Epidemiology of late-life mental disorders

Clin Geriatr Med 19 (2003) 663 – 696

Epidemiology of late-life mental disorders Celia F. Hybels, PhD*, Dan G. Blazer, MD, PhD Department of Psychiatry and Behavioral Sciences and Center for the Study of Aging and Human Development, Duke University Medical Center, Box 3003, Durham, NC 27710, USA

Mental disorders are not uncommon in late life. Although most psychiatric disorders occur less frequently in older populations, we know some mental disorders, such as dementia, are more prevalent in later years. In addition, many older adults present with symptoms that do not meet the criteria for a particular psychiatric disorder but nevertheless are clinically significant and affect quality of life, suggesting the psychiatric nomenclature may be less applicable for older adults. Epidemiology is the study of the distribution and determinants of disease frequency [1]. In studying the distribution of the disease, epidemiologists seek to determine who gets a particular disease and who does not, considering such factors as age, race, sex, place of residence, and related factors. Although other scientists such as biologists and geneticists in laboratories may work to discover the determinants or causes of disease, the unique contribution of epidemiologists lies in identifying causal factors that affect the distribution and occurrence of diseases in populations [1]. By addressing the frequency and distribution of mental disorders in older adults and the factors that affect this distribution, epidemiology has much to offer geriatricians and the field of geriatric medicine. In the sections following, the authors review the prevalence of mental disorders in late life, or the proportion of the population with a specific disorder at a particular point in time, and the incidence of mental disorders in older adults, the occurrence of new cases in a population that was previously disease free. The authors outline the epidemiologic challenges in determining the frequency of mental disorders in late life and discuss issues that are critical in understanding the prevalence of the disorders and in reviewing the evidence from epidemiologic studies of mental disorders in this population. The authors summarize the epidemiologic data for five disorders: depression, anxiety, dementia, schizophrenia, and alcoholism, including a discussion of risk factors and outcomes of these

This article was supported in part by Grants No. 1R01 AG20614-01A1 (Drs. Hybels and Blazer) and 5R01 MH54846-07 (Dr. Hybels) from the National Institutes of Health. * Corresponding author. E-mail address: [email protected] (C.F. Hybels). 0749-0690/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0749-0690(03)00042-9

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disorders. Finally, the authors conclude by discussing the implications of these epidemiologic findings for geriatric medicine.

Prevalence of psychiatric disorders In the United States, two large-scale studies have been conducted over the past two decades to examine the prevalence of mental disorders in adults. The more recent, the National Comorbidity Survey (NCS), was conducted from 1990– 1992 but did not include older adults [2]. Data from the earlier Epidemiologic Catchment Area (ECA) Survey [3] therefore are used to estimate the prevalence of psychiatric disorders in people age 65 years and older in the United States. The ECA was sponsored by the National Institute of Mental Health and was conducted from 1980– 1984 in five cities: New Haven, Connecticut; Baltimore, Maryland; St. Louis, Missouri; Durham, North Carolina; and Los Angeles, California. More than 18,000 community dwelling adults, including 5702 people age 65 years or older, were interviewed at baseline and recontacted 1 year later. People 60 years of age and older were oversampled. In addition, a supplementary sample of people residing in long-term care facilities was enrolled in the cohort. A team of trained lay interviewers administered the Diagnostic Interview Schedule (DIS) [4], a structured psychiatric interview from which DSM-III [5] diagnoses were constructed. The ECA study remains a landmark study in the field of psychiatric epidemiology because of its design and ability to use a structured instrument that could be administered by nonclinicians to generate DSM diagnoses. The ECA found the prevalence of DSM mental disorders was lower in late life than in younger adults and in mid life. Among the noninstitutionalized population age 65 years or older, the prevalence of any DIS disorder was 12.3%. This prevalence was lower than that observed in younger age groups (16.9% in people aged 18 –24 years, 17.3% in people aged 25– 44 years, and 13.3% in people aged 45 – 64). The prevalence was higher in older women (13.6%) compared with men (10.5%). Anxiety disorders were the most prevalent disorders among this age group at 5.5%. The prevalence of severe cognitive impairment was 4.9%, whereas the prevalence of any affective disorder was 2.5%. The prevalence of severe cognitive impairment was higher in men ages 65– 74 years, but was higher in women 75 years of age or older. Otherwise, with the exception of substance/ drug abuse/dependence and antisocial personality disorder, the prevalence of each mental disorder in people aged 65 or older was higher in women [6]. Similar results were reported from a study using methods similar to those used in the ECA conducted in Edmonton, Alberta, from 1983 –1986. There were 358 adults age 65 years or older in the household sample and the prevalence of any DIS disorder was 10.9% in this age group. The most prevalent disorders were any affective disorder (3.8%), any anxiety disorder (3.5%), and cognitive impairment (3.3%). The Edmonton survey also included an institutional component in which 199 persons 65 years of age or older were interviewed. The prevalence

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of any DIS disorder in this component was 72.2% in men and 77.2% in women. The most prevalent disorder was severe cognitive impairment [7]. The prevalence of mental disorders is higher in clinical and institutional samples. In a study of 350 patients age 70 years or older selected from primary care in Sweden, the prevalence of any mental disorder was 33% (16% dementia and 17% other mental disorder) [8]. The prevalence of psychiatric disorders in nursing homes ranges from 68% – 94% [9,10]. Before the conduct of these community studies, the prevalence of psychiatric disorders in older adults was not fully known and estimates of prevalence were based on clinical samples. Since the conduct of these early studies, other epidemiologic studies have been conducted in community and clinical samples and provide useful estimates of the prevalence and incidence of disorders. As discussed later, prevalence estimates vary across studies depending on factors such as case definition, the type of sample assessed, and how prevalence is defined. These factors present particular challenges to studying mental disorders in older adults. Case definition Epidemiologic studies of mental disorders in older adults have used various diagnostic schemes and instruments to define cases. Before the publication of DSM-III [5], case definition in the United States depended primarily on suspected etiology. DSM-III was innovative in providing objective criteria for assigning diagnoses. Instruments such as the DIS [4] were developed that would address specifically the criteria outlined in the nomenclature. Similarly, the Composite International Diagnostic Interview (CIDI) [11] corresponds to DSM-III-R [12] criteria. The Structured Clinical Interview for DSM-III-R [13] also has been used in some epidemiologic studies. The Geriatric Mental State Schedule –AGECAT [14] is used in Europe to identify patients that meet ICD-10 criteria. Some investigations have reported the prevalence according to more than one diagnostic criteria, because case definition can vary [15,16]. In addition, some research studies applied DSM-III hierarchic criteria, whereas others did not, which can affect the prevalence reported. Many of these criteria reflect disorders as they are seen in younger adults. Across disorders, it is less clear that the current nomenclature is applicable for disorders in late life. As discussed later, many older adults present clinically significant symptomatology that fails to meet the DSM criteria. The symptom count may be too low or the symptoms may not have been present long enough to meet the criteria for the disorder. Numerous scales have been developed to measure psychiatric symptoms in epidemiologic studies. The Center for Epidemiologic Studies – Depression (CES-D) Scale measures depressive symptoms present within the past week [17]. Similarly, the Geriatric Depression Scale (GDS) is used to screen for depression symptoms [18]. The Mini-Mental State Examination (MMSE) is used to screen for mild to moderate cognitive impairment [19]. Finally, the CAGE [20]

