CHAPTER 29 EMOTIONAL AND BEHAVIORAL PROBLEMS
Practice of Geriatrics
CHAPTER 29 EMOTIONAL AND BEHAVIORAL PROBLEMS
Timothy Howell, M.D., M.A.
Types of Problematic Behaviors
Problems in Dementia
Anxiety and Avoidant or Repetitive Behaviors
Paranoia and Psychotic Symptoms
This chapter is about problems in older adults that are vexing: those that cause dysphoria in patients, interfere with their functioning, or cause distress in their caregivers, be they family members, peers, or health care professionals. A broad range of problematic behaviors may be brought to the attention of a physician; they are too numerous to address in a brief chapter. Hence the focus here is on some common syndromes and the development of an approach that can help sort through some of the more complicated, unusual, or even novel situations that may arise.
The morbidities associated with problem behaviors are enormous. Their presence in an older adult can interfere with the delivery of optimum health care, and they are common precipitants for institutionalization. They often constitute a rationale for antipsychotic treatment in long-term care (LTC) facilities. Not only are they a source of subjective distress in elderly patients, thereby compromising their quality of life, they are also a source of objective distress for caregivers in forms of anxiety, depression, and burnout.
TYPES OF PROBLEMATIC BEHAVIORS
Many different kinds of problematic behaviors are encountered in the practice of geriatric medicine. These include dysphoric effects, such as depression, anxiety, irritability, and mania. Agitation or aggression may be verbal or physical and may present as resistance to treatments, clinging to caregivers, or disruptiveness (e.g., distressing repetitive behaviors, sundowning, or wandering). Patients may develop suspiciousness, paranoia, or even such frankly psychotic symptoms as delusions or hallucinations. Somatization can be an especially challenging issue for a busy geriatrician. The assessment and management of disorders concerned primarily with disturbances of affect are covered in the chapter on depression (Chapter 28), and those concerned with disturbances of cognition are covered in the chapters on dementia and delirium (Chapter 26 and Chapter 27, respectively).
The biopsychosocial approach is a useful one in dealing with vexing behaviors. The rationale for this approach is that clinical problems frequently are multifactorial in origin and typically call for solutions using multiple modalities. This approach facilitates the analysis of such situations and reminds us not to come to premature closure about what may be disturbing a patient but to tease apart the different strands that comprise the problem to ensure that each constituent is optimally addressed.
In developing a strategy to parse the potential components of a problem behavior using a biopsychosocial approach, one focuses first on the biologic aspects. Here the most common factors that may be causing or exacerbating a problem behavior are medications and concurrent medical problems. A newly prescribed drug may be a culprit, or a long-standing medication to which the patient has become more sensitive suddenly (e.g., due to an acute change such as a stroke) or gradually (e.g., due to physiologic changes associated with aging or the gradual progression of a chronic illness). Likewise, an acute medical problem, or the progression or exacerbation of a chronic one, may contribute to a behavioral problem. The most frequent psychobiologic factors are concurrent psychiatric disorders: cognitive (including dementia and delirium), substance-related or psychotic (including schizophrenia), mood (including depression and mania), anxiety, and somatoform (including hypochondriasis and somatization). And the most common psychosocial factors are the physical environment and interpersonal relations, especially in terms of how these may be affected by an individual’s personality style and personal history. It is at this level that one is most likely to encounter unique combinations of factors that can be tricky to sort through, and consequently where collateral sources of information can be very helpful.
PROBLEMS IN DEMENTIA
All of the problems delineated previously can occur in the context of a dementing illness. In dementia of the Alzheimer’s type (DAT), they tend to occur later in the course of the disease and have a prevalence of 70% to 90% in the moderate to severe stages. A study by Cummings1 revealed the following prevalences of noncognitive symptoms in DAT: apathy, 72%; agitation, 60%; anxiety, 48%; irritability, 42%; dysphoria, 38%; and delusions, 22%. Such psychiatric problems originate in the underlying neuropathologic processes of DAT. Disturbances of higher cortical function figure prominently. DAT patients with agnosia fail to recognize familiar people and places, and for some, this may precipitate anxiety and a tendency to get lost. With aphasia, the verbal confusion and inability to understand may provoke frustration, irritability, and catastrophic reactions. The apraxias that undermine patients’ ability to perform activities of daily living (ADLs) often do the same.
Agitation or Aggression
The word agitation, so frequently used in discussions of the problematic emotions and behaviors of DAT patients, is a term that has mixed blessings. Most everyone familiar with this patient population knows what it means. But there are frequent differences about what the term refers to, and this is a critical factor in conducting research and interpreting the rapidly growing literature on this subject. Some definitions that have been proposed include: (1) an acute or chronic syndrome of pathologic arousal, usually involving repetitive motor or verbal activities2; (2) disruptive vocal or motor behavior that causes discomfort, poses a risk, or interferes with care.3 In the latter definition, context is important. Thus, wandering in a street would be considered risky, whereas wandering in a safe yard could even be beneficial.
