Psychiatric Assessment

and Diagnosis in Older

Adults

Thomas W. Meeks, M.D.

Nicole Lanouette, M.D.
Ipsit Vahia, M.D.
Sharon Dawes, Ph.D.
Dilip V. Jeste, M.D.
Barry Lebowitz, Ph.D.

tion to several issues. There are important biological, psychological, and social changes associated with either aging itself
or with generational differences. In this review, we will address some of the most important aspects of assessment and

CLINICAL
SYNTHESIS

To provide optimal care, the approach to psychiatric evaluation and diagnosis in older adults requires special atten-

diagnosis that make geriatric psychiatry a unique subspecialty, including age-related variability in the clinical presentation of common psychiatric disorders, assessment and diagnosis of cognitive disorders and medical comorbidity, and
common psychosocial challenges faced by older adults. Although geriatric psychiatrists are uniquely positioned to address the complexities of psychiatric illness in older adults, the fact remains that the majority of older adults who seek
psychiatric care will see general adult psychiatrists without subspecialty training. However, with continued vigilance to
the issues outlined below, psychiatrists from a variety of training backgrounds can skillfully assess and diagnose psychiatric illnesses in older adults.

PSYCHIATRIC SYMPTOMS IN OLDER

ADULTS
DIAGNOSTIC

CONUNDRUMS IN THE ELDERLY

There is some confusion in the psychiatric literature regarding the incidence, prevalence, and illness course of psychiatric disorders in late life. This
can be partly attributed to a paucity of studies focused on determining the epidemiology of psychiatric illnesses in older adults (2). Moreover, there is
a common belief (and some empirical evidence)
that psychiatric disorders (except dementia) are less
prevalent in older adults than in younger populations (3). Yet, these studies have certain limitations.
Behavioral and neurovegetative symptoms of psychiatric illness frequently overlap with those of general medical conditions, and increasing age is generally accompanied by increased medical
comorbidity, which creates diagnostic conundrums
in the evaluation of older adults. In addition, agerelated changes in the body and brain, as well as
cohort effects, can lead to atypical manifestations of
psychiatric illness, resulting in inaccurate or overlooked psychiatric diagnosis (4). Increasingly, however, it is recognized that special care needs to be
given to psychiatric assessment of the older patient.
Awareness and subsequent clinical recognition of
the differences in symptoms between older and

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younger age groups may help reduce both psychiatric and medical comorbidity. Table 1 outlines
age-related differences in the clinical features of several major psychiatric illnesses. Estimates of incidence and prevalence as well as prognosis and illness course are included.

NEED

FOR AGE-SPECIFIC DIAGNOSTIC CRITERIA

IN PSYCHIATRY

It is important to note that available information

on psychiatric disorders in older adults is based on

CME Disclosure
Thomas W. Meeks, M.D., Nicole Lanouette, M.D., Sharon Dawes, Ph.D., Department of
Psychiatry, University of California, San Diego, San Diego, CA. Ipsit Vahia, M.D., Barry Lebowitz,
Ph.D., Department of Psychiatry, University of California, San Diego, San Diego, CA; and Sam
and Rose Stein Institute for Research on Aging, San Diego, CA.
These authors report no relevant financial relationships to disclose.
Dilip V. Jeste, M.D., Department of Psychiatry, University of California, San Diego, San Diego,
CA; and Sam and Rose Stein institute for Research on Aging, San Diego, CA; and VA San
Diego, CA, Healthcare System, San Diego, CA.
Grant support in the form of medication supplies for NIH funded grant: Astra Zeneca, Bristol
Myers Squibb, Eli Lilly, Janssen.
Address correspondence to Thomas Meeks, M.D., Assistant Professor of Psychiatry, Division of
Geriatric Psychiatry, VA San Diego Healthcare System, 3350 La Jolla Village Drive, Building 13,
4th floor Mail Code 116A-1, San Diego, CA 92161; e-mail: tmeeks@ucsd.edu

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research conducted using diagnostic criteria from

either the DSM or ICD, both of which were almost
invariably developed from models of illness in
mostly younger or middle-aged adults. However, it
has become increasingly evident that use of these
criteria may result in an underestimation of the
prevalence of psychiatric disorders in older persons,
largely because these criteria have not been validated in older populations (25). Symptoms of psychiatric illness in older adults do not always correspond with criteria described in the standard
diagnostic manuals, a phenomenon also seen and
more widely recognized among children and adolescents. Ultimately, as research on age-related
changes in the brain expands, we will gain a more
sophisticated understanding of differences in clinical symptoms of psychiatric illness as a function of
age. Creating age-specific diagnostic criteria on the
basis of evolving knowledge of this process will allow clinicians to better identify symptoms, diagnose illness, and devise treatments for management
of late-life psychiatric disorders. For now, awareness of variable presentations of psychiatric disorders in older adults, as reviewed in Table 1, enables
the clinician to be more attuned to the psychiatric
needs of older adults.

COGNITIVE

AND FUNCTIONAL
ASSESSMENT OF OLDER ADULTS

AGING

AND COGNITION

Unlike the disorders described in Table 1, cognitive disorders are unequivocally more prevalent as
age increases, and competency in assessing cognition is an essential skill for clinicians caring for older
adults. This encompasses the use of cognitive screening assessments, early detection and education about
dementias, treatment of comorbid disorders that masquerade as dementia, attention to family system and
caregiver issues, referral to and collaboration with
other professionals such as neurologists and neuropsychologists, and reassurance when cognitive changes
are the result of normal aging.
There is a common public (and even professional) misconception that dementia is a sine qua
non of aging. Although age is the most prominent
risk factor for dementia, half or more of adults older
than age 85 retain normal cognitive functioning
(26). Cognitive impairments that meet the diagnostic criteria for dementia should never be dismissed as normal aging. Nonetheless, it is also valuable to recognize that there are some changes in
cognition that are age-related and not considered
pathological. Examples of such age-related cogni-

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tive changes include some decline in free recall and

consistently slower processing speed. However,
more crystallized abilities (vocabulary and general
knowledge) tend to remain stable or even, in some
circumstances, increase with age (27). When appropriate, reassurance about benign cognitive
changes of aging can allay significant anxiety for
older adults, who are increasingly cognizant of illnesses such as Alzheimers disease.