666

Authors, date [ref]

Study/location/instrument

Regier et al, 1988 [6]

Epidemiologic Catchment Area (ECA) Study—community sample; five communities in the United States; DIS Edmonton, Alberta; Household sample only; DIS

Bland et al, 1988 [7]

Henderson et al, 1993 [16]

Blazer and Williams, 1980 [23]

Beekman et al, 1995 [27]

Canberra, Australia; Canberra Interview for the Elderly Community and institutional Older Americans Resources and Services (OARS) Survey; Durham, North Carolina Longitudinal Aging Study Amsterdam (LASA); CES-D and DIS

Sample size

Age

Disorder

5702

65+

DSM-III major depression

0.7 0.4 men, 0.9 women

358

65+

DSM-III major depression

825 43

70+

DSM-III-R major depression ICD-10 depressive episodes

1.2 0.9 men, 1.4 women 1.0 3.3

997

65+

Major depression Dysphoric symptomatology

3.7 14.7

55 – 85

DSM-III major depression Minor depression

2.02 12.9

3056

Prevalence (%)

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Table 1 Selected studies of the prevalence of mood disorders in community studies of older populations

Edmonton, Canada; GMS; DSM-IV

1119

65+

Steffens et al, 2000 [25]

Cache County Study, Utah DIS Liverpool, England; GMS-AGECAT Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE); CES-D Hispanic EPESE; Mexican Americans in Texas, Colorado, New Mexico, Arizona, California; CES-D EURODEP—Nine European Centres

4559

65 – 100

GMS-AGECAT depression DSM-IV major depression DSM-IV minor depression DSM-IV major depression

1070 3998

65+ 65+

Depressive illness Depressive symptoms

2823

65+

Depressive symptoms

Copeland et al, 1987 [35] Blazer et al, 1991 [34]

Black et al, 1998 [36]

Copeland et al, 1999 [37]

13808

65+

Cases and subcases of depression

11.4 0.86 3.6 2.7 men, 4.4 women 11.3 9.0

25.6 17.3 31.9 12.3 8.6 14.1

men, women men, women

Abbreviations: CES-D, Center for Epidemiologic Studies—Depression Scale [17]; DIS, Diagnostic Interview Schedule [4]; DSM-III, Diagnostic and Statistical Manual of Mental Disorders [5]; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders [12]; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders [40]; GMS, Geriatric Mental State Schedule [14]; ICD, International Classification of Disease. Data from Refs. [4,5,12,14,17,40].

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Newman et al, 1998 [24]

667

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often is used to screen for alcoholism in older adults, but it may be insufficient in detecting problems in older adults [21]. It is important, therefore, in comparing the prevalence of disorders across studies to determine how cases were measured and defined and what criteria were in place at the time the study was conducted. These definitions have the potential to affect incidence and prevalence. Sampling issues The type of sample used can influence the reported prevalence. The prevalence in samples from primary care, psychiatric clinics, and institutions may be different from the prevalence found in community populations. Samples from healthcare facilities only include persons with access to care, whereas samples from the community may exclude individuals who are unable to live independently. Selective survival is a potential bias in studies of older adults. Older adults with psychiatric disorders that began earlier in life may not survive to old age. In addition, older adults with comorbid health problems may have died from other causes and may not be available for study. Defining prevalence When comparing the reported prevalence across studies it is important to identify how prevalence is defined. Some studies may report 1-month or current prevalence, whereas others may report 6-month or 1-year or even lifetime prevalence. Prevalence is affected by the incidence of the disorder and its duration. Disorders with a long duration may have a higher prevalence, as do disorders with a high incidence. Disorders such as dementia that are chronic are detected more easily than psychiatric symptoms that may be more dynamic.

Mood disorders Depression and other mood disorders in late life have received considerable attention over the past two decades. Numerous studies have examined the etiology of late-life depression and the prevalence and outcomes associated with major depression and depressive symptoms. In addition, case definition has been debated. Although major depression is not prevalent in late life, the prevalence of clinically significant depressive symptomatology in older adults is high [22]. The prevalence of any affective disorder in the ECA studies was 2.5%. Dysthymia was the most common of the disorders in this group, with a prevalence of 1.8% (2.3% in women and 1.0% in men). The 1-month prevalence of major depression in this age group was 0.7%, with a higher prevalence in women (0.9%) compared with men (0.4%). In the ECA, the prevalence of major depression was highest among people aged 25– 44 years (3.0%) and lowest among the subjects who were 65 years or older [6].

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As summarized in Table 1, the prevalence of major depression across multiple community studies is estimated to range from less than 1% to approximately 5% [7,16,23 –27]. The prevalence of major depression in patient samples is higher, as shown in Table 2. The prevalence was 13.5% among elderly home healthcare patients [28], 6.5% among patients in primary care [29], 11.5% among hospital patients [30], and is estimated to be 4% – 15% in nursing home populations [7,9,10,31,32]. Although the prevalence of major depression is low, the prevalence of clinically significant depressive symptoms is much higher, leading to the suggestion the nomenclature may be less applicable for older adults [33]. As shown in Tables 1 and 2, the prevalence of significant depressive symptoms in community samples ranges from 3% – 26% [23,26,27,34 – 37]. The prevalence of depressive symptoms or minor depression is estimated to be as high as 9.9% in samples of older adults selected from primary care [29], 23% in hospital samples of older adults [30], and 16% –30% in nursing home populations [31,32]. In the North Carolina ECA sample, a total of 27% of subjects 60 years of age or older reported depressive symptoms. A total of 19% were diagnosed with mild dysphoria, 4% with symptomatic depression, 2% dysthymia, 1.2% mixed depression and anxiety syndrome, and 0.8% major depression [38]. Beekman et al reviewed 34 community-based studies of the prevalence of depression in late life and concluded the prevalence varied (0.4% –35%) according to caseness. The estimated prevalence of major depression was 1.8%, the prevalence of minor depression was 9.8%, and the prevalence of depressive syndromes deemed clinically relevant was 13.5% [26]. Using data from the ECA studies, the incidence of major depression among adults age 65 years or older is estimated to be 1.25 per 100 person-years at risk, with a higher incidence in older women (1.48 per 100 person-years) compared with men (0.90 per 100 person-years). The incidence is highest among people aged 18 –44 years and lowest among those 65 years or older [39]. Forsell and Winblad estimated the first incidence of DSM-IV [40] major depression among a sample of adults age 78 years or older in Sweden was 1.4% per person-year. The incidence was higher in older women (1.5%) than in older men (0.8%). Among those aged 80 –89 years the incidence was 4.2%, and among those 90 years or older the incidence was 4.1% [41]. Beekman et al used the LASA work to quantify the emergence of late-life depression. Among those subjects not depressed at the index measurement, a total of 9.7% became depressed over a 3-year follow-up period. Among those depressed at baseline, persistence occurred in 50.4% [42]. Henderson et al reported onset of depression in 2.5% of their sample over a 3 –6-year study period. A total of 13% remained depressed over the period. Depression status at follow-up was predicted by number of symptoms at baseline, deterioration in health and in activities of daily living, high neuroticism, poor current health, poor social support, low current activity levels, and high service use [43]. Late-onset depression may be different from early-onset depression. Vascular depression, or depression that may be caused by vascular brain lesions, may be more common in late-onset depression [44,45]. Van den Berg et al studied