There are many types of agitated behaviors in patients with DAT. Among the distressing repetitious behaviors are repeated screams, shouts, complaints, requests, moans, curses, and criticisms. Aggressive behaviors include, but are not limited to, hitting, spitting, scratching, and kicking. Purposeless activities range from throwing objects to pacing, from disrobing to rummaging through drawers. DAT patients may refuse the help they need, wander, or fidget. Because its causes are potentially so numerous, it is best to view such agitation as a nonspecific symptom or sign, analogous to cough or fever, which may have multiple causes.
Further complicating the process of assessing these kinds of problems is the fact that DAT patients may be unable to report or describe their symptoms. This is reflected in the fact that undiagnosed illness is more common in older adults in the early stages of DAT than in nondemented elderly. Agitation may be the only indicator of an underlying illness. Thus, one needs to be alert for concurrent medical problems, such as cardiovascular disorders, pulmonary disorders, diabetes, or neoplasms. Uncomfortable or painful conditions that may generate agitation in a dementia patient but may be inadvertently overlooked include urinary tract infections (UTIs), constipation, fecal impaction, skin breakdown, headache, sinus congestion, dental problems, dislocated joints, arthritis, or fractures. Delirium is another consideration, especially because dementia patients are more vulnerable to being “tipped over” by such causes of excess morbidity as dehydration, electrolyte disturbances, medications with central nervous system (CNS) side effects, or drug interactions. Age-associated declines in liver or kidney function may also play a role here.
Sensory impairments can compound the deterioration of abilities in dementia patients by further compromising their ability to process, interpret, and understand events in their environment. Hence, poor hearing or vision should be assessed and addressed as feasible. Some dementia patients may not be able to use or tolerate prosthetic devices such as eyeglasses or hearing aids, but these devices warrant an adequate trial before such a conclusion is drawn. It may even work out that such items can be used some of the time, and the benefits derived from even partial successes should not be underappreciated.
Among the noncognitive psychiatric problems in patients with dementing illnesses are a loss of adaptive abilities, including poor impulse control, reduced toleration of frustration, and impaired ability to calm oneself down. These difficulties may stem from involvement of the disease process in the frontal lobes and probably underlie the nearly ubiquitous phenomenon of catastrophic reactions in dementia patients. Catastrophic reactions are intense emotional and behavioral responses (e.g., anxious resistiveness, angry outbursts, tearful refusals) precipitated by common situations (e.g., dressing or bathing) in which the demented individual no longer has the cognitive ability to cope (e.g., due to an inability to appreciate the need to accomplish the task, recognize who is trying to help them, or perform the task). Psychotic symptoms occur more commonly in patients with dementia than in agematched healthy controls and include paranoia, hallucinations, and delusions. Depression occurs in approximately 20% of patients during the course of DAT. It may become manifest as agitation, pacing, insomnia (including sundowning), crying, or refusal to eat.
Treatment strategies for the emotional and behavioral problems that arise in patients with dementia start with a careful differential diagnosis and continue with systematic efforts to address the medical, psychiatric, and social or environmental components identified as contributing factors. Catastrophic reactions can often be managed by discerning the patterns (e.g., time, place, situation) in which they occur, thus identifying their precipitants (e.g., tasks, environmental factors, persons). One can help patients to cope better by foreshadowing, taking more time, and breaking tasks down into simpler steps.
Pharmacotherapy for agitated behaviors should be employed only when psychosocial interventions are insufficient. Such therapy must be judicious because dementia patients are usually more sensitive to the side effects of psychotropic medications and more prone to delirium. Agents that are sometimes useful include trazodone, antipsychotics, anticonvulsants, antidepressants, anxiolytics, and beta-blockers. All these medications have limited efficacy in this patient population, and no signs or symptoms have yet been found that predict a positive response. Hence, it is important to approach each patient with an individualized treatment plan: identify the target symptoms clearly, then track their response to titration of the medication in terms of their frequency and intensity while monitoring for side effects.
When dementia patients become acutely aggressive, safety can be ensured by removing items that could be used as weapons and calling for assistance from police, crisis intervention workers, or other trained staff. Restraints should be employed only on a brief, emergency basis, because their prolonged use is associated with significant morbidities. Dementia patients who engage in activities (e.g., driving; smoking; using appliances, machinery, or firearms; neglecting health and hygiene) that may endanger themselves or others because they have become unmindful of hazards or unable to follow directions or use safeguards raise difficult ethical issues. The challenge here is to achieve an optimal balance of patient autonomy and quality of life with safety. Close supervision, substitutions (e.g., of microwave ovens or hand tools for standard ovens or power tools), limited drivers’ licenses, and the provision of home care services (e.g., chore services, meals-on-wheels, health aides) all represent examples of creative ways in which to design individualized interventions that foster such an optimum balance.