COGNITIVE

ASSESSMENTS

The most widely recognized standardized cognitive assessment used in clinical settings is the Folstein Mini-Mental State Examination (MMSE)
(28). The MMSE is useful primarily as a screening
tool, although it may also be used as a crude proxy
for illness progression in persons with dementia.
Cutoffs for normal versus abnormal scores vary
by age and educational attainment (29), in addition
to possible cultural variations (30). Criticisms of
the MMSE have included a relative lack of assessment of certain cognitive domains (e.g., executive
functioning) and insensitivity to early dementia,
especially in older adults with high intelligence and
educational attainment (31).
Other screening cognitive tests have been developed to address possible limitations of the MMSE.
The Mini-Cog Test, which uses only three-item
registration and recall separated by the Clock
Drawing Test, is somewhat quicker to administer
than the MMSE, and is useful in certain settings
such as primary care and the emergency room, and
appears to have sensitivity and specificity for dementia similar to that of the MMSE (32). Other
examples include the Saint Louis University Mental Status examination (33) and the Montreal Cognitive Assessment (34) (Figure 1), which have more
extensive memory and executive function assessment than the MMSE.
The gold standard of cognitive assessment is formal neuropsychological testing, typically performed by a specialist in neuropsychology. Referral
for neuropsychological testing may be particularly
useful if diagnosis is uncertain (e.g., early Alzheimer
disease versus dementia of depression), as various
forms of dementia exhibit somewhat distinct profiles of relative strengths and impairments early in
the course of illness (35). Table 2 lists the most
common variants of cognitive disorders among
older adults, along with clinically distinguishing
features including typical neuropsychological profiles. In moderate-to-severe stages, most forms of
dementia eventually cause diffuse and nonspecific
impairment across multiple cognitive domains.
One must also keep in mind that the most trou-

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Table 1.

Overview of Noncognitive Psychiatric Disorders in Older Adults

Disorder
Major depression

Anxiety disorders

Major Clinical Features in Late Life

Course of Illness/Treatment

Syndrome of motor symptoms, apathy, and amotivation

without depressed mood (depression without
sadness) may be common

Medications, psychotherapy (especially cognitive behavior

therapy) and ECT have all been shown as effective
treatments

Commonly seen in older adults recovering from major

medical conditions, e.g., myocardial infarction,
stroke, diabetes, and hip fracture and linked to
mortality and morbidity in many such medical
disorders

Late-onset depression may have higher rates of

recurrence and/or persistence than early-onset
depression

Vascular depression is common and associated with

executive dysfunction (7)

Lack of established treatments for psychotic

depressionantidepressant antipsychotic (or ECT)
are generally standard of care

Somatic and psychotic symptoms are common,

especially among hospitalized elderly

Medication fear/stigma and nonadherence remain a

major barrier to treatment

Subsyndromal depression is more common than major

depression among older adults but has significant
negative functional, social, and medical
consequences

Suicide in elderly patients is more common. Rates are

highest for white males and lowest for African
American females

Elderly patients with bipolar disorder may have late

age of onset or a continuation of (sometimes
undiagnosed) early-onset illness (8)

Clinical picture largely similar to that in younger

patients but often less severe manic symptoms (8)

Mania in old age associated with significant morbidity

and mortality

Prevalence less than 0.1% among community

dwelling older adults (? selective early mortality)

Cognitive impairment is seen in persons with bipolar

disorder, even when euthymic (9, 10)

Evidence of response to most mood-stabilizing

medication and ECT, although lithium tolerability is
often problematic

Prevalence of 10% in geriatric inpatient units (8)

Clinical features sometimes similar to those of

disinhibition syndromes seen with lesions of right
frontal lobe

Seems to be no specific progression of cognitive deficits

to clinically significant dementia

Prevalence of all anxiety disorders in older adults

cited as lower than that for younger adults (1)

Agoraphobia is more common than specific or social

phobia in older adults, but is less associated with
history of panic attacks than in young adults

Anxiety symptoms commonly co-occur with depression

(30%70%)

Epidemiologic Catchment Area Study showed an

overall prevalence rate of 5.5% for all anxiety
disorders (12)

Generalized anxiety disorder (GAD) is often comorbid

with depression in older adults and seldom has
onset in late life

Although it is common to treat older persons with anxiety

using benzodiazepines, caution must be exercised,
given the potential for falls and cognitive impairment

Phobias are the most common anxiety disorder in late

life (3.1% median period prevalence rate) (13)

Panic disorder is rare in late life and symptoms of

panic are often associated with cardiopulmonary
disease (e.g., chronic obstructive pulmonary disease)

Response to selective serotonin reuptake inhibitors and

cognitive behavior therapy has been documented for
some anxiety disorders in late life

GAD has a reported median prevalence rate of 2.2%,

perhaps an underestimate

Obsessive-compulsive disorder (OCD) in older persons

is understudied. New-onset OCD in late life is
believed to be rare, and studies suggest that
symptoms are similar to those seen in younger
persons (13)