670

Authors, date [ref]

Study/location/instrument

Sample size

Age

Disorder

Prevalence (%)

Bland et al, 1988 [7]

Edmonton, Canada; Institutional component; DIS Geriatric home health care patients; SCID Primary care patients SCID; HAM-D

199

65+

DSM-III major depression

539

65+

Major depression

5.6 men, 4.7 women 13.5

224

60+

130

70+

Major depression Minor depression Dysthymia Subsyndromal depression Major depression Depressive syndromes

6.5 5.2 0.9 9.9 11.5 men, 23 women

708

Mean age, 84

319

Mean age, 84.5

DSM-III-R major depression Minor depression DSM-III-R major depression Minor depression Major depression

12.4 30.5 14.4 16.8 6

Bruce et al, 2002 [28] Lyness et al, 1999 [29]

Koenig et al, 1988 [30]

Parmelee et al, 1989 [31] Teresi et al, 2001 [32] Rovner et al, 1986 [10]

Male inpatients admitted to Veteran’s Administration hospital in Durham, NC; HAM-D MADRS Nursing home and congregate apartment residents DSM-III checklist Nursing home residents Psychiatric evaluation Intermediate care nursing homes; GMS and psychiatric assessment

50

65+

Abbreviations: DIS, Diagnostic Interview Schedule [4]; DSM-III, Diagnostic and Statistical Manual of Mental Disorders [5]; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders [12]; GMS, Geriatric Mental State Schedule [14]; HAM-D, Hamilton Rating Scale for Depression [153]; MADRS, Montgomery Asburg Depression Rating Scale [154]; SCID, Structured Clinical Interview for DSM-III-R [13]. Data from Refs. [7,10,28 – 32].

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Table 2 Selected studies of the prevalence of mood disorders in clinical samples

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671

132 depressed older adults and found early-onset depression was associated with neuroticism and parental history. Those with late-onset depression could be divided into two groups—those whose depression was preceded by a severe stressor and those with no stressor but high vascular risk factors [46]. Brilman and Ormel also found late-onset depression was more likely in those who experienced a severe event. Mild events were predictive of recurrent episodes but not first episodes in late life [47]. Numerous correlates and risk factors for major depression and depressive symptoms have been identified through various research studies. Across all age groups the prevalence of major depression seems to be higher in females [6,7]. In controlled analyses from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), Blazer et al found depressive symptoms were associated with functional disability, mild cognitive impairment, the presence of a chronic illness, impaired social support, being unmarried, and low income. In bivariate analyses, the number of depressive symptoms increased with age. In the controlled analyses, depressive symptoms decreased as age increased. Race was not associated with depressive symptoms [34]. In the Hispanic EPESE, the first large representative sample of Mexican Americans, depressive symptoms were associated with female gender, lack of insurance, financial strain, chronic health conditions, and disability. In addition, immigration status, level of acculturation and assimilation, health locus of control, and recency of immigration also were associated with depressive symptoms [36]. In the Longitudinal Aging Study Amsterdam (LASA) study, Beekman et al compared risk factors and correlates of major depression to those of minor depression. They reported major depression was more often an exacerbation of a chronic mood disturbance with roots in longstanding vulnerability factors, whereas minor depression was more related to stresses experienced in later life [27]. Beekman et al recently studied the natural history of late-life depression. Over a 6-year period, symptoms were short-lived in only 14%. There were remissions in 23%, an unfavorable and fluctuating course in 44%, and a severe chronic course in 32%. Those with minor depression had a better outcome than those with major depression, but those with minor depression were at risk for developing affective disorders [48]. In the Liverpool study, a total of 22% of the sample recovered from their symptoms over a 5-year follow-up period. A total of 30% had not recovered at one of the three follow-up waves, 24% had not recovered at two of the followup waves, and 24% had not recovered at each of the three follow-up waves [49]. Depression has been shown to predict functional decline and onset of disability [50 – 52], whereas increasing disability and declining health have been found to precede the emergence of depressive symptoms in older adults [53]. Callahan et al found patients with depressive symptoms at baseline had twice the functional impairment compared with adults without depression. Over a 6-year follow-up period, patients with depressive symptoms were more likely to report symptoms and functional impairment at follow-up. In addition, worse physical functioning and a decline in function were associated with increased depressive symptomatology at follow-up [54].

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Depression has been found to be comorbid with anxiety disorders. Beekman et al reported that in the LASA, 47.5% of people with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with an anxiety disorder also met criteria for major depressive disorder. They found, however, that a comparison of risk factors revealed more differences than similarities between the two disorders [55]. Depression also is associated with alcohol problems in late life [56]. In cross-sectional studies, depression has been associated with cognitive impairment [34]. Depression also has been shown to predict cognitive decline [57] and dementia [58]. Finally, the prevalence of depression among patients with Alzheimer disease has led to discussion of a new diagnostic category to describe depression of Alzheimer disease [59]. Finally, depression has been found to be a risk factor for mortality [60 – 62], whereas other studies have not found an association [63]. Others have found an association between depression and mortality that is attributable to the effects of intervening variables such as physical health and function [64,65]. Some research suggests only those with more severe levels of depression are at increased risk for mortality, whereas those with minor or mild depression do not have an increased risk [66]. Penninx et al found in the LASA that men and women with major depression and men with minor depression were at increased risk for mortality, whereas women with minor depression were not [67]. As discussed later, depression is also a risk factor for suicide [68].

Dementia Unlike mood and anxiety disorders, dementia and cognitive impairment are disorders of older adults, with the prevalence estimated to double every 5.1 years [69]. Over the last two decades much research has focused on the classification of the various types of impairment and the etiology of dementia and its related outcomes. Dementia was not measured in the ECA studies but the prevalence of cognitive impairment was estimated. Among community dwelling adults 65 years of age or older, the prevalence of severe cognitive impairment was 4.9% (5.1% in men and 4.7% in women). The overall prevalence increased with age, with a prevalence of 2.9% among those aged 65– 74 years, 6.8% among those aged 75– 84 years, and 15.8% among those aged 75 years or older. The prevalence was higher in men aged 65 – 74 years compared with women, but then reversed so the prevalence was higher in women aged 75 years or older compared with men [6]. As shown in Table 3, the prevalence of dementia or mild cognitive impairment in community studies of older adults ranges from 3% –23% [35,70 – 73]. Alzheimer disease and vascular dementia are the most prevalent forms of dementia, with Alzheimer disease the more prevalent [72 – 74]. The prevalence of Alzheimer disease ranges from 3.3% – 10.3% [72,74,75], and the prevalence increases with age. For example, Evans et al estimated the prevalence of Alzheimer disease was 10.3% in the East Boston EPESE. The prevalence increased with age, 3.0% in people aged 65– 74 years,

