psychiatric disorders in elderly

8/4/2019 psychiatric disorders in elderly

1/11387The Canadian Journal of Psychiatry, Vol 56, No 7, July 2011W

In Review

Psy ch ia t r ic Diso rd ers in th e Eld er ly

Ingmar Skoog, MD, PhD 1

Recent research has shown that depression, anxiety disorders, and psychosis are morecommon than previously supposed in elderly populations without dementia. It is unclear whether the frequency of these disorders increases or decreases with age. Clinicalexpression of psychiatric disorders in old age may be different from that seen in younger agegroups, with less and often milder symptoms. Concurrently, comorbidity between differentpsychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitivefunction is often decreased in people with depression, anxiety disorders, and psychosis,but whether these disorders are risk factors for dementia is unclear. Psychiatric disordersin the elderly are often related to cerebral neurodegeneration and cerebrovascular disease,although psychosocial risk factors are also important. Psychiatric disorders, common amongthe elderly, have consequences that include social deprivation, poor quality of life, cognitivedecline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidalmortality.

Can J Psychiatry. 2011;56(7):387397.

Key Words: depression, anxiety, psychosis, elderly, epidemiologic methods, prevalence, risk factors, comorbidity

Most research on mental disorders have been concernedwith dementia and to some extent with depression.

Other mental disorders, such as anxiety disorders and psychotic disorders, have received less attention. Thisreview will discuss the frequency of mental disorders in theelderly, and its relation to age. Aspects of mental disordersin the elderly without dementia, such as clinical expressionand comorbidity, cognitive function and dementia, cerebralneurodegeneration and cerebrovascular disease, and risk factors and consequences, will also be discussed.

Frequency of Mental Disorders in the ElderlyThe prevalence of mental disorders is high among theelderly,14 with a prevalence of almost 20% in peoplewithout dementia aged 65 years and older.2 While most people in epidemiologic studies are below age 90 years,it was recently reported that almost one-third of peoplewithout dementia aged 95 years ful lled criteria for a psychiatric disorder: 17% had depression, 9% anxiety, and7% a psychotic disorder.5

Most studies on the epidemiology of mental disorders inthe elderly without dementia have been concerned withdepression. Cross-sectional studies report prevalence

gures of around 5% to 10% for depression,3,612 and 1%

to 5% for major depression.2,3,13

These gures may be evenhigher in the developing world.14 This makes depression

more common than dementia in people aged 65 years andolder. The prevalence of depressive symptoms are even morecommon than the clinical diagnoses. Such subsyndromalforms of depression are nevertheless associated with adverseoutcomes, such as stroke, disability, and mortality.1518

Anxiety disorders include GAD, agoraphobia, panicanxiety disorder, OCD, social phobia, and speci c phobias.Recent research suggests that anxiety disorders may beas common, if not more common, as depression1,2,4 in theelderly. Among recent studies, prevalences between 6%and 12% have been reported in people aged 65 years andolder.24 The prevalence was 10.5% in people aged 85 years7 and 4% in those aged 95 years.5

The prevalence of GAD ranges between 1% to 10%.2,3,1922 In people aged 85 years, the prevalence was 6%,7 and inthose aged 95 years, 2%.5 Few studies have examinedthe prevalence of OCD among the elderly. Studies on populations aged 65 years and older have reported prevalences ranging from 0.2% to 1.5%.2,2225 In peopleaged 85 years, the prevalence of OCD was 3.2%7 andin those aged 95 years, 0.3%.5 Speci c phobia is oftenconsidered the most common among the anxiety disorders.Prevalence estimates vary from 2% to 12% in populationsaged 65 years and older.2,3,21,22,2629

Using DSM-IV criteria, the prevalence of social phobiawas 1.3% among people aged 55 years and older,30 1.8%


2/11388 W La Revue canadienne de psychiatrie, vol 56, no 7, juillet 2011

In Review

for those aged 65 years and older,31 and 1.9% for thoseaged 70 years and older.32 The criteria for social phobia,according to DSM-IV, require: A) fearing social situations,B) experiencing the fear as unreasonable or excessive,C) avoiding feared social situations or enduring them withintense anxiety or distress, and D) that this causes socialconsequences. Using these criteria in an elderly population,Karlsson et al32 found a 1-month prevalence of social phobia of 1.9%. However, an additional 1.6% ful lledDSM-IV-TR Criteria A, C, and D, but not Criterion B; thatis, they did not nd their fear unreasonable. Thus 3.5% hadsocial phobia that caused social consequences. DSM-IVcriteria thus exclude a large group of elderly with social phobia.The term paraphrenia was previously used to describe psychotic syndromes in the elderly. Currently usedterms are late-onset schizophrenia or late-life psychosis,encompassing visual and auditory hallucinations anddelusions arising in late life.33 Psychotic symptoms and

disorders, such as schizophrenia, are supposed to be rarein the elderly without dementia. Population studies reportthat the prevalence of self-reported psychotic symptoms inthe elderly without dementia range from 1.7% to 4.2%.2,3436 However, there may be underreporting because the elderlyare reluctant to report psychotic symptoms. Using severalsources of information (including self-reports, closeinformants, and patient records), it was recently reportedthat 10% of the elderly without dementia aged 85 years37 and 8% of those aged 95 years38 had psychotic symptoms.The prevalence was substantially lower (1%) among peoplewithout dementia aged 70 years using the same methods.39

Prevalence is affected not only by the occurrence of newcases, but also by the duration of the disorder and by itsmortality. Incidence is therefore a better measure of risk.However, studies on incidence of mental disorders in oldage are rare and rates vary considerably. The incidence of depression vary from 2 to 140 per 1000 person-years.16,4044 In the Epidemiologic Catchment Area Program study,40 the incidence of phobic disorder in people aged 65 yearsand older was 27 per 1000 person-years for males and 55for females, and the incidence of OCD was 10 per 1000 person-years in females. The incidence of social phobia was17 per 1000 person-years after age 70 years.45 Regarding

the incidence of psychotic symptoms in the elderly, 9%of people without dementia followed from age 70 to 90years developed a rst-onset psychotic symptom during thefollow-up.46 Others have reported a cumulative incidenceof 5% for psychotic symptoms during 3.6 years of follow-up in the cognitively intact elderly.34 The incidence for schizophrenia was 0.03 per 1000 person-years and for delusional disorder 0.16 per 1000 person-years for peopleaged 65 years and older.47 The incidence of rst-onset psychotic symptoms was 5.3 per 1000 person-years for people aged between 70 and 90 years.46 Another populationstudy48 estimated the incidence of visual hallucinations to25 per 1000 person-years for people aged 70 to 79 years,and 40 per 1000 person-years for people aged 80 years andolder.

What Is the Relation Between Age andFrequency of Mental Disorders?The prevalence of many factors associated with mental

disorders increases with age, including loss of closerelatives, social network, previous status in society,sensory functions, functional ability, and health.11,49 The presence of different organic factors, such as brain atrophy,cerebrovascular disease, underactivity of serotonergictransmission, hypersecretion of cortisol, and low levelsof testosterone, also increases.5052 Old age may also have positive dimensions, with freedom of time, less stressors of work, and less competition. When the previously mentionednegative factors are controlled for, age has not been shownto emerge as a risk factor for depression, even in studies thatotherwise report an age-related increase.8,53

Several cross-sectional studies, both in the past and morerecently, suggest that the prevalence of depressive disordersis highest in people aged 50 to 65 years, and decreasesthereafter.1,4,1113,5458 However, studies on representativesamples aged 65 years and older are heavily weightedtoward the age strata of 65 to 75 years, and the group aged75 years and older is therefore concealed in these types of studies.11 This is important as it seems that the prevalenceof depression may increase in people aged 75 years andolder,5,8,27,53,57,59,60and that the prevalence is higher in thoseaged 95 years and older than in those aged 90 to 94 years.61 However, a decrease in prevalence in people aged 85 years

and older was also reported in some studies.60,62,63

Thusdepression may have its highest prevalence in people duringthe 10 years before retirement age (65 years) and its lowest prevalence in those aged between 65 and 75 years, with anincrease again after age 75 years.11 Even if the prevalence of depression does not increase in the elderly, the prevalenceof depressive symptoms are constantly reported to increasewith age.56,64,65 This may re ect that elderly people withdepression may exhibit less symptoms than younger peoplewith depresson.66 The incidence of depression has beenreported to increase43 or be unaffected by age.44

The prevalence of anxiety disorders is also reported to

decrease with age.20,28,55,57,58,67

However, the pattern differsamong the anxiety disorders.67 Panic disorder is considered

