Current Knowledge and Future Direction

July 2, 2008

We are growing older. In ancient Greece, the expected life span was 20 years. In Medieval Europe, it went up to 30 years. In 1900, people reasonably could expect to live to the ripe old age of 47 years, and 39% of those born at that time survived to age 65 years in the United States. Currently, the average life span in the United States is 78 years, and 86% of those born will survive to age 65 years. The very old-people older than 85 years-are the fastest-growing population group in the country, and there are 120,000 Americans over the age of 100 years. And the trend continues.

“It is not enough to add years to one’s life . . . one must also add life to those years.” -John F. Kennedy

We are growing older. In ancient Greece, the expected life span was 20 years. In Medieval Europe, it went up to 30 years. In 1900, people reasonably could expect to live to the ripe old age of 47 years, and 39% of those born at that time survived to age 65 years in the United States. Currently, the average life span in the United States is 78 years, and 86% of those born will survive to age 65 years. The very old-people older than 85 years-are the fastest-growing population group in the country, and there are 120,000 Americans over the age of 100 years. And the trend continues.

According to the US Census Bureau, by 2020, 58% of all those born will survive to age 85 years, and by 2050, almost a quarter of the US population will be older than 65 years. Nor is the graying of our population just a local phenomenon. In 2006, for example, Japan became the first country to have 20% of the population reach age 65 years-plus. As our population grows older, physicians may anticipate seeing a greater proportion of their friends, relatives, and patients with late-life mental illness, bereavement, and perhaps even vulnerability to elder abuse. Like it or not, specialty-trained in geriatric psychiatry or not, most psychiatrists of adults will be “geriatric psychiatrists.”

Mental illnesses, at any age, are common and often long-term, and people with these chronic conditions now live longer. To compound the problem, the percentage of the population with mental illness is expected to increase as more illnesses have progressed to earlier ages of onset, resulting in a higher incidence of mental illness than in previous generations.

As physical problems increase, as family and friends die or drift away, as finances decline or other age-related stresses appear, mental health problems become more overwhelming. In addition, as people live longer, they have more opportunities for new mental disorders to develop that are sometimes linked to chronic physical conditions such as diabetes or hypertension or other brain disorders such as Alzheimer or Parkinson disease. Indeed, late-onset mental disorders account for about 25% of the cases in older adults. In addition, in a large percentage of people with degenerative or other types of dementia disorders, new-onset psychosis, agitation, anxiety, or depression also develop; this can be the cause of behavioral problems that lead to institutionalization when caregivers can no longer manage the patient at home.

Older persons with mental illness may be the most heavily burdened age group of any population, with the dual millstones of being old and mentally ill. Thus, it is no surprise that the suicide rate among the elderly is higher than in any other age group.

With this as background, the collection of articles found in this Special Report could not be more timely. They represent a broad array of many of the most common and clinically vexing mental health challenges facing older persons. Each contribution provides a scholarly review of what is known and offers clinical pearls pertinent to any clinician treating the elderly.

Three of the most common disorders throughout the adult life cycle are mood, anxiety, and substance use disorders. While most clinicians recognize how prevalent and disabling late-life depression can be, fewer are familiar with the particular manifestations and treatment requirements of late-life bipolar, general anxiety, or substance use disorders.

Anxiety disorders tend to be more prominent in the lives of older adults than many clinicians realize. Little has been written about the treatment of late-life anxiety disorders, and
clinicians often are at a loss where to begin. Calleo and Stanley address this problem and provide some answers about how to manage anxiety in older adults.

Substance use disorders, including the misuse and abuse of prescribed medications, are public health crises in the elderly that are often overlooked and thus untreated or inadequately treated. Trevisan reviews the implications of the aging of the baby boomer population and the rise in the prevalence of substance abuse among older persons.

Lavretsky provides an up-to-date primer on the unique clinical characteristics, epidemiology, differential diagnosis, etiology, and treatment of a full spectrum of mood disorders in late life.

Next, Hensley and Clayton discuss a universal and ubiquitous problem for the elderly-bereavement. One of the most painful of all the common experiences of growing old is the fact of death, frequently that of our closest and often life-long friends and relatives.

When is the depression following such a loss “just grief” and when is it a clinically significant depres-sion begging for treatment? Few areas in clinical medicine are less well understood.

The article by Kyomen and Whitfield provides a comprehensive and pragmatic review of agitation in the elderly. The causes of agitation in this vulnerable population are myriad and associated with a number of physical and mental conditions.

This outstanding collection of articles thus serves as an update and refresher course that covers key topics in geriatric psychiatry. It is an honor to present them here, and I hope you get as much out of reading them as I did.

Disclosures:

Dr Zisook reports that he has received research support from PAMLAB, ASPECT, and NIMH; he has received honoraria from GlaxoSmithKline, Wyeth, Forest, and AstraZeneca.