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18.7% among those aged 75– 84 years, and 47.2% among those 85 years or older [75]. As shown in Table 4, the prevalence of dementia in clinical samples is higher. Callahan et al found the prevalence of cognitive impairment in primary care patients aged 60 years or older was 15.7%, with mild impairment more prevalent than moderate or severe impairment. Patients with moderate to severe impairment were older, more likely to be African American, had fewer years of education, and were more likely to have cerebrovascular disease and evidence of malnutrition. In this sample, cognitive impairment was associated with increased use of health services [76]. In the Canadian Study of Health and Aging, the prevalence of dementia was 8.0% among community and institutional residents. The female:male ratio was 2:1. The age-standardized rate ranged from 2.4% among people aged 65 –74 years to 34.5% among those 85 years or older [74]. In the Edmonton study, the prevalence of severe cognitive impairment was 3.3%. In the community component, the prevalence was 3.8%, whereas in the institutional component, the prevalence was 68.5% in women and 69.4% in men [7]. Using data from the ECA studies, Eaton et al estimated the incidence of cognitive impairment among persons aged 65 years or older was 4.64 per 100 person-years at risk (4.56 in women and 4.76 in men) [39]. Jorm and Jolley reviewed studies of dementia and found the incidence of dementia and Alzheimer disease rose exponentially up to the age of 90 years, with no signs of leveling off. They did not find a sex difference in overall incidence, but women tended to have a higher incidence of Alzheimer disease in very old age, whereas men tended to have a higher incidence of vascular dementia at younger ages [77]. In the Italian Longitudinal Study on Aging, gender differences also were noted. Women carried an increased risk for Alzheimer disease, whereas men carried an increased risk for developing vascular dementia [78]. Other incidence studies have reported an annual incidence of 45– 48 per 1000 person-years [79]. Paykel et al reported the annual incidence of dementia was 2.3% for persons aged 75 –79 years, 4.6% for those aged 80– 84 years, and 8.5% for those aged 85 –89 years, approximately doubling every 5 years [80]. A similar increase in incidence with age was reported for Alzheimer disease: 0.6% for those aged 65 – 69 years, 1.0% for those aged 70 –74 years, 2% for those aged 75 –79 years, 3.3% for those aged 80– 84 years, and 8.4% for those 85 years or older [81]. Copeland et al reported from their Liverpool study the incidence of dementia was 9.2/1000 per year (Alzheimer disease 6.3, vascular dementia 1.9, and alcohol-related dementia 1.0) [72]. Data from Italy also show a higher incidence for Alzheimer disease compared with vascular dementia. The annual incidence per 1,000 person-years was 12.47 for dementia, 6.55 for Alzheimer disease, and 3.30 for vascular dementia [78]. Several possible risk factors for dementia have been identified. In the Canadian Study of Health and Aging, the occurrence of all types of dementia was higher among those with definite or questionable alcohol abuse [82]. Fewer years of education have been associated with cognitive decline [83]. The apolipoprotein E epsilon 4 allele has been identified as a susceptibility gene for the development of

674

Authors, date [ref]

Study/location/instrument

Sample size

Age

Disorder

Prevalence (%)

Regier et al, 1988 [6]

Epidemiologic Catchment Area (ECA) Study—community sample; five communities in the United States; DIS Edmonton, Alberta; household sample only; DIS

5702

65+

Severe cognitive impairment

Copeland et al, 1987 [35] Heeren et al, 1991 [70]

Liverpool, England GMS-AGECAT Leiden, The Netherlands GMS; CDR

1070 1259

65+ 85+

Riedel-Heller et al, 2001 [71]

Leipzig Longitudinal Study of the Aged SIDAM Canberra, Australia Canberra Interview for the Elderly Community and institutional

1692

75+

4.9 5.1 4.7 3.3 2.7 3.8 5.2 12 7 4 17.4 12.4

1045

70+

Bland et al, 1988 [7]

Henderson et al, 1994 [15]

358

65+

Severe cognitive impairment

Probable dementia Mild dementia Moderate dementia Severe dementia DSM-III-R dementia ICD-10 dementia ICD-10/DSM-III-R dementia Age 70 – 74 Age 75 – 79 Age 80 – 84 Age 85 +

men, women men, women

1.4/3.2 1.2/5.5 5.2/12.4 10.3/21.0

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Table 3 Selected studies of the prevalence of dementia in community studies of older populations

Evans et al, 1989 [75]

Copeland et al, 1992 [72]

Stevens et al, 2002 [73]

Canadian Study of Health and Aging, Community and institutional MMSE and clinical examination Community residents of Islington, North London, clinical examination

3263

65+

1070

65+

9008 (comm.) 1255 (inst.)

65+

1085

65+

Probable Alzheimer disease Age 65 – 74 Age 75 – 84 Age 85 + Alzheimer dementia Vascular dementia Alcohol-related dementia Dementia Alzheimer disease Vascular dementia Dementia Among those with dementia Alzheimer disease Vascular dementia Dementia with Lewy bodies Frontal lobe dementia

10.3 3.0 18.7 47.2 3.3 0.7 0.3 8.0 5.1 1.5 9.86 31.3 21.9 10.9 7.8

Abbreviations: CDR, Clinical Dementia Rating [155]; DIS, Diagnostic Interview Schedule [4]; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders [12]; GMS, Geriatric Mental State Schedule [14]; ICD, International Classification of Disease; MMSE, Mini-Mental State Examination [19]; SIDAM, Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, Multi-infarct Dementia and Dementia of other Aetiology [156]. Data from Refs. [4,6,7,12,14,15,19,35,70 – 75,155,156].

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Canadian Study Working Group, 1994 [74]

East Boston, MA— Established Populations for Epidemiologic Studies of the Elderly (EPESE) clinical examination Liverpool, England, GMS

675

676

Authors, date [ref]

Study/location/instrument

Bland et al, 1988 [7]

Edmonton, Canada; Institutional component; DIS Intermediate care nursing homes—Maryland; GMS, MMSE, and psychiatric assessment National Nursing Home Survey Pretest DIS Primary care patients SPMSQ

Rovner et al, 1986 [10]

Burns et al, 1988 [9] Callahan et al, 1995 [76]

Sample size 199 50

526 3954

Age

Disorder

Prevalence (%)

65+

Severe cognitive impairment

Mean age, 83

Primary degenerative dementia Multi-infarct dementia Parkinson disease/dementia Organic brain syndrome

69.4 men, 68.5 women 56 18 4 39

Mild cognitive impairment Moderate to severe cognitive impairment

10.5 5.2

Mean age, 79.0 60+

Abbreviations: DIS, Diagnostic Interview Schedule [4]; GMS, Geriatric Mental State Schedule [14]; MMSE, Mini-Mental State Examination [19]; SPMSQ, Short Portable Mental Status Questionnaire [157]. Data from Refs. [4,7,9,10,14,19,76,157].