Abbreviations

CT computed tomography

DSM Diagnostic and Statistical Manual of Mental Disorders

GAD generalized anxiety disorder

ICD International Classi cation of Diseases

MRI magnetic resonance imaging

OCD obsessivecompulsive disorder

WML white matter lesion



Psychiatric Disorders in the Elderly

very rare among the elderly.2,27,55 The reports on GADare inconsistent. Some report that the frequency of GADincreases with age, at least until age 55 years, or remainsstable.20,68,69 Others suggest that the highest frequencyof GAD occurs in people aged around 40 years,70,71 anddeclines thereafter.70,72 OCD is believed to be less commonamong the elderly than among younger people.23 OCD

generally has its onset in people aged around 20 years, butit has been suggested that a second peak of onset occursin late life.73 Beekman et al22 reported a peak prevalenceof OCD among women aged from 65 to 74 years (2.7%),compared with women aged 55 to 64 years (0.3%) or 75to 85 years (0.8%). The prevalence of speci c phobia26,74,75 and phobic fears76 are reported to decrease with age, withsome exceptions.21,77 New onset seems to be rare in latelife,78 and more than 80% of people aged 70 years reportedonset before they were aged 21 years.29 Also the prevalenceof social phobia may be lower among the elderly, comparedwith younger age groups.30,74,7981Social phobia also has anearly age of onset, developing in most cases during the mid-teens, with decreasing frequency thereafter.30,31,82

It has been suggested that age increases risk for psychoticsymptoms in the elderly.83 It seems that the prevalence isconsiderably higher among people aged between 8537 and95 years,38 than in younger age groups.39

Several factors may in uence whether the frequencyof mental disorders increases with age. Comorbidity,dementia, and clinical manifestations will be discussed inthe following sections of this review.

ComorbidityLittle is known about comorbid psychiatric disordersamong the elderly, although recent studies indicate thatcomorbidity between depression and anxiety disorders, aswell as between different anxiety disorders, is very high alsoin old age,1,2,4,29,32,75,78,8489with reported comorbidity of 50%to 90%. This comorbidity was already noted by Kay et al,90 who found that most affective disorders in the elderly werean admixture of depressive and anxiety symptoms. Lindesayet al27 reported that 91% of the elderly with general anxietyin the population also had depression, and Blanchard et al42 reported that 95% of those with depression had symptomsof anxiety. This comorbidity seems to be high for all typesof anxiety disorders. The very high comorbidity betweenGAD and depression91 has led to a discussion as to whether GAD should be included among the mood disorders in theupcoming DSM-5. This discussion has been concernedwith younger age groups, and it is unclear whether it isapplicable also to the elderly.There is also a high comorbidity between different anxietydisorders, such as social phobia, panic disorder, agoraphobia,GAD, and OCD.32,84,85 This emphasizes the close relation

between psychiatric disorders, and the dif culty of makingdiagnostic demarcations. Psychiatric comorbidity is also

related to greater subjective impairment and disability, andmore limitations in activities of daily living.32,84

Enforcement of exclusion criteria has been suggested toexplain the lower prevalence of anxiety disorders, especiallyGAD, among the elderly, as more comorbid disorders occur with age.20 Thus the large disparities in the prevalence between different studies partly depend on how exclusioncriteria regarding presence of other psychiatric disorders,especially depression, are applied. One important aspectwhen evaluating frequency of psychiatric disorders is thuswhether a hierarchical approach to diagnosis has been made(as in DSM-IV and ICD-10 criteria). In such a hierarchy,most anxiety disorders cannot be diagnosed in the presenceof concurrent depressive illness, as a main diagnosisof depression is given when the diagnostic thresholdfor depression is reached irrespective of the severity of anxiety symptoms.28 This has an immense in uence onthe frequency of anxiety disorders in the population. If comorbidity between depression and anxiety is higher in the elderly, this might explain some of the decrease infrequency of anxiety disorders with age.Comorbidity between mental disorders may have severalexplanations. It may re ect shared vulnerability or common pathological pathways. Another possibility is that peoplewith anxiety disorders have an increased risk to developa depressive disorder, thus shifting their diagnosis fromanxiety to depression with increasing age. However, therealso seems to be a shift in the opposite direction withincreasing age.

Clinical ManifestationsManifestations of mental disorders may be different in theelderly, compared with younger age groups, and there may be dif culties in separating symptoms of mental disordersfrom those occurring in normal aging. For example, there isan overlap in symptoms of depression and those occurringin physical disorders and in normal aging (for example, lossof appetite, tiredness, and sleep disturbances). This maylead not only to overdiagnosis59 but also to underdiagnosisif depressive symptoms are thought to be due to physicaldisorders or normal aging.6,7,42,57,92,93

Depression may also have different manifestations in theelderly.6,64,93For example, elderly people may present with asmaller number of symptoms66 or one dominating symptom.Depressed elderly people may also more often showaggressiveness, cognitive dif culties, and loss of interestand apathy, and less often symptoms of depressed mood.66 However, it has to be emphasized that the symptoms of depression most often are similar in the old and in the young.94 Depression is reported to have a poor rate of recovery inthe elderly, although it is unclear whether the recovery rateis worse than for younger depressed people,95,96 and about

one-third of depressed elderly people still have depressionat 1 to 3 years of follow-up.41,97 In contrast, social phobia



In Review

seems to have a good prognosis in the elderly, with 50% being free of social fear at 5-year follow-up.45

Also anxiety disorders may have different manifestationsamong the elderly, with fewer symptoms, less somaticand autonomic symptoms, and less avoidance, and moreagitation, irritability, talkativity, and tension,20 and withmore somatization.98 However, most anxiety disorders havesimilar symptoms in the old and in the young.99

Compared with early onset psychosis, people with late-onset psychosis have better preserved personality, less affective blunting, less formal thought disorder, more insight, andless excess of focal structural brain abnormalities andcognitive dysfunction, compared with age-matched controlsubjects.33,100 Also late-life psychosis may show lesssymptoms, and one symptom may dominate the picture.Finally, criteria for mental disorders are often validatedin younger age groups, and their use in the elderly hastherefore been questioned.66,101

Dementia and Cognitive DeclineThe prevalence of dementia and milder forms of cognitivedecline increases with age. Therefore, dementia andcognitive symptoms need to be considered in all studiesof the elderly, especially in those aged 80 years and older.It is obvious that people with dementia may underreportsymptoms and other factors owing to memory problems.It is therefore surprising that studies concerned with theelderly sometimes do not even assess dementia, which may be one reason for the reported decline with age of self-reported psychiatric disorders.Further, most criteria, including DSM-IV, exclude organiccauses of psychiatric disorders (for example, dementia).This means that with increasing age, a large proportion of the total population will be removed from the population atrisk for depression and anxiety disorders, giving lower total prevalence of depression in higher ages. Indeed, it has beenreported that the apparent decline with age for depressionand anxiety disorders disappear if people with dementia areexluded.5,63

Cognitive symptoms are one of the core symptoms for depression in DSM-IV. It is therefore not surprising thatmany studies report that people with manifest depressionexhibit signs of cognitive decline.56,59,102105 This declineis generally mild62,106 and of frontal-subcortical type,103106 and does not ful l criteria for dementia. The cognitivemanifestations of depression are probably more accentuatedamong the elderly, and may be more common in those withtheir rst episode in old age than in those with episodesearlier in life.107Anxiety disorders in the elderly,89 includingsocial phobia32 and GAD,99 are related to worse cognitive performance. In addition, psychotic symptoms108 have

been related to worse cognitive performance. Thus peoplewithout dementia aged 85 years with psychotic symptoms

or paranoid ideation performed worse on verbal ability, problem solving, and spatial ability.108

Depression109111 has repeatedly been suggested to be a prodrome or risk factor for dementia. Prospective populationstudies are contradictory, with several studies reporting thatdepression increases risk for dementia,103,112114 while othersfound no associations41,115118 A meta-analyses including

22 studies suggested that depression increased the risk for later development of dementia.111 However, this meta-analysis included a mixture of population-based studiesand studies from memory clinics, which made it dif cultto evaluate whether depression increases risk for dementiain cognitively intact people from the general population.Anxiety119 and psychotic symptoms37 may also increase risk for subsequent dementia.Psychotic symptoms, hallucinations, delusions, and paranoid ideation in a population aged 85 years were eachrelated to an increased incidence of dementia during a 3-year follow-up, but only one-third of those with these symptoms

developed dementia.37 In people who were followed fromage 70 to 90 years, only 45% of those who developedrst-onset psychotic symptoms developed dementia.46 The

mean interval between rst onset of psychotic symptomsand development of dementia was 5 years. Already Post120 reported that only 15% of elderly patients with persecutorystates in a psychogeriatric hospital developed dementia atfollow-up, and Holden121 reported that 35% of patients withlate paraphrenia had dementia within 3 years of diagnosis.Thus psychotic symptoms are risk factors or prodromesfor dementia, but still only a minority of those developing psychotic symptoms in old age will develop dementia.

