Canad. M. A. J. 588 KRAL AND GoLD: PSYCHIATRIC FINDINGS IN GERIATRIC CLINIC Mar. 18, 1961, Vol. 84

PSYCHIATRIC FINDINGS IN A to the clinic by their families or came on their own GERIATRIC OUTPATIENT CLINIC initiative because they had heard or read about the A FIVE-YEAlR REPORT* Geriatric Clinic. Analysis of the circumstances which had led to V. A. KRAL, M.D. and S. GOLD, M.S.W., the non-medical and, incidentally, also to many of Montreal the medical referrals showed that conflicts between the patients and their children were a frequent IT IS THE purpose of this paper to report on some problem. This was accentuated when the parent of the psychiatric findings which were made in the was a chronically dependent person whose needs Geriatric Clinic of the Jewish General Hospital in increased with advancing age, and when the chil- Montreal during the first five years of its activity. dren were unable or unwilling to give the needed The clinic was founded in September 1955 in an support. effort to study the problems of ageing patients and Another problem frequently encountered, mainly to provide them with the benefit of a combined in the group of self-referrals, was the impossibility clinical approach. The patients are examined medi- of the aged person to find a job. Help in finding cally, psychiatrically ard neurologically. They are work, or at least an activity offering some prestige interviewed by a social worker and where possible or status, was a frequent request. Changes in socio- tested by a clinical psychologist. Treatment is economic status were also an important factor, carried out as a combined effort of the disciplines particularly in the referral of elderly new immi- involved. grants from Israel, or from Hungary after the 1956 From September 13, 1955, when the clinic first uprising. opened, until the middle of September 1960, 221 Of the total of 221 patients, 210 (65 men and 145 patients (70 men and 151 women) were admitted women) were seen and treated by the psychiatrist. and studied. Their ages ranged from 56 to 90 with They form the basis of this report (Table II). a mean of 70.9 years. The ages of the men ranged from 59 to 88 years (mean age 72.1) and that of TABLE II.-1IA(GNO.>STIC DISTRIBUTION the women from 56 to 90 years (mean age 70.2). D)iagnosis Men 11Women Total It is interesting to compare these figures with Without psychiatric disorder. 14 5 19 the corresponding ones taken from a report on the Alrterioscleirosis and(l seniile 1)0111) disease ...... 22 31 53 psychiatric and psychological findings made in the Other organic coniditions ...... 3 3 6 same clinic during the first 10 months of its opera- Manic depressives 4 30 34 tion, September 1955 to July 1956.1 Paraphrenia ...... 2 5 7 Neurosis of later mattulrit ...... 20 71 91

TAB,E I. SEX AND AGE DISTRIBU-TION Total ...... 6.5 145 210 Number of cases Age range Mean age In the 1956 report mentioned above, four pa- 1956 1960 1956 1960 1956 1960 tients, all men, were described as clinically "with- out psychiatric disorder". They represented 8.5% Meni ...... 17 70 61-87 59-88 71.5 72.1 Wo'o mienI ...... 30 151 64-80 56-90 70.3 70.2 of the total case inaterial and 23.5%v of the male lrotal ...... 47 221 61-87 56-90 71 70.9 patients at that time. These men had been referred to the clinic for social reasons and showed only Table I shows that the sex distribution and the minor physical ailments. They also showed, on age distribution of the patients are practically psychological testing, good preservation of intel- identical. lectual functioning and good retention of per- As regards these characteristics our patient ceptual organization. On the Rorschach test they material did not change in spite of its growth in maintained good form level and gave popular numbers over the five-year period. This applies responses and well-differentiated responses as to also to the socioeconomic level, which was gener- movement, shading and colour. We could not state ally low, to the marital status and the religious at that time whether the fact that these four denomination of the patients. We are dealing there- individuals were men was of any significance, or fore with a fairly homogeneous group. due only to the small sample group. Sixty-seven per cent of the patients were medical The present study, however, reveals that we are referrals, mostly from the Outpatient Department dealing here with a problem of considerable in- of the Jewish General Hospital or its wards. The terest. In the present group of 210 patients, there referring doctors felt that the patients' problems were 19, or 9%, "without psychiatric disorder". vere mainly due to their age and were largely of a Fourteen were men and five were women, that is, psychiatric nature. Social agencies including the 21.5% of the men and 3.5% of the women patients. Social Service Department of the Jewish General The mean age of the men was 75.2 years, that of Hospital referred 25 patients, and 40 were brought the women 73.2 years. In submitting these figures to statistical analysis, it was found that there was *From the Geriatric Clinic of the Jewish General Hospital no significant difference due to age between the and the Gerontologic Unit of the Allan Memorial Institute, Department of Psychiatry, McGill University, Montreal. sexes. However, the preponderance of males in this Canad. Al. A. J. IN Mar. 18, 1961, Vol. 84 KRAL AND GOLD: PSYCHIATRIC FINDINGS GERIATRIC CLINIC 589 group of ageing people without psychiatric dis- In our study, seven patients (five women and orders was very highly significant (P < 0.001). two men) were found to be suffering from para- In other words, the probability that the sex dis- phrenia, that is, a subgroup of paranoid schizo- tribution in this sub-group