Clinical Review

ABC of mental health: Mental health in old age

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7105.413 (Published 16 August 1997) Cite this as: BMJ 1997;315:413
  1. A J D Macdonald

    Introduction

    Psychiatric care of elderly people can be more interesting than that of younger patients. Successful treatment of elderly patients requires a demanding mélange of psychological, medical, social, political, and managerial skills—an epitome of modern medicine.

    Depression

    Important biological symptoms of depression in old age are change in sleep patterns (especially reduced sleep and early morning wakening); decline in appetite and weight loss; regular variation of mood over day (especially worse in early morning); constipation; physical and mental slowing not accountable by other disorders; and suicidal thoughts.

    The prevalence of depression among people aged over 65 is 15% in the general community, 25% in general practice patients, and ≥30% in residential homes

    View this table:

    Chances of depressed patient responding to treatment

    Criteria for hospital admission of elderly patients with depression

    Those who are likely to benefit from treatment and who

    • Express suicidal ideas of a definite sort, or who attempt suicide

    • Have problems with compliance or delivery, leading to unduly protracted treatment

    • Require electroconvulsive therapy for delusions and hallucinations

    • Neglect themselves substantially, particularly their fluid intake

    • Require removal from a hostile social environment

    • Are in such distress as to need tranquillisation or skilled nursing care

    • Have physical illness that would complicate treatment

    • Harm themselves, or threaten to, for the first time (especially men)

    View this table:

    Treatment regimen for dothiepin in elderly patients

    The central question for doctors is whether a depressive state will respond to treatment (including electroconvulsive therapy); all other questions are either peripheral or secondary to medical practice. Social engineering is not the doctor's role. Even deciding to admit a patient to hospital is secondary to treatability: there is little point in admission if the patient, however suicidal, is unlikely to improve; better to reserve your place in the coroner's court and concentrate on more treatable patients.

    The categories of depression in elderly people that respond well to treatment are

    • Depression lasting more …

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