Factors Associated With Mental Disorders inthe ElderlyMost studies on risk factors for mental disorders areconcerned with depression. As in all common disorders,depression in late life results from multiple factors.11,122,123 However, it is not always easy to judge what is a cause andwhat is a consequence of the mental disorder, and in manyinstances associations are in both directions.Among associations most constantly reported for depression,many are related to aging, including female sex, adverse life

events,8,124,125

physical health,8,122,126129

disability,8,122,126,129131

institutionalization,54,132,133 medical drugs,134 decreasedsocial network and support,8,122,135137 and cerebral organicfactors,52 such as brain atrophy and cerebrovascular disease.138 In addition, previous psychiatric history,8,122,139 family history of depression,8 low education,8,60 personalityfactors,8,140,141 smoking,135 and alcohol consumption142 have been associated with depression in the elderly. Even whenhealth factors are present, psychosocial factors often play amediating role.137

Risk factors for anxiety disorders include femalesex, physical disorders,1,22 being unmarried,1,22 lower

education,1,22

adverse life events,26,143

disability,144

and personality factors.89 Risk factors for anxiety disorders in




late life are thus similar to those of depression.145 However,some authors stress that risk factors for depression andanxiety disorders are not similar,143 and risk factors for late-life depression tend to be more biological than those for late-life anxiety disorders.145 One reason may be that thereare very few studies examining biological factors in late-life anxiety disorders.

Factors related to late-life psychosis include female sex, previous schizoid and paranoid personality traits, beingdivorced, living alone, lower education, poor social network and isolation, low social functioning, sensory impairments,especially deafness, vascular disease, and more dependencein community care.100 Psychosis and psychotic symptomsin elderly populations have been associated with somaticdisorders, for example, hypothyroidism, cerebral tumours,and cardiovascular and cerebrovascular disease.100 Further,drugs, such as anticholinergics, antiparkinson, steroidsand beta-blockers, as well as alcohol and benzodiazepinewithdrawal, may produce psychotic symptoms in the

elderly.

Structural Brain DisordersStructural brain changes become more common withincreasing age,146 and have been associated with mentaldisorders in old age by several investigators. Late-lifedepression, especially major depression, has been associatedwith ventricular enlargement,147151 changes in the caudatenuclei,147,152 and the putamen,152 and with atrophy in thefrontal, temporal, and parietal lobes.150158 However, moststudies on the association between brain atrophy anddepression in the elderly have been cross-sectional and performed in clinical samples. One longitudinal population- based study157 reported an association between temporallobe atrophy on CT at baseline and development of major depression during a 5-year follow-up. Another longitudinal population-based study158 reported a cross-sectionalassociation between temporal and parietal lobe atrophyassessed with MRI at baseline and concurrent depressivesymptoms, but no association with depression occurringduring follow-up. A third longitudinal study159 in elderlywithout dementia examined the association between meandepressive symptom scores over time and change in brainatrophy on MRI during 9 years. Cross-sectional associations between temporal and frontal lobe atrophy and depressivesymptoms, and a longitudinal association between volumedecline in frontal white matter and depressive symptomscore over time were reported.159

The cellular mechanisms that underlie the association between brain atrophy and depression in the elderly remainlargely unknown. Postmortem studies have reportedon cellular alterations such as neuronal death, neuronalshrinkage, decrease in dendritic and glial density, and celldeath in the frontal cortex and hippocampus in the elderlywith major depression.160161

Anxiety disorders have been related to brain changes inyounger age groups.162 In relation to anxiety disorders in

the elderly, worries in GAD were associated to decreasedvolume in the prefrontal cortex.163

Subtle brain changes, such as degenerative or vascular changes, have also been hypothesized to enhancevulnerability to psychotic symptoms in the elderly,83,164 butreports are disparate. Some studies report a higher ventricle-to-brain ratio, larger third ventricle volume, and volume

reductions of the left temporal lobe or superior temporalgyrus. In a study165 on people aged 85 years, basal gangliacalci cations, but no other brain changes, were associatedwith increased frequency of psychotic symptoms.

Cerebrovascular DiseaseCerebrovascular diseases such as stroke166 and ischemicWMLs146 become more common with increasing age.The concept of vascular depression167 suggests thatcerebrovascular diseases, such as stroke and WMLs, areespecially important for the etiology of depression in old

age. However, the symptoms of depression may not differ between depressed stroke patients and patients withoutstroke.168

Depression is common after stroke.169173 A systematicreview169,170 found a pooled estimate of 33% for depressionafter stroke. In the study by Linden et al,173 stroke wasrelated to an odds ratio for depression of 3.2 in women and4.0 in men 1.5 years after the index stroke. Depression isimportant to detect in stroke patients, as it is associated withworse outcome.174176 Depressed stroke patients have morecognitive impairments,172 more days in hospital,177 and usemore care than those who are nondepressed.178

The association between stroke and depression may alsogo in the opposite direction, as several studies15,179,180reportthat depression increases the risk for rst-incidence stroke.Reasons include that depression is associated with increased platelet activation181 and increased insulin resistance.182 Another explanation may be that late-life depression isrelated to silent cerebrovascular diseases, such as ischemicWMLs, which may increase incidence of stroke.WMLs are very common in the elderly,146,183 and mostlikely re ect ischemic demyelination.184 The cause of WMLs is probably that longstanding hypertension causes

lipohyalinosis and thickening of the vessel walls withnarrowing of the lumen of the small perforating arteriesand arterioles that nourish the deep white matter. In living people, WMLs can be detected on brain imaging.Cross-sectional studies, often from patient samples,consistently show associations between WMLs anddepression,152,155,156,158,185,186although not all studies supportthis association.153,187 The results from longitudinal population-based studies are con icting. Three prospectiveMRI studies188190 and 1 CT study157 reported that WMLsincreased the risk of subsequent depression, while 2 MRIstudies could not con rm these ndings.158,191 Part of the

relation between white matter changes and depression may be mediated by loss of functional ability.192WMLs in elderly



In Review

depressed patients may in uence outcome of depression,such as time to relapse193 and response to antidepressanttherapy.194 Depression may also in uence the developmentof WMLs. One recent study195 reported that depression at baseline was associated with faster progression of WMLsduring follow-up. Ischemic WMLs have also been reportedin late-onset paranoid psychosis,196 while little is known

about the impact of WMLs on anxiety disorders in theelderly.

SexWomen live longer than men, and at the age of 95 years,the female-to-male ratio is 4:1.5 Female sex is the mostconsistent risk factor for depression and some anxietydisorders. The female preponderance of depression is mostaccentuated in middle life,55,57 and the sex difference maydiminish with increasing age.197 Some studies1,5,7,41,102 arein line with this opinion. However, depression is generallyreported to be more common in women, also among the

elderly.2,4,8,12,27,63,90

The prevalence of most anxiety disorders is higher inwomen than in men.1,4,27,28,67 However, there is a different pattern among the anxiety disorders. GAD is more commonin women than in men in most studies in the elderly.2,3,20 Similarly as in depression, some authors suggest that theratio of women to men for GAD decreases with age.20 Moststudies report that OCD is more common among womenthan among men. This sex difference is suggested to beeven more pronounced among the elderly.22,88 However, arecent Canadian study25 reported that elderly people withOCD were more likely to be men, compared with thosehaving another anxiety disorder or a mood disorder. Fear of social situations,32 and phobic fears and simple phobiaare generally more common in women than in men,29,198 especially fears of animals and the natural environment.This may have several explanations.29 First, some fears (for example, spiders and heights) may be innate in humans.199 As part of gender socialization, boys may be, to a greater extent than girls, encouraged to expose themselves andhabituate toward these stimuli.29 Second, fears maydevelop more often in girls owing to gender differences inrole modelling or in information regarding the danger of different exposures.Many clinical studies report that late-onset schizophreniais more common among women, with female-to-maleratios ranging from 1.9:1.0 to 22.5:1.0.33 Cross-sectional population studies on psychotic disorders in the elderlyreport disparate results, with female-to-male ratios rangingfrom 0.7:1.0 to 1.5:1.0.90,200 Among people aged 8537 and95 years, there were no sex differences.38

Consequences of Mental DisordersMental disorders are thus very common and haveconsistently been reported to have a poor outcome in the

elderly. Among the consequences of depression are socialdeprivation,201 loneliness,8 poor quality of life,14,201,202

disability,14,131,201,202 increased use of health and home careservices,42,203 decline in cognition,102,104,105increased risk for physical disorders (for example, stroke),15,204 chronicity,14,97 suicide,205 and an increased nonsuicidal mortality.206

Among the consequences of anxiety disorders are anincreased mortality rate, increased risk for ischemicheart disease and stroke, and an increased suicide risk.

