorders (Shulman & Post, 1980; Snowdon, 1991). Many unipolar depressives are apparently ‘converted’ into bipolars in old age after a latency of many years and numerous depressive episodes (Stone, 1989; Snowdon, 1991). This is also true of many young unipolar patients. Akiskal et al. (1983) found that 20% of young depressed patients with no prior history of mania became manic after an average 3-year prospective follow-up. Indeed, most clinicians are aware of subtle hypomanic shifts in ‘unipolar’ depressed and dysthymic patients. Because the study of the elderly lends itself to a retrospective cohort analysis, the longitudinal course of affective disorders is more readily revealed.

The notion of a spectrum of affective disorder as described by Akiskal (1983) is appealing. Milder expressions of the disorder include temperaments such as dysthymic, or hyperthymic. The range of expression continues from unipolar single episode to recurrent unipolar, bipolar II with mild hypomania to bipolar I with full-blown manic episodes. In this conceptual framework, mania is considered a more severe form of the disorder.

Introduction

A Darwinian might question the role of sexual behavior in the elderly, pointing out that the purpose of any species was to increase its kind, and coitus beyond the menopause had little to contribute to this aim. If so, he would be mistaken, because the sexual act is not only penetration and fertilization, but is preceded by grooming, whose purpose in primates is to reinforce social bonds. As the human child takes at least 15 years to reach physical maturity, the survival of the last born will depend on this bond lasting until the mother is 65, and the male 70 (due to the need of the female to chose her mate on his status he is usually older by five years (OPCS, 1992)). The earlier death of the male (his expectation of life in the UK in 1988 was 72.4 compared to 78 for the female (OPCS, 1992)) might suggest that he plays a lesser role in child-rearing, or is not really adapted to monogamy (Reynolds & Kellett, 1991). The advantage to the species of prolonging life beyond this point is more controversial, though the elderly may stabilize society as carriers of the culture and provide support for their progeny in rearing their children. Either way, the preservation of the marriage bond can improve the quality of the couple's lives as they compensate for their declining abilities. Male carers of demented wives do better when the sexual contact is retained (Morris, Morris & Britton, 1988).

Introduction

The average age of those patients still living in the large mental hospitals of the nineteenth and early twentieth centuries has steadily risen. These ‘old long-stay patients’ are often left behind in the hospital's remaining wards as younger more active patients are found places in community housing projects, group homes and psychiatric ‘hospital’ hostels (cf. Jones, 1989). Staff remaining behind with their patients are likely to be older and reluctant to contemplate finding a place for either themselves or their patients ‘in the community’. Should the mental health services continue to offer an asylum to these ageing schizophrenic patients whose adult life may well have been shaped by past institutional regimes? Are sheltered work opportunities or group living attractive options for these retirement-age patients? Does living in the community offer any real improvement in the quality of life for an elderly ex-asylum inmate? Or is a hostel or nursing home nothing more than a miniature asylum in the community, a parish madhouse replacing the county asylum? The aim of this chapter is to examine the empirical evidence and consider the policy options surrounding the move out of the asylum for the elderly person with chronic schizophrenia.

The decline of the psychiatric hospital

The number of mental hospital beds in both the United States and Europe has been reducing steadily in recent years and this downward trend seems to be accelerating. What happens to these disappearing patients is a question of concern to clinicians and policy makers alike.

Historical developments

Several factors have contributed to a growing interest and concern for elderly individuals with a history of schizophrenia. Demographic changes in an aging society as well as the reduced hospital mortality of schizophrenic patients, once at a very high risk especially for tuberculosis, have enabled an increasing number of these persons to become of age. Due to more active strategies in treatment and rehabilitation, such as effective control of productive symptomatology by antipsychotic medication as well as the provision of outpatient and complementary facilities, the duration of inpatient stay has dramatically decreased. Thus, individuals with a history of schizophrenia have become more visible in the community. Extensive long-term follow-up research has revitalized therapeutic activity and optimism even for the chronically hospitalized, because the outcome of schizophrenia was found to be more favorable than expected. ‘It is worth trying to help schizophrenics’ (Bleuler, 1974) once thought to suffer from a disease process inevitably leading to dementia.

Epidemiology of the elderly with schizophrenia

The incidence of schizophrenia in the elderly (i.e. onset of the disorder after age 65) is considered to approximate zero if the frequent paranoid states in the elderly, organic psychoses and similar delusional disorders without first-rank symptoms of schizophrenia are carefully ruled out (Bleuler, 1972; Huber, Gross & Schüttler, 1979).

Community studies on the prevalence of schizophrenia among the elderly (Krauss, 1989) have found rates ranging from 0.1% to 1.7%. For an overall estimate of the prevalence, some of these figures are possibly too low, because many chronic patients live quite adapted in homes and most prevalence studies did not include individuals in residential care.

The Geriatric Psychiatry Section of the World Psychiatric Association held its 1990 Symposium in Melbourne, Australia, with the theme of ‘Functional Psychiatric Disorders in the Elderly’. Having regard to the constant exposure of dementia in recent conferences all over the world, it was noted that the functional psychiatric disorders had received far less attention. As any practising clinician in geriatric psychiatry can readily attest to the number of patients whose functional psychiatric disorder requires attention, such a situation of neglect requires some redress.

Cambridge University Press, through the perspicacity and energy of Dr Richard Barling noted this conference theme and requested E. C. to make a proposal for the publication of a multi-authored volume on this subject. D. A. agreed to be a coeditor to accomplish the task. Some individual chapter authors were recruited on the basis of papers presented at the Melbourne Symposium, while others who had been unable to attend that meeting were invited to contribute because of their acknowledged expertise in particular areas which the editors considered pertinent to the theme of this text.

The editors are very grateful to the chapter authors, who took to the task given to them with goodwill and enthusiasm.

In the process of planning this book the term ‘functional’ exercised our minds as, in the context of geriatric psychiatry, such terms give rise to considerable debate.