2005 overview: Key learning points in old age psychiatry

It is difficult to pick out any seminal papers in 2005 that have had a major impact on practice in Old Age Psychiatry, arising from the quality of the original research. I have therefore chosen themes that are topical, perhaps slightly away from the mainstream, and hopefully of practical relevance to clinicians.

Key learning point 1

Capacity And Coercion

Hospitals throughout the developed world are overflowing with older people: two thirds of medical admissions and three quarters of medical beds are occupied by people over 65 in the UK. Depending on how one defines "mental illness", up to 60 % of these over 65s have "mental illness", most commonly depression, dementia and delirium (and of course, delirium superimposed on dementia).

These conditions may impair the individual"s capacity to make autonomous decisions, and this capacity may fluctuate during the course of a hospital admission. A common hospital scenario is the patient with moderate dementia, keen to go home, but not absolutely sure where home is, accompanied by relatives or neighbours who insist she/he is "not safe" to be at home.

Medical, nursing, social work and occupational therapy staff often seem reluctant to make decisions in this example, and call in a Psychiatrist to adjudicate. Brindle and Holmes discuss these ethical issues in an editorial in Age and Ageing (ref. 1), based on their experience of 400 referrals over 4 years to a Liaison Old Age Psychiatry Service in Leeds, UK, under the subheadings "Assessment of Capacity", "Legal Powers" and "The Role of Psychiatric Services".

One learning point is that individual autonomy is paramount, and in the majority of cases, patients" wishes to go home can be respected if appropriate services are in place. Older people benefit from hospital admission when required, but discharge pathways – and the link back to the Community – need to be improved.

Key learning point 2

Driving And Dementia

With demographic changes, there are an increasing number of older drivers on the roads, and competent drivers faced with increasingly pressurized driving conditions. Whilst most older people are safe, road deaths and injuries remain a major public health problem.

Although most attention is paid to prevention of childhood accidents, for every child that dies on the roads in the UK, 4 over 65s die. Most of these are pedestrians, not drivers, and older people die from impacts that do not cause death in younger people.

In considering driving and dementia, if older people are forbidden from driving because of cognitive impairment, they are placed at risk of death and injury as pedestrians. Diminished hearing, eyesight, mobility and reaction time may all play a part in this, as well as cognitive impairment.

Clinicians are frequently asked to give an opinion on fitness to drive. An interesting paper from America (ref. 2) assessed perceptions of driving skill in people with mild cognitive impairment and early Alzheimer's (AD) against the gold standard of a rigorous driving test. Older drivers with mild AD overestimated their driving ability most, their carers/spouses also overestimated their partners skill/safety.

A neurologist made the most accurate judgement, but he too was prone to error and slightly overestimated capacity to drive safely. The learning point that doctors should regard subjective judgements on driving capacity with scepticism, and Licensing Authorities should make driving tests/examinations more accessible for older people with mild AD.

Key learning point 3

Vascular Brain Damage Is Increasingly Recognised To Underly Mental Illness In Old Age

The concept of "vascular depression" was first described in 1995. Baldwin (ref. 3) reviewed recent literature to conclude that there is considerable evidence linking depression in later life with vascular brain disease, but the interaction is bidirectional, not necessarily causal.

Inflammatory mechanisms in the brain may mediate both depression and vascular disease. The implication for primary care physicians is that good control of blood pressure and cardiac function in mid-life may prevent brain decay in late life – which may manifest as depression, AD, or vascular dementia; or a combination of all three.

A review by Thanvi, Lo and Robinson (ref. 4) suggested that up to 12 % of cases of parkinsonism are caused by "vascular parkinonism". It is important to distinguish this condition from idiopathic Parkinson's Disease, as the structural damage to the basal ganglia in vascular parkinsonism results in poor response – but manifest side effects – with L-DOPA therapy.