Distressing repetitive Behaviors
Distressing repetitive behaviors such as yelling, demanding, clinging, and criticizing occur in about half of all outpatients with dementia and are often quite taxing to caregivers. They are usually due to the dementing process itself but may be caused by environmental stressors, pain, or depression. Reasoning with or confronting the patient is generally not helpful and may be counterproductive. Trying to determine if the repetitive behavior has some underlying meaning (e.g., fear of abandonment) can sometimes suggest helpful responses (e.g., periodic reassurance). Distraction, behavior modification, and stress reduction may be efficacious. If pain or depression is suspected but is difficult to confirm because of a patient’s inability to communicate, an empirical trial of an analgesic or antidepressant may be warranted.
The term sundowning usually refers to late afternoon or nocturnal increases in confusion in dementia patients, typically associated with agitation, restlessness, or wandering. Given the variable definitions of this problem, it is difficult to establish its prevalence, but overall, it appears that nearly half of outpatients with dementia develop sleep problems. Untreated, the nocturnal type of sundowning can rapidly lead to caregiver exhaustion in the home setting and may thereby precipitate institutionalization. Causes to be considered in patients with sundowning include such medical problems as nocturia, congestive heart failure (CHF) with paroxysmal nocturnal dyspnea (PND), and delirium. Most major psychiatric disorders that occur with dementia can be associated with insomnia and sundowning. Psychosocial stressors such as relocation, bereavement, and placement in an institutional setting (e.g., with fewer social cues about when to sleep) may also be contributory factors. Dementias themselves alter sleep architecture and thus may predispose to sundowning. Finally, patients with premorbid histories of being “night owls” or working in such jobs as night watchman or baker may revert to old sleep-wake patterns. Management of sundowning consists of providing a stable sensory environment (e.g., comfortable temperature, quiet surroundings, and perhaps a nightlight to facilitate orientation in the dark) and addressing specific medical, psychiatric, and psychosocial factors identified, as clinically indicated. It is important to use much caution when prescribing hypnotic-sedative medications because these frequently have only time-limited effectiveness, may exacerbate cognitive impairment, and cause paradoxical or other untoward side effects.
Sexual problems arise in more than 10% of patients with dementia and cause considerable distress in their partners. Both hypersexuality and loss of interest in sex may result from the dementia itself, from medications, or from a concurrent affective disorder. If the dementia is mild, counseling may enhance communication about specific issues for a couple. Adjustment of prescribed medications associated with impotence or anorgasmia (e.g., antihypertensives, selective serotonin reuptake inhibitors) or hypersexuality (e.g., dopaminergic antiparkinsonian drugs) may restore normal sexual function. Likewise, treatment of a co-morbid depression or mania may restore a diminished libido or a hyperactive libido, respectively. For dementia patients with delusions of infidelity or delusions that others are their spouses, neuroleptic medications may diminish the intensity (if not cause remission) of the delusions. There are case reports of estrogens for the treatment of male patients with dementia whose problems with sexual aggression have proved severe and refractory to other treatments. Teaching caregivers to reframe sexual requests as calls for attention and closeness may also be helpful. Reassuring the unaffected partners that such behaviors are due to the dementia and are not a reflection on their relationships can go a long way toward reducing the embarrassment and distress that they may feel.
Wandering is yet another class of behavioral disturbance that can stem from dementia and may have multiple causes. By exposing patients to environmental hazards or causing them subjective fright, wandering can pose serious problems in the delivery of care, whether at home or in institutional settings. Its prevalence appears to correlate with the severity of the dementia (about 20% of patients with mild dementia, and about 50% of those with severe dementia). Wandering can arise when a patient with Alzheimer’s disease gets lost. It can be precipitated by relocation, environmental stimuli, boredom, psychosis, agitated depression, or hypomania. Wandering may be an unanticipated behavioral side effect of medication (e.g., akathisia due to antipsychotics, or looking for a bathroom after administration of a diuretic). Aimless wandering can be a manifestation of the dementia itself.
Wandering in patients with dementia is managed as clinically indicated according to the cause or causes uncovered and the principles discussed earlier. In addition, posting signs may help to direct dementia patients who can still read or recognize icons. Boredom can be alleviated by providing an exercise program and a schedule of meaningful activity. Involving cognitively impaired patients in useful tasks that call on skills they still retain can also enhance their self-esteem. Alarm systems are available to alert others when Alzheimer’s patients wander away from supervised areas. Finally, if the wandering is not otherwise problematic, providing an enclosed environment, such as a garden or indoor courtyard, in which the patient can safely wander can meet the needs of both patients and caregivers.
Dealing with Diagnostic and Prognostic Ambiguities
In working with dementia patients who have emotional and behavioral problems, considerable diagnostic ambiguity may be encountered, especially at first, in trying to sort through the multiple factors that may be contributing to any one individual’s set of problems. Enlisting the aid of caregivers by forming ad hoc treatment teams facilitates the gathering and sifting of information that can clarify the particular picture of a given patient. Their working knowledge of the patient and ongoing astute observations can provide major dividends. This approach also helps with prognostic ambiguities because very often it is difficult to determine how much improvement is realistic to expect or aim for. Even when an optimal result has been achieved, something else may happen that requires starting the process all over again (e.g., a fall with a hip fracture, or another stroke). One can work with family members or nursing staff to identify target symptoms, develop interventions, and track the results (e.g., using flow sheets). Then, by making modifications according to the results and instituting other changes that may be necessary in the course of the patient’s dementia, all participants can be reassured that all that can be done is being done. Thus, the process of developing an ad hoc team can also address the sense of collective helplessness or guilt that is sometimes engendered by these kinds of problems, in which care providers (including physicians) may feel at a loss about what can be accomplished in the presence of a progressive illness for which there is still no definitive cure.