OCD and panic disorder are less common and usually

begin in young adulthood

Posttraumatic stress disorder (PTSD) may develop in

late life after exposure to trauma/stress or be part of
a chronic lifelong illness, but lower rates of PTSD
among older adults suggest increased recovery with
age, underreporting of symptoms, or a healthy
survivor effect due to increased mortality associated
with PTSD (14)

Prevalence estimated at 2% in community-dwelling

older adults, 10% of those seen in primary care
settings (5), and 15%25% in nursing home
residents (6)

CLINICAL
SYNTHESIS

Bipolar disorder

Epidemiology

PTSD decreases in prevalence with age

Psychotic disorders

Substance use disorders

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Prevalence of psychotic symptoms in older adults

high in one study. Up to 10% of 85 year olds
without dementia may exhibit psychotic symptoms
(15)

Negative symptoms tend to be more prominent among

patients with onset in earlier life and positive
symptoms decrease in severity. However, among
persons with late onset schizophrenia (LOS),
paranoid ideation is a common clinical symptom (16)

Among older persons with schizophrenia clinical course

can vary significantly (17)

Approximately 23% of patients with schizophrenia

have onset after the fifth decade (3) with the oldest
reported case of schizophrenia at age 100 (19)

Persons with very late onset schizophrenia-like

psychosis (VLOSLP) often report hallucinations (18)

Approximately 15%20% of older persons with

schizophrenia have a persistently deteriorating clinical
course

Comorbid depression and nonprogressive cognitive

deficits are common in older persons with
schizophrenia

In one study 49% of older persons met criteria for

remission and 17% met criteria for clinical recovery,
with 13% of patients rating themselves as aging
successfully (compared to 27% of age matched peers
without schizophrenia) (20)

LOS refers to persons with onset after age 40 and

VLOSLP refers to onset after age 60 (18)

In older persons, psychotic symptoms may indicate

delirium and medical comorbidity must be assessed

Prevalence of tobacco smoking varies widely among

older persons, depending on gender, age, and
cultural background (21)

Smoking is associated with increased mortality,

morbidity, respiratory disease, depression, cancer
and reduction in instrumental activities of daily living
scores (22)

Older adults respond to counseling and medical advice

regarding cessation. However, persons older than age
65 are less likely to receive medications for smoking
cessation (23)

Prevalence of illegal drug use is uncommon but

abuse of prescription and over-the-counter
medications is not rare

Among illegal substances, the most commonly abused

were opiates, followed by cocaine. Among
prescription medications, benzodiazepines were most
commonly abused, although prescription opiate
abuse may be on the rise

Illegal drug use and prescription/over-the-counter

medication abuse may result from self-treatment for
insomnia, anxiety, pain, or depression (21)

Prevalence of alcohol use disorders decreases with

age, although older men report higher rates than
older women (0.8% of men and 0.5% of women
met DSM-IV criteria for alcohol dependence) (21)

Alcohol abuse is seen more commonly in patients with

comorbid pain and psychiatric diagnoses. Conversely,
older adults with chronic medical conditions tend to
restrict alcohol consumption (21). Tolerance to alcohol
also decreases as a function of pharmacokinetic and
pharmacodynamic changes. As the baby boomer
generation ages, this problem may grow, as average
alcohol consumption is greater in this generation (24).

For treatment of alcohol-related disorders, a combination

of psychosocial treatment and psychoeducation is
effective. In general, better outcomes have been
reported with use of integrated care services than in
specialized care settings. Study of pharmacotherapy
(e.g., naltrexone and acamprosate) in older adults is
limited.

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Figure 1.

The Montreal Cognitive Assessment.

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1. Crystallized knowledge includes abilities that

are relatively unaffected by aging and are related to acquired knowledge, such as the
meanings of words and general facts. Example
of crystallized knowledge assessments are vocabulary tests (e.g., Peabody Picture Vocabulary Test) (57), general knowledge tests (e.g.,
Wechsler Scales Information Subtest) (58), or
regular and irregular word reading tests (e.g.,
Wide Range Achievement Test) (59). Office
testing of general knowledge may include inquiring about current and past presidents or
famous world events, although cultural differences should always be considered in such assessments.
2. Processing speed decrements are among the
most consistent age-related cognitive
changes. Assessments include the Trail Making Test Part A (60) and Digit Symbol Coding (61).
3. Attention is a very broad concept encompassing a range of skills, from keeping track of
information to responding to targets over
long periods of time (vigilance). This may be
assessed in a variety of ways such as the Continuous Performance Test (62). Office-based
cognitive screens often include an assessment
of attention (e.g., repeating digits or spelling
words backward). Impairment in attention
could drastically alter test results for any other
cognitive domain, at times rendering other
tests uninterpretable.
4. Receptive and expressive language refers to a
persons abilities to understand what is being
said and respond in an appropriate manner

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(either orally or written), respectively. One of

the most common receptive language tasks is
the Token Test (ability to follow instructions)
(63), with fluency tasks (category or letter fluency) (64) or naming tasks (e.g., Boston
Naming Test) (65) being commonly used expressive language tasks.
5. Visuospatial and constructional skills encompass the ability to identify objects and shapes
and to draw in a coherent manner. Most of
these tasks require some amount of physical
dexterity, whether constructing jigsaw puzzles
(Wechslers Object Assembly), making patterns from colored blocks (Wechslers Block
Design) (53), or drawing complex figures
(Rey-Osterrieth Complex Figure Test) (66).
6. Memory includes many subtypes but neuropsychological testing typically assesses episodic memory, i.e., memory of events, times,
or places related to unique personal experiences. This may be done in verbal or visual
domains, over short or long delays, and with a
variety of tasks (e.g., Rey Auditory Verbal
Learning Task or California Verbal Learning
Test) (67, 68). Working memory is generally
regarded as a distinct concept akin to attention and referring more to the ability of a person to manipulate information in his or her
short term memory (69). Some common tests
of working memory are the Wechsler subscales for Digit Span and Letter-Number Sequencing (58).
7. Executive function is a widely used concept
that is difficult to define, because it encompasses so many different concepts (e.g., set
shifting, fluency, pattern recognition, mental
flexibility, and inhibition) (70). Classic tests
of executive function include the Wisconsin
Card Sorting Test (pattern recognition and
set shifting) (71), the Trail Making Test Part
B (set shifting), and the Stroop Tasks (response inhibition) (72).

