UNDERSTANDING AND HANDLING MENTAL DISORDERS IN THE AGED

THE serious psychiatric disturbances of old people are a m atter for experts, but lesser psychological symptoms and em otional disturbances are frequent and sometimes alarm ing. A good deal o f psychiatric illness in the aged goes unrecognised until it is well advanced as it develops in­ sidiously, takes the form o f physical illness, or the per­ son may not choose or even know where to go for help. Alternatively, he fears that if he voices his fears he may be thought ‘m ad’ and ‘put aw ay’. Old people may develop a few isolated psychiatric symptoms at any time w ithout it meaning much. Perhaps they become depressed for a while during or after a physical illness, see illusionary figures or scenes when half asleep, or become forgetful or confused for short periods. These become significant however, if ac­ companied by disturbed behaviour. The im portant thing is that rapidly developing new symptoms, be they physical or mental, need urgent investigation. When mental illness strikes, relatives are often nonplussed. From a practical point o f view it is helpful to distinguish between suddenly occurring mental illness and that which develops m ore gradually.

T H E serious psychiatric disturbances o f old people are a m atter fo r experts, but lesser psychological sym ptom s and em otional disturbances are frequent and som etimes alarm ing.
A good deal o f psychiatric illness in the aged goes unrecognised until it is well advanced as it develops in sidiously, takes the form o f physical illness, or the per son m ay not choose or even know where to go for help.A lternatively, he fears th at if he voices his fears he may be thought 'm ad ' and 'put aw ay'.
Old people m ay develop a few isolated psychiatric sym ptom s at any tim e w ithout it m eaning much.P erhaps they becom e depressed for a while during or after a physical illness, see illusionary figures or scenes when h alf asleep, or becom e forgetful or confused for short periods.These becom e significant however, if ac com panied by disturbed behaviour.The im portant thing is that rapidly developing new sym ptom s, be they physical or m ental, need urgent investigation.W hen m ental illness strikes, relatives are often nonplussed.From a practical p oint o f view it is helpful to distinguish between suddenly occurring m ental illness and that which develops m ore gradually.

Suddenly Occurring Psychiatric Distrubances
The com m onest are states o f confusion in the old people which show in bew ilderm ent, loss o f bearings, and forgetfulness o f simple facts about themselves, events, tim e, etc.In extrem e cases they m ay even fail to recognise m em bers o f their families.This may be ac com panied by physical restlessness: the person looks aro u n d in an agitated way, talks irrelevantly, or just m utters and m um bles incoherently.Sometimes he responds to chance stimuli in an appropriate fashion, for instance he im agines that a voice heard in the street is talking to him , and may even reply.Visions may occur which are som etim es very frightening: for instance, he may see long-dead relatives or experience forebodings about the future.
C onfusion in the elderly is rather like tem peratures in children, in that there are many causes, they tend to arise rapidly and sometimes for quite trivial reasons, and may present a very alarm ing picture.Fortunately, m any settle down as rapidly with appropriate treatm ent.There is always a definite precipitating cause and the outlook is probably the best for any o f the psychiatric disturbances in old age because the underlying condition is usually rem ediable.O ften the cause is em otional as old people are easily knocked o ff their balance psychologically.Anything that interferes with routine or lessens their contact with fam iliar things can do this -ju st moving to a new room , an em otional shock, or a fright such as results from a slight fall.Also if vision or hearing is im paired so that they are not receiving enough cues from their environm ent.C onfusion can be the first sign o f an infection with the tem perature and fever only appearing later.Look for signs o f com m on illnesses: in fluenza, a cough or wheezing (m any a pneum onia is heralded by confusion), a urinary infection indicated by burning on urination, or frequent passing o f urine.These sym ptoms may only be mild but the confusion can be severe.