To illustrate these principles, consider the case of Mr. A, an 84-year-old retired baker with CHF and moderate DAT, who lives with his daughter, Mrs. B. She is a 62-year-old widow who brings him with her to the clinic. She is exhausted by his wandering out of their house in the middle of the night and his habit of resistance when she attempts to redirect him. She feels badly that she is becoming so frustrated with him because she realizes that he can no longer be responsible for his behavior. A review of the situation with her reveals a number of possible causes of the behavior: (1) a diuretic that is given bid; (2) symptoms suggestive of a UTI and perhaps PND; (3) a somewhat depressed affect but no apparent psychosocial stressors. An assessment strategy is developed with the daughter, and she returns in a week with a log that reveals that: (1) her 30-year-old son, who still lives at home, has been noisy at night when he returns from his second-shift job; (2) her father has a predominantly sad mood, as well as a poor appetite, low energy, anhedonia, and undue pessimism. This observation confirms that her father indeed has a depressive disorder superimposed on his dementia. In addition, a careful physical examination shows that the CHF is under good control, whereas a urine culture reveals a bladder infection.
Subsequent medication adjustments include changing the diuretic to a once daily schedule in the morning, a course of antibiotic for the UTI, and a sedating antidepressant to help with sleep as well as mood. Mrs. B begins to participate in an Alzheimer’s support group and instructs her son to come in quietly through the back door when he returns from work. On follow-up a few weeks later, Mr. A’s UTI and depression have resolved, and he is no longer up during the night, distressed and looking for the bathroom. He is, however, awaking regularly at 5 AM, ready to go to work. Mrs. B is able to redirect him by feeding him an early breakfast, and she is much less tired because she is able to go to bed a little sooner and sleep through the night. Less stressed, she feels better about herself and, with support from others in her group, more confident as a care-giver.
ANXIETY AND AVOIDANT OR REPETITIVE BEHAVIORS
To date, anxiety disorders in the elderly have been less well studied than depression or dementia. This may stem in part from the ubiquity of anxiety, which is almost taken for granted and is underappreciated as a clinical problem. Another challenging factor in the study of anxiety in older adults is that of confounding variables. It is often difficult to gauge the significance of anxiety symptoms in elderly patients in whom those symptoms overlap with those arising from medical problems and their treatments. Further, the current cohort of elderly patients may be generally less comfortable in discussing psychological feelings and hence are more likely to focus on the somatic symptoms of anxiety.
Despite these obstacles to research, a picture is emerging from a number of studies indicating that anxiety disorders are some of the most common psychiatric problems encountered in an older population. The National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study found a 1-month prevalence of all anxiety disorders in a community-dwelling population 65 years of age and older to be 5.5% (6.8% in women and 3.6% in men). The most common anxiety disorder found was phobic disorder (4.8%), followed by obsessive-compulsive disorder (OCD, 0.8%) and panic disorder (0.1%).4 The symptoms of anxiety include psychological feelings of uncomfortable apprehension and such psychomotor signs as tremulousness and muscle tension. The autonomic symptoms of anxiety include shortness of breath, tachycardia, diaphoresis, dry mouth, lightheadedness, gastrointestinal distress, and flushing. Signs of vigilance that are also characteristic of the experience of anxiety include edginess, poor concentration, and an exaggerated startle response.
The differential diagnosis of anxiety includes adjustment disorder with anxiety, generalized anxiety disorder (GAD), phobias, panic disorder, OCD, post-traumatic stress disorder (PTSD), and anxiety disorder due to general medical condition (which used to be referred to as organic anxiety disorder). Adjustment disorders with anxiety occur in response to an identifiable stressor, such as a financial setback. But in older adults less severe stressors, such as a relocation from one room to another in a nursing home or a new illness, even if not severe or disabling, may give rise to an adjustment disorder. Interventions are focused on reducing the burden of the stressor or enhancing the coping skills of the patient. GAD is characterized by apprehension that is persistent (at least 6 months and often years in older adults), frequent, and unwarranted by the circumstances (either excessive or unrealistic). Based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, the patient with GAD finds the anxiety difficult to control and experiences three or more anxiety symptoms.5 This disorder can be treated with relaxation therapies and judicious use of anxiolytic medications (keeping in mind the side effects of benzodiazepines to which older patients are more vulnerable, such as sedation, falls, and cognitive impairment).
