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In Review

Psychiatric Disorders in the Elderly


Ingmar Skoog, MD, PhD1
Recent research has shown that depression, anxiety disorders, and psychosis are more common than previously supposed in elderly populations without dementia. It is unclear whether the frequency of these disorders increases or decreases with age. Clinical expression of psychiatric disorders in old age may be different from that seen in younger age groups, with less and often milder symptoms. Concurrently, comorbidity between different psychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitive function is often decreased in people with depression, anxiety disorders, and psychosis, but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders in the elderly are often related to cerebral neurodegeneration and cerebrovascular disease, although psychosocial risk factors are also important. Psychiatric disorders, common among the elderly, have consequences that include social deprivation, poor quality of life, cognitive decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal mortality. Can J Psychiatry. 2011;56(7):387397.

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

ost research on mental disorders have been concerned with dementia and to some extent with depression. Other mental disorders, such as anxiety disorders and psychotic disorders, have received less attention. This review will discuss the frequency of mental disorders in the elderly, and its relation to age. Aspects of mental disorders in the elderly without dementia, such as clinical expression and comorbidity, cognitive function and dementia, cerebral neurodegeneration and cerebrovascular disease, and risk factors and consequences, will also be discussed.

more common than dementia in people aged 65 years and older. The prevalence of depressive symptoms are even more common than the clinical diagnoses. Such subsyndromal forms of depression are nevertheless associated with adverse outcomes, such as stroke, disability, and mortality.1518 Anxiety disorders include GAD, agoraphobia, panic anxiety disorder, OCD, social phobia, and specific phobias. Recent research suggests that anxiety disorders may be as common, if not more common, as depression1,2,4 in the elderly. Among recent studies, prevalences between 6% and 12% have been reported in people aged 65 years and older.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 in those aged 95 years, 2%.5 Few studies have examined the 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 people aged 85 years, the prevalence of OCD was 3.2%7 and in those aged 95 years, 0.3%.5 Specific phobia is often considered the most common among the anxiety disorders. Prevalence estimates vary from 2% to 12% in populations aged 65 years and older.2,3,21,22,2629 Using DSM-IV criteria, the prevalence of social phobia was 1.3% among people aged 55 years and older,30 1.8%
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Frequency of Mental Disorders in the Elderly


The prevalence of mental disorders is high among the elderly,14 with a prevalence of almost 20% in people without 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 people without dementia aged 95 years fulfilled criteria for a psychiatric disorder: 17% had depression, 9% anxiety, and 7% a psychotic disorder.5 Most studies on the epidemiology of mental disorders in the elderly without dementia have been concerned with depression. Cross-sectional studies report prevalence figures of around 5% to 10% for depression,3,612 and 1% to 5% for major depression.2,3,13 These figures may be even higher in the developing world.14 This makes depression
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In Review

for those aged 65 years and older,31 and 1.9% for those aged 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 with intense anxiety or distress, and D) that this causes social consequences. 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% fulfilled DSM-IV-TR Criteria A, C, and D, but not Criterion B; that is, they did not find their fear unreasonable. Thus 3.5% had social phobia that caused social consequences. DSM-IV criteria thus exclude a large group of elderly with social phobia. The term paraphrenia was previously used to describe psychotic syndromes in the elderly. Currently used terms are late-onset schizophrenia or late-life psychosis, encompassing visual and auditory hallucinations and delusions arising in late life.33 Psychotic symptoms and disorders, such as schizophrenia, are supposed to be rare in the elderly without dementia. Population studies report that the prevalence of self-reported psychotic symptoms in the elderly without dementia range from 1.7% to 4.2%.2,3436 However, there may be underreporting because the elderly are reluctant to report psychotic symptoms. Using several sources of information (including self-reports, close informants, and patient records), it was recently reported that 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 people without dementia aged 70 years using the same methods.39 Prevalence is affected not only by the occurrence of new cases, but also by the duration of the disorder and by its mortality. Incidence is therefore a better measure of risk. However, studies on incidence of mental disorders in old age 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 years and older was 27 per 1000 person-years for males and 55 for females, and the incidence of OCD was 10 per 1000 person-years in females. The incidence of social phobia was 17 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 90 years developed a first-onset psychotic symptom during the follow-up.46 Others have reported a cumulative incidence of 5% for psychotic symptoms during 3.6 years of followup 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 people aged 65 years and older.47 The incidence of first-onset psychotic symptoms was 5.3 per 1000 person-years for people aged between 70 and 90 years.46 Another population study48 estimated the incidence of visual hallucinations to 25 per 1000 person-years for people aged 70 to 79 years, and 40 per 1000 person-years for people aged 80 years and older.

What Is the Relation Between Age and Frequency of Mental Disorders?


The prevalence of many factors associated with mental disorders increases with age, including loss of close relatives, 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 serotonergic transmission, hypersecretion of cortisol, and low levels of 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 mentioned negative factors are controlled for, age has not been shown to emerge as a risk factor for depression, even in studies that otherwise report an age-related increase.8,53 Several cross-sectional studies, both in the past and more recently, suggest that the prevalence of depressive disorders is highest in people aged 50 to 65 years, and decreases thereafter.1,4,1113,5458 However, studies on representative samples aged 65 years and older are heavily weighted toward the age strata of 65 to 75 years, and the group aged 75 years and older is therefore concealed in these types of studies.11 This is important as it seems that the prevalence of depression may increase in people aged 75 years and older,5,8,27,53,57,59,60 and that the prevalence is higher in those aged 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 Thus depression may have its highest prevalence in people during the 10 years before retirement age (65 years) and its lowest prevalence in those aged between 65 and 75 years, with an increase again after age 75 years.11 Even if the prevalence of depression does not increase in the elderly, the prevalence of depressive symptoms are constantly reported to increase with age.56,64,65 This may reflect that elderly people with depression may exhibit less symptoms than younger people with depresson.66 The incidence of depression has been reported 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 differs among the anxiety disorders.67 Panic disorder is considered
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Abbreviations
CT DSM GAD ICD MRI OCD computed tomography Diagnostic and Statistical Manual of Mental Disorders generalized anxiety disorder International Classification of Diseases magnetic resonance imaging obsessivecompulsive disorder

WML

white matter lesion

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very rare among the elderly.2,27,55 The reports on GAD are inconsistent. Some report that the frequency of GAD increases with age, at least until age 55 years, or remains stable.20,68,69 Others suggest that the highest frequency of GAD occurs in people aged around 40 years,70,71 and declines thereafter.70,72 OCD is believed to be less common among the elderly than among younger people.23 OCD generally has its onset in people aged around 20 years, but it has been suggested that a second peak of onset occurs in late life.73 Beekman et al22 reported a peak prevalence of OCD among women aged from 65 to 74 years (2.7%), compared with women aged 55 to 64 years (0.3%) or 75 to 85 years (0.8%). The prevalence of specific phobia26,74,75 and phobic fears76 are reported to decrease with age, with some exceptions.21,77 New onset seems to be rare in late life,78 and more than 80% of people aged 70 years reported onset before they were aged 21 years.29 Also the prevalence of social phobia may be lower among the elderly, compared with younger age groups.30,74,7981 Social phobia also has an early age of onset, developing in most cases during the midteens, with decreasing frequency thereafter.30,31,82 It has been suggested that age increases risk for psychotic symptoms in the elderly.83 It seems that the prevalence is considerably higher among people aged between 8537 and 95 years,38 than in younger age groups.39 Several factors may influence whether the frequency of mental disorders increases with age. Comorbidity, dementia, and clinical manifestations will be discussed in the following sections of this review.

related to greater subjective impairment and disability, and more limitations in activities of daily living.32,84 Enforcement of exclusion criteria has been suggested to explain the lower prevalence of anxiety disorders, especially GAD, 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 exclusion criteria regarding presence of other psychiatric disorders, especially depression, are applied. One important aspect when evaluating frequency of psychiatric disorders is thus whether 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 presence of concurrent depressive illness, as a main diagnosis of depression is given when the diagnostic threshold for depression is reached irrespective of the severity of anxiety symptoms.28 This has an immense influence on the 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 in frequency of anxiety disorders with age. Comorbidity between mental disorders may have several explanations. It may reflect shared vulnerability or common pathological pathways. Another possibility is that people with anxiety disorders have an increased risk to develop a depressive disorder, thus shifting their diagnosis from anxiety to depression with increasing age. However, there also seems to be a shift in the opposite direction with increasing age.

Comorbidity
Little is known about comorbid psychiatric disorders among the elderly, although recent studies indicate that comorbidity between depression and anxiety disorders, as well as between different anxiety disorders, is very high also in old age,1,2,4,29,32,75,78,8489 with 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 were an admixture of depressive and anxiety symptoms. Lindesay et al27 reported that 91% of the elderly with general anxiety in the population also had depression, and Blanchard et al42 reported that 95% of those with depression had symptoms of anxiety. This comorbidity seems to be high for all types of anxiety disorders. The very high comorbidity between GAD and depression91 has led to a discussion as to whether GAD should be included among the mood disorders in the upcoming DSM-5. This discussion has been concerned with younger age groups, and it is unclear whether it is applicable also to the elderly. There is also a high comorbidity between different anxiety disorders, such as social phobia, panic disorder, agoraphobia, GAD, and OCD.32,84,85 This emphasizes the close relation between psychiatric disorders, and the difficulty of making diagnostic demarcations. Psychiatric comorbidity is also
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Clinical Manifestations
Manifestations of mental disorders may be different in the elderly, compared with younger age groups, and there may be difficulties in separating symptoms of mental disorders from those occurring in normal aging. For example, there is an overlap in symptoms of depression and those occurring in physical disorders and in normal aging (for example, loss of appetite, tiredness, and sleep disturbances). This may lead not only to overdiagnosis59 but also to underdiagnosis if depressive symptoms are thought to be due to physical disorders or normal aging.6,7,42,57,92,93 Depression may also have different manifestations in the elderly.6,64,93 For example, elderly people may present with a smaller number of symptoms66 or one dominating symptom. Depressed elderly people may also more often show aggressiveness, cognitive difficulties, and loss of interest and 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 in the elderly, although it is unclear whether the recovery rate is worse than for younger depressed people,95,96 and about one-third of depressed elderly people still have depression at 1 to 3 years of follow-up.41,97 In contrast, social phobia
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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 manifestations among the elderly, with fewer symptoms, less somatic and autonomic symptoms, and less avoidance, and more agitation, irritability, talkativity, and tension,20 and with more somatization.98 However, most anxiety disorders have similar 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, and less excess of focal structural brain abnormalities and cognitive dysfunction, compared with age-matched control subjects.33,100 Also late-life psychosis may show less symptoms, and one symptom may dominate the picture. Finally, criteria for mental disorders are often validated in younger age groups, and their use in the elderly has therefore been questioned.66,101

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 population studies are contradictory, with several studies reporting that depression increases risk for dementia,103,112114 while others found no associations41,115118 A meta-analyses including 22 studies suggested that depression increased the risk for later development of dementia.111 However, this metaanalysis included a mixture of population-based studies and studies from memory clinics, which made it difficult to evaluate whether depression increases risk for dementia in 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 each related 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 from age 70 to 90 years, only 45% of those who developed first-onset psychotic symptoms developed dementia.46 The mean interval between first onset of psychotic symptoms and development of dementia was 5 years. Already Post120 reported that only 15% of elderly patients with persecutory states in a psychogeriatric hospital developed dementia at follow-up, and Holden121 reported that 35% of patients with late paraphrenia had dementia within 3 years of diagnosis. Thus psychotic symptoms are risk factors or prodromes for dementia, but still only a minority of those developing psychotic symptoms in old age will develop dementia.

Dementia and Cognitive Decline


The prevalence of dementia and milder forms of cognitive decline increases with age. Therefore, dementia and cognitive symptoms need to be considered in all studies of the elderly, especially in those aged 80 years and older. It is obvious that people with dementia may underreport symptoms and other factors owing to memory problems. It is therefore surprising that studies concerned with the elderly sometimes do not even assess dementia, which may be one reason for the reported decline with age of selfreported psychiatric disorders. Further, most criteria, including DSM-IV, exclude organic causes 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 at risk for depression and anxiety disorders, giving lower total prevalence of depression in higher ages. Indeed, it has been reported that the apparent decline with age for depression and anxiety disorders disappear if people with dementia are exluded.5,63 Cognitive symptoms are one of the core symptoms for depression in DSM-IV. It is therefore not surprising that many studies report that people with manifest depression exhibit signs of cognitive decline.56,59,102105 This decline is generally mild62,106 and of frontal-subcortical type,103106 and does not fulfil criteria for dementia. The cognitive manifestations of depression are probably more accentuated among the elderly, and may be more common in those with their first episode in old age than in those with episodes earlier in life.107 Anxiety disorders in the elderly,89 including social phobia32 and GAD,99 are related to worse cognitive performance. In addition, psychotic symptoms108 have been related to worse cognitive performance. Thus people without dementia aged 85 years with psychotic symptoms
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Factors Associated With Mental Disorders in the Elderly