O ther physical illnesses such as diabetes or thyroid disease, or liver or kidney disease m ay cause a disturbed m etabolic state and consequent confusion.R etention of urine as a result o f enlargem ent o f the prostate is a com m on cause, as are operations o f any sort.C onfusion also occurs in the course o f heart failure, coronary disease or because o f a stroke.Sometimes, it appears before other physical sym ptom s have become evident, or where the underlying disease is insidious and not easily recognised, such as anaem ia.It is essential therefore that everyone with suddenly occuring confu sion be thoroughly investigated m edically as soon as possible.
M any medicines cause confusional states.Always en quire therefore w hat the old person has been taking, and collect all pills lying aro u n d or in cupboards to show to the doctor, or take them to the hospital with you.P ar ticularly im p o rtan t are sleeping pills (especially if the contain brom ides and barbiturates), tranquillisers, an ti depressants, pills taken for heart conditions, cortisone and its derivations, and drugs used for parkinsonism .Never take anything for granted.Old people are forget ful or may be unheedful o f instructions and take m ore th an the prescribed dose, or continue to take their old m edicine as well as the new when the doctor changes the prescription.A lternatively they may be attending m ore than one d o cto r and each be unaw are o f what the other is prescribing.Rem em ber too that old people often do not tolerate drugs as well and that quite small doses may have large effects.
C onfusion can result from excessive intake of alcohol, or if the old person is a heavy drinker, when he dim inishes his intake.This most frequently happens if he is taken ill or adm itted to hospital, and gives rise to a delirious state with or w ithout terrifying visions.T rem ulousness, restlessness, a fast pulse and sweating are characteristic o f this condition.The possibility o f alcoholism as a cause o f confusion in the elderly is easily overlooked because the extent o f their drinking may not be appreciated or they may be secret drinkers.
C onfusion can occur as a result o f diseases o f the brain.For instance, a clot or bleeding inside the skull which may be due to a fall or injury, or occur spon taneously because o f vascular disease.The injury may not even have been serious (i.e. a bum p on the head) and can have taken place some time previously (even m onths), so th at it is possible to miss the connection.The characteristic feature, however, is that the person becomes stuporous at times, but this m ay fluctuate so that he is quite clear m entally at others.Sometim es acute confusion can be due to underlying psychiatric illness, which is not related to organic changes in the brain.For instance, in the condition called hypom ania where the person becomes over-active m entally with a grasshopper-like flitting from idea to idea.There may well have been sim ilar attacks pre viously or the person may be prone to, and have had treatm ent for, depressive illness.It is difficult for a laym an to be sure ab out the presence o f this condition although he m ay have a clue because o f it having occur red previously and the fact that the level o f con sciousness is not affected.

Chronic or Gradually Developing Psychiatric Disturbance
H ere there are tw o m ain questions to answer.1. H as the person really changed in him self, that is, is his personality recognisably different.If so, this is characteristic o f the condition called dem entia or m ental decay.
2. H ave new sym ptom s or behaviour been super im posed on his norm al personality?W e will deal with each in turn.

D EM EN T IA (M ental Decay)
H ere the personality changes so th at the old person becomes a caricature or travesty o f w hat he was.He may, for instance, always have been 'd ifficu lt' and now he becomes impossible in the sam e sort o f way.This change m ay be fairly gradual so th at it is m ost notice able in those who do not see him every day, and they will often rem ark how old he seems to have becom e lately.T he deterioration is due to actual physical change in the b rain , but some o f the early sym ptom s m ay be sim ilar to those found in depressive illness or in neurotic states.It is im p o rtan t to distinguish between them as the tre a t m ent differs.In the form er, m em ory will be im paired, perhaps for small and unim portant things at first and patchily, but in time great gaps will becom e app aren t.They tend to become easily confused and one has an im pression o f dilapidation and o f being distinctly 'offb eam '.
They tire easily and do not seem to m anage as well as before -take longer to dress and do it badly, leave b u t tons undone or are careless ab o u t personal hygiene.They 'p o tte r' and may w ander aimlessly aro u n d the house at night.Judgem ent is faulty: at first finer critical ability is affected but later there is faulty reasoning.Tem per tends to change too.M ost ju st becom e a bit dull, but som e are crotchety or petulant and quick to take offence.O thers becom e selfish and hoard food and articles.They m ay lose their sense o f social rightnesspick their noses in public, eat noisily, or dress dirtily.This condition is usually associated with an increased liabilty to serious physical illness and they need special attention to their health.