When an older patient shows avoidant behaviors not founded on realistic concerns, it is important to consider the possibility of phobias or panic disorder. Phobias involve fears that are persistent and excessive or irrational and are triggered immediately by exposure to a specific object or situation. Patients with a phobia retain insight into the fact that their reactive fear is unwarranted but continue to feel it nonetheless, to the point where they avoid the precipitating stimulus or endure it only with much subjective distress. A more specific diagnosis of social phobia can be made when the affected individual experiences an unwarranted fear of scrutiny, humiliation, or embarrassment in social contexts. Panic attacks can occur in older as well as younger adults, but when they occur for the first time in late life, they are more likely to be mistaken for myocardial infarctions, transient ischemic attacks, or other acute medical problems. Panic attacks typically involve discrete periods of unwarranted, usually spontaneous, and very intense fear or discomfort; they reach a peak within 10 minutes and are accompanied by strong autonomic anxiety symptoms as well as a fear of dying, losing control, or “going crazy.” The diagnosis of panic disorder is made when patients experience recurrent panic attacks and then develop (1) a persistent concern that they may have additional attacks, (2) worries about the implications or consequences of their attacks, or (3) changes in their behavior (typically avoidant in nature). Because of the intense nature of the attacks, such patients often become fearful of the fear itself and thus avoid (or endure only with a lot of subjective distress) the situations in which they first experienced the attacks and in which escape would be difficult or embarrassing. Phobias can be treated with cognitive-behavioral interventions (e.g., systematic desensitization). Panic disorder may respond to similar interventions, antidepressant medications (the selective serotonin reuptake in hibitors have been found to be beneficial, as are the older tricyclics), or sometimes both.
Both OCD and PTSD involve symptoms that are repetitive in nature, although in different ways. Obsessions consist of recurrent persistent thoughts, impulses, or images that are experienced by patients as intrusive and inappropriate. Among the most common themes of obsessions are contamination, pathologic doubt, bodily concerns, need for symmetry, aggression, and sexual images or impulses. They do not include excessive worries about real-life problems. Some obsessions may generate strong feelings of shame, which can prevent the patient from even reporting the symptoms. Compulsions are actions that are analogous to obsessions. They involve repetitive behaviors that patients feel driven to perform because of obsessions and are typically aimed at preventing, or at least reducing the likelihood of, some dreaded event. In OCD, insight is retained; patients realize that these phenomena are products of their own minds, and they initially experience the obsessions or compulsions as distressing and try to ignore, suppress, or otherwise neutralize them. Late-onset OCD is rare. Patients may present for the first time in late life, however, because of age-related changes or other medical or psychiatric problems. Transient OCD symptoms, for example, may occur in the context of a major depressive episode. Another diagnostic concern with geriatric patients who have OCD of long standing is that they may have had to cope with their obsessions or compulsions for so long (even decades) that they have gotten used to them and no longer view them as irrational. If available, information from collateral sources about the early course of the OCD in such patients can help to clarify the nature of the current symptoms.
PTSD involves exposure to a traumatic event in which the individual is confronted by or threatened with death, injury, or violation of the self, and consequently experiences intense fear, horror, or helplessness. As a consequence, PTSD causes persistently increased levels of arousal, and the patients repeatedly reexperience the event and avoid stimuli that remind them of it. Symptoms of increased arousal include insomnia, outbursts of anger, poor concentration, hypervigilance, and an exaggerated startle response. Avoidance behaviors include efforts to steer clear of thoughts, feelings, conversations, people, places, or activities reminiscent of the traumatic event. Patients with PTSD may also have trouble recalling significant aspects of the trauma and have a restricted range of affect or a foreshortened sense of the future. They may feel estranged from other people or lose interest in and drop out of activities in which they used to participate. Repetitive nightmares, flashbacks when awake, and intrusive, distressing memories or images are all ways in which a patient may persistently reexperience the trauma.
Little research has been published thus far on the efficacy of treatments for OCD or PTSD in geriatric patients. Cognitive and behavioral therapies have been used with some success in younger patients. Pharmacotherapy specific for OCD consists of the selective serotonin reuptake inhibitors, including fluvoxamine, and the tricyclic antidepressant clomipramine. The latter may not be well tolerated by older patients, given its strong sedative, anticholinergic, and hypotensive side effects. Medications for PTSD are more empirical: antidepressants, anxiolytics, and mood stabilizers have all been employed with varying degrees of success.
Finally, anxiety in older patients may be a consequence of a concurrent or underlying but still undiagnosed medical condition or a side effect of some medical treatment. Examples of these include cardiopulmonary disorders associated with discomfort or hypoxia, most endocrine disorders, and chronic pain syndromes. Neurologic disorders with which anxiety may be associated include masses, infections, focal seizures, vertigo, and movement disorders. Steroids, sympathomimetics, antidepressants, and stimulants are examples of medications that can cause anxiety as a side effect. Drug toxicity (e.g., excess digoxin or thyroid supplementation) or withdrawal (e.g., alcohol, sedative-hypnotics) may also be a culprit. Treatment strategies depend on the nature of the problems uncovered: eliminating or minimizing anxiogenic substances, reducing or changing anxiogenic medications, and addressing contributing medical problems.7
PARANOIA AND PSYCHOTIC SYMPTOMS
Elderly patients occasionally have difficulties in reality testing, such as paranoia, delusions, or hallucinations. Although the NIMH ECA study4 revealed that schizophrenia, a specific psychotic disorder, has a relatively low prevalence among community-dwelling elderly (0.2% to 0.9%), other research has found higher levels of psychotic symptomatology in certain clinical settings: (1) persecutory ideation in the community, 4%; (2) paranoid disorder in an outpatient geriatric psychiatry clinic, 17%; (3) delusions in a nursing home, 21%.8 Some risk factors that may predispose older adults to the development of psychotic symptoms include cognitive impairment and sensory deprivation, especially impaired hearing or vision. Recently widowed older adults may occasionally experience the presence of their deceased spouses in the form of auditory or visual hallucinations. These experiences are typically benign and may even be comforting to the surviving partner; hence they do not usually require treatment.