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Table 4 Selected studies of the prevalence of dementia in clinical samples

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677

Alzheimer disease [84] but only accounts for a portion of the disease onset [85,86]. Head trauma has been found to be associated with later development of Alzheimer disease, although the results are not consistent [87,88]. Devanand et al found in their sample of 1070 persons age 60 years or older living in the community that depressed mood moderately increased the risk for developing dementia over a 1 –5-year period, particularly Alzheimer disease [58]. Yaffe et al found in a sample of nondemented older women that cognitive scores decreased as the number of depressive symptoms increased [57]. Geerlings et al found among persons with more than 8 years of education that depressed mood predicted incident Alzheimer disease. Depressive symptoms did not predict Alzheimer disease in persons with 8 years or less of education [89]. Several protective factors also have been noted. The prevalence of Alzheimer disease has been found to be lower in users of nonsteroidal anti-inflammatory drugs (NSAIDS) [90]. Regular physical activity has been found to be a protective factor for cognitive decline in older adults [91]. Dementia also is associated with adverse outcomes. Persons with cognitive impairment, dementia, or Alzheimer disease have been shown to have an increased risk for mortality [76,92 – 94]. Stump et al found patients with moderate to severe cognitive impairment had an increased risk for mortality, whereas mild cognitive impairment was not associated with an increased risk [95]. Dementia also has been shown to be a risk factor for functional decline [96].

Anxiety disorders Although depression and dementia in late life have received considerable attention, anxiety disorders have been less researched. And yet, anxiety disorders among older adults are prevalent. In the community component of the ECA, the prevalence of any anxiety disorder in older adults was lower than the prevalence in younger adults. The prevalence of any anxiety disorder among persons aged 65 years or older was 5.5%, whereas the prevalence was 7.7% in adults aged 18 – 24 years, 8.3% in those aged 25– 44 years, and 6.6% in those aged 45– 64 years. The prevalence was higher in older women (6.8%) compared with older men (3.6%). Anxiety disorders were in fact the most prevalent disorders among community dwelling older adults, more prevalent than dementia. These ECA estimates did not include generalized anxiety disorder (GAD), because GAD was not assessed at all the sites, suggesting the true prevalence of anxiety disorders in late life is even higher. In the ECA studies, the most prevalent anxiety disorder reported was phobic disorder (4.8%). The prevalence of panic disorder (0.1%) and obsessive – compulsive disorder (0.8%) were much lower [6]. Other community studies conducted in other western countries have confirmed the high prevalence of any anxiety disorder. As shown in Table 5, the prevalence of anxiety disorders in community populations ranges from 2% – 10% [7,35,97 – 99]. The prevalence of anxiety disorders among older adults in institutions seems to be higher. In the institutional component of the Edmonton survey, the prevalence

678

Authors, date [ref]

Study/location/instrument

Sample size

Age

Disorder

Prevalence (%)

Regier et al, 1988 [6]

Epidemiologic Catchment Area (ECA) Study—community sample; five communities in the United States; DIS

5702

65+

DSM-III anxiety disorder

Epidemiologic Catchment Area (ECA) Study—community sample; Durham, St. Louis, and Los Angeles Edmonton, Alberta; household sample; DIS

NA

65+

Phobic disorder Panic disorder Obsessive-compulsive disorder Generalized anxiety disorder

5.5 3.6 men, 6.8 women 4.8 0.1 0.8 2.2

65+

DSM-III anxiety/somatoform disorder

Blazer et al, 1991 [101]

Bland et al, 1988 [7]

Institutional component

358

199

Phobic disorder Panic disorder Obsessive-compulsive disorder Anxiety/somatoform disorder Phobic disorder

3.5 2.7 4.1 3.0 0.3 1.5 1.4 7.1 0.0 1.6

men, women

men, women men, women

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Table 5 Selected studies of the prevalence of anxiety disorders in community and clinical samples

Panic disorder Obsessive-compulsive disorder

Beekman et al, 1998 [99]

Forsell and Winblad, 1998 [97] Kvaal et al, 2001 [100]

Liverpool, England; GMS-AGECAT Guy’s/Age Concern Survey, London Constructed interview Longitudinal Aging Study Amsterdam (LASA); CES-D and DIS

Community survey Structured psychiatric interview Geriatric inpatients STAI

1070 890

65+ 65+

966

78+

Neurotic disorder Generalized anxiety disorder Phobic disorder DSM-III anxiety disorders Generalized anxiety disorder Phobic disorder Panic disorder Obsessive-compulsive disorder Feelings of anxiety

3107

55 – 85

98

70+

Anxiety symptoms

men, women men, women

47 men, 41 women

Abbreviations: CES-D, Center for Epidemiologic Studies—Depression Scale [17]; DIS, Diagnostic Interview Schedule [4]; DSM-III, Diagnostic and Statistical Manual of Mental Disorders [5]; GMS, Geriatric Mental State Schedule [14]; STAI, Spielberger’s State-Trait Anxiety Inventory [158]. Data from Refs. [4 – 7,14,17,35,97 – 101,158].

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Copeland et al, 1987 [35] Lindesay et al, 1989 [98]

0.0 1.6 1.4 4.7 2.4 3.7 10.0 10.2 7.3 3.1 1.0 0.6 24.4

679

680

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of any anxiety disorder was 7.1% in women and 1.4% in men [7]. In a sample of 526 nursing home patients, 19, or 3.6%, had one or more anxiety disorders [9]. As with other disorders, the prevalence of symptoms (such as feeling anxious) in populations of older adults is even higher than the prevalence of the disorders. As shown in Table 5, the prevalence can be as high as 24% in community populations [97] and more than 40% in hospital samples [100]. Among the anxiety disorders, GAD and phobic disorder are the most prevalent. The prevalence of GAD is estimated to be 2% –7% [98,99,101]. In the Duke ECA, among those persons with GAD, 3% had an onset at age 65 years or older [101]. In the ECA studies, the 1-month prevalence of any phobic disorder was 4.8% among those aged 65 years or older, with a higher prevalence in women (6.1%) compared with men (2.9%) [6]. The prevalence was higher among African Americans than Whites or Hispanics [102]. The prevalence in community samples ranges from 3% – 10% [7,99]. The Guy’s/Age Concern Study provided data by age by phobic subtype. The prevalence of agoraphobia was 7.8% (3.4% men, 10.7% women), social phobia, 1.3% (0.8% men, 1.7% women), and specific phobia, 2.1% (0.6% men, 3.0% women) [98]. Panic disorder is less common than the other anxiety disorders among older adults, with an estimated prevalence of 1% or less [6,7,98,99]. The prevalence of obsessive – compulsive disorder is low, with a prevalence of less than 2% [6,7,99]. The prevalence of both panic disorder and obsessive –compulsive disorder is higher in institutional samples [7]. The annual incidence of phobic disorder among adults aged 65 years or older is estimated from the ECA data to be 4.29 per 100 person-years at risk, with a higher incidence in women (5.52) compared with men (2.66). The estimated annual incidence of panic disorder among people aged 65 years or older also estimated from the ECA is 0.04 per 100 person-years at risk, with a higher incidence in older women, whereas the estimated annual incidence of obsessive-compulsive disorder is 0.64 per 100 person-years at risk, 1.00 in women, and 0.12 in men [39]. Segui et al recently studied late-onset panic disorder among patients at two clinics in Spain. Of 5301 patients seen over the study period, 8.3% (n = 442) presented with panic disorder. Among these, age at onset was older than 60 years in 27 patients, or 6.1%. Patients with late-onset panic disorder were less likely to report a family history of panic disorder, scored lower on clinical severity scales, and exhibited fewer and milder symptoms during the panic attacks. In addition, dysthymic disorder, but not major depressive disorder, was more common among those panic disorder patients with late-onset [103]. In a 3-year study, a history of depression or anxiety and an insufficient social network were associated with anxiety symptoms [97,104]. Feelings of anxiety also have been found to be associated with dementia, current depression, and being female [97]. In the LASA, risk factors for the development of anxiety symptoms over a 3-year period included vulnerability factors (being female, high neuroticism, hearing/eyesight problems) and stressors (recent life events, especially death of one’s partner). Female sex and neuroticism increased the chronicity of anxiety symptoms in older adults, but life events were not related to chronicity