CLINICAL
SYNTHESIS

bling symptoms of dementia are often the accompanying psychological and behavioral changes,
which affect up to 80% of persons with dementia
across the illness course and which frequently increase caregiver burden and the likelihood of patient institutionalization (55). Evaluation for depressive symptoms, psychosis, sleep disturbance,
and agitation is a crucial part of the evaluation of
cognitive disorders in older adults, and progress is
being made toward establishing reliable diagnostic
categorization of such neuropsychiatric symptoms
of dementia (56).
There are several traditionally distinct (although
admittedly sometimes overlapping) cognitive domains that can be assessed with neuropsychological
testing, and abbreviated assessments of each domain are also possible in the clinical setting. Some
of the most frequent cognitive domains as conceptualized by neuropsychology today are described
below:

Cognitive testing of older adults should be

conducted with several caveats in mind. For example, there is a lack of age-appropriate normative data on many tests for the oldest-old age
groups and certain cultural groups. Many older
people have sensory or motor impairments that
may interfere with certain tasks independently
from cognition per se. Subtle cognitive deficits
may be very difficult to detect, especially in highfunctioning or highly educated older adults.
Even the best of cognitive testing may leave questions unanswered, and in these circumstances the

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trajectory of change in cognition over time can be

very informative.

CAPACITY/COMPETENCE
Clinicians may often be asked to evaluate the
decision-making capacity of older adults. Competency usually refers to an evaluation derived
from legal adjudication. Decisional capacity is
the preferred term when describing a clinicians
evaluation of a patients decision-making abilities. Evaluation of decisional capacity is most
commonly prompted when a patient declines a
recommended treatment (73). Two other common scenarios involve capacity to drive and to
decide on ones living environment (74). Clinicians are required in a few and allowed in most
states to report cases of dementia to motor vehicle departments. There is no clinical consensus
for how to determine when a person should have
his or her drivers license revoked. Although the
safety of the public and patient is clearly important, this must be balanced with the possible adverse consequences of license revocation on a
persons sense of independence and practical mobility. On-road driving tests may represent the
best available option in questionable cases.
Equally contentious at times is the dilemma of
when an older adult needs to enter a structured
living environment (i.e., assisted living or nursing home), also reflecting basic ethical conflicts between paternalism and respect for
autonomy.
Older adults are certainly at increased risk for
impaired decisional capacity. Dementia is often
the most prominent illness in clinicians minds
when considering impaired decisional capacity.
Psychosis and depression may also impair decisional capacity in older adults via emotional factors, such as paranoid delusions or severe hopelessness. However, psychiatric illness and
dementia do not invariably impair decisional capacity (75, 76). Several qualities have been consistently described as necessary for decisional capacity. The four most commonly cited criteria
are
1) consistent communication of a choice,
2) factual understanding,
3) appreciation of a situation and potential
consequences of a decision, and
4) rational manipulation of information (77).
Because of the increased risk for impaired decisional capacity, it is vitally important to encourage
older patients to execute advanced directives proactively before such impairments occur.

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FUNCTIONAL

ASSESSMENTS

Psychiatry is perhaps unique among medical specialties in that it has traditionally emphasized functional impairment as part of its disease constructs,
but functional assessments are especially germane
in the evaluation of older adults and are an essential
component of what distinguishes geriatrics as a subspecialty (78). Functional impairment increases
with age and is often overlooked or marginalized in
importance if one focuses too narrowly on symptomatology. All psychiatric assessments of older
adults should include a basic history of functioning
in both instrumental (e.g., driving, cooking, and
managing finances) and basic (e.g., grooming, eating, and walking) activities of daily living. Standardized assessments are available as well, including
the Lawton Instrumental Activities of Daily Living
scale (79) and the Older Americans Resources and
Services (OARS) Multidimensional Functional Assessment Questionnaire (80).
Given the link between the use of most psychotropic medications and increased risk for falls (81),
specific assessments of mobility may also be useful
for psychiatrists caring for older adults. Perhaps the
simplest and most sensitive screening for fall risk is
the Timed Get-Up and Go Test (82). This test
entails asking the patient to rise from a chair without using his or her arms, walk about 10 feet, turn
around, and sit back down (again without using his
or her arms). If the patient takes more than 10
seconds to complete the examination or exhibits
obvious unsteadiness, then further evaluation of
gait and balance is indicated.

MEDICAL ASSESSMENT OF OLDER

ADULTS WITH PSYCHIATRIC SYMPTOMS
Nowhere is the mind-body connection more evident than in the psychiatric assessment of older
adults. Although a medical assessment is an integral
part of the initial evaluation for all persons presenting with psychiatric symptoms, it is especially important for older adults. Older adults are at increased risk for delirium (83), polypharmacy (84),
and many medical conditions, all of which can
present primarily or even exclusively with psychiatric symptoms. As providers with both psychological
and medical training, psychiatrists are uniquely positioned to provide an integrated medical and psychological evaluation of the older adult presenting
with behavioral or psychological symptoms. Even
when a medical disorder is not the direct physiological cause of psychiatric illness, the impact of
chronic medical illness on quality of life and functional ability is often apparent in the lives of older