Social phobia is associated with lower social and mentalfunctioning, and reduced quality of life in the elderly.32,82 Among the consequences of psychotic symptoms aredisability in daily life, dependence on community care,cognitive dysfunction, increased risk for dementia, andincreased mortality.100 Studies on attempted207210 andcompleted suicides205,211 in old age have reported a stronger association with depression, with less alcoholism and fewer personality disorders, than in younger age groups. Psychoticdisorders and anxiety disorders are also associated with anincreased risk of suicide in the elderly.205 Suicidal attemptsin the elderly are often characterized by a greater degree of lethal intent.208,211 Although it is often suggested that suicidein the elderly primarily is a question of undiagnosed,untreated depression, it was reported that two-thirds of elderly people who died by suicide in Gothenburg, Sweden,had a history of treatment for affective illness and 48% hadhad such treatment 6 months before their suicide.212 These

ndings emphasize that once diagnosed, depression in theelderly must be managed with persistence.It is constantly reported that depressed elderly people havean increased risk of dying, compared with the general population.41,204,206,213216 The association between anxiety

disorders and mortality is more complex, with a U-shapedcurve,215 while hallucinations and paranoid ideations wererelated to increased mortality in women aged 85 years.37

AcknowledgementsDr Skoog has received honoraria as a speaker for Esai,Janssen Cilag, General Electric, Shire, P zer, and Novartis.The Canadian Psychiatric Association proudly supports theIn Review series by providing an honorarium to the authors.

References1. Gum AM, King-Kallimanis B, Kohn R. Prevalence of mood,

anxiety, and substance-abuse disorders for older Americans in thenational comorbidity survey-replication. Am J Geriatr Psychiatry.2009;17:769781.

2. Ritchie K, Artero S, Beluche I, et al. Prevalence of DSM-IV psychiatric disorder in the French elderly population. Br JPsychiatry. 2004;184:147152.

3. Prville M, Boyer R, Grenier S, et al. The epidemiology of psychiatric disorders in Quebecs older adult population. Can JPsychiatry. 2008;53:822832.

4. Byers AL, Yaffe K, Covinsky KE, et al. High occurrence of mood and anxiety disorders among older adults: The NationalComorbidity Survey Replication. Arch Gen Psychiatry.2010;67:489496.

5. Brjesson-Hansson A, Waern M, stling S, et al. One-month

prevalence of mental disorders in a population sample of 95-year-olds. Am J Geriatr Psychiatry. 2011;19(3):284291.




6. Ernst C, Angst J. Depression in old age. Is there a real decreasein prevalence? A review. Eur Arch Psychiatry Clin Neurosci.1995;245:272287.

7. Skoog I, Nilsson L, Landahl S, et al. Mental disorders and theuse of psychotropic drugs in an 85-year-old urban population. IntPsychogeriatr. 1993;5:3348.

8. Beekman ATF, Deeg DJH, van Tilburg T, et al. Major and minor depression in later life: a study of prevalence and risk factors.J Affect Disord. 1995;36:6575.

9. Baiyewu O, Smith Gamble V, Lane KA, et al. Prevalence estimatesof depression in elderly community-dwelling African Americansin Indianapolis and Yoruba in Ibadan, Nigeria. Int Psychogeriatr.2007;19:679689.

10. Beekman ATF, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychatry.1999;174:307311.

11. Palsson S, Skoog I. The epidemiology of affective disorders in theelderly: a review. Int Clin Psychopharmacol.1997;12(Suppl 2):S3S13.

12. McDougall FA, Kvaal K, Matthews FE, et al. Prevalence of depression in older people in England and Wales: the MRC CFAStudy. Psychol Med. 2007;37:17871795.

13. Steffens DC, Skoog I, Norton MC, et al. Prevalence of depression

and its treatment in an elderly population: the Cache County study.Arch Gen Psychiatry. 2000;57:601607.14. Gureje O, Kola L, Afolabi E. Epidemiology of major depressive

disorder in elderly Nigerians in the Ibadan Study of Ageing:a community-based survey. Lancet. 2007;370:957964.

15. Liebetrau M, Steen B, Skoog I. Depression as a risk factor for the incidence of rst-ever stroke in 85-year-olds. Stroke.2008;39:19601965.

16. Luijendijk HJ, van den Berg JF, Dekker MJHJ, et al. Incidenceand recurrence of late-life depression. Arch Gen Psychiatry.2008;65:13941401.

17. Magruder KM, Calderone GE. Public health consequences of different thresholds for the diagnosis of mental disorders. Compr Psychiatry. 2000;41(2 Suppl 1):1418.

18. Rowe SK, Rapaport MH. Classi cation and treatment of sub-threshold depression. Curr Opin Psychiatry. 2006;19(1):913.19. Larkin BA, Copeland JR, Dewey ME, et al. The natural history of

neurotic disorder in an elderly urban population. Findings from theLiverpool longitudinal study of continuing health in the community.Br J Psychiatry. 1992;160:681686.

20. Krasucki C, Howard R, Mann A. The relationship between anxietydisorders and age. Int J Geriatr Psychiatry. 1998;13:7999.

21. KirmiziogluY, Dogan O, Kugu N, et al. Prevalence of anxietydisorders among elderly people. Int J Geriatr Psychiatry.2009;24(9):10261033.

22. Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders inlater life: a report from the Longitudinal Aging Study Amsterdam.Int J Geriatr Psychiatry. 1998;13(10):717726.

23. Torres AR, Prince MJ, Bebbington PE, et al. Obsessivecompulsivedisorder: prevalence, comorbidity, impact, and help-seeking inthe British National Psychiatric Morbidity Survey of 2000. Am JPsychiatry. 2006;163(11):19781985.

24. Bebbington PE. Epidemiology of obsessivecompulsive disorder.Br J Psychiatry Suppl. 1998(35):26.

25. Grenier S, Prville M, Boyer R, et al. Prevalence and correlates of obsessive-compulsive disorder among older adults living in thecommunity. J Anxiety Disord. 2009;23:858865.

26. Chou KL. Speci c phobia in older adults: evidence from thenational epidemiologic survey on alcohol and related conditions.Am J Geriatr Psychiatry. 2009;17(5):376386.

27. Lindesay J, Briggs K, Murphy E. The Guys/Age Concern survey.Prevalence rates of cognitive impairment, depression and anxiety inan urban elderly community. Br J Psychiatry. 1989;155:317329.

28. Manela M, Katona C, Livingston G. How common are the anxietydisorders in old age? Int J Geriatr Psychiatry. 1996;11:6570.

29. Sigstrm R, stling S, Karlsson B, et al. A population-based studyon phobic fears and DSM-IV speci c phobia in 70-year olds.J Anxiety Disord. 2011;25(1):148153.

30. Cairney J, McCabe L, Veldhuizen S, et al. Epidemiology of social phobia in later life. Am J Geriatr Psychiatry. 2007;15(3):224233.

31. Schneier FR, Johnson J, Hornig CD, et al. Social phobia.Comorbidity and morbidity in an epidemiologic sample. Arch GenPsychiatry. 1992;49(4):282288.

32. Karlsson B, Klenfeldt IF, Sigstrm R, et al. Prevalence of social phobia in non-demented elderly from a swedish population study.Am J Geriatr Psychiatry. 2009;17:127135.

33. Howard R, Rabins PV, Seeman MV, et al. Late-onset schizophreniaand very-late-onset schizophrenia-like psychosis: an internationalconsensus. The International Late-Onset Schizophrenia Group. AmJ Psychiatry. 2000;157(2):172178.

34. Henderson AS, Korten AE, Levings C, et al. Psychotic symptoms inthe elderly: a prospective study in a population sample. Int J Geriatr Psychiatry. 1998;1008;13:484492.

35. Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioraldisturbances in dementia: ndings from the Cache County Study onMemory in Aging. Am J Psychiatry. 2000;157:708714.

36. Livingston G, Kitchen G, Manela M, et al. Persecutory symptomsand perceptual disturbance in a community sample of older people:

the Islington study. Int J Geriatr Psychiatry. 2001;16:462468.37. stling S, Skoog I. Psychotic symptoms and paranoid ideation in anondemented population-based sample of the very old. Arch GenPsychiatry. 2002;59(1):5359.

38. stling S, Borjesson-Hanson A, Skoog I. Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds. AmJ Geriatr Psychiatry. 2007;15(12):9991004.