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[105]. In the Guy’s/Age Concern Survey, agoraphobia was associated with higher levels of dependency in the tasks of daily living [98]. Blazer et al found early morning anxiety was a symptom in 32.1% of elderly and middle-aged patients hospitalized for depression 1 – 2 years following hospitalization, suggesting mixed/anxiety depression may be present in patients who do not recover fully from major depression [106]. In older adults, anxiety disorders are frequently comorbid with each other and with other psychiatric disorders. A total of 10% of older adults with an anxiety diagnosis in the LASA suffered from two or more anxiety diagnoses [107]. In a study of 182 patients aged 60 years or older seen for major depression, Lenze et al found a high prevalence of current and lifetime anxiety disorders. A total of 35.2% of the subjects had at least one lifetime diagnosis for an anxiety disorder and 23.1% had a current diagnosis of an anxiety disorder. The most common current comorbid conditions were panic disorder (9.3%), specific phobia (8.8%), and social phobia (6.6%). Agoraphobia was present in 2.2%, obsessive – compulsive disorder in 1.7%, and post-traumatic stress disorder in 0.6% of the patients. Generalized anxiety symptoms were present in 27.5% of the depressed patients [108]. Comorbidity between anxiety disorders and physical disease is also prevalent. In the LASA, chronic somatic disease was more prevalent among those with an anxiety diagnosis compared with those without (12% versus 7%) [107]. Finally, anxiety symptoms may be prevalent in patients with dementia. In a study of 92 patients with vascular dementia and 92 patients with Alzheimer disease, 72% of the patients with vascular dementia and 38% of those with Alzheimer disease had two or more symptoms of anxiety [109]. In a sample of adults in Stockholm, however, the prevalence of anxiety disorders was distributed equally between the nondemented group in whom the prevalence was 3.2% and a demented group in whom the prevalence was 3.3% [110].

Schizophrenia Paranoid and psychotic symptoms are not uncommon among community dwelling older adults. As shown in Table 6, the prevalence of psychotic symptoms ranges from 4% – 10% [111– 113]. The prevalence of psychotic symptoms is higher when older adults living in institutions or group settings are included, as evidenced by selected studies shown in Table 6. For example, Henderson et al found the point prevalence of psychotic symptoms was 5.7% in an Australian community survey of adults aged 70 years or older. They found the prevalence of symptoms was 24.2% among older adults living in sheltered accommodations, however, resulting in an overall study prevalence of 7.5% [114]. Although the prevalence of psychotic symptoms is notable, the prevalence of schizophrenia in community populations of older adults is low. In the ECA studies, the prevalence of DSM-III schizophrenia was 0.1% among community dwelling

682

Table 6 Selected studies of the prevalence of psychotic disorders in community and clinical samples Study/location/instrument

Sample size

Age

Disorder

Regier et al, 1988 [6]

Epidemiologic Catchment Area (ECA) Study—community sample; five communities in the United States; DIS Edmonton, Alberta; household sample; DIS institutional sample

5702

65+

DSM-III schizophrenia

358 199

65+

DSM-III schizophrenia DSM-III schizophrenia

Copeland et al, 1998 [125]

Liverpool, England; GMS-AGECAT

5222

65+

Christenson and Blazer, 1984 [111] Blazer et al, 1996 [113]

Older Americans Resources and Services (OARS) Study Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) CES-D Community survey in Stockholm CPRS Canberra, Australia, Canberra Interview for the Elderly, community and sheltered housing Islington Study, England GMS Goteberg, Sweden, community and institutional sample CPRS

997

65+

DSM-III-R schizophrenia Delusional disorder Persecutory ideation

0.1 0.1 men, 0.1 women 0.0 0.0 men, 0.8 women 0.12 0.04 4

3931

65+

Paranoid symptoms

9.5

1420

75+

Paranoid ideation

6.3

1377 community, 143 sheltered housing

70+

Psychotic symptoms

720

65+

347

85

Persecutory symptoms and perceptual disturbance Psychotic symptoms Hallucinations Delusions Paranoid ideation

Bland et al, 1988 [7]

Forsell and Henderson, 1998 [122] Henderson et al, 1998 [114]

Livingston et al, 2001 [112] Ostling and Skoog, 2002 [159]

Prevalence (%)

5.7 in community, 24.2 in sheltered housing 3.9 10.1 6.9 5.5 6.9

Abbreviations: CES-D, Center for Epidemiologic Studies—Depression Scale [17]; CPRS, Comprehensive Psychopathological Rating Scale [160]; DIS, Diagnostic Interview Schedule [4]; DSM-III, Diagnostic and Statistical Manual of Mental Disorders [5]; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders [12]; GMS, Geriatric Mental State Schedule [14]. Data from Refs. [4 – 7,12,14,17,111 – 114,122,125,159,160].

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Authors, date [ref]