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HISTORY

OF PRESENT ILLNESS

Given the prevalence of delirium and psychiatric

illness due to a medical condition in late life, it is
important for a clinician to keep these diagnoses at
the top of the differential diagnosis when conducting psychiatric evaluations of older adults (88). Obtaining a thorough understanding of the time course
of the psychiatric symptoms can be one of the best
clues as to whether delirium or a medical condition
is implicated in the etiology (e.g., increased suspicion for a medical etiology when symptom onset is
acute or when new physical symptoms overlap
chronologically with new psychiatric symptoms)
(87). Some cases may be readily apparent (e.g., confusion and hallucinations accompanying 2 days of
fever and cough associated with pneumonia), but
many require a higher level of vigilance (e.g., depression associated with hypercalcemia due to an
occult parathyroid adenoma) (89). There may also
be complex reciprocal relationships between medical conditions and psychiatric symptoms (e.g., the
interplay between anxiety and dyspnea in chronic
obstructive pulmonary disease) (90).
The nature and pattern of psychiatric symptoms
may also yield clues as to whether they may be due
to medical illness. For example, visual, olfactory, or
tactile (versus auditory) hallucinations increase suspicion for medical causes (91). Early morning
awakening is a classic symptom of melancholic depression, whereas repeated nighttime awakenings
often occur with nocturia due to benign prostatic
hypertrophy, persistent pain, or severe gastroesophageal reflux (92). In addition, cognitive impairment

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accompanied by inattention and an altered level of

consciousness points toward delirium, often underrecognized as a medical emergency (83).

PAST

PSYCHIATRIC HISTORY

Most primary psychiatric illnesses (other than

cognitive disorders) manifest well before old age,
such that the first episode of an illness after age 40
significantly raises suspicion for an underlying
medical problem (93). As in the history of present
illness, one should assess whether prior symptoms
or episodes could have been related to medical illness. If no prior link to medical illness is identified,
it is, of course, important to rememberand remind our medical colleaguesthat previous psychiatric illness does not preclude delirium or psychiatric illness due to a medical condition being
part of the current presentation.

SUBSTANCE

CLINICAL
SYNTHESIS

adults and relevant to psychiatric assessment and

treatment (85). For instance, medical illness is associated with increased risk for suicide among older
adults (86).
As with any medical or psychiatric assessment,
the best approach is to start with a thorough history. A medical history is, of course, part of any
psychiatric evaluation. We will therefore highlight
some special considerations to keep in mind in the
initial psychiatric assessment of older adults. Always consider obtaining collateral information,
particularly when patients exhibit any cognitive impairment (87). Even cognitively intact older adults
may withhold or fail to recognize important historical information that family members can provide,
although balancing the relative validity of contradictory perspectives requires consideration of several possible competing motivations and family dynamics.

USE HISTORY

Although often overlooked in older adults, substance abuse, particularly alcohol and prescription
drug abuse (94, 95), is an important potential contributor to medical and psychiatric problems.
Thus, it is always worth evaluating whether substance intoxication, withdrawal (especially postoperatively), abuse, or dependence could be contributing to an older adults presenting psychiatric
symptoms. A lifetime of substance use may lead to
multiple medical sequelae in older adults (96, 97),
including various cancers, nutritional deficiencies,
and organ failure, all of which may themselves
cause secondary cognitive and psychological symptoms.

MEDICAL

HISTORY

Some of the most relevant disorders to investigate, because of their contribution to neuropsychiatric symptoms and/or their high comorbidity with
psychiatric illnesses include endocrine disorders
(e.g., hypo-/hyperthyroidism, hypo-/hyperparathyroidism, and diabetes mellitus) (98), cardiovascular disorders (e.g., coronary artery disease and
cerebrovascular disease) (99), and rheumatological
disorders (e.g., rheumatoid arthritis, osteoarthritis,
and polymyalgia rheumatica) (100). Persistent pain
disorders are quite common in older adults, are
often comorbid with anxiety and depression, and
may increase suicide risk (101, 102). Taking a sexual history may seem uncomfortable or unnecessary
with older adults, but this reluctance reflects an
ageist attitude. Sexual functioning is often an im-

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Table 2.

Overview of Cognitive Disorders Among Older Adults

Disorder
Alzheimer disease (AD)

Epidemiology/Etiology

Major Clinical Features

Treatments

The most common etiology of dementia, accounting for Insidious onset and slowly progressive over 812
up to two thirds of cases (36)
years after diagnosis

Acetylcholinesterase inhibitors (e.g., donepezil,

rivastigmine, and galantamine) as well as
memantine (an N-methyl-D -aspartic acid
glutamate receptor antagonist) appear to
offer modest cognitive and functional
benefits for up to 1 year, but their value
over a longer time frame is not well
established (37)

Prevalence is about 1% in persons aged 6064 and

roughly doubles every 5 years thereafter

Diagnosis is made clinically, as definitive

diagnosis can only be made at autopsy

Much research is being devoted to develop

true disease-modifying drugs, such as
those that target the cascade of -amyloid
deposition

Major histological hallmarks are -amyloid plaques

and neurofibrillary tangles consisting of tau protein,
beginning especially in the hippocampus/entorhinal
cortex

Overall heritability at the population level is high,

but no clinically useful genetic testing exists

Psychosocial interventions such as caregiver

psychoeducation can help ease family
burden and reduce behavioral complications
from the illness (38)

Risk factors include advanced age, apolipoprotein e4

genotype, and lower education. Other possible risk
factors include head trauma, depression,
cerebrovascular disease, physical inactivity, and
diabetes mellitus

Early symptoms include short-term episodic

memory loss and word-finding difficulty

Rare familial autosomal dominant cases (early-onset

disease before age 65) are associated with
mutations in presenilin-1 and -2 and amyloid
precursor protein

