Pharmacological and psychotherapeutic treatment of personality disorders in the elderly

Personality disorders in older adults: findings from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

To examine the prevalence, sociodemographic correlates, psychiatric and medical comorbidities, and the disability of personality disorders among adults age 65 years and older.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, focusing on a subsample of 8,205 adults age 65 years and older.

RESULTS

A total of 8.07% (SE: 0.37) of American adults age 65 years and older presented at least one personality disorder. The most prevalent personality disorder was the obsessive-compulsive personality disorder. The overall pattern of associations between each personality disorder and lifetime psychiatric comorbidity correlates was statistically significant. Participants with a personality disorder show a lower quality of life than their counterparts.

CONCLUSIONS

Personality disorders in older adults are highly associated with disability, medical, and psychiatric disorders. These findings highlight the need to develop more effective prevention and intervention programs in this specific population.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.

[Prevalence, diagnosis and treatment of personality disorders in older adults]

AIM

This article addresses manifestation, course, diagnosis and treatment of personality disorders in older adults (>60 yrs).

METHOD

A literature search, using "Cochrane Central Register of Controlled Trials (CENTRAL)", Cochrane Database of Systematic Reviews (CDSR)", "PsychINFO 2000-present" and "PUBMED", concerning relevant literature from 1980-2009. Keywords were "personality disorder", "elderly", "older adults", "prevalence", "diagnosis" and "treatment". The combinations of these keywords resulted in 32 relevant hits.

RESULTS

Prevalence studies addressing specific personality disorders show that within different subpopulations personality pathology of clusters A and C (odd respectively anxious behaviour) are quite common in older adults whereas cluster B personality disorders (impulsive behaviour) is more prevalent in younger adults. Besides, it appears that the personality questionnaires and interviews used in adult care are not yet validated for older adults in mental health care and nursing homes. Furthermore, there is no convincing reason why psychotherapy variants proven to be effective for adults (<50 yrs) wouldn't be feasible for older adults. Particularly with respect to cognitive (behavioural) therapy and schema therapy, there is some evidence from case studies suggesting that these therapies are well applicable to the elderly.

CONCLUSION

Prevalence rates appear questionable since the assessment methods applied in the epidemiological studies correspond inadequately to the specific behavioural manifestations of elderly persons with personality pathology. In addition, the number of specific (test)diagnostic tools for older adults are scarce. Currently, there is a lack of empirical data concerning treatment of personality disorders in older adults. However, at this moment several studies are focussed to improve diagnostics and therapy of personality disorders in geriatric psychiatry in the Netherlands and Belgium.

A preliminary study of the diagnostic accuracy of the Gerontological Personality disorders Scale (GPS)

BACKGROUND

There is still a lack of diagnostic instruments that are specifically developed to diagnose personality disorders in the elderly.

OBJECTIVE

To develop a reliable and valid screening instrument to assess personality disorders in older adults.

METHOD

The draft version of the screening instrument (52 items) consists of two sections: one for patients and one for informants. The diagnostic accuracy of the instrument has been assessed in the Netherlands in 159 elderly patients in an ambulatory department of geriatric psychiatry and 96 informants.

RESULTS

In the patient section, sixteen items had a reasonable score for both sensitivity and specificity (approximately 70%). The internal consistency was moderate for habitual behavior (HAB; 7 items) and good for biographical information (BIO; 9 items). The test and retest reliability was moderate for HAB and excellent for BIO. The informant section, on the other hand, had a low score for sensitivity (45%) and a good score for specificity (78%).

CONCLUSION

A specific instrument has been developed to diagnose personality disorders in older adults. However, further research is necessary to improve the diagnostic accuracy of the Gerontological Personality disorders Scale (GPS).

Personality disorders and self-perceived quality of life in an elderly psychiatric outpatient population

The aim of this work was to assess the impact of personality disorder and traits on the subjective assessment of quality of life by a sample of elderly psychiatric outpatients (60 years or more). Sixty of the total number of subjects interviewed were included in the test sample since they met the Vragenlijst Klinishe Persoonlijkheid (VKP) criteria for personality disorder. A control sample was also formed, composed of 50 subjects without personality disorders or traits. Quality of life was assessed using the LEIPAD questionnaire. Personality disorder diagnoses were prevalently distributed in cluster C (25%) and in cluster A (20%). A total of 48.3% of patients (n = 29) had more than 1 personality disorder. Sixty percent of the sample (n = 36) presented with comorbid Axis I psychiatric disorders, in most cases depressive pathologies. Comparing the case and control groups, worse LEIPAD scores were achieved by subjects with personality disorders. Between clusters of personality disorders, the worst scores were observed in subjects with more than 1 personality disorder diagnosis. Elderly people who presented with a personality disorder were more vulnerable to late-life distress, especially those with more than one diagnosis. In keeping with linear regression analysis, widowhood, divorcehood and living with others appear to be variables able to negatively influence quality of life in this population. While the VKP needs to be adapted to the application in the elderly, it does seem to be a particularly useful screening instrument.

Personality disorders in late life

There is growing empiric evidence to suggest that a large number of elderly patients who have chronic depression frequently have comorbid personality disorders as well. In addition, contrary to commonly held clinical beliefs, a recent meta-analysis suggests that rates of personality disorders among older adults are essentially equivalent to that of younger groups. Although understudied, personality-disordered elderly patients have been shown to be less responsive to mental health interventions, and personality dysfunction may be one of the most relevant factors to account for when examining late-life depression remission and relapse. The paper considers briefly the notion of personality and personality disorders in late-life, examines prevalence rates including a recent meta-analysis, explores relevant issues associated with treatment, and discusses new developments in treatment.