How does one know if the slight changes in m em ory and m ental capacities so often found in elderly people will progress?Some fall-off in intelletual capacity occurs quite norm ally but this is not an illness in itself and will no t get m uch worse from year to year.N o rm al ly too, there is none o f the dilapidation o f the personali ty an d deterioration o f social behaviour seen in a senile dem entia.O m inous signs are a rapid decline over a couple o f m onths, som etim es precipitated by a physical illness or an operation.
N arrow ing or obstruction o f the arteries o f the brain by the accum ulation o f fatty tissue in the walls, or to spasm or a clot (as a result o f a stroke) can also give rise to dem entia.The sym ptom s are however m ore patchy and fluctuating, and often associated with confusion.T here may be periods lasting for m onths when the per son is quite clear m entally, or shows only slight loss of intellectual powers.This confuses relatives as he ap pears to be so well.A lternatively, each attack m ay leave a residue which adds up over a period to give quite con siderable im pairm ent.It is characteristic o f this condi tion th at there is a lack o f control o f the em otions so th at the old person reacts im m ediately to circum stances, i.e. he m ay laugh or cry too easily, or become tactless.T reatm ent can be helpful, depending on the extent of the changes in the arteries.It is directed m ainly at the underlying conditions, particularly the blood pressure, and often the m ental effects can be slowed and in cer tain cases even halted.At the very least, the acute episodes occur fu rth er apart.

D EPR ESSIO N
The com m onest psychiatric conditions are depression and neurotic and ad justm ent reactions.
The form er occurs in different degrees o f severity ranging from a fit o f the blues to a condition o f deep and lasting m isery with great suffering and incapacity.In its severest form this is a specific disease and needs urgent treatm en t because o f the risk o f suicide.It is so universal and im portant a condition that we will describe it in som e detail.
Depression is a great deceiver because it has m any guises.It is obvious enough when the person com plains th at he feels w reteched and unhappy, and has feelings of hopelessness, guilt and futility.He looks miserable and w orried and his whole posture is dejected.The problem arises when depression appears as som ething else.For instance, it m ay ap pear as an intensification of the per son's norm al rath er pessimistic or m isanthropic per sonality.O r it m ay show as a protracted state of joylessness, a state o f general dissatisfaction, or a chronic w orry state.Scratch a little however, and you will usually find a very depressed person.Sometimes the depression is m asked by m ental denial -the patient may smile and say there is nothing wrong, but the smile strikes one as an arrangem ent o f the facial muscles rather th an a tru e reflection o f the way he feels.This condition can be difficult to recognise and an ex perienced d o cto r will be necessary to treat it.A special variety o f depression appears in the form o f hypochrondriasis -continuing com plaints o f bodily pains and dysfuntion w ithout actual physical illness.The person may have som e physical basis for these com plaints, but not enough to w arrant his m any dem ands for pills and treatm ent.C haracteristically one gets the impression that the com plaint is m ore im portant than the cure.H ypochondrias is not however, a 'put o n ' condition.It indicates m ental unrest and if it comes on fairly sudden ly in old age, should arouse one's suspicions as it represents a hidden depressive illness which responds well to m odern medical m ethods.
How does the non-expert tell w hether an old person is severely depressed?Firstly, there is the fixity o f the sym ptom s.If they have endured for weeks or m onths and do not respond to alleviating circum stances -say, good news or a pleasurable happening.One often gets the feeling too, in the m ore severe form s, that they wallow in despondency or w rap themselves in a blanket o f self-concern and despair.O n e's own reaction can be helpful in reaching a conclusion, because the feeling of depression is contagious so that those who are in contact with it tend to feel that way themselves.The most characteristic sym ptom however is that the person just seems to have lost interest in life.Everything seems too m uch: he m ay not be able to concentrate on a new spaper, and has given up his usual interests and activities.There may also be physical changes.Loss of appetite causes weight loss and the skin looks dry and sallow.The person is clearly physically slowed and one gets the im pression that the inner m achine has ju st run down.