Rapid forgetting that is not helped by cues and

anomia are characteristic early features on
neuropsychological testing
Depression, psychosis, apathy, sleep disturbance,
and agitation/aggression are common
Medial temporal atrophy progressing to general
cortical atrophy frequently seen with structural
neuroimaging and parietotemporal
hypoperfusion seen with functional imaging, but
overall neuroimaging findings do not have
clinically useful sensitivity nor specificity (36)

Mild cognitive impairment (MCI) Definitions vary but MCI is most often characterized by Amnestic MCI is probably closely related to early
memory impairment more than 1.5 SD below agemanifestations of AD (39)
and education-matched norms along with subjective
memory complaints but without functional
impairments

Recent trials of cholinesterase inhibitors and

vitamin E failed to show significant benefit
(40, 41)

Some have proposed a nonamnestic subtype of MCI in Depression is commonly associated with MCI and Close clinical monitoring is warranted to
which similar cognitive deficits are present in
may increase risk for conversion to AD (42)
detect conversion to dementia
domains other than memory without functional
impairment

Dementia of depression

Approximately 10% of persons per year with MCI

develop dementia but a substantial portion of
persons with MCI remain stable or even
improve(42)

Treating possible associated risk factors for

dementia is probably helpful (e.g.,
treatment of risk factors for cerebrovascular
disease, encouragement of mental and
physical activity)

Increased age and depression severity are associated

with more cognitive impairment (43)

Many cognitive domains may be affected by

impaired attention and processing speed
associated with major depression (43)

Antidepressant pharmacotherapy or ECT may

improve cognitive symptoms associated
with dementia

Cerebral white matter hyperintensities associated with

vascular disease may increase risk of cognitive
impairment in depression (43)

Executive functions are often impaired, implicating Antidepressants with anticholinergic side
frontal-subcortical circuits also involved in
effects are best avoided to avoid worsening
depression etiology; memory impairments are
cognition
also common although these are more likely to
reflect retrieval than storage deficits

Depression and dementia have a complex relationship

with several possible explanations, including
depressive symptoms as prodromal to dementia,
depression as a causative factor in dementia, and
shared risk factors between the two disorders

Poor effort and excessive worry about cognitive

symptoms may be clues to depression-related
cognitive impairment during cognitive testing

Severe cognitive impairment may hinder the

effectiveness of certain psychotherapies for
depression in older adults

Cognitive impairment often persists even after

remission of depression, with up to 40% of
affected persons developing frank dementia at
3-year follow-up (44)
Dementia with Lewy bodies
(DLB)

Probably the second most common form of dementia

The classic triad of symptoms includes

No U.S. Food and Drug Administration (FDA)
parkinsonism (mostly rigidity and bradykinesia),
approved treatment but cholinesterase
fluctuating levels of consciousness, and visual
inhibitors do appear to have modest
hallucinations
benefits (45)

Lewy bodies (-synuclein inclusions) are spread

diffusely in the neocortex in addition to the
brainstem locations characteristic of Parkinsons
disease (PD)

Motor symptoms and cognitive symptoms have

Parkinsonism does not respond as well to
onsets within relatively close time periods (1
dopaminergic agents as classic PD (which
2 years)
also often cause psychotic symptoms)

Also at times characterized by amyloid plaques more

classically associated with AD (46)

Falls, autonomic instability, and REM behavior

High sensitivity to motor side effects with
sleep disorder may also be clues to Lewy body
antipsychotics (probably quetiapine and
pathology (46)
clozapine are the least offensive in this
regard)
Prominent attentional, visuospatial, and executive
function impairments on neuropsychological
testing relative to AD, but memory impairment
still often notable (46)

Continued

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MEEKS ET AL.

Table 2.

Overview of Cognitive Disorders Among Older Adults (Continued)

Disorder
PD dementia

Epidemiology/Etiology

Major Clinical Features

Affects 30%50% of persons with PD (47)

Treatments

Prominent deficits early in visuospatial functioning, Rivastigmine is FDA-approved to treat PD

attention, and executive functioning (48); more
dementia but other cholinesterase inhibitors
of a subcortical pattern with relative sparing of
probably work as well (45)
episodic recall compared with AD

Lewy bodies (neuropathological hallmarks of PD) may

spread from basal ganglia to more diffuse cortical
regions

Levodopa appears to have little impact on

cognitive symptoms associated with PD
dementia (49)
Dementia in PD is a risk factor for psychosis, e.g., Anticholinergics that may be used to treat
levodopa induced or spontaneous psychotic
PD-associated tremor are best avoided
symptoms (50)
when cognitive impairment is present

Frontotemporal dementia (FTD) Formerly thought of as Picks disease, FTD now

represents several distinct dementing syndromes
that preferentially affect the frontal and temporal
lobes in their early courses

Often has an earlier onset than other dementias

(e.g., sixth decade) and a stronger familial
loading

There are no FDA-approved treatments for

FTD and scant reports of randomized
controlled trials

Three common subtypes are described: behavioral

variant FTD, semantic dementia, and progressive
nonfluent aphasia (51)

Behavior changes including disinhibition, apathy, Cholinesterase inhibitors and memantine have
and socially inappropriate behaviors and
no solid data to support their use in the
executive dysfunction dominate the early clinical treatment of FTD
course of the behavioral variant FTD

Probably accounts for 5%15% of all dementia

diagnoses

There may be overlap with extrapyramidal

disorders including progressive supranuclear
palsy, corticobasal degeneration, and FTD with
parkinsonism (51)

CLINICAL
SYNTHESIS

Dementia in PD typically develops late in the

illness, after many years of prominent motor
symptoms (i.e., rigidity, bradykinesia, and
resting tremor)