39. Sigstrm R, Skoog I, Sacuiu S, et al. The prevalence of psychotic symptoms and paranoid ideation in a non-demented population sample of 7082 year olds. Int J Geriatr Psychiatry.2009;24:14131419.

40. Eaton WW, Kramer M, Anthony JC, et al The incidence of speci cDIS/DSM-III mental disorders: data from the NIMH EpidemiologicCatchment Area Program. Acta Psychiatr Scand. 1989:79:163178.

41. Copeland JRM, Davidson IA, Dewey ME, et al. Alzheimersdisease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool. Br JPsychiatry. 1992;161:230239.

42. Blanchard MR, Waterreus A, Mann AH. The nature of depressionamong older people in Inner London, and the contact with primarycare. Br J Psychiatry. 1994;164:396402.

43. Palsson SP, stling S, Skoog I. The incidence of rst-onsetdepression in a population followed from the age of 70 to 85.Psychol Med. 2001;31:11591168.

44. Norton MC, Skoog I, Toone L, et al. Three-year incidenceof rst-onset depressive syndrome in a population sample of older adults: the Cache County study. Am J Geriatr Psychiatry.2006;14:237245.

45. Karlsson B, Sigstrm R, Waern M, et al. The prognosis andincidence of social phobia in an elderly population. A 5-year follow-up. Acta Psychiatr Scand. 2010;122:410.

46. stling S, Palsson SP, Skoog I. The incidence of rst-onset psychotic symptoms and paranoid ideation in a representative population sample followed from age 7090 years. Relationto mortality and later development of dementia. Int J Geriatr Psychiatry. 2007;22:520528.

47. Copeland JR, Dewey ME, Scott A, et al. Schizophrenia anddelusional disorder in older age: community prevalence, incidence,comorbidity, and outcome. Schizophr Bull. 1998;24:153161.

48. Tien AY. Distributions of hallucinations in the population. SocPsychiatry Psychiatr Epidemiol. 1991;26:287292.

49. Skoog I. Mental disorders associated with aging. In:Heggenhougen K, Quah S, editors. International encyclopedia of public health. Vol 6. San Diego (CA): Academic Press; 2008. p 174182.



In Review

50. Veith RC, Raskind MA. Review. The neurobiology of aging: does it predispose to depression? Neurobiol Aging. 1988;9:101117.

51. Alexopoulos GS. Biological abnormalites in late-life depression.J Geriatr Psychiatry. 1989;22:2534.

52. Blazer DG, Hybels CF. Origins of depression in later life. PsycholMed. 2005;35:112.

53. Blazer D, Burchett B, Service C, et al. The association of age anddepression among the elderly: an epidemiological exploration.J Gerontol. 1991;46:M210M215.

54. Bland RC, Newman SC, Orn H. Prevalence of psychiatric disordersin the elderly in Edmonton. Acta Psychiatr Scand.1988;77(Suppl 338):5763.

55. Regier DA, Farmer ME, Rae DS, et al. One-month prevalenceof mental disorders in the United States and sociodemographiccharacteristics: the Epidemiologic Catchment Area Study. ActaPsychiatr Scand. 1993;88:3547.

56. Blazer D, Swartz M, Woodbury M, et al. Depressive symptomsand depressive diagnoses in a community population. Arch GenPsychiatry. 1988;45:10781084.

57. Lehtinen V, Joukamaa M, Lahtela K, et al. Prevalence of mentaldisorders among adults in Finland: basic results from the MiniFinland Health Survey. Acta Psychiatr Scand. 1990;81:418425.

58. Jorm AF. Does old age reduce the risk of anxiety and depression?A review of epidemiological studies across the adult life span.Psychol Med. 2000;30(1):1122.

59. Kay DWK, Henderson AS, Scott R, et al. Dementia and depressionamong the elderly living in the Hobart community: the effectof the diagnostic criteria on the prevalence rates. Psychol Med.1985;15:771788.

60. Lobo A, Saz P, Marcos G, et al. The prevalence of dementia anddepression in the elderly community in a southern European population. Arch Gen Psychiatry. 1995;52:497506.

61. Forsell Y, Jorm AF, Strauss EV, et al. Prevalence and correlatesof depression in a population of nonagenarians. Br J Psychiatry.1995;167:6164.

62. Fichter MM, Bruce ML, Schrppel H, et al. Cognitiveimpairment and depression in the oldest old in a Germanand in US communities. Eur Arch Psychiatry Clin Neurosci.

1995;245:319325.63. Saunders PA, Copeland JRM, Dewey ME, et al. The prevalence

of dementia, depression and neurosis in later life: The LiverpoolMRC-ALPHA Study. Int J Epidemiol. 1993;22:838847.

64. Bowling A. The prevalence of psychiatric morbidity among peopleage 85 and over living at home. Associations with reported somaticsymptoms and with consulting behaviour. Soc Psychiatry Psychiatr Epidemiol. 1990;25:132140.

65. Girling DM, Huppert FA, Brayne C, et al. Depressive symptomsin the very elderly. Their prevalence and signi cance. Int J Geriatr Psychiatry. 1995;10:497504.

66. Bryant C. Anxiety and depression in old age: challenges inrecognition and diagnosis. Int Psychogeriatr. 2010;22(4):1113.

67. Flint AJ. Epidemiology and comorbidity of anxiety disorders in theelderly. Am J Psychiatry. 1994;151:640649.

68. Weisberg RB. Overview of generalized anxiety disorder:epidemiology, presentation, and course. J Clin Psychiatry.2009;70(Suppl 2):49.

69. Angst J, Gamma A, Baldwin DS, et al. The generalized anxietyspectrum: prevalence, onset, course and outcome. Eur ArchPsychiatry Clin Neurosci. 2009;259(1):3745.

70. Carter RM, Wittchen HU, P ster H, et al. One-year prevalenceof subthreshold and threshold DSM-IV generalized anxietydisorder in a nationally representative sample. Depress Anxiety.2001;13(2):7888.

71. Wittchen HU, Hoyer J. Generalized anxiety disorder: nature andcourse. J Clin Psychiatry. 2001;62(Suppl 11):1519; discussion2011.

72. Hunt C, Issakidis C, Andrews G. DSM-IV generalized anxietydisorder in the Australian National Survey of Mental Health andWell-Being. Psychol Med. 2002;32(4):649659.

73. Nestadt G, Bienvenu OJ, Cai G, et al. Incidence of obsessive-compulsive disorder in adults. J Nerv Ment Dis.1998;186(7):401406.

74. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity,and comorbidity of 12-month DSM-IV disorders in the NationalComorbidity Survey Replication. Arch Gen Psychiatry.2005;62(6):617627.

75. Stinson FS, Dawson DA, Patricia Chou S, et al. The epidemiologyof DSM-IV speci c phobia in the USA: results from the National

Epidemiologic Survey on Alcohol and Related Conditions. PsycholMed. 2007;37(7):10471059.

76. Liddell A, Locker D, Burman D. Self-reported fears (FSS-II) of subjects aged 50 years and over. Behav Res Ther.1991;29(2);105112.

77. Boyd JH, Rae DS, Thompson JW, et al. Phobia: prevalence and risk factors. Soc Psychiatry Psychiatr Epidemiol. 1990;5(6):314323.

78. Lindesay J. Phobic disorders in the elderly. Br J Psychiatry.1991;159:531541.

79. Mohammadi MR, Ghanizadeh A, Mohammadi M, et al. Prevalenceof social phobia and its comorbidity with psychiatric disorders inIran. Depress Anxiety. 2006;23(7):405411.

80. Wells JE, Browne MA, Scott KM, et al. Prevalence, interferencewith life and severity of 12 month DSM-IV disorders in Te RauHinengaro: the New Zealand Mental Health Survey. Aust N Z JPsychiatry. 2006;40(10):845854.

81. Trollor JN, Anderson TM, Sachdev PS, et al. Prevalence of mentaldisorders in the elderly: the Australian National Mental Health andWell-Being Survey. Am J Geriatr Psychiatry. 2007;15(6):455466.

82. Stein MB, Kean YM. Disability and quality of life in social phobia:epidemiologic ndings. Am J Psychiatry. 2000;157(10):16061613.

83. van Os J, Howard R, Takei N, et al. Increasing age is a risk factor for psychosis in the elderly. Soc Psychiatry Psychiatr Epidemiol.1995;30:161164.

84. Cairney J, Corna LM, Veldhuizen S, et al. Comorbid depression andanxiety in later life: patterns of association, subjective well-being,and impairment. Am J Geriatr Psychiatry. 2008;16(3):201208.

85. McCabe L, Cairney J, Veldhuizen S, et al. Prevalence andcorrelates of agoraphobia in older adults. Am J Geriatr Psychiatry.