of our material was due phrenia characterized by late onset, a long pre- to chance is less than 1 in 1000. servation of personality, a relatively well-organized Review of the psychological test results of the system of delusions and relatively few hallucina- patients of this group, as far as these were avail- tions. able, showed the same characteristics as mentioned The main bulk of the functional group was above, i.e. well-preserved intellectual function, made up of affective disorders. There were 34 relatively high intelligence quotient (I.Q.) as com- cases of this type, 30 women and four men. Two pared with the rest of the material and adequate of the women were clearly manic. The other 32 responses on the Rorschach test. The Bender had recurrent depressions of the retarded or the Gestalt test in these people revealed only minor agitated type. The diagnosis was based on the difficulties. clinical picture, a history of previous depressive One is therefore tempted to conclude that male- or manic attacks and the family history, where ness, combined with good intellectual endowment, available. It is interesting to note that the propor- seems to have a protective effect against psychiatric tion of affective to paraphrenic disorders in our disease in old age. It should be remembered, how- group was exactly the same, 4.8:1, as that found ever, that longevity, maleness and intellectual en- by Roth among aged mental hospital patients. It dowment are genetically determined. It is possible indicates that manic-depressive illness is a common that environmental factors may also have been mental disorder, even among the aged, the clinical operative in the preservation of the mental health manifestations of which are frequently sympto- of these aged persons. Our sample group is still too matically masked8 and etiologically hidden behind small to allow of the necessary comparative socio- so-called precipitating factors.9 logical studies. The numerically largest group among our cases, It seems interesting, however, that in a previous and also the most important one from the point of study on similar case material it was found that view of rehabilitation, were those described as memory impairment of the type usually found in "neuroses of later maturity", a term coined by senile dementia occurred approximately twice as Cameron.10 This group comprised 91 patients, 71 frequently in women as in men, whereas the "mild" women and 20 men. type of senescent memory dysfunction occurred with The problems of these patients were primarily equal frequency in both sexes.' Furthermore, long- those of adjustment to the biological, psychological term treatment of senescent people by an oral and social facts of ageing. They had to adjust to androgen led to statistically significant improve- new and mostly unfavourable situations at a time ment in the recall of logical and meaningful ma- of life when the capacity for adaptation weakens. terial, which lasted for a certain time.3' The most important factors involved were the loss

Our next group was composed of 59 cases, 34 of prestige among family and friends, the loss of wvomen and 25 men, with clinical signs of chronic a lifelong occupation, be it a job or housekeeping, brain disease. There were 41 patients with senile decreased earning capacity and frequently a dras- psvclcoses (27 women and 14 men). The prepon- tically decreased income. This led to increasing derance of women in this group is in keeping with dependence on others at a time when the spouse or our previous observation' and with those made ly lifelong friends were being lost. In addition, there others.5 The organic group comprises 12 cases was among the men the realization of loss of of psychosis with arteriosclerotic brain disease strength, endurance and sexual potency, and among (four women and eight men); one patient with the women the loss of attractiveness. treated general paresis of the insane (G.P.I.), with A small number of patients showed a picture of negative spinal fluid findings, who had difficulties neurotic reactions as they occur in younger age in adjustment to his changed situation in life; one groups. Some women were suffering from phobic patient with presenile dementia, and four patients reactions, one man from an obsessive-compulsive with Parkinson's disease with psychiatric distur- neurosis. Four patients (three men and one bances. Two of these had delusional psychoses. woman) were diagnosed as having chronic per- The next group comprised 41 patients with func- sonality disorders. Their difficulties became more tional psychoses, that is, 19.5% of all cases. Thus, manifest with age. These patients had shown the incidence of this group of mental disorders in borderline adjustments throughout their lives and our material is about the same as that among the broke down again under the combined physical, residents of an old-people's home where it psychological and social stress of advancing age. amounted to 14.86X,6 but considerably less than Most patients in this group presented the clinical that described by Roth7 among the aged patients picture of a flat depression with feelings of weak- of a mental hospital in which 59.3%e were found to ness, tiredness, irritability and sometimes even be suffering from functional psychoses; 49.1% from hostility towards one or more members of the affective disorders and 10.2%, from late para- family. Most of them complained of sleeplessness phrenia. and also of loss of appetite, whereas others showed 590 KRAL AND GOLD: PSYCHIATRIC FINDINGS IN GERIATRIC CLINIC Mar. 18 1961, Vol. 84

