Old Age

3 D Disaster of Old Age
Depression, Dementia, and Debility

Symptoms of aging present themselves differently in different people and at different ages. Here we deal with mental and behavioural disorders of old age.

  • To read about handling the ravages of old age click here.
  • To read about sleep problems in old age click here.

There are some disorders that become more prevalent as age increases. Mental disorder in old age can be divided into two broad categories:

  • Organic disorders

These are characterized by confusion, which may be acute (i.e. delirium) or chronic (i.e. dementia);

  • Functional disorders

Such as depression, anxiety and panic; but also psychotic disorders, such as late-onset schizophrenia (formerly known as “late paraphrenia”).

In addition, alcohol and drug misuse can (like many disorders) continue into old age, or emerge for the first time when the person is older. Similarly, personality difficulties can worsen with ageing or appear for the first time.



Depression is the most common psychiatric disorder found in old people. Depression occurring for the first time in old age is most often due to cell death,  biochemical alterations in the brain due to aging and undetected cerebrovascular disease with compromised blood supply to parts of the brain causing subtle brain abnormalities. Depression or depression-like symptoms in old age may also be the first sign of Dementia, especially Fronto-temporal Dementia.

Depression in old age may also be precipitated by adverse life circumstances: bereavement; loss of health; threat of bereavement or loss of health in a key figure.

Depressive illness in old people shows a wide range of clinical presentations. The typical picture of low mood, inability to feel pleasure (anhedonia), sleep disturbance and loss of appetite may predominate. Some people become apathetic, and withdrawn. Others may display disturbances in their cognitive abilities which may be so marked as to mimic dementia (pseudodementia). Still others may present with a picture of severe agitation and restlessness. Some may even display  delusions of ill health e.g. that they are dying of cancer, or that their digestive system has stopped working.


Dementia refers to a global impairment of mental function which follows a chronic and progressive course. The impairment of mental function is commonly associated with a deterioration in emotional control, social behavior, motivation and the ability to perform activities of daily living (ADLs). Dementia is related to progressive cerebral degeneration, which may be caused by a variety of pathological processes. (Read More)


Elderly people seem particularly likely to develop confusion in response to a wide range of stimuli – either physical insults or sudden social change due to a reduced ability of the aged brain to cope with such events. An acute confusional episode may sometimes be the first evidence of an underlying dementia. (Read More).

Late Onset Psychosis:

As they age individuals become rather more inflexible in their attitudes and fearful of adverse influence by the outside world. Elderly people are often physically and financially disadvantaged,  are often the victims of attack or deception. They may, therefore, suffer from fear of persecution. This may be compounded by memory disturbances which makes them believe that objects that they have misplaced, have been stolen this  paranoid misinterpretation may be the first sign of dementia.

old age

Clinical Assessment and Management

People who present with beavioral disorders in old age require:

  • An assessment of the cause and severity of the cognitive impairment and behavioural abnormalities;
  • An assessment of deficits in function and the need for care;
  • An assessment of the person’s social situation;
  • Provision of treatment and care appropriate to the identified needs;
  • Support for carers – both practical and emotional;

About 50% of elders presenting with behavioral problems have concurrent physical health problems. The burden of care produced by a physically sick elder is greater than that of a fit one; therefore, diseases should be sought and treated where appropriate.


Six drugs have been approved  for treating the cognitive symptoms of Alzheimer’s disease / Dementia. Four act in different ways to delay the breakdown of acetylcholine, a chemical in the brain that facilitates communication among nerve cells and is important for memory. Alzheimer’s disease is associated with inadequate levels of this important neurotransmitter. One acts by a different mechanism. It shields brain cells from overexposure to another neurotransmitter called glutamate, excess levels of which contribute to the death of brain cells in people with Alzheimer’s. The sixth is an improves acetylcholine production boosting brain metabolism. They all improve mental function memory.

In general, medication is most effective when treatment is begun in the early stages. All medication slows the progression of cognitive symptoms and reduce problematic behaviors in some people. While the overall “treatment effect” of these medications is modest, studies show that when they do work, they can make a significant difference in a person’s quality of life and day-to-day functioning (“activities of daily living”). 

Patients with depression and anxiety respond well to antidepressants. Those with psychotic features and some behavioural disturbances such as agitation respond to  anti psychotic agents. Contrary to popular misconception these medications can be safely used in older people.