2006;14(6):515522.86. King-Kallimanis B, Gum AM, Kohn R. Comorbidity of

depressive and anxiety disorders for older Americans in thenational comorbidity survey-replication. Am J Geriatr Psychiatry.2009;17:782792.

87. Kvaal K, McDougall FA, Brayne C, et al. Co-occurrence of anxiety and depressive disorders in a community sample of older people: results from the MRC CFAS (Medical Research CouncilCognitive Function and Ageing Study). Int J Geriatr Psychiatry.2008;23:229237.

88. Mohammadi MR, Ghanizadeh A, Rahgozar M, et al. Prevalence of obsessive-compulsive disorder in Iran. BMC Psychiatry. 2004;4:2.

89. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al. Anxietydisorders in older adults: a comprehensive review. Depress Anxiety.

2010;27(2):190211.90. Kay DWK, Beamish P, Roth M. Old age mental disorders in Newcastle upon Tyne. I. A study of prevalence. Br J Psychiatry.1964;110:146158.

91. Brown TA, Chorpita BF, Barlow DH. Structural relationshipsamong dimensions of the DSM-IV anxiety and mood disordersand dimensions of negative affect, positive affect, and autonomicarousal. J Abnorm Psychol. 1998;107(2):179192.

92. Rorsman B, Grsbeck A, Hagnell O, et al. A prospective study of rst-incidence depression. The Lundby study, 195772. Br J

Psychiatry. 1990;156:336342.93. Wallace J, Pfohl B. Age-related differences in the symptomatic

expression of major depression. J Nerv Ment Dis. 1995;183:99102.94. Musetti L, Perugi G, Soriani A, et al. Depression before and after

65. A re-examination. Br J Psychiatry. 1989;155:330336.95. Alexopoulos GS, Meyers BS, Young RC, et al. Recovery in geriatric

depression. Arch Gen Psychiatry. 1996;53:305312.




96. Alexopoulos GS, Chester JG. Outcomes of geriatric depression. ClinGeriatr Med. 1992;8:363376.

97. Beekman ATF, Deeg DJH, Smit JH, et al. Predicting the course of depression in the older population: results from a community basedstudy in the Netherlands. J Affect Disord. 1995;34:4149.

98. Rubio G, Lopez-Ibor JJ. Generalized anxiety disorder: a 40-year follow-up study. Acta Psychiatr Scand. 2007;115(5):372379.

99. Mantella RC, Butters MA, Dew MA, et al. Cognitive impairmentin late-life generalized anxiety disorder. Am J Geriatr Psychiatry.2007;15(8):673679.

100. stling S. Psychotic symptoms in the elderly. Curr Psychos Ther Rep. 2005;3:914.

101. Jeste DV, Blazer DG, First M. Aging-related diagnostic variations:need for diagnostic criteria appropriate for elderly psychiatric patients. Biol Psychiatry. 2005;58(4):265271.

102. Fuhrer R, Antonucci TC, Gagnon M, et al. Depressivesymptomatology and cognitive functioning: an epidemiologicalsurvey in an elderly community in France. Psychol Med.1992;22:159172.

103. Palsson S, Aevarsson O, Skoog I. Depression, cerebral atrophy,cognitive performance and incidence of dementia. Population studyof 85-year-olds. Br J Psychiatry. 1999;174:249253.

104. Palsson S, Larsson L, Tengelin E, et al. The prevalence of

depression in relation to cerebral atrophy and cognitive performancein 70- and 74-year-old women in Gothenburg. The Womens HealthStudy. Psychol Med. 2001;31:3949.

105. Palsson S, Johansson B, Berg S, et al. A population study on thein uence of depression on neuropsychological functioning in85-year-olds. Acta Psychiatr Scand. 2000;101:185193.

106. Beats BC, Sahakian BJ, Levy R. Cognitive performance in testssensitive to frontal lobe dysfunction in the elderly depressed.Psychol Med. 1996;26:591603.

107. van Ojen R, Hooijer C, Bezemer D, et al. Late-life depressivedisorder in the community. I. The relationship between MMSEscore and depression in subjects with and without psychiatrichistory. Br J Psychiatry. 1995;166:311315.

108. stling S, Johansson B, Skoog I. Cognitive test performance in

relation to psychotic symptoms and paranoid ideation in non-demented 85-year-olds. Psychol Med. 2004;34:443450.109. Jorm AF, van Duijn VM, Chandra V, et al. Psychiatric history and

related exposures as risk factors for Alzheimers disease:a collaborative re-analysis of case-control studies. Int J Epidemiol.1991;20(Suppl 2):S43S47.

110. Devanand DP, Sano M, Tang MX, et al. Depressed mood andthe incidence of Alzheimers disease in the elderly living in thecommunity. Arch Gen Psychiatry. 1996;53:175182.

111. Ownby RL, Crocco E, Acevedo A, et al. Depression and risk for Alzheimer disease: systematic review, meta-analysis, andmetaregression analysis. Arch Gen Psychiatry. 2006;63:530538.

112. Geerlings MI, den Heijer T, Koudstaal PJ, et al. Historyof depression, depressive symptoms, and medial temporallobe atrophy and the risk of Alzheimer disease. Neurology.2008;70(15):12581264.

113. Dotson VM, Beydoun MA, Zonderman AB. Recurrent depressivesymptoms and the incidence of dementia and mild cognitiveimpairment. Neurology. 2010;75(1):2734.

114. Saczynski JS, Beiser A, Seshadri S, et al. Depressive symptomsand risk of dementia: the Framingham Heart Study. Neurology.2010;75(1):3541.

115. Becker JT, Chang YF, Lopez OL, et al. Depressed mood is not arisk factor for incident dementia in a community-based cohort. AmJ Geriatr Psychiatry. 2009;17(8):653663.

116. Persson G, Skoog I. Subclinical dementia: relevance of cognitiveand affective symptoms and signs. A nine year prospective study.J Geriatr Psychiatry Neurol. 1992;5:172178.

117. Henderson AS, Korten AE, Jacomb PA, et al. The course of depression in the elderly: a longitudinal community-based study inAustralia. Psychol Med. 1997;27:119129.

118. Palsson S. 2000. Population studies on depression in the elderly.Prevalence, incidence and relation to cognitive function anddementia [dissertation]. [Gothenbury (SE)]: University of Gothenburg.

119. Gallacher J, Bayer A, Fish M, et al. Does anxiety affect risk of dementia? Findings from the Caerphilly Prospective Study.Psychosom Med. 2009;71(6):659666.

120. Post F. Persistent persecutory states of the elderly. Oxford (GB):Pergamon; 1966.

121. Holden NL. Late paraphrenia or the paraphrenias? A descriptivestudy with a 10-year follow-up. Br J Psychiatry. 1987;150:635639.

122. Djernes JK. Prevalence and predictors of depression in populationsof elderly: a review. Acta Psychiatr Scand. 2006;113:372387.

123. Bruce ML. Psychosocial risk factors for depressive disorders in latelife. Biol Psychiatry. 2002;52:175184.

124. Clayton PJ, Halikas JA, Maurice WL. The depression of widowhood. Br J Psychiatry. 1972;120:7178.

125. Harlow SD, Goldberg EL, Comstock GW. A longitudinal study of the prevalence of depressive symptomatology in elderly widowedand married woman. Arch Gen Psychiatry. 1991;48:10651068.

126. Geerlings SW, Beekman AT, Deeg DJ, et al. Physical health andthe onset and persistence of depression in older adults: aneight-wave prospective community-based study. Psychol Med.

2000;30;369380.127. Beekman ATF, Kriegsman DMW, Deeg DJH, et al. The associationof physical health and depressive symptoms in the older population:age and sex differences. Soc Psychiatry Psychiatr Epidemiol.1995;30:3238.

128. Braam AW, Prince MJ, Beekman ATF, et al. Physical health anddepressive symptoms in older Europeans: results from EURODEP.Br J Psychiatry. 2005;187:3542.

129. Gureje O, Ademola A, Olley BO. Depression and disability:comparisons with common physical conditions in the Ibadan Studyof Aging. J Am Geriatr Soc. 2008;56:20332038.

130. Prince MJ, Harwood RH, Blizard RA, et al. Impairment, disabilityand handicap as risk factors for depression in old age. The GospelOak Project V. Psychol Med. 1997;27:311321.

131. Braam AW, Delespaul P, Beekman ATF, et al. National contextof healthcare, economy and religion and the association betweendisability and depressive symptoms in older Europeans: resultsfrom the EURODEP concerted action. Eur J Ageing. 2004;1:2636.

132. Weyerer S, Hfner H, Mann AH, et al. Prevalence and courseof depression among elderly residential home admissionsin Mannheim and Camden, London. Int Psychogeriatr.1995;7:479493.

