Epidemiology
The high frequency of mental health problems in the elderly is significant; they impact mental status and emotional states and potentially influence the course of physical illness. Epidemiologic studies since the 1950s have documented a 15% to 25% prevalence of serious menial disorders in those “-”– 65 yr old. More than 25% of stale mental hospital patients in the USA (> 50% in the United Kingdom) arc s 65 yrofage.
Psychiatric problems are a primary or secondary diagnosis in 70% to 80% of nursing home residents; one sludy identified 9A!X of nursing home residents as having menial disorders, according to criteria in I he Diagnostic and Statistical Manual of Mental Disorders, Fourth Kdition (IXSM-IV). Because of improved general medical care in the community, patients admitted to nursing homes tend to be sicker, both mentally and physically, than in the past. However, mental disorders, particularly organic disorders, have always been prevalent in nursing home patients.
Organic disorders (most commonly, Alzheimer’s disease) affect about 10% of those > 65 yrold—the rate is considerably higher (at least 25%) in those s- 85 yr old. Significant symptoms of depression have been described in 15%J of community-dwelling elderly persons, and of schizophrenia, in 0.5% to 1.0%. The prevalence of alcohol abuse is difficult to determine but is considered to be high, conservatively estimated at 2% to 5%. Suicide occurs more often in elderly men than in any olher age group (see Suicide, below).
Discrepancies in the prevalence rales of depression in the elderly may be explained by noting that different classificalions of depression are often compared. Lower prevalence figures typically take into account only primary depressions, ie, those occurring without physical disorders or drug side effects. Secondary depressions accompany or result from somatic illness or adverse drug effects. The elderly are al greater risk than other age groups for secondary depressions because they have more physical illness and Ihc highest rate of drug use. For example, one study found that 24% of 406 elderly men seen for physical disorders in a primary care selling complained of clinically significant depressive symptoms; other studies report even higher frequencies of depressive symptoms in such persons. Thus, higher prevalence figures are more accurate because they include both primary and secondary depressions.
Symptoms and Signs
Psychiatric symptoms that develop in later life are often dismissed as normal manifeslations of aging. Even schizophrenia-like symptoms may be dismissed as eccentricity or misdiagnosed as senility. Treatment cannot be planned if a problem is not acknowledged and identified.
Memory and intellectual difficulties: Significant changes in intellectual functioning are no longer readily dismissed, given the heightened awareness of Alzheimer’s disease. But the degree to which depression, anxiely, and other psychiatric disorders can inlerfere with cognition is still underappreciated. Pseudodementia (eg. depression or psychosis mimicking dementia) is an extreme form of such interference.
Change in sleep pattern (see also Ch. II): Complaints of diminished sleep time are often met with assurances that it is a normal part of aging. However, such a change should be viewed clinically as a group characteristic that does not apply to all individuals. Not all studies have found that total sleep lime is reduced in later life. Furthermore, the reduction is typically gradual; a change in sleep pattern should not be taken for granted, especially if it is of recent onset. An older person who reports noticeable reduction in sleep time (not just sleeping less at night because of daytime naps) should be evaluated.
Besides signaling potential medical (eg. musculoskeletal, genitourinary, cardiac) problems, changes in sleep pattern can be a hallmark of psychiatric disorders. Early morning awakening may be an important clue to an underlying depression; difficulty in falling asleep or restless sleep with frequent awakenings may signal an anxiety disorder.
Change in sexual interest or capacity (see also Chs. 68 and 69): As a group, healthy older men and women with a history of normal sexual activity and current opportunity retain an interest and capacity for sexual experience, although individuals may be exceptions. Significant changes, particularly of recent onset, call for diagnostic assessment with a focus on medical and surgical factors, drug side effects, and psychiatric causes. Medical problems and drug side effects affect the sexual function of men more than women, since these factors can interfere with erectile and ejaculatory capacity.
Common medical causes of erectile dysfunction include atherosclerosis (especially in diabetic patients), hypothyroidism, malnutrition, and Parkin_son”s disease. Among possible drug causes, alcohol consumption should be considered; alcohol in high amounts not only serves as a depressant, thereby negatively influencing sexual interest, but also can interfere with erectile and ejaculalory capacity. Depression or anxiety in both men and women can lower motivation for romantic involvement and diminish sexual satisfaction. Regardless of the cause, many sexual problems can be ameliorated or eliminated with proper intervention.