Very limited data suggest serotonergic

medications (e.g., paroxetine and trazodone)
may somewhat improve behavioral
symptoms associated with FTD (52)

Because of the heterogeneity of diseases under the

Semantic dementia implies specific loss of word
umbrella term of FTD, neuropathological features are
meaning and comprehension difficulties,
quite variable; tau protein abnormalities are common
sometimes accompanied by prosopagnosia (51)
Progressive nonfluent aphasia is marked by
agrammatic and telegraphic speech
Vascular dementia (VaD)

Probably accounts for 10%15% of all dementias (53)

Patchy neuropsychological testing results may

occur, depending on the nature of the brain
areas affected by cerebrovascular lesions

Long-term treatment of chronic hypertension

may prevent cognitive decline (53)

May be due to large vessel strokes, accumulation of

Chronic microvascular disease often manifests
Effect of glycemic control in diabetes mellitus
subcortical/lacunar strokes, or strategic strokes (i.e.,
with a more subcortical dementia profile (e.g., and of lipid lowering with statin drugs on
those affecting areas particularly important in
executive dysfunction, poor memory retrieval
long-term dementia risk remains unclear
cognition such as the medial temporal lobe,
with relatively preserved cued recall)
thalamus, or basal ganglia)
Increasingly, overlap has been recognized between VaD Classic presentations of large strokes would
and AD, as cerebrovascular pathological changes
include more sudden or subacute worsening of
may initiate a cascade of molecular events that
cognition and stepwise progression of any
result in changes characteristic of AD (53)
cognitive worsening

portant component of the physical and emotional

health of older adults, and many psychotropic medications may adversely affect sexual desire and/or
performance.

MEDICATIONS
One of the best contributions a physician can
make to an older adults care is a thorough review of
all his or her medications (84). Iatrogenic psychiatric symptoms can arise from medication side effects
and drug-drug interactions but often go undetected
(103). Medication assessments should include obtaining a full list of all medications the patient is
taking including over-the-counter and herbal medications and supplements, assessing dosing schedules, determining how often patients are really taking medications (looking for over- and underuse),
asking about side effects, and checking for drugdrug interactions (104). If potential problems, such

focus.psychiatryonline.org

Despite some positive clinical trials, the

benefit of cholinesterase inhibitors and
memantine in VaD appears modest at best
and not clearly indicative of a favorable
risk-benefit profile (54)

as unnecessary or redundant medications or possible psychiatric side effects, are identified, working
with a patients primary care physician or team to
minimize these problems can be invaluable in improving an older adults medical and psychiatric
condition. Particular attention should be given to
minimizing the cumulative anticholinergic burden
of medications in older adults, often the result of
several concomitant medications whose anticholinergic effects are underrecognized (105). Geriatric
care is often as much or more about removing iatrogenic culprits of illness as prescribing additional
treatments.

EXAMINATION
Although psychiatrists typically do not do physical examinations as part of their initial medical
assessment, these may be appropriate under certain
circumstances. Certainly routine vital signs, includ-

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MEEKS ET AL.

ing pain severity, weight, and orthostatic blood

pressure measurements, may identify medical conditions that may alter ones diagnosis or treatment
as well as potentially serious side effects of psychotropic drugs (e.g., anticholinergic or proadrenergic
drug-induced tachycardia predisposing to cardiac
complications, antiadrenergic-induced orthostasis
predisposing to falls, and medication-associated
weight gain or loss predisposing to a host of adverse
medical consequences) (106, 107). Although vital
signs may be an important clue to medical emergencies, one must also keep in mind age-associated
changes in the physiology of vital signs (e.g., infection in the absence of fever or increased carotid
sinus sensitivity) (108, 109).
Examinations for tardive dyskinesia and parkinsonism are particularly important when a clinician
is prescribing antipsychotics for older adults, given
that age increases the risk of these motor complications (110). The mental status examination of older
adults consists largely of the same components included in the assessment of younger adults, with the
notable exception that more extensive cognitive assessment, including evaluation for delirium, is often needed. Evaluation for suicidal ideation should
be at the forefront of clinical assessments in light of
the elevated rates of completed suicide among older
adults, mostly accounted for by white men (111).

LABORATORY

TESTING AND IMAGING

Depending on an older adults presentation and

the treatment options being considered, a variety of
laboratory tests may be indicated in the medical
assessment of an older adult presenting with psychiatric symptoms. Laboratory tests to consider
routinely obtaining include the following: 1) thyroid function tests (e.g., thyroid-stimulating hormone), because thyroid disease may cause depression, anxiety, and cognitive impairment (112); 2)
electrolyte levels, because alterations of these may
significantly affect the central nervous system (e.g.,
hyponatremia-induced delirium due to the syndrome of inappropriate antidiuretic hormone or
selective serotonin reuptake inhibitor treatment)
(113); 3) renal function tests (blood urea nitrogen
and serum creatinine), because renal function is often reduced by age or age-associated illness, which
may significantly affect the pharmacokinetics of
medications (114); 4) hepatic function tests (e.g.,
alanine aminotransferase and aspartate aminotransferase), because psychopathological conditions may
significantly contribute to chronic liver disease via
alcohol use and comorbid hepatitis C infection
(115); 5) complete blood count, because anemia
may explain fatigue/depression, leukocytosis may