133. Henderson AS, Jorm AF, Mackinnon A, et al. The prevalence of depressive disorders and the distribution of depressive symptomsin later life: a survey using Draft ICD-10 and DSM-III-R. PsycholMed. 1993;23:719729.

134. Dhondt ADF, Hooijer C. Iatrogenic origins of depression in theelderly. Is medication a signi cant etiologic factor in geriatricdepression? Considerations and preliminary approach. Int J Geriatr Psychiatry. 1995;10:18.

135. Green BH, Copeland JRM, Dewey ME, et al. Risk factors for depression in elderly people: a prospective study. Acta Psychiatr Scand. 1992;86:213217.

136. Prince MJ, Harwood RH, Blizard RA, et al. Social support de cits,loneliness and life events as risk factors for depression in old age.The Gospel Oak Project VI. Psychol Med. 1997;27:323332.

137. Aren PA, Reynolds CFI. The impact of psychosocial factors onlate-life depression. Biol Psychiatry. 2005;58:277282.

138. Skoog I. Neuropsychiatric aspects of vascular cognitiveimpairment. In: Miyoshi K, Morimura Y, Maeda K, editors. Neuropsychiatric disorders. Tokyo (JP): Springer Japan KK; 2010. p 149162.

139. van Ojen R, Hooijer C, Jonker C, et al. Late-life depressive disorder in the community, early onset and the decrease of vulnerability withincreasing age. J Affect Disord. 1995;33:159166.



In Review

140. Cederblad M, Dahlin L, Hagnell O, et al. Intelligence andtemperament as protective factors for mental health. A cross-sectional and prospective epidemiological study. Eur ArchPsychiatry Clin Neurosci. 1995;245:1119.

141. Duberstein PR, Palsson SP, Waern M, et al. Personality and risk for depression in a birth cohort of 70-year-olds followed for 15 years.Psychol Med. 2008;38:663671.

142. Bekaroglu M, Uluuku N, Tanriver S, et al. Depression in an elderly population in Turkey. Acta Psychiatr Scand. 1991;84:174178.

143. Vink D, Aartsen MJ, Comijs HC, et al. Onset of anxietyand depression in the aging population: comparison of risk factors in a 9-year prospective study. Am J Geriatr Psychiatry.2009;17:642652.

144. Corna LM, Cairney J, Herrmann N, et al. Panic disorder in later life: results from a national survey of Canadians. Int Psychogeriatr.2007;19(6):10841096.

145. Vink D, Aartsen MJ, Schoevers RA. Risk factors for anxietyand depression in the elderly: a review. J Affect Disord.2008;106(12):2944.

146. Simoni M, Pantoni L, Pracucci G, et al. Prevalence of CT-detectedcerebral abnormalities in an elderly Swedish population sample.Acta Neurol Scand. 2008:118:260267.

147. Beats B, Levy R, Frstl H. Ventricular enlargement andcaudate hyperdensity in elderly depressives. Biol Psychiatry.1991;30:452458.

148. Alexopoulos GS, Young RC, Shindledecker RD. Brain computedtomography ndings in geriatric depression and primarydegenerative dementia. Biol Psychiatry. 1992;31:591599.

149. Elkis H, Friedman L, Wise A, et al. Meta-analysis of studiesof ventricular enlargement and cortical sulcal prominence inmood disorders. Comparisons with controls or patients withschizophrenia. Arch Gen Psychiatry. 1995;52:735746.

150. Rabins PV, Pearlson GD, Aylward E, et al. Cortical magneticresonance imaging changes in elderly inpatients with major depression. Am J Psychiatry. 1991;148:617620.

151. Schweitzer I, Tuckwell V, Ames D, et al. Structural neuroimagingstudies in late-life depression: a review. World J Biol Psychiatry.2001;2:8388.

152. Krishnan KRK, McDonald WM, Doraiswamy PM, et al. Neuroanatomical substrates of depression in the elderly. Eur ArchPsychiatry Clin Neurosci. 1993;243:4146.

153. Rainer MK, Mucke HA, Zehetmayer S, et al. Data from the VITAStudy do not support the concept of vascular depression. Am JGeriatr Psychiatry. 2006;14:531537.

154. Almeida OP, Burton EJ, Ferrier N, et al. Depression with lateonset is associated with right frontal lobe atrophy. Psychol Med.2003;33:675681.

155. Kumar A, Bilker W, Jin Z, et al. Atrophy and high intensity lesions:complementary neurobiological mechanisms in late-life major depression. Neuropsychopharmacology. 2000;22:264274.

156. Kumar A, Mintz J, Bilker W, et al. Autonomous neurobiological pathways to late-life major depressive disorder: clinical and pathophysiological implications. Neuropsychopharmacology.2002;26:229236.

157. Olesen PJ, Gustafson DR, Simoni M, et al. Temporal lobeatrophy and white matter lesions are related to major depressionover 5 years in the elderly. Neuropsychopharmacology.2010;35(13):26382645.

158. Ikram MA, Luijendijk HJ, Vernooij MW, et al. Vascular brain disease and depression in the elderly. Epidemiology.2010;21:7881.

159. Dotson VM, Davatzikos C, Kraut MA, et al. Depressive symptomsand brain volumes in older adults: a longitudinal magneticresonance imaging study. J Psychiatry Neurosci. 2009;34:367375.

160. Hercher C, Turecki G, Mechawar N. Through the looking glass:examining neuroanatomical evidence for cellular alterations inmajor depression. J Psychiatr Res. 2009;43:947961.

161. Khundakar AA, Thomas AJ. Morphometric changes in early- andlate-life major depressive disorder: evidence from postmortemstudies. Int Psychogeriatr. 2009;21:844854.

162. Damsa C, Kosel M, Moussally J. Current status of brain imaging inanxiety disorders. Curr Opin Psychiatry. 2009;22(1):96110.

163. Mohlman J, Price RB, Eldreth DA, et al. The relation of worryto prefrontal cortex volume in older adults with and withoutgeneralized anxiety disorder. Psychiatry Res. 2009;173(2):121127.

164. Hfner H, Lf er W, Riecher-Rssler A, et al. [Schizophrenia and

delusions in middle aged and elderly patients. Epidemiology andetiological hypothesis]. Nervenarzt. 2001;72:347357. German.

165. stling S, Andreasson L-A, Skoog I. Psychotic symptoms and basalganglia calci cation in a population-based sample of 85-year-olds.Int J Geriatr Psychiatry. 2003;18:983987.

166. Liebetrau M, Steen B, Skoog I. Stroke in 85-year-olds. Prevalence,incidence, risk factors and relation to mortality and dementia.Stroke. 2003;34:26172622.

167. Alexopoulos GS, Meyers BS, Young RC, et al. Vascular depression hypothesis. Arch Gen Psychiatry. 1997;54:915922.

168. Cumming TB, Churilov L, Skoog I, et al. Little evidence for different phenomenology in post-stroke depression. Acta Psychiatr Scand. 2010;121;424430.

169. Hackett ML, Yapa C, Parag V, et al. Frequency of depressionafter stroke: a systematic review of observational studies. Stroke.2005;36:13301340.

170. Hackett ML, Anderson CS. Predictors of depression after stroke: a systematic review of observational studies. Stroke.2005;36:22962301.

171. Rao R, Jackson S, Howard R. Depression in older people withmild stroke, carotid stenosis and peripheral vascular disease:a comparison with healthy controls. Int J Geriatr Psychiatry.2001;16:175183.

172. Pohjasvaara T, Leppavuori A, Siira I, et al. Frequency and clinicaldeterminants of poststroke depression. Stroke. 1998;29:23112317.

173. Linden L, Blomstrand C, Skoog I. Depressive disorders after 20months in elderly stroke patients. A case-control study. Stroke.2007;38:18601863.

174. Ramasubbu R, Robinson RG, Flint AJ, et al. Functional impairment

associated with acute poststroke depression: the Stroke Data Bank Study. J Neuropsychiatry Clin Neurosci. 1998;10:2633.

175. Schulz R, Beach SR, Ives DG, et al. Association betweendepression and mortality in older adults: the Cardiovascular HealthStudy. Arch Intern Med. 2000;160:17611768.

176. Pohjasvaara T, Vataja R, Leppavuori A, et al. Depression is anindependent predictor of poor long-term functional outcome post-stroke. Eur J Neurol. 2001;8:315319.

177. Schubert DS, Taylor C, Lee S, et al. Detection of depression in thestroke patient. Psychosomatics. 1992;33:290294.

178. Kotila M, Numminen H, Waltimo O, et al. Post-stroke depressionand functional recovery in a population-based stroke register. TheFinnstroke study. Eur J Neurol. 1999;6:309312.