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683

adults aged 65 years or older [6]. As shown in Table 6, a similar prevalence was reported from Liverpool and Edmonton [7,35]. This low prevalence of DSM schizophrenia may be in part because of the psychiatric nomenclature in place at the time these studies were conducted. To meet criteria for DSM-III schizophrenia, the symptoms had to be present before the age of 45 years [5]. People who were unable to determine or remember when the symptoms first appeared and people whose symptoms first appeared after age 45 years therefore did not meet the criteria for schizophrenia. Over the last two decades, much attention had focused on individuals who fulfill all the criteria for schizophrenia except that the onset of symptoms was after age 45 years. The diagnosis of late-onset schizophrenia was allowed in DSM-III-R [12], whereas in DSM-IV, the age requirement was dropped from the criteria [40]. An international consensus recently concluded that late-onset schizophrenia (after age 40 years) and very late-onset schizophrenia like psychosis (after age 60 years) have face validity and clinical usefulness [115]. Had the current nomenclature, therefore, been in place when some of these earlier studies were conducted, the reported prevalence may have been higher. Another possible reason for the low prevalence is that of mortality, particularly from suicide. Black and Fisher found the risk for death is higher in younger individuals with schizophrenia compared with rates expected in the general population [116]. This could result in fewer adults with schizophrenia surviving to older age. Older adults with schizophrenia, therefore, are composed of two groups: first, those whose schizophrenia symptoms appeared before age 45 years or younger adults with schizophrenia who have aged, and second, those with late-onset schizophrenia. Both of these groups are prevalent, although the early-onset group is more common. Harris and Jeste estimated that the proportion of patients with schizophrenia that began after age 40 years is approximately 23.5% [117]. Some differences have been noted between the early-onset and late-onset cases of schizophrenia. Yassa et al assessed patients in a psychogeriatric unit. Among 288 patients with an index admission at age 65 years or later, 2.4% had a well recorded first episode of symptoms of schizophrenia at age 45 years or later. Those with late onset were all women. Although they had bizarre delusions and auditory hallucinations, negative symptoms were rare [118]. Castle and Murray found the patients with late-onset schizophrenia had better premorbid functioning. Specifically, 50% of the early-onset compared with 15% of the late-onset had poor premorbid work adjustment. Also, 22% of late-onset compared with 43% of earlyonset showed poor premorbid social adjustment and 66% of the late-onset group compared with 33% of the early-onset group were or had been married [119]. These findings are similar to those reported by Jeste et al that patients with lateonset schizophrenia had a higher percentage who were ever married compared with those with younger onset [120]. Neither the ECA nor the Edmonton community samples noted a gender difference in the prevalence of schizophrenia [6,7]. Gender differences have been noted with regard to time of onset of symptoms. Castle and Murray found the mean age of onset was 31.2 years for men and 41.1 years for women [119]. These

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findings are similar to those reported by Lindamer et al, that a significantly greater proportion of female patients with schizophrenia than males had late-onset schizophrenia (41% versus 20%) [121]. These investigators also noted gender differences in symptoms, specifically, that women overall had more severe positive psychotic symptoms and that women with late-onset had significantly less severe negative symptoms than men with early-onset, men with late-onset, and women with early onset. Also, age of onset was negatively correlated with severity of negative symptoms for women, but not for men [121]. Schizophrenia and psychotic symptoms have been found to be associated with social isolation [111,114,122,123], poor health, disability or impairment in physical functioning [111,114,124], divorced marital status or living alone [114,122], depressive symptomatology or use of psychotropic medications [113,114,122], lower education [113,114], sensory deficits [111,112], African American race, lower income, less exercise [113], and alcohol use [112]. There are few data examining the incidence and outcome of schizophrenia in older adults. Copeland et al found in their Liverpool community sample the 2-year incidence of schizophrenia was 3.0 for new cases, 45.0 for new and relapsed cases, and 15.6 for delusional disorder per 100,000 per year. They found none of the cases identified at baseline had recovered fully after 2 years, but none were deluded at the time of the follow-up [125]. Henderson et al reported that the incidence of psychotic symptoms in their sample of adults aged 70 years or older was 6.0% over 3– 4 years [114]. As described previously, studies have found psychotic symptoms to be associated with depressive symptomatology [113,114,122]. Meyers and Greenberg found in a study of consecutively admitted older patients with major depression that the prevalence of delusions was 45% [126]. The prevalence of paranoid symptoms also has been reported to be higher in those with dementia or impairment in cognitive functioning. Forsell and Henderson found the prevalence of paranoid ideation was 12.1% in patients with cognitive dysfunction compared with 2.6% in those without [122]. Lyketsos et al found in the Cache County Study the prevalence of delusions was 18.5% in the community subjects with dementia, compared with 2.4% in those without dementia. Similarly, the prevalence of hallucinations was 13.7% in those with dementia, compared with 0.6% in those without dementia [127]. In a study of outpatients with schizophrenia and normal control subjects aged 40 – 85, however, Zorrilla et al did not find any evidence of faster cognitive decline in outpatients with schizophrenia [128]. Finally, Jeste et al found that older patients with schizophrenia reported fewer comorbid physical illnesses than healthy comparison subjects, but their illnesses tended to be more severe [129].

Problems with alcohol use Although alcohol use among older adults is less common than among younger adults, the prevalence is high, and many older adults drink in excess. In the 1990 Health Interview Survey, more than 46% of the respondents age 55 years or older

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reported they were current drinkers. The prevalence decreased with age. Among those aged 55 –64, 52.9% were current drinkers, whereas the prevalence was 47.6% among those age 65 – 74 years, 33.1% among those age 75– 84 years, and 24.7% among those age 85 years or older. More than 18% of those age 65 years or older reported drinking every day [130]. Adams et al followed a cohort of 270 healthy people age 60 years or older for 7 years and found a 2% decline per year in the percent of subjects consuming any alcohol, suggesting that an age-related decline observed in cross-sectional studies may be a true decline and not a cohort effect [131]. Although moderate alcohol use has been shown to be protective against mortality in older populations [132], many adults consume alcohol in excess with adverse consequences. Saunders et al estimated from the Liverpool study that the prevalence of current drinking problems was 9.4 per 1,000 subjects aged 65 years or older. Overall, they found 6.1% of the men and 2.4% of the women drank in excess. Among those subjects who reported drinking regularly, a total of 19.5% of the men and 19.6% of the women exceeded the recommended limits [133]. As shown in Table 7, the prevalence of problem drinking in older adults is estimated to be as high as 14% [134,135], with a higher prevalence in men than in women [21]. Definitions of problem drinking may need to be different for older adults compared with younger adults. Specifically, because of changes in body composition with increasing age, even small amounts of alcohol can lead to higher blood alcohol concentrations than would be seen in a younger adult [136], and recommended limits may need to be adjusted [137]. Although the prevalence of problem drinking in older adults is high, the prevalence of DSM alcohol abuse/dependence is low. In the ECA studies, the 1-month prevalence of alcohol abuse/dependence among people aged 65 or older residing in the community was 0.9%, with a higher prevalence in men. The prevalence was lower among people aged 65 years or older compared with those aged 18 – 24 years (4.1%), 35 –44 years (3.6%), and 45– 64 years (2.1%) [6]. The overall prevalence was higher in the Edmonton community sample than that found in the ECA [7]. The incidence of alcohol abuse/dependence among people aged 65 years or older is estimated from the ECA data to be 0.63 per 100 person-years of risk, 0.27 for women and 1.20 for men [39]. These data suggest that although many older adults with alcoholism are younger alcoholics who have aged, others are adults who develop problems with alcohol use in late life. Atkinson et al studied age of onset in a sample of 132 older men admitted to a Veteran’s Administration (VA) geriatric outpatient alcoholism treatment program. Late onset, defined as onset of first alcohol problem at or after age 60 years, occurred in 15% of the sample and in 29% of those age 65 years or older. Compared with earlier onset cases, they found that late-onset alcohol problems were milder and more circumscribed and were associated with less family alcoholism and greater psychologic stability [138]. Alcohol problems may be more difficult to detect in older adults. Because fewer older adults are employed, many elders no longer drive, and some older adults live alone, problems with occupational and social functioning and impairments in

686

Authors, date [ref]

Study/location/instrument

Sample size

Age

Disorder

Prevalence (%)

