Author
RIEDEL-HELLER S.G.; BUSSE A.; ANGERMEYER M.C.;
Title
The state of mental health in old-age across the ‘old' European Union: a systematic review.
Journal citation/publication details
Acta Psychiatrica Scandinavica, 113(5), May 2006, pp.388-401.
Summary
This review focuses on studies conducted in some of the 15 countries of the pre-enlargement European Union. It finds that mental disorders in old age are common, especially dementia and depression. It is clear that the prevalence of dementia increases with age, but the evidence on depression is not clear cut. Evidence on disorders related to substance use, mild cognitive impairment, psychotic syndromes, anxiety and psychosomatic disorders in old age is much more limited, making it difficult to draw conclusions.
Context
It is widely acknowledged that ‘old' Europe is getting older, and that the health problems of older people will become an increasingly important policy and practice issue. However, traditional psychiatric research and epidemiological studies have frequently excluded older participants. This review aims to describe ‘the current knowledge of the occurrence and pattern of mental disorder in old-age'.
Methods
What sources were used?
Medline, PsycINFO and PSYNDEX.
What search terms/strategies were used?
A ‘primarily over inclusive search strategy' was used, combining the term ‘prevalence' and a range of specific disorders and their synonyms. The search appears to have been conducted separately for each of the 15 countries, and was limited to material published in English or German from 1 January 1990 on subjects aged 65 or over.
What criteria were used to decide on which studies to include?
This is not very clear, beyond the statement that ‘only those studies identified by the authors as representative community studies were selected for review'.
Who decided on their relevance and quality?
This is not stated.
How many studies were included and where were they from?
The number is not stated although they can be computed from Tables 1-7. The countries covered are Belgium , Denmark , Finland , France , Germany , Great Britain , Greece , Ireland , Italy , the Netherlands , Spain and Sweden (i.e. 13 of the 15 countries of ‘old' Europe ).
How were the study findings combined?
The findings are presented using the broad International Classification of Diseases (ICD)-10 categories.
Findings of the review
Organic mental disorders
Prevalence rates of dementia syndromes are low among those aged 65 but rise exponentially with age, although reported prevalence rates vary ‘substantially'. Alzheimer's disease is the most common cause of dementia, followed by vascular dementia, with the former found to be the main contributor to the steep increase in prevalence with age. Despite increasing interest in mild cognitive impairment (a transitional state between normal ageing and dementia) there have been relatively few epidemiological studies. Most of the concepts are ‘insufficiently operationalized' and reported prevalence rates vary widely from 3% to over 50%.
Disorders caused by substance use
There is relatively little evidence on alcoholism in later life but such studies as exist suggest that prevalence rates are ‘rather low', although higher in men than women. There are far more studies showing that psychotropic drug use is high among older people (prevalence rates of 12-33%), especially among women. It is not clear from the paper whether this refers to prescribed medicines, illicit drugs and/or substances such as nicotine and caffeine.
Schizophrenia, schizotypal and delusional disorders
Although psychotic symptoms ‘are a familiar problem to those involved in medical and social services for the elderly', there have been few field studies and prevalence rates vary according to case definition and the methods of case identification used. Community prevalence estimates for schizophrenia in those over 65 are low according to most studies, but one has reported a rate of 10% in the non-demented population when considering psychotic symptoms more widely and using ‘multiple sources of information'. Psychotic symptoms are more common in women, and become more common with increasing age if a broader definition is used.
Mood disorders
The prevalence of major depressive disorders ‘as defined by the current classificatory systems' is low (under 5%) except in some Nordic countries where rates of up to 27% have been found when considering all severity levels of depression. However, ‘there is no doubt that clinically relevant depressive syndromes in old age are very common'. There is no consensus about whether the prevalence of depression increases or decreases with age, but it is clear that women are more likely to be depressed than men. However, sex differences decline with advancing age. Studies in bipolar disorders among older people are rare and no prevalence data were identified.
Neurotic, stress-related and somatoform disorders
Anxiety disorders have been less studied among older people than among children and younger adults. Prevalence estimates for clinically significant anxiety symptoms exceed 20%, although they are lower (4-14%) for anxiety disorders defined according to current diagnostic criteria. Generalised anxiety disorder and phobias account for most anxiety in later life, and there is considerable comorbidity with depression. Prevalence rates among women are twice as high as among men, but there is evidence that rates decline with increasing age. Somatoform (psychosomatic) disorders ‘have long been ignored by old-age psychiatry' and studies using definitions for classificatory systems find prevalence rates to be low. One German study found a 0% prevalence rate on this basis, but also demonstrated that ‘somatoform symptoms are very common in old age'. Over 70% of the sample reported at least one symptom, and over 23% more than eight.
Authors' conclusions
The results presented give a broad-brush picture of the prevalence of various disorders among older people in Europe , and the degree to which there is research evidence about them. In particular, they note that, apart from dementia and depression, data are scarce. In addition, real differences across geographical and cultural borders are also of great interest, but methodological differences in case definition and methods of case identification make it impossible so far to come to conclusions on this issue. The authors note some recent pan-European epidemiological initiatives but argue that ‘concerted action' is needed to improve the methodology of epidemiology research, tailored to the ‘special challenges' of old age and able to produce comparable data across Europe.
Implications for policy or practice
None are discussed.
Related references
None