179. Bos MJ, Lindn T, Koudstaal PJ, et al. Depressive symptoms and

risk of stroke: the Rotterdam Study. J Neurol Neurosurg Psychiatry.2008;79:9971001.180. Salaycik KJ, Kelly-Hayes M, Beiser A, et al. Depressive symptoms

and risk of stroke: the Framingham Study. Stroke. 2007;38:1621.181. Musselman DL, Tomer A, Manatunga AK, et al. Exaggerated

platelet reactivity in major depression. Am J Psychiatry.1996;153:13131317.

182. Okamura F, Tashiro A, Utumi A, et al. Insulin resistance in patients with depression and its changes during the clinicalcourse of depression: minimal model analysis. Metabolism.2000;49:12551260.

183. Fernando MS, Ince PG, on behalf of the MRC Cognitive functionand Ageing Neuropathology Study Group. Vascular pathologies andcognition in a population-based cohort of elderly people. J NeurolSci. 2004;226:1317.

184. Pantoni L, Garcia JH. Pathogenesis of leukoaraiosis: a review.Stroke. 1997;28:652659.


11/11


185. OBrien J, Desmond P, Ames D, et al. A magnetic resonanceimaging study of white matter lesions in depression andAlzheimers disease. Br J Psychiatry. 1996;168:477485.

186. Herrmann LL, Le Masurier M, Ebmeier KP. White matter hyperintensities in late life depression: a systematic review.J Neurol Neurosurg Psychiatry. 2008;79:619624.

187. Skoog I, Palmertz B, Andreasson L-A. The prevalence of white-matter lesions on computed tomography of the brain in dementedand nondemented 85-year-olds. J Geriatric Psychiatry Neurol.

1994;7:169175.188. Godin O, Dufouil C, Maillard P, et al. White matter lesions as a predictor of depression in the elderly: the 3C-Dijon study. BiolPsychiatry. 2008;63:663669.

189. Steffens DC, Krishnan KR, Crump C, et al. Cerebrovascular diseaseand evolution of depressive symptoms in the cardiovascular healthstudy. Stroke. 2002;33:16361644.

190. Teodorczuk A, OBrien JT, Firbank MJ, et al. White matter changes and late-life depressive symptoms: longitudinal study. Br JPsychiatry. 2007;191:212217.

191. Versluis CE, van der Mast RC, van Buchem MA, et al. Progressionof cerebral white matter lesions is not associated with developmentof depressive symptoms in elderly subjects at risk of cardiovascular disease: The PROSPER Study. Int J Geriatr Psychiatry.2006;21:375381.

192. Teodorczuk A, Firbank MJ, Pantoni L, et al. Relationship between baseline white-matter changes and development of late-lifedepressive symptoms: 3-year results from the LADIS study.Psychol Med. 2010;40:603610.

193. OBrien J, Ames D, Chiu E, et al. Severe deep white matter lesionsand outcome in elderly patients with major depressive disorder:follow up study. BMJ. 1998;317:982984.

194. Simpson S, Baldwin RC, Jackson A, et al. Is subcortical diseaseassociated with a poor response to antidepressants? Neurological,neuropsychological and neuroradiological ndings in late-lifedepression. Psychol Med. 1998;28:10151026.

195. Chen PS, McQuoid DR, Payne ME, et al. White matter andsubcortical gray matter lesion volume changes and late-lifedepression outcome: a 4-year magnetic resonance imaging study.

Int Psychogeriatr. 2006;18:445456.196. Breitner JC, Husain MM, Figiel GS, et al. Cerebral whitematter disease in late-onset paranoid psychosis. Biol Psychiatry.1990;28(3):266274.

197. Jorm AF. Sex and age differences in depression: a quantitativesynthesis of published research. Aust N Z J Psychiatry.1987;21:4653.

198. Fredrikson M, Annas P, Fischer H, et al. Gender and age differencesin the prevalence of speci c fears and phobias. Behav Res Ther.1996;34(1);3339.

199. Poulton R, Menzies RG. Fears born and bred: toward amore inclusive theory of fear acquisition. Behav Res Ther.2002;40(2):197208.

200. Regier DA, Boyd JH, Burke JD Jr, et al. One-month prevalence of mental disorders in the United States. Based on ve EpidemiologicCatchment Area sites. Arch Gen Psychiatry. 1988;45:977986.

201. Gurland B. The impact of depression on quality of life of theelderly. Clin Geriatr Med. 1992;8:377386.

202. Beekman ATF. 1996. Depression in later life: studies in thecommunity [dissertation]. CopyPrint 2000 [Enschede (NL)]:University of Twente.

203. Kennedy GJ, Kelman HR, Thomas C, et al. Hierarchy of

characteristics associated with depressive symptoms in an urbanelderly sample. Am J Psychiatry. 1989;46:220225.204. Vaillant GE, Orav J, Meyer SE, et al. Late-life consequences of

affective spectrum disorder. Int Psychogeriatr. 1996;8:1332.205. Waern M, Runeson BS, Allebeck P, et al. Mental disorder in elderly

suicides: a casecontrol study. Am J Psychiatry. 2002;159:450455.206. Saz P, Dewey ME. Depression, depressive symptoms and mortality

in persons aged 65 and over living in the community: a systematicreview of the literature. Int J Geriatr Psychiatry. 2001;16:622630.

207. Lyness JM, Conwell Y, Nelson JC. Suicide attempts in elderly psychiatric inpatients. J Am Geriatr Soc. 1992;40:320324.

208. Nowers M. Deliberate self-harm in the elderly: a survey of oneLondon borough. Int J Geriatr Psychiatry. 1993;8:609614.

209. Draper B. Suicidal behaviour in the elderly. Int J Geriatr Psychiatry.1994;9:655661.

210. Wiktorsson S, Runesson B, Skoog I, et al. Attempted suicidein the elderly: characteristics of suicide attempters (70+) and ageneral population comparison group. Am J Geriatr Psychiatry.2010;18:5767.

211. Conwell Y, Rotenberg M, Caine ED. Completed suicide at age 50and over. J Am Geriatr Soc. 1990;38:640644.

212. Waern M, Beskow J, Runesson B, et al. High rate of antidepressanttreatment in elderly suicides. Br Med J. 1996;313:1118.

213. OBrien JT, Ames D. Why do the depressed elderly die? Int JGeriatr Psychiatry. 1994;9:689693.

214. Murphy JM, Monson RR, Olivier DC, et al. Affective disorders andmortality. Arch Gen Psychiatry. 1987;44:473480.

215. Mykletun A, Bjerkeset O, Overland S, et al. Levels of anxietyand depression as predictors of mortality: the HUNT study. Br J

Psychiatry. 2009;195(2):118125.216. Pennix BWJH, Geerlings SW, Deeg DJH, et al. Minor and major depression and the risk of death in older persons. Arch GenPsychiatry. 1999;56:899895.

Manuscript received August 2010, revised, and accepted November 2010.1 Professor in Social Psychiatry and Epidemiology, Institute of Neuroscience and Physiology, Section for Psychiatry Section, Unit of Neuropsychiatric Epidemiology, University of Gothenburg, Gothenburg,Sweden.

Address for correspondence: Dr I Skoog, NeuropsychiatricEpidemiology, Neuropsykiatri SU/Mlndal, Wallinsgatan 6,431 41 Mlndal, Sweden; [email protected]

Rsum : Troubles psychiatriques chez les personnes gesLa recherche rcente indique que la dpression, les troubles anxieux, et la psychose sont plus communsquon ne lavait suppos auparavant chez les populations ges sans dmence. On ne sait pas aveccertitude si la frquence de ces troubles saccrot ou dcrot avec lge. Lexpression clinique des troublespsychiatriques en ge avanc peut tre diffrente de celle quon observe dans des groupes moins gs, lessymptmes tant moins nombreux et souvent moins orides. Paralllement, la comorbidit entre diffrentstroubles psychiatriques est immense, ainsi que la comorbidit avec les troubles somatiques. La fonctioncognitive est souvent diminue chez les personnes souffrant de dpression, de troubles anxieux, et depsychose, mas il reste dterminer si ces troubles sont des facteurs de risque de dmence. Les troublespsychiatriques chez les personnes ges sont souvent lis la neurodgnrescence crbrale et lamaladie crbrovasculaire, bien que les facteurs de risque psychosociaux soient galement importants.Les troubles psychiatriques, rpandus chez les personnes ges, ont des consquences, notamment ladfavorisation sociale, une mauvaise qualit de vie, le dclin cognitif, lincapacit, le risque accru de troublessomatiques, le suicide, et la mortalit non suicidaire accrue.

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