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point to an undetected infection, and many psychotropic drugs have hematopoietic side effects (116);
6) lipid panel and fasting glucose, particularly if a
patient is already taking or considering starting
medications that could cause metabolic syndrome
(117); 7) rapid plasma reagin to test for syphilis and
HIV antibodies if the patient has risk factors and
consents, because prejudicial views of older adults
may lead clinicians to dismiss their current or past
sexual activity (118); 8) urine drug screen to assess
for substance use and breathalyzer or blood alcohol
level, especially in emergency room settings, where,
again, age may inappropriately lower clinicians
vigilance for substance use (95); 9) urinalysis, because urinary tract infection may present exclusively with mental status changes in older adults
(119); 10) vitamin B12 and folate levels, because
deficiencies of these increase with age and may contribute to both depression and cognitive impairment (42); and 11)drug levels of any prescription
drugs patients are taking, especially those with low
therapeutic indices (e.g., lithium, anticonvulsants,
digoxin, and tricyclic antidepressants).
Other diagnostic tests to be considered in certain situations include the following: 1) chest
radiograph for respiratory symptoms, signs of delirium, or fever; 2) neuroimaging (magnetic resonance imaging or computed tomography) to
evaluate for stroke, mass lesions, or normal pressure hydrocephalus (120); 3) electrocardiogram
for acute mental status change, cardiorespiratory
symptoms, or consideration of psychotropic
agents that may alter cardiac conduction (e.g.,
lithium, tricyclic antidepressants, and certain antipsychotics) (121); 4) electroencephalogram for
paroxysmal symptoms that could be due to seizures, unusual or subacute dementias (e.g.,
Creutzfeld-Jacob disease), or diagnostic confusion between delirium versus dementia (although
generalized slowing is present in both delirium
and more advanced cases of dementia) (122); and
5) lumbar puncture in patients with atypical cognitive disorders, fever without a clear etiology, or
suspected neurosyphilis (123).
Many invasive (e.g., lumbar puncture) or expensive (e.g., magnetic resonance imaging) tests may be
unnecessary with a careful history and physical examination. Although the use of neuroimaging is
clinically routine in the assessment of delirium, dementia, and late-onset psychiatric disorders, there
is debate as to its cost-effectiveness and clinical yield
in the absence of historical (e.g., acute onset) or
physical examination findings (e.g., focal neurological symptoms) that raise suspicion for certain neurological disorders (124, 125). The explosion of
research in functional neuroimaging has yet to yield

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MEEKS ET AL.

significant clinical applications, although this is anticipated in upcoming years with promising techniques
such as in vivo amyloid imaging (126). Currently, the
only psychiatric application of functional neuroimaging approved by Medicare is the use of positron emission tomography in differentiating Alzheimer-type
versus frontotemporal dementia in patients with clinically unclear illness (127).

Although medical disorders and neurobiological

changes associated with aging are at the forefront of
considerations in psychiatric assessments of older
adults, a balanced biopsychosocial perspective remains crucial as well. The comfort level of older
adults (at least the current cohort) with mental illness and psychiatric evaluation must be considered
to develop the rapport needed for any other aspect
of assessment (128). Older adults also tend to face
somewhat unique psychosocial stressors that may
have tremendous relevance for the symptoms at
hand. For instance, acting as a caregiver for a disabled relative is associated with high rates of depression and is often used in research as a prototypical
model of stress (129). Accumulating medical (and
at times psychiatric or cognitive) illnesses often result in disability and loss of independence (including forced moves to senior living communities) that
challenge the resilience and self-concepts of older
adults. Other forms of loss, including deaths of
friends and family, are common, and grief reactions
may ensue that warrant careful attention for clinically significant depressive symptoms (130). DSMIV-TR (131) outlines several features that are believed to help distinguish normal versus abnormal
bereavement, such as suicidal ideation, persistent
worthlessness, and severe, persistent functional impairment. Such losses and personal disabilities may
trigger psychological struggles regarding ones own
mortality that may be very relevant in psychotherapy with older adults, but clinicians often avoid this
topic because of discomfort (132). Another sometimes surprising stressor for older adults is retirement, which may challenge persons whose selfidentity and structured activities center around
their occupation (133). Although these challenges
confronting older adults may seem daunting, it is
also worthwhile to note the positive coping strategies used by many older adults so that clinicians also
work to facilitate the persons innate strengths. Possible psychological benefits of increased age include, on average, better emotional regulation
(134) and, according to many cultural beliefs, increased wisdom (135).

focus.psychiatryonline.org

CLINICAL
SYNTHESIS

PSYCHOSOCIAL ASSESSMENT OF OLDER

ADULTS

For these and other reasons, social support is an

important predictor of the health outcomes of older
adults (136, 137). Psychiatric assessment and care
of older adults thus requires careful attention to
social networks and often includes family members
in the assessment and treatment of the older adult
in a manner akin to that used for children and
adolescents (with important similarities and differences in the dynamics encountered, including
struggles for autonomy and role reversals). The increasing diversity of the aging population in the
United States also warrants increasing attention to
culturally competent psychiatric assessments, including awareness of linguistic barriers, differing
cultural concepts of both aging and illness, and possible roadblocks to health care access (138).

CONCLUSIONS
In summary, psychiatric assessment of older
adults is both challenging and rewarding. Therapeutic nihilism and ageism may taint the enthusiasm some clinicians have for working with older
adults affected by neuropsychiatric illness, but careful attention to the issues summarized briefly in this
review can help ensure that such clinical experiences are rewarding for both older patients and the
clinicians who care for them. Psychiatric assessment
of older adults should remind psychiatrists of why
they are often called upon to set the example for
biopsychosocial care in clinical medicine. Medical
comorbidity requires attention to clinical issues
that overlap with other fields of medicine, unique
psychosocial stressors, and the stigma of mental illness associated with aging require careful attention
to the human relationship between clinician and
patient, and the importance of social support and
extended family involvement call for a broad, systems-based approach to the psychiatric care of older
adults. Integrating these various components of assessment and diagnosis will be crucial for the wide
variety of psychiatrists who will be increasingly
called upon to care for the rapidly expanding population of older adults.
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THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY