Depression (see Chapter 5) is the most common psychiatric disorder in old people, and first admission rates for depression are highest in the 50-70 age group. Mixed anxiety-depressive states frequently present in primary care with psychiatric symptoms, insomnia, physical problems, or social difficulties ('failure to cope'). Most depressive episodes recover in the short term, but long-term prognosis is worse than for younger patients. At least 70 per cent develop further episodes.

Suicide rates rise with age, and suicide in elderly people is often associated with clinical depression as well as with social isolation.

Depression in old people may be associated with cognitive impairment and therefore be difficult to distinguish from early dementia. A careful history, mental state examination, and brain scan often help to make the distinction, but the two disorders may coexist.

Antidepressant drugs are effective, but low doses should initially be used because unwanted effects, such as postural hypotension with tricyclics, are more severe than in younger adults. If successful, antidepressants should be continued for 1-2 years in old people, perhaps even for life, because of the high likelihood of relapse. ECT is readily considered in the elderly, as it acts more quickly than medication and, apart from transient mental confusion, often has fewer unwanted effects. ECT may be lifesaving in a severely depressed patient who is dehydrated due to refusal to eat and drink.

Mania (see Chapter 5)

Although first admission rates for mania show a slight increase with age, it remains an unusual presentation. It is important to exclude physical causes such as a brain tumour, cerebrovascular disease, or medication such as steroids, especially if a careful search (old case notes, interviewing relatives) fails to reveal any previous history. Patients with long-standing bipolar illness tend to suffer less


mania and more depression if they survive into old age. Transient depressive symptoms occur during most manic illnesses in the elderly. Physical illness or injuries often result from self-neglect and overactivity, so inpatient treatment is desirable.

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