Fear oldeath: Research shows thai while the elderly often think about death, they fear dealh less than do other age groups. Thinking or talking about death is not the same as fearing or dreading it. Thoughts or conversations about death are naturally more common in the elderly, since they more likely have peers and relatives who have died or are dying. Dread of death is uncommon in persons who are not dying or experiencing some major loss, although reports show a normal and common dread of death in middle-aged persons, who may suddenly perceive how little time is left. At this stage, people find themselves confronting an existential awareness of their own mortality; with further aging, they adapt to this realization.
A terminal illness, an underlying depression, or other emotional conflict—not the awareness Of aging itself—predisposes certain elderly persons lo death anxiety. In these cases, confronting mortality is different; a terminal illness brings an awareness of dying that can lead to despondency. Eventually, most people come to terms with their fate and can reasonably accept their condition. Depression at any age clouds a person’s thinking and often increases thoughts about death. A noticeable and persistent uneasiness about death may signal underlying depression that could benefit from trealment. Evaluation is all the more important given the high rate of suicide in the elderly and the role of depression as a major risk factor.

The epidemiology of elder abuse and neglect has been better understood since the publication of the 1986 survey by the Family Research Laboratory at the University of New Hampshire. In this survey of 2020 randomly selected elderly people living in the Boston metropolitan area, 3.2% reported being abused. Abuse was defined as physical abuse, which included hitting, slapping, and pushing; neglect, which involved depriving a person of something needed for daily living; and chronic verbal aggression, which included verbal threats and insults. Because the survey did not cover all forms of elder mistreatment (eg, financial exploitation), the 3.2% figure underestimates the problem.
Recently, the Women’s Initiative of the American Association of Retired Persons categorized elder abuse and neglect as follows: (1) early onset spousal and partner abuse and neglect continuing into later life, (2) late onset spousal and partner abuse and neglect during later life, and (3) abuse and neglect by adult children and other relatives.
The Family Research Laboratory investigators found that most abuse is committed by one spouse against another; 65% of abuse cases were between spouses, and only 23% involved an adult child abusing a parent. Elderly husbands were abused twice as often as elderly wives. It is not known whether the abuse perpetrated by wives is a continuation of early onset spousal abuse done in a spirit of retaliation or self-protection. It is known that elderly wives are more seriously injured by their husbands than elderly husbands are by their wives.
This study also found that the abusers usually were dependent on the person they abused. The study indicates that a significant risk factor for abuse and neglect is a close proximity of living arrangements of victim and abuser. In the study, abuse occurred at all economic levels and in all age groups among the elderly

The epidemiology of elder abuse and neglect has been better understood since the publication of the 1986 survey by the Family Research Laboratory at the University of New Hampshire. In this survey of 2020 randomly selected elderly people living in the Boston metropolitan area, 3.2% reported being abused. Abuse was defined as physical abuse, which included hitting, slapping, and pushing; neglect, which involved depriving a person of something needed for daily living; and chronic verbal aggression, which included verbal threats and insults. Because the survey did not cover all forms of elder mistreatment (eg, financial exploitation), the 3.2% figure underestimates the problem.
Recently, the Women’s Initiative of the American Association of Retired Persons categorized elder abuse and neglect as follows: (1) early onset spousal and partner abuse and neglect continuing into later life, (2) late onset spousal and partner abuse and neglect during later life, and (3) abuse and neglect by adult children and other relatives.
The Family Research Laboratory investigators found that most abuse is committed by one spouse against another; 65% of abuse cases were between spouses, and only 23% involved an adult child abusing a parent. Elderly husbands were abused twice as often as elderly wives. It is not known whether the abuse perpetrated by wives is a continuation of early onset spousal abuse done in a spirit of retaliation or self-protection. It is known that elderly wives are more seriously injured by their husbands than elderly husbands are by their wives.
This study also found that the abusers usually were dependent on the person they abused. The study indicates that a significant risk factor for abuse and neglect is a close proximity of living arrangements of victim and abuser. In the study, abuse occurred at all economic levels and in all age groups among the elderly.