Regier et al, 1988 [6]

Epidemiologic Catchment Area (ECA) Study—community sample; five communities in the United States; DIS Edmonton, Alberta; household sample; DIS institutional sample

5702

65+

DSM-III alcohol abuse/dependence

Bland et al, 1988 [7]

Adams et al, 1992 [135] Adams et al, 1996 [21]

Elderly patients seen in emergency departments, CAGE Primary care patients, CAGE

Mirand and Welte, 1996 [134] Thomas and Rockwood, 2001 [82]

Community population, Erie County, New York Canadian Study of Health and Aging—clinical sample clinical examination

358 199

65+

205

65+

Current alcohol abuse

0.9 1.8 0.3 1.7 0.0 0.0 14

5065

60+

2325

60+

Drinking in excess of recommended limits Heavy drinking

15 men, 12 women 6

2873

65+

DSM-III alcohol abuse/dependence DSM-III alcohol abuse/dependence

Alcohol abuse Questionable alcohol abuse

Abbreviations: CAGE [20]; DIS, Diagnostic Interview Schedule [4]; DSM-III, Diagnostic and Statistical Manual of Mental Disorders [5]. Data from Refs. [4 – 7,20,21,82,134,135].

8.9 3.7

men, women men, women

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Table 7 Selected studies of the prevalence of alcohol problems in community and clinical samples

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driving may not be as useful criteria for detecting problems in older adults. Screening instruments designed for younger populations may be less applicable for older adults [21,139]. Curtis et al found in a study of new admissions to medical service that 60% of screen-positive young patients with alcoholism were identified by their house officers, compared with only 37% of elderly patients with screenpositive alcoholism. Older patients with alcoholism were less likely to be detected if they were White, female, or had completed high school. Even when detected, older patients with alcoholism were less likely than younger patients to be treated, and if treatment were recommended, it was less likely to be initiated [140]. Older patients with alcoholism can be treated successfully and seem to respond well to medically-oriented treatment [141,142]. Adults with late-onset alcoholism may be more treatment-compliant [138]. Goodwin et al found that alcohol use among older adults was associated with male gender, higher income, more education, and better performance on cognitive function tests [143]. Thomas et al, however, found in their Canadian work that alcohol abuse was associated with cognitive impairment and short-term mortality [82]. Meyers et al found problem drinkers reported their drinking had diminished the quality of their life and they were less likely to be satisfied with their social relationships [144]. Callahan and Tierney found in their sample of primary care patients age 60 years or older that patients with alcoholism were younger, had fewer years of education, and were more likely to be male, Black, smokers, and malnourished [145]. Hurt et al studied 216 elderly patients treated for alcoholism and found the frequency of medical conditions among these patients was higher than would be expected for the general population of similar age [141]. Adams et al found the prevalence of alcohol-related hospitalizations among people age 65 years or older was 54.7 per 10,000 population for men and 14.8 per 10,000 population for women [146]. Finlayson et al found alcoholism was associated with increased psychiatric comorbidity, particularly tobacco dependence, organic brain syndrome, and affective disorder [56]. Similarly, Saunders et al found in a sample of men age 65 years or older that those with a history of heavy drinking for 5 years or more had a greater than fivefold risk for suffering from a psychiatric disorder at the time of the interview [147].

Suicide Although suicide rates among older adults overall have decreased over the past several decades, they remain disproportionately high for people aged 65 years or older. In 1950, the suicide rate among people aged 65 years or older in the United States was 30.0 per 100,000 residents. In 1998, the rate had decreased to 16.9 per 100,000 persons. This rate, however, is higher than the rate for people age 45 – 64 years (14.1), 25 –44 years (14.6), and 15 – 24 years (11.1). The rates for older White men are particularly high and did not see the decrease observed in other older adults. In 1998, the death rate for White men aged 65 years or older was 36.6, compared with 11.6 for older African American men, 21.0 among older

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Asian men, and 20.0 for older Hispanic men. Among women, the rate was much lower, 4.7 per 100,000 residents age 65 years or older [148]. The most common method of suicide among older adults was using a firearm, but a higher proportion of older adults compared with younger adults used less violent methods including cutting/stabbing, drowning, and asphyxiation/CO poisoning. A smaller proportion of older adults compared with younger adults gave a warning in the previous week or month. Finally, older adults were less likely to have had a previous suicide attempt [149]. Risk factors for suicide in older adults identified through a longitudinal community study include depressive symptoms, poorer self-perceived health, poorer sleep quality, and absence of a relative or friend to confide in [150]. Conwell et al studied a sample of patients age 60 years or older who had been seen recently in primary care. Depressive illness, physical illness burden, and functional limitations were more common among those who completed suicide and they were more likely to have been prescribed antidepressants, anxiolytic agents, or narcotic analgesics [68].

Implications for geriatric medicine These prevalence estimates show that, although as a group mental disorders are less prevalent in older adults than in younger age groups, these disorders are not uncommon in late life and, across disorders, their subclinical forms are associated with impairments in function and decreased quality of life. Research in the field of geriatric psychiatry has increased greatly over the last two decades as investigators try to identify those social, demographic, environmental, biologic, and genetic factors that may put older adults at risk for developing disorders or symptoms for the first time or for contributing to the recurrence of a disorder or symptoms that had been in remission. Across disorders, with the exception of dementia, there seem to be two distinct groups of older adults with psychiatric disorders or clinically significant symptoms: those whose symptoms or disorder has been present throughout adulthood (or those with early onset) and those whose symptoms appear for the first time in late life (or late onset). As the authors have described, some research has suggested these two groups may have different risk factors and etiologies. Regardless of their origins, these symptoms can have a significant impact in an older adult possibly experiencing at the same time changes such as retirement, decline in physical health, bereavement, and other events. Much attention in recent years has focused on the projected changes in the demographic composition of the population, particularly in the United States but also in other developed countries. Specifically, the proportion of the population that is 65 years of age or older is expected to increase dramatically over the next 30 years. In addition, the actual number of older adults is expected to increase as treatments for various chronic diseases become available and life expectancy increases. Jeste et al recently provided a consensus statement on the upcoming crisis in geriatric mental health [151]. They provide estimates that the number of people

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age 65 years or older with a psychiatric disorder in the United States will increase from approximately 4 million in 1970 to 15 million in 2030. Specifically, they believe current studies have underestimated the true prevalence of psychiatric disorders in late life because of exclusion criteria and misattribution to normal aging or physical health reasons. Added to this the higher prevalence of meaningful symptoms suggests the current prevalence of disorders is higher than estimated here from these studies. Given an expected increase of people in the 65 years or older age group, who bring with them a higher lifetime prevalence of mental disorders than the current cohort of older adults, the result will be a significantly higher number of adults over 65 years of age with mental disorders. These projected estimates have implications for professionals in the field of geriatric medicine who are generally the providers of healthcare, physical and mental, to older adults. Blazer recently acknowledged the foresight of geriatric medicine in attending to geriatric syndromes that focus on quality of life, and called on geriatric psychiatry to adopt once again a multidisciplinary approach to assessment and management of psychiatric disorders in late life [152].

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