Most studies on risk factors for mental disorders are concerned 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 and what is a consequence of the mental disorder, and in many instances 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 decreased social network and support,8,122,135137 and cerebral organic factors,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 personality factors,8,140,141 smoking,135 and alcohol consumption142 have been associated with depression in the elderly. Even when health factors are present, psychosocial factors often play a mediating role.137 Risk factors for anxiety disorders include female sex, 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
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late life are thus similar to those of depression.145 However, some authors stress that risk factors for depression and anxiety disorders are not similar,143 and risk factors for latelife depression tend to be more biological than those for late-life anxiety disorders.145 One reason may be that there are very few studies examining biological factors in latelife anxiety disorders. Factors related to late-life psychosis include female sex, previous schizoid and paranoid personality traits, being divorced, living alone, lower education, poor social network and isolation, low social functioning, sensory impairments, especially deafness, vascular disease, and more dependence in community care.100 Psychosis and psychotic symptoms in elderly populations have been associated with somatic disorders, for example, hypothyroidism, cerebral tumours, and cardiovascular and cerebrovascular disease.100 Further, drugs, such as anticholinergics, antiparkinson, steroids and beta-blockers, as well as alcohol and benzodiazepine withdrawal, may produce psychotic symptoms in the elderly.

the elderly, worries in GAD were associated to decreased volume in the prefrontal cortex.163 Subtle brain changes, such as degenerative or vascular changes, have also been hypothesized to enhance vulnerability to psychotic symptoms in the elderly,83,164 but reports are disparate. Some studies report a higher ventricleto-brain ratio, larger third ventricle volume, and volume reductions of the left temporal lobe or superior temporal gyrus. In a study165 on people aged 85 years, basal ganglia calcifications, but no other brain changes, were associated with increased frequency of psychotic symptoms.

Cerebrovascular Disease
Cerebrovascular diseases such as stroke166 and ischemic WMLs146 become more common with increasing age. The concept of vascular depression167 suggests that cerebrovascular diseases, such as stroke and WMLs, are especially important for the etiology of depression in old age. However, the symptoms of depression may not differ between depressed stroke patients and patients without stroke.168 Depression is common after stroke.169173 A systematic review169,170 found a pooled estimate of 33% for depression after stroke. In the study by Linden et al,173 stroke was related to an odds ratio for depression of 3.2 in women and 4.0 in men 1.5 years after the index stroke. Depression is important to detect in stroke patients, as it is associated with worse outcome.174176 Depressed stroke patients have more cognitive impairments,172 more days in hospital,177 and use more care than those who are nondepressed.178 The association between stroke and depression may also go in the opposite direction, as several studies15,179,180 report that depression increases the risk for first-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 is related to silent cerebrovascular diseases, such as ischemic WMLs, which may increase incidence of stroke. WMLs are very common in the elderly,146,183 and most likely reflect ischemic demyelination.184 The cause of WMLs is probably that longstanding hypertension causes lipohyalinosis and thickening of the vessel walls with narrowing of the lumen of the small perforating arteries and 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 and depression,152,155,156,158,185,186 although not all studies support this association.153,187 The results from longitudinal population-based studies are conflicting. Three prospective MRI studies188190 and 1 CT study157 reported that WMLs increased the risk of subsequent depression, while 2 MRI studies could not confirm these findings.158,191 Part of the relation between white matter changes and depression may be mediated by loss of functional ability.192 WMLs in elderly
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Structural Brain Disorders


Structural brain changes become more common with increasing age,146 and have been associated with mental disorders in old age by several investigators. Late-life depression, especially major depression, has been associated with ventricular enlargement,147151 changes in the caudate nuclei,147,152 and the putamen,152 and with atrophy in the frontal, temporal, and parietal lobes.150158 However, most studies on the association between brain atrophy and depression in the elderly have been cross-sectional and performed in clinical samples. One longitudinal populationbased study157 reported an association between temporal lobe atrophy on CT at baseline and development of major depression during a 5-year follow-up. Another longitudinal population-based study158 reported a cross-sectional association between temporal and parietal lobe atrophy assessed with MRI at baseline and concurrent depressive symptoms, but no association with depression occurring during follow-up. A third longitudinal study159 in elderly without dementia examined the association between mean depressive symptom scores over time and change in brain atrophy on MRI during 9 years. Cross-sectional associations between temporal and frontal lobe atrophy and depressive symptoms, and a longitudinal association between volume decline in frontal white matter and depressive symptom score over time were reported.159 The cellular mechanisms that underlie the association between brain atrophy and depression in the elderly remain largely unknown. Postmortem studies have reported on cellular alterations such as neuronal death, neuronal shrinkage, decrease in dendritic and glial density, and cell death in the frontal cortex and hippocampus in the elderly with major depression.160161 Anxiety disorders have been related to brain changes in younger age groups.162 In relation to anxiety disorders in
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depressed patients may influence outcome of depression, such as time to relapse193 and response to antidepressant therapy.194 Depression may also influence the development of WMLs. One recent study195 reported that depression at baseline was associated with faster progression of WMLs during follow-up. Ischemic WMLs have also been reported in late-onset paranoid psychosis,196 while little is known about the impact of WMLs on anxiety disorders in the elderly.