TABLE III.-OUTCOME OF TREATMENT Seventeen patients died. The most frequent No treatment needed ...... 19 causes of death were cardiac failure and carcinoma, Recovered ...... 10 which is not surprising in this age group. Twenty- Improved ...... 45 Maintained ...... 41 five patients had to be hospitalized. This includes Deteriorating ...... 3 nine patients who had to be committed to mental Hospitalized ...... 25 hospitals. Ten patients moved to other cities and Moved away ...... 10 Dead ...... 17 40 discontinued attendance at the clinic after a Unknown ...... 40 few visits. It is probable that some of these may have died. Total ...... 210 Of the remaining 118 patients, 19 without psychi- atric disorders did not require psychiatric treat- compulsive eating, particularly at night. Nearly all ment. Of the 99 patients with psychiatric disorders, patients of this group had many somatic com- 55 either recovered completely or showed consider- plaints, only a few of which had any substantiation able improvement in their clinical condition since in fact. Hypochondriacal fears regarding the heart, referral to the clinic. Forty-one patients could be lungs, the gastrointestinal tract and, occasionally, maintained on a functioning level without greater impending mental disease were frequent. It is difficulties. Ten of these were placed in an old- possible that the diagnosis was missed in some of people's home or in nursing homes. Three patients these patients because the depressive picture was continued to deteriorate in spite of our efforts, but considered neurotic and situational, whereas it may not to an extent which necessitated commitment. well have been manic depressive. It is not within the scope of this paper to dis- CONCLUSIONS cuss in detail the findings on psychological testing. Ninety per cent of our patients have been found The general trend found previously1 was con- to suffer from mental disorders of one type or firmed: Psychological testing revealed signs of another. All of these patients also suffered from organic impairment of brain function in many more some of the physical ailments wvhich so frequently patients than was evident on clinical examination accompany old age. This tends to indicate the and in daily living. This is taken as an indication need for the closest co-operation between the of the remarkable capacity of the ageing organism physician and the psychiatrist in the treatment of to compensate for organic deficit. We believe with geriatric patients. The therapeutic results achieved Rothschild and Sharp1' that "personal factors" may seem to indicate that these patients benefited by be operative in this respect, part of which seem to this close co-operation. be genetically determined, as evidenced bv the Nearly half of these patients suffered from mental findings in our first subgroup. disorders which were caused or at least precipitated As regards treatment and its results, the most by the attitude of society towards the ageing rewarding therapy was that for recurrent depres- patient or the attitude of the patient towards his sions. Electroconvulsive therapy was used in a own ageing. It may not be unreasonable to expect number of cases, either alone or in combination that if and when this attitude changes many an old with antidepressants, such as imipramine or phenel- patient may lead a happier and healthier life. zine sulfate, and recovery was observed in 10 of 32 cases, and improvement in a great manv others. SUMMAIRY The manic and paraphrenic patients were treated The psychiatric findings in a geriatric clinic of a by tranquillizers, whereas the main group, namely general hospital are reported. The diagnostic categories the patients with neuroses of later maturitv, were encountered, the treatment methods employed and the treated by psychotherapy, which in our material was conclusions drawn from these findings are discussed. of necessity mainly supportive and environmental. Thanks are extended to B. Grad, Ph.D., for the statistical We can confirm Stern's12 observation that the analysis of the data, and to MIrs. I. Svatek for her co- psychotherapeutic approach in a setting of this kind operation in this study. has to be more indirect and has to include various REFERENCES medical A and physical measures. major part of the 1. KRAL, Vr. A. AND WIGDOR, B. T.: Canad. Psychiat. A. J., psychotherapy had to be carried out by the social 2: 185, 1957. 2. KRAL, V. A.: Psychiat. Res. Rep. No. 11: 30, 1959. worker. Providing work for the patients on the 3. KRAL, V. A. AND WIGDOR, B. T.: Geriatrics, 14: 450, 1959. 4. Ident.: Further studies on the androgen effect on senes- open market or at least in a workshop and intro- cent memory function. In Press. 5. MALZRBERG, B.: A statistical review of mental disorders in ducing them into age clubs or similar groups were later life. In: Mental disorders in later life, 2nd ed., edited by 0. J. Kaplan, Stanford UJniversity Press, of the greatest benefit. Patients with neurotic de- Stanford, Calif., 1956. 6. KRAL, V. A.: J. Gerontol., 13: 169, 1958. pression also received antidepressants, and it was 7. ROTH, M.: J. Ment. Sc., 101: 281, 1955. our impression that this was a beneficial adjuvant 8. KRAL, V. A., Canad. M. A. J., 79: 1, 1958. 9. KRAINES, S. H.: Mental depressions and their treatment, to psychotherapy for these patients.'3 Patients The Macmillian Company, New York, 1957. 10. CAMERON, N.: Neuroses of later maturity. In: Mental of the organic group who presented with the disorders in later life, 2nd ed., edited by 0. J. Kaplan, Stanford University Press, Stanford, Calif., 1956. picture of a depression initiating or accompanying 1T1.ROTHSCHILD, D. AND SHARP, M. L.: Dis. Nerv. Syste-, 2: 49. 1941: correction 2: 174, 1941. organic brain disease also received antidepressants 12. STERN, K.: J. Gerontol.. 3: 48, 1948. with some benefit. 13. GRAIJER, H. AND KRAL, V. A.: Gonad. M. A. J., 83: 1423,