A number of psychiatric disorders affecting older adults are characterized by or associated with psychotic symptoms. Paranoid delusions have been found to occur in up to 40% of older adults with delirium. Recent research in dementia has shown that up to 40% of patients with Alzheimer’s disease or vascular dementia develop psychotic symptoms during the course of their illness. Among the most common delusions is the idea that others are stealing, breaking in, or poisoning food. Hallucinations have been reported to occur in up to one third of patients with Alzheimer’s disease. Both major depression and mania can appear for the first time in late life and may be associated with psychotic features. The reader is directed to other chapters of this book for a broader discussion of psychosis in the context of dementia, delirium, and mood disorders. Here we will focus on schizophrenia, delusional disorder, and the organic psychoses (i.e., those due to medical problems or drugs).
Schizophrenia, usually a chronic disorder, is characterized by at least two of the following symptoms: delusions, hallucinations, disorganized speech (derailment or incoherence), catatonic or grossly disorganized behavior, and what have come to be called “negative symptoms” (flattened affect, alogia, avolition). In addition, the diagnostic criteria for schizophrenia include a marked decline from baseline in psychosocial functioning as reflected in work performance, interpersonal relations, or self-care. Most adults in late life with schizophrenia have grown old with their illness; in 90% of these, the onset of the disorder occurred prior to age 46. There is a growing body of research on late-onset schizophrenia (LOS). While the diagnostic criteria are the same as those for the early-onset form, in LOS negative symptoms and disorganized speech appear to be less prominent, whereas persecutory delusions tend to be more common. Risk factors associated with LOS include female sex, sensory deficits, social isolation, eccentric personality, and a family history of schizophrenia. A prototypical case might be that of an elderly woman, hard of hearing and with cataracts but no prior overt psychiatric history, who otherwise manages to live alone successfully. She periodically calls 911, fearful that someone is trying to poison her water supply, but she cannot be reassured, much to the consternation of those trying to help.
Diagnosis of a delusional disorder entails the presence of one or more nonbizarre delusions for at least a month in the absence of schizophrenia, a psychotic mood disorder, or organic psychosis. The delusions are usually quite circumscribed; aside from the delusions and their ramifications, the functioning of patients with delusional disorders is not significantly impaired, nor is their behavior otherwise overtly odd or bizarre. Subtypes of delusional disorder include erotomanic, grandiose, jealous, persecutory, somatic, and mixed types.
Organic psychoses include those caused by an underlying medical condition or drug toxicity. Brain disease (cerebrovascular, degenerative, traumatic, neoplastic, infectious, and immunologic) may contribute to the development of psychotic symptoms in older patients. Hydrocephalus, seizure disorders, and hepatic or renal failure can do likewise. Other potential medical causes include electrolyte disturbances, vitamin deficiencies (thiamine, folate, B12, niacin), and hypoactivity or hyperactivity of the thyroid, parathyroid, or adrenal glands. Among medications with the potential to induce psychosis are anticholinergics, dopaminergics, steroids, stimulants, digoxin, cimetidine, benzodiazepines, anticonvulsants, lidocaine, and procainamide. It is especially important to consider all these factors in those elderly patients with long-standing psychoses such as schizophrenia. If their psychotic symptoms become more disorganized, or if they develop new ones out of character with the usual ones, a separate organic psychosis may be superimposed on the chronic disorder.
The treatment of psychotic symptoms in older adults consists primarily of identifying and addressing any contributing medical problems (including difficulties with medications and other substances that may be implicated) and providing the patient with a safe, reassuring, and supportive environment. For delusions or hallucinations that are distressing to patients or that interfere with their function or care, judicious use of an antipsychotic medication is indicated. Here, the choice among the many available neuroleptics is fraught with difficulties because of their many side effects. Whereas the less potent antipsychotics (e.g., chlorpromazine, thioridazine) are often associated with relatively less risk of extrapyramidal side effects (EPSE), they carry relatively more risk for significant sedation, orthostasis, and anticholinergic symptoms (including blurred vision, dry mouth, constipation, urinary retention, and cognitive impairment). And while the risks for such side effects are relatively lower with the highly potent neuroleptics (e.g., haloperidol, fluphenazine, thiothixene, trifluoperazine), their use raises the risks of EPSE, including parkinsonian symptoms, akathisia, and dystonia. Although there are no data available that support this approach objectively, one strategy is to become familiar with the use of neuroleptics of intermediate potency (e.g., molindone, loxapine, perphenazine), which, at least theoretically, have risks intermediate between those of the less and more potent neuroleptics. All these medications, if used on a long-term basis, carry a significant risk in older patients for the development of the abnormal involuntary movements characteristic of tardive dyskinesia (TD). Hence their use in LTC settings is regulated,10 and patients taking them require periodic screening for TD.