The above description will usually be clear enough to distinguish mild from severe cases and b oth from organic dem entia as there is no fall-off o f intellectual ability and no loss of memory.There is a slowing of m ental and physical functions in both conditions, but in depression one gets the impression that this is due to inertia rather than a real inability to m ove and think fast.Last, but not least, the depressive old person seems to labour under a heavy load whilst that one with brain degeneration does not really suffer.He is ju st not the m an he once was.
These are products o f fear and conflict, m anifesting themselves in neurotic reactions or adaptational responses.They are set o ff by external stress or an unhappy life situation, or result from disturbance in the unconscious m ind so that no obvious cause can be found.The old person retains his intellectual capacities and can participate in his daily life, although he may protest that he cannot.He suffers however, from a variety o f unw arranted fears or phobias about neutral objects or situations (heights, open or closed spaces, etc.); or he may develop repetitive thoughts that he can not rid him self of, or have to perform rituals such as hand-washing, counting, etc. N eurotic sym ptom s may appear to be 'put o n '; and certainly the person seems to m ake the m ost o f them in m anipulating family and relatives.However, they are illnesses in their own right and beyond his control.They deserve treatm ent, but often, because the person becomes dem anding and dif ficult, the family lose patience and tell him to 'pull him self together.'It is not easy to separate true neurotic sym ptom s from exaggerated norm al reactions to unsatisfactory cir cum stances.All o f us can become som ewhat neurotic under stress, and certainly, m any elderly people have a great deal to cope with in the way o f deprivation, physical loneliness, etc.They are particularly vulnerable because o f early brain changes which do not am ount to dem entia but do limit their capacity for adjustm ent.This may cause a spum e o f psychological reactions in sitautions which previously would have left them un affected.However, it is usually possible to recognise the true neurotic because he has a lifelong pattern o f similar behaviour or character qualities, and a background of disturbed childhood and family life.In addition, he will always have been som ewhat im m ature in his reactions or anxious and conflict-ridden.
N eurotic sym ptom s are not at all uncom m on in the aged, either as one or m ore single m anifestations such as a fear o f heights or an obsession, to full blown cases of neuroses.Q uite often the disturbance appears as psychosom atic sym ptom s such as spasm o f the bowel, asthm a, skin conditions, etc., and their true nature may escape recognition because the underlying psychological disturbance is not clearly evident.Family doctors see a great num ber o f such reactions, many o f which resolve when the stress which has caused them disappears.In contrast to younger people neurosis appears to arise from environm ental stress rather than from inner con flict.The ground m ay have been prepared in childhood, but signs did not appear until their powers to cope have waned in age.
A neurotic in the fam ily can be very trying and it is easy to become irritated by or resentful o f him.M ake no m istake, though, they suffer, and need help.The problem is th at o n e's usual ways o f dealing with people do not seem to help.P ersuasion, upbraiding, punishing or trying to reform ju st gives rise to resentm ent and hos tility, which m akes lifer m iserable for everyone.There is som ething which can be done though, and often enough this lies in alleviating pressing circum stances rather than psychiatric treatm ent 'per se'.M ost such situations are triggered by the m aterial condition o f the old p erso n 's life and should be carefully looked at -perhaps he is w orried about a pending operation or there is a financial problem .O r it may just be loneliness and a feeling o f neglect.Family relationships will usually need atten tio n and the help o f an outside detached person such as a friend, the family doctor, possibly a social w orker, a psychologist, or a psychiatrist should be sought.Relatives, with the best will in the world can n o t, because o f their personal involvem ent, see the wood for the trees and talking it over with som eone else is always useful.How ever, if the problem is due to entrenched neurosis, this is a m atter for experts.O ne way to tell is th at a d if ficult old person alm ost certainly was a difficult young person.In these cases a consultation with a psychiatrist m ight be arranged through your family doctor.