Key learning point 4

Disability And Depression Are Inextricably Linked

A major worldwide study, published in 1994, established a clear association between depression and physical disability in under 65s – this association transcended cultures. Does this association hold true for older people, or are variable attitudes to old age and access to health care more potent factors?

A pan-European study, entitled EURODEP, sought to answer this question. The study, published in the British Journal of Psychiatry in July 2005 (ref. 5), produced consistent findings in 14 sites from 11 European countries: disability has a similar relationship to depression as it does in younger people.

The practical significance for clinicians that depression should not be treated in isolation : psychiatrists and primary care physicians need to treat optimally associated physical disability too for best long term results.

Key learning point 5

Specialist Palliative Care In Dementia

In the UK, people die in hospices almost solely from cancer, although cancer only accounts for 25 % of total deaths. Frequently, patients with dementia are actively excluded from hospice care, despite it being known that patient dying from dementia have health care needs comparable to those of cancer patients (ref. 6).

Specialist hospices for people with advanced dementia, focussing on terminal care, do exist in North America, and the challenge is to see their introduction in Europe. An alternative model is outreach from a traditional hospice, to provide palliative care expertise to demented patients dying in nursing homes.

A randomized controlled trial (ref. 7), again from America, found positive results for this outreach model : nursing home patients having the hospice intervention had less hospital admissions and spent less time in hospital. Although this study was not targetted specifically at people with dementia, 65 % of the participants had Mini Mental State Examination scores of 0 – 9 : as in most nursing homes, many residents had dementia whether or not it has been formally diagnosed.

The key learning point is that patients with dementia have as much right to exert choice in their end of life care as anyone else: making a diagnosis of dementia should facilitate discussion and choice, not exclude people from specialist care.

Key learning point 6

Conventional Antipsychotics May Carry Higher Mortality Than Atypicals

Many clinicians have moved away from prescribing atypical antipsychotics for older people, following warnings in 2004 from Licensing Authorities (and the drug companies themselves), that olanzapine and risperidone slightly increase the risk of stroke. Retrospective analysis of schizophrenia trials had suggested the risk of stroke was increased from 1% in controls, to 3% in over 65 trial participants taking either olanzapine or risperidone.

However, reverting to prescribing established antipsychotics such as haloperidol may be more hazardous. A recent study published in the New England Journal of Medicine (ref. 8) analysed 23,000 over 65s prescribed antipsychotics between 1994 and 2003.

Inevitably, some of the prescriptions were for non-licensed indications other than schizophrenia, eg., BPSD, psychotic depression. Within six months of starting treatment, 18% of those on a conventional antipsychotic had died, compared to 15% prescribed an atypical. Whilst this issue is not yet fully resolved, choosing an atypical antipsychotic may be justified for many cases after weighing up risks and benefits.

References

1. Brindle N and Holmes J. Capacity and Coercion: dilemmas in the discharge of older people with dementia from general hospital settings. Age And Ageing 2005; 34 (1); 16-20

2. Brown LB et al. Prediction of on-road driving performance in patients with early Alzheimer's Disease. Journal of the American Geriatrics Society 2005; 53 (1); 94-98

3. Baldwin RC. Is vascular depression a distinct sub-type of depressive disorder? A review of causal evidence. International Journal of Geriatric Psychiatry 2005; 20 (1); 1-11

4. Thanvi B, Lo N and Robinson T. Vascular parkinsonism – an important cause of parkinsonism in older people. Age and Ageing 2005; 34 (2); 114-119

5. Braam AW et al. Physical health and depressive symptoms in older Europeans. Results from EURODEP. British Journal of Psychiatry 2005; 187; 35-42

6. Hughes JC, Robinson L and Volicer L. Specialist palliative care in dementia. British Medical Journal 2005; 330 (7482); 57-58

7. Casarett D et al. Improving the use of hospice services in nursing homes: a randomized controlled trial. JAMA 2005; 294 (2); 211-217

8. Wang et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine 2005; 353 (22); 2335-2341