The newer atypical antipsychotics have begun to be used with geriatric patients with some success, but these too require caution. Clozapine can be helpful in some patients with Parkinson’s disease with delusions or hitherto refractory schizophrenia, but it has all the side effects of a less potent antipsychotic and also lowers the threshold for seizures. Risperidone and olanzapine appear to be associated with some reduction in the likelihood of EPSE in some older patients if employed at lower doses.
For patients who, given the nature of their delusions (e.g., as in those with LOS), refuse treatment, one can obtain psychiatric consultation and, in cases of imminent danger, court-ordered evaluation and treatment. When danger is not imminent and the patients refuse to see a psychiatrist (as is not infrequently the case), one can attempt to build a therapeutic alliance over a period of time to the point where sufficient trust is established for them to consider taking medication to relieve distress. This may be accomplished by “agreeing to disagree” about the issues about which they are delusional (e.g., whether someone is breaking into their apartment and leaving salt on the table) and working with them on nonanxiety-provoking medical or social concerns for which they are open to interventions (e.g., management of their hypertension or arranging transportation to the clinic).
Not infrequently, geriatricians encounter older patients with troubling somatic complaints that seem to defy even the most thorough diagnostic and therapeutic efforts. These patients often consume an inordinate amount of time and resources, undergo risky procedures and treatments, and generate anxiety and frustration in their health care providers. Many of them are individuals who “transduce” their subjective psychological distress into bodily sensations of discomfort.11 Such clinical phenomena, referred to generically as somatization, are probably best understood from a biopsychosocial perspective as occurring in the context of an illness. Just as in physics one can meaningfully study light as both a particle and a wave, so also one can fruitfully view illness as both a disease process and how the patient experiences that disease. Thus, somatization can occur not only in clinical situations in which there appears to be no demonstrable organ system or cellular dysfunction but also when patient complaints or responses to treatment appear to be disproportionate to demonstrable disease processes. In both instances, there are problems to be addressed in the patient’s experience of internal or interpersonal difficulties. Very little research data on somatization in older populations are available, but it has been estimated that up to 60% of primary care patients present with somatic complaints that express psychological distress. Somatization can occur in the context of transient emotional distress, mood and anxiety disorders, psychophysiologic disorders, psychotic disorders, malingering, factitious disorders, personality disorders, and somatoform disorders.
Hypochondriasis is a somatoform disorder characterized by the fears or beliefs of the patient that he or she has a serious disease, stemming from a misinterpretation of somatic symptoms. These beliefs persist for many months (or even years) despite appropriate medical assessment and reassurance and cause significant subjective distress or impaired functioning. Such beliefs are not delusional in their intensity, which distinguishes them from a psychotic disorder, nor are they limited strictly to concerns about physical appearance, which would constitute a (rare) body dysmorphic disorder. In undifferentiated somatoform disorder a patient has one or more somatic complaints and subsequent distress or functional impairment that, despite an appropriate work-up, cannot be accounted for by a known medical condition or exceeds what is expectable on the basis of the patient’s history and clinical findings. Older patients with these disorders may feel misunderstood and abandoned by impatient physicians, become hostile, or resort to doctor-shopping.
A number of theories have been developed to explain the genesis of such somatoform disorders. These have been nicely reviewed by Kaplan and colleagues.11 Some neurobiologic theories postulate that abnormal processing of afferent sensory information by the central nervous system amplifies normally imperceptible stimuli, which the patient then experiences and labels as problematic. Others propose that some patients have interhemispheric communication problems such that emotions are expressed through physical complaints rather than verbally. Psychodynamic theories interpret somatization as a way of resolving underlying emotional conflicts (e.g., a desire for comfort and nurturance versus a fear of rejection).
Behavioral theories propose that somatization is learned under the influence of environmental reinforcers. A patient may present with an illness, complaining of chest pain and anxiety, for example. By focusing on the chest pain to the exclusion of the anxiety, the physician and others reinforce the somatic complaint while at the same time downplaying the perceived significance of the emotional complaint. For some patients, who have such experiences repeatedly, their “illness behavior” is thus shaped by the interactions into a somatizing pattern. Sociocultural theories of somatization put forth the notion that in a culture one learns socially acceptable ways of handling emotional issues, including those involved in illnesses. The degree to which the direct expression of feelings is permitted, tolerated, or encouraged varies from one culture to another. Somatization may then become a means of indirect expression of emotions in cultures in which open demonstrations of feeling are less acceptable. In such cultures, taking a patient’s somatic complaints literally may give rise to significant misinterpretations.
