No abstract
Epidemiologic studies have consistently shown an exponential increase in the prevalence of dementia in the very old, but different standards of the investigators and the instruments, as well as the selection of the samples, limit the comparison of these studies. They usually include only a small number of participants aged 90 years and older. This investigation focuses on whether there is an exponential increase in the prevalence of dementia in people aged 90 years and older. The Berlin Aging Study (BASE) consists of a representative sample of elderly aged 70 to 105 years stratified by age and gender. Analyses of a BASE first sample (N = 156) with 52 participants aged 90 years and older showed an exponential increase in dementia from age 70 up to age 94 years, but the group aged 95 years and older (N = 26) showed a plateau near 45%, with no further increase in dementia prevalence.
An increasing life expectancy leads to a higher number of persons aged 70-84 years and persons aged 85 years and older. Information concerning changes in the spectrum of psychiatric morbidity is rare. The Berlin Aging Study was based on a representative age- and gender-stratified sample (n = 516) of Berlin citizens aged 70-100 years and older. In this inter-disciplinary study, an intensive investigation was carried out by psychologists, sociologists, internists and psychiatrists. This report focuses on subjectively reported complaints (Beschwerdeliste, BL), observed psychopathological symptomatology (Brief Psychiatric Rating Scale, BPRS) and psychiatric diagnoses following the criteria of DSM-III-R (based on the Geriatric Mental State Examination, GMSA). On the self-rating scale (BL) 10% of all persons reported severe subjective complaints, 32% moderate complaints. On the BPRS, 17% showed severe psychopathological symptomatology, 75% at least mild symptoms. Following the criteria of DSM-III-R, 23.5% of all persons had a psychiatric disease, 4.2% a disease of severe intensity. When the DSM-III-R diagnoses "Not Otherwise Specified" (NOS) were included 40.4% of all subjects were diagnosed by the clinical judgement of the psychiatrists to have a psychiatric disease. The most frequent psychiatric diseases were insomnia (18.8%), depression NOS (17.8%) and dementia (13.8%). Dementia showed the well-known age-related increase, whereas no other incidences of psychiatric morbidity were age-related. Persons aged 70-84 years did not differ in the investigated psychiatric variables from persons aged 85 years and older, the only exception being the prevalence of dementia.
The purpose of this study was to determine prevalence rates of psychiatric morbidity in the elderly, distinguishing different levels of psychiatric caseness as compared to the diagnoses of the DSM-III-R. In a cross-sectional population-based study in Berlin (West), Germany, 516 people aged 70 to 95+ were randomly selected from the obligatory city registry (1990-1993) and stratified by age and gender (N = 43 men and N = 43 women in each of six 5-year age groups). Psychiatric and physical examinations were carried out in an extensive standardized assessment. Distinct psychopathological syndromes occurred in 72.7% of the elderly (54.6% of the men, 79.1% of the women). A clinically defined psychiatric disorder was found in 49.4% of the elderly (95% confidence interval 43.9%- 54.9%; 36.4% of the men, 54.0% of the women). Excluding insomnia, the overall psychiatric morbidity was 40.4% (30.9% m, 43.8% w). Excluding clinical diagnoses that were not otherwise specified in the DSM-III-R, the overall prevalence of specified DSM-III-R diagnoses was 23.5% (16.3% m, 26.0% w). Excluding dementia, which is known to be age-related, the prevalence was 11.3% (8.5% m, 12.2% w) and no significant effect between the age groups was seen. A considerable proportion of clinically relevant psychiatric morbidity in the elderly does not meet the criteria of specified DSM-III-R diagnoses, although these cases are in need of care. The data show that the threshold and severity of caseness accounts for important differences when overall psychiatric morbidity is assessed.
The determination of need of care is an important problem for public health. In an epidemiological perspective the question is whether the right people get the right treatment. The answer depends on a variety of methodological issues such as case-definition, case-identification, sampling, and treatment assessment. Case-definition is done by patients themselves and by experts such as physicians or scientists. This study compares the clinical approach of family physicians with the standardized approach of epidemiologists. In two epidemiological studies, the Berlin Aging Study (BASE) and the WHO Study on Psychological Problems in General Health Care (WHO/PPGHC), diagnosis and treatment of major depression in the field were analyzed. In spite of different methods, both studies showed a high rate of unrecognized major depressions as defined by DSM-III-R criteria. This lack of case-recognition by the primary care physicians corresponds to the fact that less than then percent of these patients were treated with antidepressants and none of them had been seen by a psychiatrist. The question to be discussed is whether these results speak for an underrecognition of cases that are in need of care under clinical conditions or an inflation of the respective numbers by standardized methods.
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