disability,14,131,201,202 increased use of health and home care services,42,203 decline in cognition,102,104,105 increased 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 an increased mortality rate, increased risk for ischemic heart disease and stroke, and an increased suicide risk. Social phobia is associated with lower social and mental functioning, and reduced quality of life in the elderly.32,82 Among the consequences of psychotic symptoms are disability in daily life, dependence on community care, cognitive dysfunction, increased risk for dementia, and increased mortality.100 Studies on attempted207210 and completed suicides205,211 in old age have reported a stronger association with depression, with less alcoholism and fewer personality disorders, than in younger age groups. Psychotic disorders and anxiety disorders are also associated with an increased risk of suicide in the elderly.205 Suicidal attempts in the elderly are often characterized by a greater degree of lethal intent.208,211 Although it is often suggested that suicide in 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% had had such treatment 6 months before their suicide.212 These findings emphasize that once diagnosed, depression in the elderly must be managed with persistence. It is constantly reported that depressed elderly people have an 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-shaped curve,215 while hallucinations and paranoid ideations were related to increased mortality in women aged 85 years.37

Sex
Women live longer than men, and at the age of 95 years, the female-to-male ratio is 4:1.5 Female sex is the most consistent risk factor for depression and some anxiety disorders. The female preponderance of depression is most accentuated in middle life,55,57 and the sex difference may diminish with increasing age.197 Some studies1,5,7,41,102 are in line with this opinion. However, depression is generally reported 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 in women than in men.1,4,27,28,67 However, there is a different pattern among the anxiety disorders. GAD is more common in women than in men in most studies in the elderly.2,3,20 Similarly as in depression, some authors suggest that the ratio of women to men for GAD decreases with age.20 Most studies report that OCD is more common among women than among men. This sex difference is suggested to be even more pronounced among the elderly.22,88 However, a recent Canadian study25 reported that elderly people with OCD were more likely to be men, compared with those having another anxiety disorder or a mood disorder. Fear of social situations,32 and phobic fears and simple phobia are 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 and habituate toward these stimuli.29 Second, fears may develop more often in girls owing to gender differences in role modelling or in information regarding the danger of different exposures. Many clinical studies report that late-onset schizophrenia is more common among women, with female-to-male ratios ranging from 1.9:1.0 to 22.5:1.0.33 Cross-sectional population studies on psychotic disorders in the elderly report disparate results, with female-to-male ratios ranging from 0.7:1.0 to 1.5:1.0.90,200 Among people aged 8537 and 95 years, there were no sex differences.38

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

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Consequences of Mental Disorders


Mental disorders are thus very common and have consistently been reported to have a poor outcome in the elderly. Among the consequences of depression are social deprivation,201 loneliness,8 poor quality of life,14,201,202
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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, Neuropsychiatric Epidemiology, Neuropsykiatri SU/Mlndal, Wallinsgatan 6, 431 41 Mlndal, Sweden; Ingmar.Skoog@neuro.gu.se

Rsum : Troubles psychiatriques chez les personnes ges


La recherche rcente indique que la dpression, les troubles anxieux, et la psychose sont plus communs quon ne lavait suppos auparavant chez les populations ges sans dmence. On ne sait pas avec certitude si la frquence de ces troubles saccrot ou dcrot avec lge. Lexpression clinique des troubles psychiatriques en ge avanc peut tre diffrente de celle quon observe dans des groupes moins gs, les symptmes tant moins nombreux et souvent moins florides. Paralllement, la comorbidit entre diffrents troubles psychiatriques est immense, ainsi que la comorbidit avec les troubles somatiques. La fonction cognitive est souvent diminue chez les personnes souffrant de dpression, de troubles anxieux, et de psychose, mas il reste dterminer si ces troubles sont des facteurs de risque de dmence. Les troubles psychiatriques chez les personnes ges sont souvent lis la neurodgnrescence crbrale et la maladie crbrovasculaire, bien que les facteurs de risque psychosociaux soient galement importants. Les troubles psychiatriques, rpandus chez les personnes ges, ont des consquences, notamment la dfavorisation sociale, une mauvaise qualit de vie, le dclin cognitif, lincapacit, le risque accru de troubles somatiques, le suicide, et la mortalit non suicidaire accrue.
The Canadian Journal of Psychiatry, Vol 56, No 7, July 2011 W 397