When working with somatizing patients, it is important to do more than “rule in” or “rule out” an underlying medical or psychiatric disease process; it is important to listen actively to the patient to learn the place of the complaints in the context of the person’s body, intrapsychic life, and interpersonal relations and culture. In addition to determining the pattern of somatization according to these criteria, one can watch for low self-esteem, guilt, or difficulties with handling anger or assertiveness. The ways in which the patient interacts with other family members and health care providers and how he or she uses medical services can provide significant clues to the roles the symptoms may be playing in everyday life. An understanding of the patient’s personal beliefs about the nature and meaning of the symptoms and illness and how he or she copes with stress can be very revealing. Questions about what a patient thinks has caused the problem, why it began when it did, how it affects him, and what kind of treatment he thinks he should receive can help to clarify his experience of the problem. Likewise, eliciting the patient’s hopes and fears about the illness may provide important insights.11
For patients whose somatization represents a transient response to an acute stressor, the prognosis is generally good. These patients typically respond well to appropriate reassurances and education about their problems. Chronic somatization, however, calls for a more sophisticated approach. A key component is the cultivation of an empathic doctor-patient relationship, the development of a therapeutic alliance characterized by trust and caring. This is often not easy because treating physicians, when confronted with patients who seem to resist their best efforts to help, may find themselves feeling helpless, hopeless, inadequate, angry, guilty, or fearful. Such feelings may be further compounded by another set of feelings about developing such strong reactions in the first place (e.g., feeling guilty about feeling angry).
The first step in addressing such responses is to recognize that one is having them, and allowing oneself to fully feel them rather than dismissing or trying to ignore them can facilitate this process. The next step is to consider what such strong feelings represent, because very often they can provide a great deal of information about these patients. In ways analogous to how the forehead of a febrile patient makes one’s hand feel warm, so the feelings engendered by the complaints of somatizing patients can reveal important clues about their condition. A not uncommon phenomenon in patients who have difficulty in directly communicating their ideas and feelings is that, through their behavior, they end up causing others around them to have the same feelings that they have. Thus, some chronically depressed or angry patients, for example, who find it difficult or impossible to articulate their discontents, may generate resonating feelings of sadness or frustration in those who come in contact with them.
The feelings elicited by working with somatizing patients, then, are not something to feel guilty about but rather should be appreciated for what they are: valuable sources of information that can help to clarify the issues involved and can be tapped by shifting diagnostic modalities. The challenging task is to resist the temptation to either suppress them or react blindly to them, but instead to work them through like other clinically demanding diagnostic tasks, thoughtfully, respectfully, and sensitively.
The insights obtained in this manner can be used to overcome the apparent barriers to delivering care to chronically somatizing patients and to gradually build a therapeutic alliance. Seeing such patients on a regular basis at short intervals “whether they need to be seen or not” can do much to establish a foundation of dependability and constancy on which to build. By not making the follow-up contingent on the presence of somatic complaints, the doctor-patient relationship is reinforced instead. Care should be taken to schedule the frequency of follow-up according to the individual patient’s needs. Too short or too long an interval could lead to the symptoms becoming worse. A solicitous approach that communicates acceptance and respect for the patient as a person can promote enhanced self-esteem. It can also help to derail the all-too-common self-fulfilling prophecies through which such patients anticipate rejections from physicians, behave in such a way that they are rejected, and thereby confirm their original expectations. These dynamics are often well-reflected in such clinical phenomena as doctor-shopping and excessive use of medical resources. A consistent approach, in which the reality of the symptoms is not contested but respectfully assessed with a careful physical examination (no matter how strange the complaint) and judicious laboratory testing, will go a long way toward reassuring these patients that they are being taken seriously. Careful attention to patients’ affect and nonverbal communications can facilitate this ongoing process.
Premature interpretations connecting somatic complaints with psychological issues are generally best avoided. Usually these patients have heard such responses before and associate them with prior rejections. Over an extended period of time, during which a sound therapeutic alliance is established, it may be possible to learn to make such connections for some, though probably not all patients, particularly if these interpretations are couched in terms of stress (including the stress of the symptoms themselves). In nearly all cases, attending patiently to the patient’s story, beliefs about the illnesses, and expectations of care will enhance the doctor-patient relationship. This in turn can enable the treating physician to discover the patient’s strengths as well as weaknesses and then support the best ways of coping. If the patient expresses impatience at the length of time it y take to accomplish some of these things, he or she can be reminded that such enterprises take time, and that if the situation were so easily remediable, it would already have been resolved.
Another critical component in the management of chronic somatization is the setting of appropriate, attainable treatment goals. Here is where a strategy of caring, as opposed to curing, can yield substantive results. Instead of aiming for the total elimination of somatic complaints, one can set as “target goals” such things as a reduction in the number of hospitalizations, diagnostic procedures, emergency room visits, or urgent phone calls to the office, or an increase in the number of social outings. These indirect psychosocial markers, when used on an individual basis of how the patient is doing (as opposed to what he may be saying) can be employed as measures of progress.
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